Euthanasia: The Hippocratic Tradition and Trust
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This brochure aims to encourage discussion of the relevance of the Hippocratic medical ethic in fostering trust between patients and their doctors.

What is Euthanasia?

Any action or omission which is intended to end the life of a patient supposedly in his/her interests.

What do Medical Associations state about Euthanasia?

The British Medical Association Report in 1988 stated:

`The law should not be changed and the deliberate taking of a human life should remain a crime. This rejection of a change in the law to permit doctors to intervene to end a person's life is not just a subordination of individual well-being to social policy. It is, instead, an affirmation of the supreme value of the individual, no matter how worthless and hopeless that individual may feel.'

The World Medical Association has proposed the following wording for a declaration on euthanasia:

`Euthanasia, that is the act of deliberately ending the life of a patient either at his own request or at the request of his close relatives, is unethical. This does not prevent the physician from respecting the will of a patient to allow the natural process of death to follow its course in the terminal phase of sickness.'

What about the Hippocratic ethic?

The Hippocratic code of ethics was founded in 400 BC. It prohibited doctors from killing patients; the sick were treated regardless of race, colour, creed or status. This included slaves and the wounded enemy, and doctors became non-combatants. Hippocrates recognised (a) that the sick are very vulnerable and (b) that doctors are in a position of power over them. This ethic has been accepted world-wide.

Is this ethic now out-dated?

No. It was reformulated as the Declaration of Geneva 1948 on the recommendation of the British Medical Association, which stated `The spirit of the Hippocratic oath cannot change...'

The Declaration of Geneva states: `The health and life of my patient will be my first consideration; I will maintain the utmost respect for human life...'

Does the structure of the NHS undermine the medical ethic?

No. A doctor's primary responsibility is to the patient irrespective of his/her employer, or government policy. A doctor must work within the medical code. The trust between patients and doctors would be eroded if doctors complied with State or Company policies which endangered the health of patients.

In 1941 4,261 Dutch doctors signed a letter to the German Rijkscommisaris in Occupied Holland: `... Although we do not deny that the care of the community and social hygiene measures constitute part of the task of the physician, we can recognise this duty only insofar as it proceeds from and is not in conflict with the first and holiest precept of the physician, namely the respect for life and for the physical well-being of the individual who entrusts himself to his care.' Many of the signatories were sent to concentration camps, but the Nazi euthanasia programme was never imposed in Holland, and Dutch doctors never signed the certificates declaring men fit for work - a preliminary to deportation for slave labour.

What is the situation in Holland now?

Perhaps because there are no bad memories, euthanasia is practised widely in Holland now, and there are official guidelines, although technically it remains illegal.

A Government-sponsored committee chaired by Attorney-General Remmelink published its Report in September 1991. This was based on the information given by 405 doctors, enquiry into 7,000 deaths and analysis of 2,250 questionnaires. It provides the most extensive, reliable and accurate source of information to date on the way euthanasia is practised in Holland.

Death by request: The report shows that in the year 1990/91 2,300 patients were killed by their doctors at their request, and there were 400 assisted suicides. [Vol I, p 13]

Without request: The officially accepted rules of conduct which specify that a request for euthanasia must be submitted by the patient, are often ignored. [Vol I, p 15, Vol II, p 16] In 1990, only 454 euthanasia deaths were registered as such.

27% of all physicians said they had taken measures to end the lives of patients who had not specifically requested it. [Vol II, p 46]

Of 49,000 deaths directly influenced by clinical management in 1990 19,675 (40%) were euthanasia deaths; of these, 13,816 were cases of non-voluntary and involuntary euthanasia.

8% of patients who were killed without their consent were the demented elderly. [Vol II, table 6.7 p 52] The reasons given were `low quality of life', `no prospect of improvement', and `the family could not take it any more'.

In 45% of patients killed by involuntary euthanasia this was done without the knowledge of the patient's family. [Table 6.8, p 52]

The report does not quantify euthanasia in neonates or psychiatric patients, but it says that decisions to withhold or withdraw treatment from premature or severely handicapped infants are taken `in about half of all cases'. [Vol I, p 17] Decisions about the end of life are taken for psychiatric patients: `A relatively large proportion of these cases concern patients unable to formulate their wish'. [Vol I, p 18]

What definition of euthanasia did the Dutch Committee use?

Euthanasia was defined as `active termination of life upon a patient's request'; consequently in the Report's Conclusions the voluntary cases were highlighted.

Has euthanasia in Holland affected trust between doctors and patients?

Yes. The former Attorney General T M Schalken has found that some groups live in fear and uncertainty. The Dutch Patients' Association stated in 1985 that `In recent months the fear of euthanasia has increased considerably.' Some severely handicapped adults from Amersfoort wrote to the Parliamentary Committee on Health Care and Justice stating:

`We feel our lives threatened ... We realise that we cost the community a lot ... Many people think we are useless ... often we notice that we are being talked into desiring death ... We will find it extremely dangerous and frightening if the new medical legislation includes euthanasia'.

`Declaration of the Will to Live' cards were printed by the Sanctuary Association to protect the signer who did not wish euthanasia to be performed on him or her.

A survey concluded that `The majority of residents of homes for the aged are afraid of involuntary euthanasia'.

What about Britain?

In a MORI poll in Britain carried out in 1987, 59% of the public agreed with the proposition that if euthanasia were legalised, more old people would be frightened to go into hospital.

Is the subject of medical ethics relevant to medical education?M

Yes. Following the evidence given in the Nuremberg Trials of harmful experiments and the killing of human beings by doctors in the name of science, the British Medical Association stated `They departed from the traditional medical ethic which maintains the value and sanctity of every individual human being,' adding `In medical education, the traditional aims and ethics of Medicine should pervade the curriculum . . . These principles . . . should be part of the medical graduation ceremony.' It was the Charter of Medicine suggested by the BMA which resulted in the 1948 Declaration of Geneva.

Traditional ethics and justice

Every citizen enjoys equal protection against murder. This is a basic right. But in Holland a doctor has been prosecuted for failing to carry out euthanasia after having agreed to do so.

A Government policy giving doctors a duty, within their terms of service, to perform euthanasia would discriminate against both doctors and their patients. Doctors who refused to kill would have considerable difficulty in getting appointments, both in hospital and general practice. Patients would suffer by being deprived of the services of the doctor who could not in any circumstances regard them as disposable.

What about the quality of life?

Dr R Barry Jones, MD, FRCP, wrote in 1981:

`The major focus of debate is the severely malformed neonate. If the baby is so malformed that it seems impossible that it could ever lead a life of quality, should it be allowed to live at all, or indeed should active steps be taken to hasten its death, in plain English to kill it?

One answer to the dilemma is to say that this is a medical decision - only a physician skilled in evaluating the newborn is in a position to decide, or advise the parents what to decide. This is nonsense. Whether or not a patient will benefit or not from a particular line of treatment at a particular time is a medical matter. Whether the child should be fed and nurtured, or sedated and starved to death, is no part of a doctor's brief.

Who will be next? The old? All handicapped people? The socially undesirable (whatever we choose that to mean)?

Dr Christoph Hufeland, Goethe's doctor, wrote in 1806:

`The physician should and may do nothing else but preserve life. Whether it is valuable or not, that is none of his business. If he once permits such considerations to influence his actions, the doctor will become the most dangerous man in the state.'

References

  1. British Medical Journal, 14 May 1988. Copies of The Euthanasia Report are available from Profession Divisions Publications (Ethics), P.O. Box 295, London WC1H 9TE
  2. The Lancet, 27 June 1987
  3. B.M.J. `War Crimes and Medicine', June 1947 (reprinted with permission, Medical Education Trust)
  4. Adopted at a conference of the World Medical Association, 1948
  5. The Dutch Physician's Protest, translated by the late Conrad Baars M.D. in The Netherlands in Time of War
  6. Report of the Ministry of Justice and Ministry of Welfare, Public Health and Culture Vols I and II
  7. Jaarverslag Openbaar Ministerie (Government Annual Report, Ministry of Justice) for 1990, p 56
  8. Letter in The Times October 30th 1991 from Luke Gormally, Director of the Linacre Centre
  9. Dr Richard Fenigsen, `A Case Against Dutch Euthanasia,' The Hastings Centre Report, January/February 1989
  10. J H Segers, `Elderly Persons on the Subject of Euthanasia,' Issues in Law and Medicine 1988 3: 407-24, quoted in The Lancet in `Euthanasia: A Contemporary Moral Quandary' by William Reichel and Arthur J Dyck, 2nd Dec 1989
  11. Bernard Levin, `Under Patient's Orders - to Kill', The Times 11th Dec 1989
  12. See: Report of the House of Commons Social Services Committee (HC 123) on the working of the Conscience Clause of the Abortion Act, 24th Oct 1990
  13. `The Quality of Life,' in Child Care, Health and Development 1981 Vol 7 2, 65-66
  14. Journal of Practical Medicine and Surgery, 1806