Why Not Euthanasia
by Karel F. Gunning MD
If today we accept the intentional killing of a patient as a solution for one problem, then tomorrow we will find a hundred problems for which killing must be accepted as a solution. During World War II, euthanasia was considered to be a solution for over 100,000 German patients who were killed as unwanted by doctors under Nazi Germany.
In the Netherlands, a government-installed committee headed by the former Attorney General, Mr. Remmelink, investigated the extent of euthanasia practiced in 1990. The conclusion of the excellent Remmelink Report (see summary in Table) was that, on a total annual mortality of nearly 130,000, a lethal drug was given in only' 2,300 cases (1.8% of all deaths). As the Dutch government defines euthanasia as "ending a patient's life at his own explicit request", there remain many other cases of killing the patient which we would call euthanasia, and which are not called euthanasia, but which are called "normal medical practice" by the Dutch government. There are 400 cases of assisted suicide and 1000 cases where a lethal drug was given without request. Then there were over 11,000 cases where life saving treatment was omitted with the explicit intention of shortening a patient's life, while only 4,000 cases at the latter's request. And in nearly 5,000 cases pain treatment was intensified with the implicit intention of shortening life. Together in almost 20,000 cases (15.4% of all deaths) the patient died after a doctor's decision to hasten death, in almost 11,000 cases at the patient's own request.
A change in the law since 1994 makes it possible today for a doctor to end a patient's life without being prosecuted, provided he follows some guidelines: he must consult a colleague (not necessarily a specialist in palliative care); he must write a report answering some 50 questions, and so on. This report is given to the public prosecutor who decides whether to prosecute or not. But this decision is made on the basis of the report. Its author is the doctor himself. According to Dutch law, one cannot be expected to accuse oneself. The chief witness - the patient -- is dead at this point. In most cases, the doctor can report as he likes. This means that our patients are no longer protected.
In 1996, a report similar to the Remmelink Report was produced over the year 1995. Comparing the two reports (see table), we find that the number of cases where the patient died after a doctor's decision to hasten death, had increased from almost 20,000 (over 15% of total deaths) to almost 27,000 (nearly 20% of total deaths) of which over 13,000 were done at the patient's request. Of the cases which should have been reported according to the guidelines of the new law, only 41% were actually reported. In fact, the new law protects the doctor, not the patient.
What About The 'Slippery Slope'?
The first case of euthanasia in Holland where a doctor killed her mother allegedly at the latter's request, was in 1975. This doctor was sentenced to a two weeks prison term on probation. Twenty years later we got down to 27,000 cases of intentional killing per year. It shows that not only had the numbers increased, but that the mentality toward euthanasia is going down the slippery slope. Of course, if treatment is refrained from or if a high dose of medication is given without the intention to kill but for the patient's benefit, this is regarded as very good medical practice.
The situation in which euthanasia can be practiced with impunity is also increasing. First, only in cases of unbearable and uncontrollable suffering near the end of life, can euthanasia at the patient's request exempt a doctor from prosecution. Today, the handicapped, new borns, comatose patients, and even completely healthy but depressed people have been euthanized without punishment by the courts. Some Dutch doctors, hearing about the British successes with palliative care, answered that they did not need to study it, as they could apply euthanasia instead.
What this change in mentality means in practice, is shown by a few examples. An internist, called to see a lady with lung cancer who breathed with great distress, told her that he could help her, but that he would prefer to admit her to his hospital. The patient refused, as she feared to be euthanized. But the doctor told her that he would be on duty during the weekend and would admit her himself. She did go on Saturday. On Sunday night, she was breathing normally. On Monday morning the doctor was off duty. In the afternoon, he came back to the hospital but the patient was dead. A colleague had come in that morning and said, "We need that bed for another case. It makes no difference for her whether she dies today or after a fort night". So, the patient was euthanized against her explicit will.
I, myself, had a discussion with a colleague about administering morphine. I maintained that large does are needed to kill a patient. At first he denied this, but suddenly said, "You are right. I remember a case of an old man who could die any day. His son came to see me. He was booked for a holiday and did not want to come home for his father's funeral. He wanted the funeral to be over with before he left. So I went to see the old man and gave him a huge dose of morphine. In the evening I came back to declare death, but the patient was happily sitting on the edge of his bed. At last, he had gotten enough morphine to kill his pain." My colleague told this story as if it were the most normal thing to do: to kill a patient in order to please the family.
Two Ethical Systems
Nowadays, there are two competing ethical systems. The oldest, which I call humanitarian, is the ethics of the Universal Declaration: the Hippocratic Oath formulated in 400 B.C. by Hippocrates who was no Christian. He believed that the doctor was a powerful man who could decide on life or death. As the patient could not know whether a white powder was meant to kill or cure him, he had to simply trust his doctor. That is why Hippocrates made doctors swear that they would never use their knowledge and experience to kill, either before or after birth; not even at the patient's own request. In this humanitarian ethic, the well being of the individual is central.
The other ethic I call utilitarian because it is not for the patient's well being, but the well being of others which prevails. The doctor judges the quality and the sense of a patient's life whether he is a burden or useful to society, etc. This way of thinking was described in a very clear editorial in California Medicine, September of 1970. It said that medical ethics had been based so far on the notion that all men's lives had equal value, but that this could no longer be maintained as over population was threatening us and we were no longer prepared to accept every quality of life. Choices would have to be made on the basis of medical evaluation. Intentional killing was still abhorrent, so one had to begin with abortion and then go on to voluntary euthanasia. But in the end, we would have death control as well as birth control, and we doctors should prepare ourselves for this new task.
Many people think that legalizing euthanasia will make them autonomous. But, in fact, it is the doctor who is made free to do as he thinks right. In the end, it is not the patient, but the doctor who decides when life should be ended. Is this what we really want? Respect for human life will diminish: violence will increase.
Here is another option. Instead of killing the patient, we can kill the pain. Britain is far ahead of us in dealing with the symptoms of terminal diseases: pain, vomiting, constipation, shortness of breath, itching, fear of the future, loneliness, and so on. Today, we can help these patients effectively.
The big question is, Will the United Nations maintain the humanitarian ethic of the Universal Declaration on Human Rights which recognizes each man's right to life? Or, Will we accept the utilitarian ethic of death with its elimination of unwanted people? We cannot at the same time defend people's right to life and allow them to be killed. We need a clear strategy to make sure that our children inherit the kind of world the U.N. has promised to build.
K.F. Gunning, MD
- President World Federation of Doctors Who Respect Human Life. (WRDWRHL) He lives with his wife in Rotterdam. The Compassionate Healthcare Network, CHN is a member of the WFDWRHL. Dr. Gunning is quoted on several other pages on CHN.
1 P.J. van der Maas, J.J.M. van Delden & L. Pijnenborg. 1991.Medische beslissingen rond het levenseinde. SDU Den Haag.
2 G.van der Wal & P.J. van der Maas. 1996. Euthanasie en andere medische beslissingen rond het levenseinde. SDU - Den Haag.
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