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09 July 1998

Deathly Indecision

Dr Liz Frayn, recently qualified and raring to go, asks why other young doctors seem reluctant to take responsibility for their decisions

At the 166th annual conference of the British Medical Association (BMA) in Cardiff this week, a group of junior doctors pushed through a significant proposal. The delegates voted overwhelmingly to launch a consultation document on the ethical dilemmas of withdrawing or withholding treatment from patients who have no prospect of recovery and consequently to rethink the BMA's position on physician-assisted suicide, something it has traditionally opposed.

As a new doctor, I am interested in why this topic seems to occupy junior doctors so much more than their senior colleagues. Why are young doctors in the 1990s suddenly so motivated by this age-old dilemma?

Individual doctors have always privately held a diverse range of views on the issue, despite the previously intransigent BMA position against euthanasia. The junior doctors want to get these differences of opinion out in the open, and resolved, on a profession-wide basis. I think this concern springs, not from a fervent belief in assisted suicide, but rather from a sense of insecurity at work.

In my experience, one of the constant complaints of young doctors is that they are over-burdened with responsibility. This lack of confidence is not only apparent in discussions of assisted suicide. For example, at the BMA conference junior doctors also raised concerns about being expected to explain to patients surgical procedures which they themselves felt ill-equipped to understand. They apparently feel isolated and inexperienced in a minefield of ethical dilemmas, and want back-up from guidelines and consensus.

A perceptive report by Isobel Allen in 1997, 'Committed but Critical', based on focus group discussions with doctors under 40, made the striking observation that 'young doctors feel increasingly uncomfortable in the practice of medicine'. She highlighted several factors contributing to this sense of unease, including 'the intensity of work, lack of support and feelings of isolation, and more demand for medical intervention and advances in drugs and medical technology'. She also commented that the 'shadow of legislation' loomed over many of the discussions, a worry almost unknown to previous generations of doctors.

This insecurity is the main reason for young doctors putting the issue of assisted suicide on the agenda. However, there may be a further factor behind their enthusiasm. In reading Allen's report, you get the impression that there is very little in medicine that genuinely excites today's junior doctors. Where advances are mentioned in the report, it is in a negative light: they make life more difficult, work more intense, and they raise unrealistically high expectations in patients. There is surely something symbolic about the fact that young professionals feel so passionately about what is in many ways an end point of medicine, a perpetual problem that will never go away. In short, the focus on death seems to express a more general pessimism about the potential of medicine to help people stay alive and healthy.

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