Irish Medical Council drops ban on deliberate killing of patients

Newly published ethical guidelines given to doctors by the Irish Medical Council no longer contain a ban on the deliberate killing of Irish patients. The regulations for medical profession in Ireland had previously included a prohibition on deliberate killing, but that measure is not included in the Council’s 9th edition of its medical guide, published this month.

 While also updating guidance on conscientious objection, the new ethical code drops guidance around abortion and assisted human reproduction.

The updated Guide to Professional Conduct and Ethics for Registered Medical Practitioners – which underpins the values and principles of being a doctor in Ireland – replaces the 8th edition, published in May 2016. The guide had previously been updated following Ireland’s vote to repeal the eighth amendment and the commencement of the Health (Regulation of Termination of Pregnancy) Act 2018. 

The 2018 guide had provided amended guidance for doctors, after a consultation process took place on issues relating to doctors’ professional conduct and ethics.

Guidance around assisted human reproduction has also been removed from the ethical guidelines by the Irish Medical Council. The obligation that doctors “must not take part in the creation of new forms of human life solely for experimental purposes. You must not engage in human reproductive cloning” – included in previous guidance – has now been scrapped.

The Iona Institute has blasted the updates featured in the medical code, describing the newly updated guide as a “momentous move” “clearly paving the way for euthanasia”.

The Guide which came into effect on January 1st, says it seeks to support doctors by providing principles-based guidance on how best to work in partnership with patients and covers a wide range of scenarios which are likely to arise over the course of their career.

END OF LIFE CARE

While the 2016 Guide included the line: “You must not take part in the deliberate killing of a patient” under principle 46.9 under ‘End of Life Care’, this line is not included in the updated guide.

 The line which tells doctors, “Usually, you will give treatment that is intended to prolong a patient’s life” has also been removed from the section on End of Life Care.

Responding to this, the Iona Institute said the shift represented “a huge and almost unnoticed change to the code of conduct that governs doctors in Ireland” – adding that the ethics code had taken “backward steps.” In a statement, it said: “What has taken place represents a seismic shift in true medical ethics that date back to Hippocrates in Ancient Greece.”

“It seems perfectly clear what is happening. If the Government legalises euthanasia, the ethics code for doctors will no longer get in the way,” the organisation said.

While doctors were previously told that there was “no obligation” to start or continue treatment,  including resuscitation, or provide nutrition and hydration by medical intervention, under certain circumstances, they are now directly told that they “should not start or continue treatment, including resuscitation, or provide nutrition and hydration by medical intervention” under such circumstances. 

These circumstances are if the treatment Is unlikely to work; might cause the patient more harm than benefit; and is likely to cause the patient pain, discomfort or distress that will outweigh the benefits.

While the guide previously told doctor that they “should explain the reasons for your decision and listen carefully to the views of others” in the circumstance where there is a disagreement within the healthcare team or between the healthcare team and the patient or the patient’s family about whether it is appropriate to withdraw treatment, or not to start a treatment, this line has been dropped.

In addition, the line which tells doctors that they “play an important role in supporting patients, families and the community to deal with the reality of death” ha been removed from the guidance.

The line which previously told doctors they should “carefully consider when to start and when to stop attempts to prolong life” has also been dropped from the guide, in a reduced End of Life Care section.

The line which read, “You should respect a refusal of treatment in a patient’s advance healthcare plan or directive” no longer features, but the guidance says that doctors “should involve patients (and/or persons with decision-making authority in relation to the patient) in decision-making about their end- of-life care, respecting their will, preference any Advance Healthcare Directive and decision-making capacity.”

CONSCIENTIOUS OBJECTION 

On conscientious objection, doctors were previously told that if they objected to a treatment, they had to inform the patient that they had a right to seek treatment from another doctor. They also had to give the patient “enough information” to enable them to transfer to another doctor to get the treatment they wanted.

However, under the updated code, this is expanded, telling doctors that in addition to those points, they are now obliged to “make such arrangements as may be necessary to enable the patient to obtain the required treatment.” It also tells doctors that they must ‘not mislead or obstruct a patient’s access to the lawful procedure, treatment or form of care based on your conscientious objection.”

The Iona Institute, which promotes the importance of conscientious objection, said that the new code weakened the previous section on conscientious objection. It also pointed out that the guide no longer forbids doctors from taking part in human embryo experimentation or in human cloning.

The new guidance also adds the obligation: “You must provide care, support and follow-up for patients who have had a lawful procedure, treatment or form of care to which you have a conscientious objection.”

The medical code removes some of the previous guidance around assisted human reproduction, which informed doctors that treatments such as IVF should only be used after thorough investigation has shown that no other treatment is likely to be effective. 

“You should make sure that patients have been offered appropriate counselling and have had enough time to consider the information before giving informed consent to any treatment,” doctors were previously told, but this no longer features.

The guide previously told doctors that assisted human reproduction services should only be provided by suitably qualified professionals, in appropriately accredited facilities, and in line with international best practice, but the new version no longer includes this statement .

The guidance previously told medics: “If you offer donor programmes to patients, you must have strong governance structures and keep accurate records so that the identity of the donor can be traced. Donor programmes should be altruistic and non-commercial. You should also comply with industry accreditation standards for donation programmes,” – however this is also gone.

The ban on taking part in the creation of new forms of human life solely for experimental purposes, or engaging in human reproductive cloning, has also been lifted.

The code’s section on telemedicine has been reduced, removing in its entirety a warning to doctors that they must “satisfy” themselves that services provided through telemedicine are “ safe and suitable” for patients. 

The guidance telling medics they should explain to patients that there are “aspects of telemedicine that are different to traditional medical practice – for example, a consultation through telemedicine does not involve a physical examination and any additional risks that may arise as a result” has also been scrapped.

Guidance on termination of pregnancy – included in a section in the 2016 guide – has been scrapped altogether in the 2024 guide.

The guide contains repeated references to assisted decision-making, less than a year after the commencement of the Assisted Decision-Making (Capacity) Act of 2015 – addressing some of the implications of that act.

It states: “In accordance with the legislation, the Guide confirms that where adults are considered not to have decision-making capacity, you must seek and listen to their views and involve them in decisions about their healthcare to the extent that they are willing and able to be involved.

“Where a person lacks capacity to make their own decision, the Guide sets out a long list of obligations including giving effect, as far as is practicable, to the patient’s past will and preferences, considering their beliefs and values and considering the views of any person named by the patient as a person to be consulted and any decision-making supporter or person with legal authority to act on behalf of the patient. 

“Doctors must also consider the likelihood of the patient ever recovering capacity and must ensure that decisions they make are proportionate to the significance and urgency of the situation and as limited in duration as possible in the circumstances,” it adds.

There is specific guidance in relation to advance healthcare planning in the Guide, recognising that an Advance Healthcare Directive is a legally binding document in accordance with the Assisted Decision-Making (Capacity) Act 2015 and reflecting the language of that Act. The guidance says that where a patient is assessed as lacking decision-making capacity, a doctor should take “all reasonable steps” to ascertain whether a patient has made an Advance Healthcare Directive.

In its statement, The Iona Institute said it was important to note that the Minister for Health oversees appointments to the Medical Council. 

“Very few members of the Council are elected by doctor themselves. Notably, GPs were not consulted ahead of the change being made,” it added.

“The new code is a gigantic step backwards from an ethical point of view,” the organisation continued, adding: “No longer telling doctors that they cannot take part in the deliberate killing of patients is not medical ethics, it is the opposite. It is shameful that the Medical Council has gone down this path, clearly with the blessing of the Minister for Health. Hopefully the doctors of Ireland will push back against this incredibly retrograde step.”