Appearance before the Euthanasia Study Commission
Gonzalo Herranz
department of Bioethics, University of Navarra
Spanish Senate, 16 June 1998
1. The attitude of the medical profession to euthanasia
A. What the National Physicians Associations' Codes of Ethics Say
B. Statements by international medical ethics bodies
a. association World Medical Association in its Madrid (1988) and Marbella (1992) Declarations
b. The Permanent committee of European Doctors, in its Berlin (1987) and Cascaes (1993) Declarations
c. The International Medical Orders lecture
d. Statements by national medical bodies on euthanasia
2. The Recommendations of the National Bioethics Committees
Madam President and Members of the Commission:
First of all, I would like to offer my sincere thanks for the opportunity to perform before you. The thanks are staff. But it is also corporate, as the invitation has been extended to me through the Spanish Medical Association. I think it is only right, when dealing with euthanasia, that the voice of the medical profession should be heard.
You already know that 16 years ago I left my Chair of Anatomy pathology and took the strange decision for many to dedicate myself to the study, the teaching and the internship of medical ethics. I am very glad that I did so, because it has allowed me to awaken in many students and young colleagues a lively and studious interest in the ethical problems of medicine. It has enabled me to cooperate with colleagues in the medical organisations of the European Union in the first efforts to identify our common ethical heritage and to plan its enrichment and transmission to new generations. I have also had several opportunities, in Brussels, Strasbourg and Madrid, to act before parliamentary committees studying medical ethical issues.
purpose of my intervention
I come to this session with the best wish to help you study the serious questions that the legal regulation of euthanasia raises in our society. I would like to warn you in advance that my testimony is based on the intensive monitoring and critical reading of the already vast bibliography on euthanasia, on the direction of some works of research on terminal illness, on therapeutic futility and the communication needs of the terminal patient, and on contacts with the members of the Medical Ethics Commissions of the association World Medical Association and of the committee Permanent Medical Association of the European Union, of which I am, for the second time, Vice-president.
Confession of bias
I think it is appropriate to point out that my attitude is against the legalisation of euthanasia and the financial aid medical approach to suicide. I cannot deny that this conviction is part of my religious convictions. I fully share the doctrine set out by Pope John Paul II in his Encyclical Evangelium vitae, which, whatever one's views on subject may be, must be considered a classic of modern-day bioethics. My attitude also stems from the professional conditioning that we doctors receive in the course of our professional career Education . However, since I have been working in medical ethics, this bias has become more and more conscious, and I think also more rational and well-founded. I have come to understand more and more deeply the thinking of those who argue in favour of euthanasia and medically assisted suicide, but I have come to understand more and more deeply that euthanasia is incompatible with the medical ethics of respect for persons.
Contents
I believe that the best contribution I can make to the work of this Commission is to offer a perspective on:
1. The attitude of the medical profession to euthanasia. To do this I will show you what is said in A) the Codes of Ethics of National Medical Associations; and B) the Declarations of international medical ethics bodies.
2. Recommendations of National Bioethics Committees. These are highly reputable bodies that in many countries have been established to inspire, guide and publicise the social discussion on important points of ethics. In Spain we unfortunately lack a national (bio)ethics committee .
I believe that these two points can offer a very broad and core topic culturally diverse perspective on the issue under study.
Finally,
3. I would like to offer some personal considerations about the negative effects of the legalisation of euthanasia.
1. The attitude of the medical profession to euthanasia
A. What the National Physicians Associations' Codes of Ethics Say
I have recently reviewed what the Codes of Ethics and Medical Ethics of 39 countries (22 in Europe and 17 in America) in more than a hundred different editions have to say about the four major problems of end-of-life ethics (euthanasia, financial aid medical suicide, therapeutic incarceration and palliative care). I leave you an offprint of work published in an Italian journal. I could extend my data to 46 countries, with the inclusion of the Codes of Medical Ethics of 7 National Medical Associations in Asia and Oceania.
The results are as follows: they do not deal with subject, three; they marginally allude to it, twelve; they deal with it explicitly, but do not define themselves on the four specific aspects analysed, thirteen; they offer a detailed exhibition , eighteen. Although the Codes vary widely in content and style, there is no break in the common tradition of rejecting euthanasia and medical financial aid suicide. The condemnation of therapeutic obstinacy is also general, as is the positive mandate to alleviate suffering and to apply palliative remedies. Significantly, the Rules of Conduct for Physicians of the progressive Royal Dutch Society of Physicians are silent on the relationship of the physician to the terminally ill patient, a silence that means a great deal.
This rare unanimity, in time and space, on the intangibility of human life that has just taken place, should give cause for reflection, since, curiously and by different routes (utilitarian arguments, healing vocation, moral imperative, adherence to traditions), one arrives, in different cultural areas, at the same firm prohibition of euthanasia. The times in which we live are not very propitious for proposing and defending absolute or simply strong moral norms. Not only are they not fashionable: the dominant post-modernism is incompatible with hard convictions. One conclusion must be drawn: respect for terminal life belongs to the ethical minimum that defines the core of the medical profession: this is an evidence-based assertion, which overrides the religious, cultural and economic variability of the internship of medicine.
B. Statements by international medical ethics bodies
From agreement with international professional bodies, euthanasia and financial aid medical suicide are incompatible with medical ethics. This is the universal view, as the following statements show.
a. association World Medical Association, in its Madrid (1988) and Marbella (1992) Declarations
Statement on euthanasia
Adopted by the 39th World Medical Assembly, Madrid, Spain, October 1987
Euthanasia, i.e. the deliberate act of ending a patient's life, even at the patient's own request or at the request of relatives, is contrary to medical ethics. This does not prevent the physician from respecting the patient's wish to let the natural process of dying take its course in the terminal phase of his illness.
Statement on suicide with financial aid medical
Adopted by the 44th World Medical Assembly, Marbella, Spain, September 1992
Recently, a number of cases of suicides involving financial aid medical suicide have been brought to the public's attention. In these cases, a machine invented by a doctor has been used, instructing the person concerned how to use it. Thus, the person is financial aid encouraged to commit suicide. In other cases, the doctor has provided the person with medication together with information on the dosage necessary to cause death. In other words, the person is provided with the means to commit suicide. It is almost certain that the persons who have committed suicide were seriously ill, perhaps terminally ill, and in great pain. In addition, the persons were apparently with all their Schools and voluntarily made the decision to commit suicide. Very often, patients who are tempted by suicide show signs of the depression that accompanies terminal illness.
Suicide by medical financial aid , like euthanasia, is unethical and should be condemned by the medical profession. When the physician's financial aid is intentionally and deliberately directed at allowing a person to end his or her life, then the physician is acting unethically. However, the right to refuse medical treatment is a basic right of the patient, so a physician who respects the patient's wish, even if it results in the patient's death, is not acting unethically.
b. The Permanent committee of European Doctors, in its Berlin (1987) and Cascaes (1993) Declarations
Declaration of Berlin on the financial aid to the dying (CP 87/16)
Preamble. The practice of medicine implies respect for the life and dignity of the human person in all circumstances. Any act aimed at deliberately causing the death of a patient is contrary to medical ethics. The physician must respect the will of the person he is assisting to initiate and continue the treatment that he, in conscience, deems appropriate. The attendancetherapeutic and psychological care of the dying is included in these obligations, for the dying are entitled to humane consideration and treatment.
Declaration: Physicians have a duty to give attendancetherapeutic and psychological care to their patient to the end. Physicians should endeavour to obtain, as far as possible, the informed consent of the patient whom they are assisting. When the patient loses consciousness, physicians should assist the patient with the medical means best suited to the patient's genuine interests and maintain those means as long as there remains any hope of improvement. When the incurable disease enters its irreversible terminal phase, physicians may limit their treatment to the relief of physical and moral suffering and shall endeavour as far as possible to maintain the quality and dignity of a life that is coming to an end.
Cascais Declaration on Living Wills/Advance Directives (CP 93/83).
Living wills/advance directives (CP 93/83 Final)
Statement of the standing committee of doctors of the EC on living wills/advance directives adopted during the Plenary Meeting held in Cascais on 12-13 November 1993
Introduction
The Standing Committee is opposed to any legislation giving living wills/advance directives the force of law, because if that were the case, it would constrain the ability of the doctor to treat the patient to the highest professional and ethical standards.
Such a document can only be a written expression of the wish and intention of the patient, made at the time when the patient was fully "compos mentis", which can later be of use as a basic framework of care.
The Standing Committee recognises that approaches to this issue are determined by a range of social, cultural and religious factors, which mean that there are wide variations in legal provision and professional attitudes from one country to another. While respecting these national differences, the Standing Committee has identified basic principles.
Recommendations
1. This form of expression of wish and intention is not intended to promote active euthanasia.
2. Doctors should not be obliged to act contrary to their consciences. The doctor should inform the patient at the outset of any objections which she/he may have to the content of an individual expression of wish and intention and, if necessary, assist the patient in transferring to the care of another colleague.
3. Doctors should at all times seek to act in the best interests of their patients and to recommend the treatments which they consider most appropriate.
4. The doctor/patient relationship is based on mutual respect, trust and good communication. Doctors should explain treatment options to patients and ensure that they have sufficient information on which to base decisions.
In the absence of contrary evidence, a valid statement of wish and intention is of value in representing a patient's settled wish when the patient may no longer be competent to express a view. The patient is responsible for ensuring that the existence of his/her advance directive is known to those who may be asked to comply with its provisions. Those who interpret it must take account of the possibility that the patient's views about treatment may change as his or her clinical condition changes.
5. Patients may wish that every possible treatment should be provided to the point of death. They also have the right to refuse treatment at ah times.
6. Patients who become incompetent should retrain the same rights in respect of health care as those who remain competent.
7. It should be possible for a statement of wish/intention to be overridden where the clinical circumstances are not precisely covered by their provisions. Such circumstances are a matter of clinical judgement and would merit further discussion.
8. If there are discussions about developing policy on the use of statements of wish/intention, representatives of medical and other health professions should be involved while the complexity and sensitivity of the various factors which must be taken into account should be drawn to the attention of the public and appropriate authorities.
c. The lecture International Medical Orders
includes the following articles in its Principles of Medical Ethics for Europe, Paris, 1987:
article 1º. The vocation of the physician is to defend the physical and mental health of man and to alleviate his suffering with respect for the life and dignity of the human person, without discrimination as to age, race, religion, nationality, social status, political ideology or any other reason, in time of peace as in time of war.
In the section on financial aid to the dying, article 12th, which reads:
In all circumstances, medicine implies constant respect for life, for moral autonomy and for the patient's freedom of choice. In the case of incurable and terminal illness, the physician may confine himself to alleviating the physical and moral suffering of the patient, administering appropriate treatment and maintaining, as long as possible, the quality of a life that is coming to an end. It is obligatory to care for the dying until the end and to act in such a way as to preserve their dignity.
In these international declarations, we already have the typical elements of the ethics of euthanasia. It is possible to identify as basic ideas:
- respect for, and the intangibility of, human life, of which the physician must be the guarantor and guardian.
- respect for the autonomy of the patient, who is called upon to determine the extent to which medical measures relevant to the case are applied.
- the obligation to alleviate the physical and moral suffering of the patient by means of a competent palliative internship .
- the duty to maintain as far as possible the quality and dignity of declining life.
- the strict prohibition of euthanasia and financial aid medical suicide.
- the deontological condemnation of therapeutic gestures lacking in reasonableness and good judgement, which are fiercely seeking a cure that is already impossible.
It is also clear that there are certain ideological parallels, even close similarities, and even coincidences in the texts. Between Art. 12 of the Principles of Medical Ethics for Europe (January 1987) and the Berlin Declaration of the Permanent committee(October 1987) there is an almost total coincidence of ideas and even of text:
d. Statements by national medical bodies on euthanasia
Spain. Statement on euthanasia
(Adopted by the General Assembly on 21 June 1986)
In articles and talk shows, the expressions "financial aid to die" or "death with dignity" are frequently used. Such expressions are confusing because, although they may appear acceptable, they often conceal attitudes contrary to medical ethics.
Medical assistance to the dying is one of the most important and noble professional duties of the physician, whereas euthanasia is the deliberate destruction of a human life, and even if it is performed at the request of the victim or out of pity for the person who performs it, it is still a crime that is deeply repugnant to the sincere medical vocation.
In accordance with Articles 28.1 and 28.2 of our Code of Medical Ethics and Deontology, physicians are obliged to fulfil their genuine role in assisting and caring for the dying of their patients by competent treatment of pain and distress. He or she should strive for the greatest possible material well-being; he or she should, according to the circumstances, provide spiritual attendanceand human comfort to the dying; he or she should also support the dying person's relatives. The physician also dignifies death and financial aidwhen he refrains from painful and unjustified treatments and when he suspends them because they are no longer useful.
But the physician would be betraying his vocation as a healer and protector of human life if he were to kill a sick person or assist in his voluntary suicide. A physician can never deliberately cause death: that is not what medicine is for. Even if a law were to permit it, a physician may never use the power and prerogatives that society has granted him or her to carry out a capital punishment ordered by a court of law or to end the life of a sick person, even if requested to do so by the sick person, or by his or her family, or by a hospital care provider, committee.
A doctor is guilty of a serious breach of ethics if he refuses to provide a dying person with competent medical care attendanceand, above all, if he arrogates to himself the unbridled power to voluntarily destroy a human life.
A Declaration on the incorrect use of the term passive euthanasia, 1995, which recommends its exclusion in the debates: if euthanasia is deliberate killing, understanding the suspension of futile treatments as passive euthanasia is not euthanasia. Nor is passive euthanasia euthanasia caused by the omission of care necessary to save life: that is active euthanasia committed, executed, by omission.
United Kingdom
BMA: The law should not be changed. Deliberately killing a human being must remain a crime. This rejection of any change to the current law, so that doctors would be allowed to intervene to end a person's life, (...) is, above all, an affirmation of the supreme value of the individual, no matter how worthless or hopeless he or she may be.
We could add the Chamber of German Doctors, the Order of Physicians of France, the Spanish Medical Association and the Royal Dutch Medical Association association .
2. The Recommendations of the National Bioethics Committees
This section was never made.
I have published some articles in the official journal of the WTO on the effects of the legalisation of euthanasia. From them I extract a few paragraphs.
From one, published in 1991.
My thesis is clear: any legislation tolerant of euthanasia, no matter how restrictive it pretends to be on paper, leads to an increasing brutalisation of medicine, as it degrades it scientifically and ethically.
The ethical decline is not difficult to calculate. In the dynamics of legal permissiveness, decriminalising euthanasia begins to mean that killing without pain is an exceptional way of treating certain illnesses, which is only authorised for extreme and very strictly regulated situations. But, without delay, inexorably, as a result of social habituation and pro-euthanasia activism, decriminalisation ends up meaning that killing for compassion is a de facto accepted therapeutic alternative, and so effective that doctors cannot morally refuse it. The reason is obvious: euthanasia - a clean, quick, 100 per cent efficient, painless, compassionate, much more comfortable, aesthetic and economical intervention than standard treatment - becomes an invincible temptation for certain patients and their relatives. And for some doctors too, since the sweet death of one or another of their patients saves them a lot of time and effort: those invested in studying the case in depth, in palliating their symptoms, in visiting them, in accompanying them in the difficult final moment.
Restrictions imposed by law become a dead letter, they fall before the growing thrust of social demand, which increases in the face of judicial tolerance, since any legalised permissiveness is intrinsically expansive.
Once euthanasia is decriminalised, the serious thing for the doctor is that his specific virtues - compassion, prevention of suffering, non-discrimination between his patients - are turned against him, so that he is driven by them to apply this supreme "therapeutic" with ever greater zeal: he cannot deny a patient the liberating death which, in similar circumstances, he has already given to others; nor can he delay until later what is already now presented as an effective remedy. The concept of terminal illness will become wider and wider; the medical indications for euthanasia will become more extensive and earlier and earlier.
A doctor who has performed euthanasia will either repent definitively or will no longer be able to stop killing: if he is ethically consistent with himself, and believes he is doing something good, he will do so in less and less dramatic cases and, in the name of the ethics of compassion, by skirting legal barriers. For if the law, as seems likely in first generation euthanasia laws, will only authorise euthanasia for those who ask for it freely and voluntarily, how can the doctor deny it to those who are unable to ask for it, but whose life is more degraded or more burdensome? He is sure that the patient would undoubtedly ask for a gentle death if he had a moment of lucidity. Once euthanasia is authorised, the doctor's virtues are turned against him, making him a criminal, full of compassionate zeal.
Moreover, euthanasia erodes the scientific vocation of medicine. It is, for example, easier to suppress the problem of senile dementia with euthanasia than to solve it by researching the neurobiology of brain ageing; it is easier to cleanse humanity of rubbish Genetics by means of eugenic abortion or neonatal euthanasia than to go deeper into the pathogenesis and therapeutics of biochemical or morphological malformations.
Even the most upright doctor needs to guard against his weaknesses and, paradoxically, against the excesses of his virtues. To decriminalise euthanasia would be tantamount to plunging medicine into a self-aggressive illness. The obligation to respect and care for all human life is a wonderful and inspiring moral force. With it, we must develop a solid, scientific and humane palliative medicine that will uproot from our hospitals the scandalous error of therapeutic overkill and, by contrast, highlight the cold inhumanity that, disguised as compassion, hides in euthanasia.
The expansive dynamism of the acceptance of euthanasia.
The moral drama of euthanasia unfolds in four stages of progressive eclipse of respect for life and the person.
1. At first, when the doctor agrees to compassionate killing, he conceives of euthanasia as an exceptional intervention, a last resort resource, which is only justified in extreme situations of torturing pain, refractory to the most energetic treatments, and which is only authorised in response to a repeated and moving request from a rational and lucid patient. Faced with the inoperability of symptomatic remedies and the tragic nature of the clinical status , the doctor surrenders to the idea that only death can free his patient from his unbearable life. In fear and trembling, full of anguish and compassion, the doctor kills his first patient. But at the same time he breaks something of inestimable value: his utmost, virginal respect for life.
If he were to repent and never do it again, he would save his medical vocation. But if he self-justifies his action, if he continues to believe that euthanasia is an acceptable professional action, he will no longer be able to extricate himself from the euthanasia cascade.
2. The doctor, having apostatised from his faith in the sacredness of life, falls inexorably into the heresy of quality of life absolutism. More or less soon he comes to the pessimistic and dramatic conclusion that there is no shortage of lives on the way to the loss of quality, that they are practically no longer worth living, so painful and devoid of dignity and value of life they are becoming. In a few years, either by virtue of permissive legislation or tolerant jurisprudence, or public opinion manipulated by the press and television, euthanasia, from being a very exceptional remedy, ends up becoming an almost ordinary medical resource , a therapeutic option like any other, certainly controversial like so many others that are accepted by some doctors and rejected by others, and which professional journals never cease to talk about. Its results, as in the Netherlands, are audited and compared with other therapeutic alternatives in economic terms and in terms of measuring the satisfaction of doctors and relatives. Euthanasia gains respectability and prestige, as it is presented to society as a quick and painless therapeutic alternative, carried out with skill and good internship, more comfortable and aesthetic, incomparably more efficient and even more compassionate than palliative treatment.
Under the guise of an orthodox and highly professional intervention, euthanasia gains place as an ordinary medical act, and is presented as a priority option for many clinical situations, especially when it is desired and requested by the patient or their relatives.
In the statusof permanent scarcity of economic resources in which medicine will live forever, euthanasia will end up being accredited as a very efficient treatment, with an optimal cost/benefit ratio, which enormously lightens the health expense, which gives relief to those involved, and satisfaction to those who ask for it.
3. And also to those who cannot ask for it. Euthanasia in this third stage springs from the doctor's irreducibly paternalistic beneficent power. If a doctor considers that euthanasia is a service to which everyone has a right, he cannot refuse it to those who are unable to ask for it. The doctor then assumes, by virtue of his therapeutic privilege, the function of subjective agent of the incapable patient. Faced with the profoundly insane, the severely malformed, or the persistent vegetative patient, the doctor, freed from his commitment to the utmost respect for life, reasons thus in his heart: "It is horrible to live in these conditions of biological or psychological precariousness. No one in their right mind would want to live like that. Death is preferable to this impoverished life. I, at status, would demand, by means of an enforceable living will, that I be given a sweet death". The doctor thus acquires a discretionary power over the life and death of the incapable.
4. But that is not all: the doctor who regards euthanasia as a virtuous act will end up judging that there are patients whose desire to continue living is irrational and capricious, because he considers that the life they have ahead of them is either biologically detestable, or an intolerable family or social burden, or an economic waste. His argument goes like this: "The desire of some patients to live is an irrational whim, an economic luxury, a burden on others, an unjust, selfish abuse and contrary to genuine solidarity. To satisfy this merely vitalistic desire to continue living, because that is what the sick or those who represent them demand, is not only an injustice, but also an irrational consumption of resources, both economic and human. That money and that work effort could be invested in more beneficial and interesting things".
This is, unfortunately, not an imaginary status : Dutch general practitioners state that 10% of the euthanasia acts they perform are on patients who are conscious and capable of deciding, but who, for paternalistic reasons, are not consulted about euthanasia.