Editorial Euthanasia and assisted suicide: The physician's role

The American Medical Association's Council on Ethical and Judicial Affairs defines euthanasia as the act of bringing about the death of a hopelessly ill and suffering person in a relatively quick and painless way for reasons of mercy. Voluntary euthanasia is euthanasia that is provided for a competent person with his informed consent. Involuntary euthanasia is euthanasia performed without a person's consent. Assisted suicide is to provide the means whereby a suffering person may kill himself.

Euthanasia was practiced by the ancients, the term means “good death.” It was the practice of dying in peace and with dignity. For the physician, it meant caring for the patient with compassion and alleviating pain and suffering. However, the physician of ancient times could also cause the death of his patients. One physician would heal with compassion, another would provide the poison draught to cause death of the patient. The sick person did not know whether to expect to be healed or to be killed by the physician. The Oath of Hippocrates (500 BC) was the first attempt from a group of concerned physicians to establish a set of ethical principles that would guide the practice of medicine. This set of moral principles defined the physician as a healer, rejecting the role of purveyor of death. The principle of “primum non nocere,” first do no harm, became one of the guidelines in the doctor–patient relationship and remained for 2500 years (Cameron 2001; Porter 2006).

By the late nineteenth century, supported by utilitarian philosophy and Darwinian survival of the fittest, the concept of a right to death surfaced in Europe. Articles appeared in the German medical literature. In 1920, Karl Binding and Alfred Hoche published the manuscript “Permitting the Destruction of Unworthy Life.” Members of the intellectual elite; Binding was a prominent jurist and Hoche a professor of psychiatry. With the intent to benefit society, the authors advised eliminating those whose life was devoid of value and a burden to society. The victims were those near death who requested to die, “idiots,” whose life was without a purpose, and those in a comatose state due to trauma with little chance of recovery. The publication was a landmark for the euthanasia program that would follow; widely discussed in academic circles. Advocates of euthanasia, few at first, gradually increased in number, many were academic physicians and professors at medical schools. The systematic, organized killing began in the 1930s. It started with the killing of infants and children with congenital defects and mental retardation followed by disabled and mentally ill adults and the terminally ill. The killing criterion was subsequently expanded to include adults and children with ‘antisocial behavior’ and those with minor handicaps. Children and adults from psychiatric institutions were killed by lethal injection. When this method proved costly and awkward, gas chambers were built in some hospitals. Patients were transferred to these hospitals for extermination. The impetus for the program was medical economics. It is important to note that this program was not instituted by the Nazi government, but by the medical community. The Nazi government was only too happy to support and sanction the program and decriminalize the killing. With the assistance of the state, the killing became impersonal and automatic. It is a clear example of the “slippery slope.” Physicians supervised the extermination of inmates at the concentration camps. The killing by the physicians preceded the genocide of the Holocaust (Willke 1998; Lifton 2000).

The European Experience

The Right to Death movement prospered in Europe during the latter part of the past century. Several countries established euthanasia policies and are practicing both euthanasia and assisted suicide, some for several decades.

The Netherlands has the most extensive experience with euthanasia and assisted suicide. In the Netherlands, voluntary euthanasia and physician assisted suicide have been lawful since 2002 but have been permitted by the courts since 1984. At present, involuntary euthanasia is practiced widely in the Netherlands, the decision to kill the patient made by the family. Frequently, it is the Dutch physician who decides who lives and who dies. Medical professionals are not interested in eliminating the pain and suffering of patients near death but choose to eliminate the patient. There is no significant hospice system in Holland (Patient Rights Council 2011).

In Switzerland, physician- and non-physician-assisted suicide has been tolerated by the courts for several decades. Switzerland is the only country where a non-physician can assist the suicide. In 2001, the Swiss National Council confirmed the assisted suicide law but kept the prohibition of euthanasia. In the euthanasia clinics in Switzerland people from all over the world come to be killed; the law allows for non-Swiss residents. A survey conducted in 2008 showed that a majority of the clients of these clinics had no physical or psychiatric condition, they were simply “tired of living” (Time World 2009; Humphry 2010).

Euthanasia and physician assisted suicide have been legal in Belgium since 2002. In 2009, Luxembourg became the fourth country in Europe to legalize and decriminalize physician assisted suicide and euthanasia (The World Federation of Right to Die Societies 2008).

The Experience in the United States

In 1997, Oregon state legalized physician assisted suicide but not euthanasia (Humphry 2010). In December 2008, Montana, legalized assisted suicide by court order, bypassing legislative and voter approval (National Right to Life 2008). In November 2008, the state of Washington legalized assisted suicide through the ballot, 60% of voters voted “yes.” The law was enacted in March 2009 (Medical News Today 2009). Right to die groups in this country have tried unsuccessfully through popular vote to introduce laws in California, Hawaii, Michigan, Maine, and Vermont.

Comment

Aging is a process that all humans must live through. Aging from childhood to adulthood implies deterioration and ultimately ends in death. Pain and suffering come to all, more so toward the end of life. The social scientist Francis Fukuyama explains: “What we consider to be the highest and most admirable human qualities are related to the way we react to, confront and succumb to pain and suffering, and death. In the absence of these human evils there would be no sympathy, compassion, courage, heroism, solidarity or strength of character. A person who has not confronted suffering or death has no depth. Our ability to experience these emotions is what connects us potentially to all other human beings, both living and dead” (Fukuyama 2003).

The proponents of euthanasia support the practice based on the principle of autonomy of the individual and the ethic of compassion. The autonomy of the individual is thought by some to override all other moral standards. Modern culture views pain and suffering as disgraceful and undignified, and insists the pain and suffering experience be removed by any means. The argument of compassion for the individual person's pain and suffering is used to justify the use of euthanasia or assisted suicide. True compassion means suffering with the person, sharing his burdens, resulting in a desire to succor and remedy. True compassion can never justify the taking of an innocent life. Taking the suffering person's life is not the solution to his pain and suffering.

A desire for death may appear at times of stress and pain and suffering, especially if the person is uncomfortable and anxious. The infirm is frequently unaware of what medicine can do to treat the pain and make him comfortable. Medical science can provide the means to relieve the pain and suffering. With effective comfort and dignity care, the dying person is allowed to make peace with family and community. In many cases the dying person can be a witness to others and be an example of love and caring.

In an article in the New England Journal of Medicine (12 July 2012), Prokopetz and Lehmann (2012) purport to redefine the role of the physician in assisted suicide. Euthanasia and physician assisted suicide are illegal in most of the US, however, the authors state there appears to be a growing national trend toward acceptance. They admit the majority of physicians and professional physician organizations are not “comfortable with the idea of physicians playing an active role in ending patient's lives.” For this reason, they propose a system that removes the physician from direct involvement in the process. “We envision the development of a central state or federal mechanism to confirm the authenticity and eligibility of patients’ requests, dispense medication, and monitor demand and use. Such a mechanism would obviate physician involvement beyond usual care.” The authors conclude that with the practice controlled and monitored by the state or federal government there would be transparency and uniformity in the process and the physician would not have to be directly involved in causing the death of the patient.

The authors list several objections to legalizing assisted suicide, and affirm that most have been invalidated by the Oregon experience. The authors claim that data from places where assisted suicide is legal show no evidence of abuses and compromised patient safety, no evidence of involuntary euthanasia, or the practice extended to non-terminal patients or those suffering from depression.

The objection that euthanasia and assisted suicide “undermine the sanctity of life” is reduced to tension between preservation of life versus personal autonomy, and declared a religious issue. The taking of innocent life is not a religious issue. It is a crime, a violation of the right to life, the most basic of human rights.

Their recommendation to have a central governmental agency control and monitor the suicides in order for the physician to avoid personal contact is especially alarming. The killing would become impersonal and automatic; reminiscent of the German experience of the past century. In addition, eliminating physician support of the patient at the end of life would be a tragic loss, for the patient and the profession. This is an important function of the physician patient encounter, insomuch as, it is the physician's privilege and duty to assist the patient at the time of illness and the time of death.

The ends of medicine are health, cure, and care. The killing of the patient is not a goal of the physician patient encounter. There is no role for the physician in euthanasia and assisted suicide. The physician must care for the ailing patient with love and compassion, treating physical and emotional pain always with respect, preserving the person's dignity, and never cause any harm. The taking of innocent life is never a moral act.

I will use that regimen which, according to my ability and judgment, shall be for the welfare of the sick, and I will refrain from that which shall be baneful and injurious.

(Oath of Hippocrates, c 500 BC)