Deep concerns over processes in Medical Council

Minutes of the Council’s ethics committee reveal a flawed approach to revising the ethicas guide

The recent removal of the ethical stricture on euthanasia and assisted suicide by the Medical Council in its new ethics guide (ninth edition), without debate and consultation, has troubled many doctors. As a clinician who both teaches and undertakes research in ethics, I was prompted to review how this came about. I requested the minutes of the ethics committee from the Medical Council. The retrieval of these took almost four months and necessitated a Freedom of Information request. The findings were a cause of great concern with regard to the processes, mechanisms, and integrity of ethical reasoning within the Council.

One of the key tenets of the most basic teaching in clinical ethics is that ethics, as a source of learning and research over millennia, is separate from law. While the two will often interact, clinicians need to have competence in both.  Two phrases from the August 2020 ethics committee meeting minutes undermine this important distinction. The first chilling phrase was: “All citizens are required to act within the law therefore medical ethics will be shaped by the law of the land.” In a country where contraception, divorce, and homosexuality were forbidden by law until quite recently, this should give pause for thought. For those who think the Houses of the Oireachtas are going to be a beacon of clear and progressive ethical thinking, the recent referendum debacle should act as a salutary rejoinder.

This then progressed to an action line by the ethics committee: “If an issue is covered by legal provisions, these provisions apply.” By this, the committee is saying what is legal is ethical, which has been quoted subsequently as the rationale for dropping the long-standing and well-reasoned ethical stricture on euthanasia and assisted suicide. That this ethically impoverished stance was adopted speaks volumes about either ethical illiteracy or else an unarticulated strategy to remove an important ethical principle from the guide.

It was notable in this regard that at no stage in the minutes were any conflicts of interest indicated, and, in particular, whether any member shared with the committee that they were supporters of euthanasia or assisted suicide.

Compounding this radical change was a failure to appropriately communicate this to the wider profession. It is not even clear that this fundamental change was clearly and appropriately articulated to the full members of the Medical Council when they were asked to endorse the working process and outcomes of the ethics committee.

The lack of appropriate communication and signalling affected the 2021 consultation on the ethics guide. As with others, I tendered a submission, unaware as we all were that the Council was adopting an ‘if it’s legal, it’s ethical’ stance. This would have radically altered submissions if this had been known.

The lack of openness was then compounded when a wide range of professional bodies – including representatives of the ICGP, the RCPI, the RCSI, Colleges of Anaesthesiology and Psychiatry, HSE, and National Doctors Training and Planning – were invited to a targeted consultation on revising the guide on 8 June 2022. This would have been an ideal opportunity to expose the topic to debate among a broad range of medical disciplines. The dropping of the stricture on deliberate killing was one of the few sections (and the most significant change) which was not presented at this meeting.

That this under-the-radar process should occur when significant public and political debate on euthanasia and assisted suicide was ongoing and prominent is very concerning. Private Members Bills on the topic go back to 2015. Widespread coverage of a full Dáil debate and vote occurred in 2020, near the time of the change in direction of the ethics committee.

It would be worrying if the Medical Council decided to dig in and take a defensive stance rather than considering that they may have erred in their processes, thinking, and communication. Many were unhappy at the failure of the Council at the joint Oireachtas committee on assisted dying to clarify that it had been opposed to assisted suicide and euthanasia up until the unheralded radical change from 1 January 2024.

In particular, the Council’s portrayal of concerns about its processes and content as ‘misinterpretation by some’ in this public domain was condescending and dismissive. It is not in the spirit of modern medical openness. Medical bodies and institutions can err just as individual clinicians can.

Uncorrected, this chain of events and failure to communicate and engage appropriately on a major ethical issue will do lasting damage to the credibility and standing of the Medical Council as a focus for considered ethical reflection and support for not only present and future generations of doctors, but also patients and the public.

Prof Des O’Neill is a Consultant Geriatrician. He has been involved in research and teaching on clinical ethics at undergraduate and postgraduate levels for many years.