Doctors and euthanasia
Gonzalo Herranz.
Published in the journal OMC, 1998.
The pathetic end of Ramón Sampedro has affected us all. Much has been said and written about him in the media speech, sometimes with more morbidity than lucidity. And it will continue to be talked about, as it has opened a wound in Spanish society that is very difficult to heal. The promoters of euthanasia, of its decriminalisation and of its internship, will take care of this and will remind us of Ramón Sampedro's testament and message in well-calculated doses. They know that he has entered the gallery of symbols and they will try to make the most of his death.
It is curious that we doctors have hardly taken part in the comments and debates that followed the distressing event. It is surprising, because euthanasia and financial aid suicide are, in principle, considered to be matters of direct concern to doctors. What is the meaning of this absence, this silence?
It could mean that we do not have much to say, because the matter is clear. There is, on the one hand, a clear legal ban on euthanasia. Euthanasia remains a crime. The article 143,4 of the new Penal Code penalises it more mildly than before, but it does penalise it. There is, on the other hand, a clear deontological prohibition of euthanasia. Our Code of Medical Ethics and Deontology declares euthanasia or mercy killing to be against medical ethics.
It would, however, be unrealistic to infer from this that we doctors have already solved the problem and that, by virtue of the legal and deontological prohibition of deliberately killing our patients, we all think the same way and are flatly opposed to euthanasia. Such a conclusion would be as erroneous as the one deduced from certain opinion polls, crudely simplistic and blind to the complexity of moral life, which say exactly the opposite: that the vast majority of doctors are in favour of the legalisation of euthanasia and of the medical financial aid suicide.
In the narrow space of this grade , I would like to offer a few loose points for reflection addressed to doctors, because it is in the interest of doctors, more than anyone else, to reflect on the relationship between euthanasia and medicine.
1. The deontological unanimity of respect for terminal life
From agreement with the professional ethics of physicians, euthanasia and financial aid medical suicide are incompatible with medical ethics. This is the universal view, consolidated by the World Medical Association ( association ) in its Madrid (1988) and Marbella (1992) Declarations.
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 incarnation and palliative care). The results are as follows: they do not deal with subject, three of them; they marginally allude to it, ten; they deal with it explicitly, but do not define it on the four specific aspects analysed, eleven; they offer a detailed exhibition , fifteen. 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 is coming to an end should give us pause for thought. By very different paths (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. Respect for terminal life belongs to the ethical minimum that defines the core of the medical profession: it is an evidence-based statement.
2. Euthanasia, a thing for doctors or a thing for philosophers?
It seems, then, from what the Codes say, that euthanasia is not a matter for doctors. Jack Kevorkians and Herbert Cohens, the medical activists of euthanasia and financial aid suicide, can be counted on the fingers of one hand. The majority of doctors believe that such interventions could be tolerated, but only in very exceptional and tragic cases, which are very difficult to evaluate. And while they think this way, they pray to God that they will never meet any of them, and that, if this should happen, that someone who wants to apply death will be nearby; that they will not do it even if they are tied up: doctors are not there to kill. The few accounts published by a small issue of Dutch doctors who have practised euthanasia show them full of doubts and anxieties, victims of Hamlettian doubts, undecided, almost paralysed, between the intellectual acceptance of euthanasia and the ethical repugnance of ending a human life. They tell us that they have had a very hard time.
In contrast to this reluctant and uncertain attitude of doctors towards euthanasia and financial aid suicide, activists for a dignified death, many of them professors at Philosophy, not only approve of such liberating interventions, but are enthusiastic about them.
From the Canadian professor's proposal we can deduce a solid consequence: that we doctors are, of all those who inhabit the earth, the least qualified to be in charge of putting an end to the lives of the sick. We do it very badly, as the Netherlands, laboratory of social experimentation, reveals.
3. The Dutch example: learning from the head of others
A little over a year ago, the congress of the German Doctors, a massive meeting and rabidly fond of voting on everything that can be voted on, unanimously agreed to express their concern about what is happening in the Netherlands. They said in these words. "We are deeply concerned about the development internship and the legal regulation of euthanasia in the Netherlands. And while humanitarian motivations may play a role in this development, we see that, without anyone preventing it, ending the lives of terminally ill patients is becoming an integral part of the Dutch doctor's official document ".
In the Netherlands, it is true, euthanasia is on the increase. From year to year more and more applications are found. What started out as something exceptional for extreme and desperate situations, has become in a few years a first-line therapeutic alternative, like any other. What is only authorised by law for those who freely and insistently ask for it, is being applied to those who are incapable of doing so.
Statistics published by the committee appointed by the Attorney General show figures that regularly show yearly increases. The committee reports that more than half of the euthanasias are not declared. Of those that are reported, the patient is involved in the process of deciding to end his or her life in about half of the cases. In the remaining 40%, this is not possible because of weakened consciousness or dementia, while in the remaining 10% the patient does not intervene for paternalistic reasons: i.e. his or her life is ended without warning.
Given the blatant and illegal abuse of euthanasia in the Netherlands, the Royal Dutch Society of Physicians is recommending that doctors abandon euthanasia in favour of the medical financial aid suicide, which is immune to many of the misuses of euthanasia. Elderly people's distrust of doctors and hospitals is a widespread phenomenon, which is causing a diffuse state of medical withdrawal among the geriatric population. They know that many doctors have included euthanasia as a very effective therapeutic option.
When the possible legalisation of euthanasia was raised in the House of Lords for the fifth time this century, the chairman of committee appointed for the purpose, Lord Walton of Trenchant, thought that the best way to find out what euthanasia is in the flesh was to take the 14 members of the committee Medical Ethics Committee to the Netherlands and examine what was going on there in detail. The unanimous conclusion of the committee is that the UK should not legislate on euthanasia, as the Dutch experience sample with evidence that it is impossible to put legal limits on potential abuses. This is almost the same as that of a New York psychiatrist, Prof. Hendin, Director of the American Foundation on Suicide, who, after a long research on the ground in the Netherlands in order to determine to what extent the Dutch experience of financial aid to suicide could be imported to the United States, came to the conclusion that there was not much to learn from it: "The people I met in the Netherlands, on both sides of the discussion, were intelligent and sincerely concerned. If they were not, their experience would be of little value to us. But it is clear: very intelligent and compassionate people can, with very humanitarian intentions, end the lives of others in an inappropriate way".
Compassion, without rationality, justifies behaviour that no longer respects the doctor's professionalism, his judgement goal. This is what the Dutch experience teaches us.
4. In favour of euthanasia, within the profession?
There are doctors who allow themselves to be seduced by death. It is not desirable, but it is likely that we will soon see a colleague or several, which is more effective, who will accuse themselves of having ended the lives of some of their patients, of having practised illegal euthanasia. They will tell us that they have done so because, for them, honest and responsible professionals, medical financial aid suicide and euthanasia are a way, plenary session of the Executive Council of skill, of caring for patients who wish to die with dignity and honour. They are aware that their self-accusation may be taken as test that they have committed a crime, but they take the risk and are willing to be victims of a judicial system that they consider obsolete, insensitive and unjust. Their gesture - they will add - is a protest against coercive legislation, as they consider the law prohibiting financial aid to suicide and compassionate euthanasia to be inhumane. Their honesty impels them to risk their degree program and to fight for a new generation of civil rights. In passing, they will denounce the hypocrisy of the medical profession, for - they will tell us - cooperation to suicide is a widespread internship among doctors, who clandestinely help many patients to die. They will conclude that to relieve patients of their suffering through death is to act according to the best traditions of medical ethics, and that to deny sweet death is to violate the respect due to life, an act of cruelty incompatible with the compassionate heart of the physician.
This is a poignant dialectic, one that strikes a deep chord in the hearts of the public and also of MPs eager to distinguish themselves on degree program . It is all too easy for a country to succumb to a message so full of apparent compassion and humanity.
We must respond to this rhetoric of sentiment with the simplicity of the basic and non-negotiable. With the simple argumentation with which a doctor responded to a patient who found no meaning in his suffering and wanted to die, an argumentation that the patient was able to understand and accept. I recount the case: the patient lived alone, had been on dialysis for six years, had small vessel disease in both legs, but strongly refused amputation. The pain was terrible. Strong painkillers gave him nausea and frightening hallucinations that tortured him, so he had to endure the pain with light painkillers. His doctor agreed, reasonably, to the patient's request for dialysis fail . The patient knew that he had at most two weeks of very miserable and painful life left. Three days after stopping dialysis, he asked the doctor in a very moving way to end his life. No," the doctor said, "you are asking me to do something that no one can ask of anyone else: to end a human life. I cannot do that. And I have three reasons. The first is that it would destroy the most basic of human relationships. No one can kill another. Wars, gas chambers, the electric chair, gallows, poisons, rifles: for me all these are wrong, I feel it in my marrow. The second reason is that of a coward: what if someone comes along and sees me do it? I imagine that in the end they wouldn't put me in jail, but they would give me a very hard time before releasing me. So, because I'm afraid, I ask him to endure his pain. The third reason comes from doctors' relationships with patients. If doctors start killing, it can't be stopped. And everybody will become afraid of doctors and become distrustful. I can't do that.
The patient began to feel sorry for himself, as tears ran down his cheeks. Forgive me, Doctor," he said, "Forgive me for asking order". He was a great patient who understood that gratifying his request meant an exorbitant price for others. In the end, euthanasia is an unbearable harm to society, an ecological catastrophe that destroys medicine.
Because doctors are flawed. We are human, very human. This means that we have ups and downs, that we are sometimes very tired, irritable, fed up with the fight, lost, against death, or the fight, never won, against ourselves. There are patients that we don't like, that we don't want to see in the least. Sometimes we feel like having a little more order, a little more time in our lives, to be left in peace. If the law were to authorise us to eliminate human lives, what could we do on days when we are pessimistic or aggressive, when we are stressed, or when we feel like finishing soon? We are human. And the possibility of euthanasia or financial aid suicide is too close a danger. Not only for the patients who ask us for it, or for the ones who burst in on us and do not ask for it. It is a mortal danger for ourselves. The absolute prohibition of killing our sick is a wonderful and inspiring moral force.