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ISSUES IN
LAW & MEDICINE
CONTENTS
Preface
.....................................................................iii
Verbatim
Other People’s Lives: Reflections on Medicine,
Ethics, and Euthanasia
Richard Fenigsen, M.D., Ph.D.............................................................95
PART I. IN DEFENSE OF MEDICINE
Chapter I.
Chapter II.
Chapter III.
Chapter IV.
Chapter V.
Chapter VI.
Chapter VII.
Chapter VIII.
Chapter IX.
Chapter X.
Chapter XI.
Chapter XII.
Chapter XIII.
Chapter XIV.
Chapter XV.
Chapter XVI.
Bioethics Versus Medicine ................................95
On the Ethics of Physicians ............................107
The Attack on Medicine .................................110
The Responsibility and the Morale of
Physicians ..................................................115
The Motivation of Physicians ..........................125
Speaking the Truth .........................................128
The Medical Mind ..........................................137
More on the Medical Mind .............................151
On Therapy ....................................................164
The Traditional Clinician ................................170
What is Happening to Physicians’
Manners and Morals? .................................174
The Lost Skills, The Bad Habits ......................177
Farewell to Clinical Medicine? ........................195
Nurses Misled.................................................202
Is Medicine Still for the Patient? .....................205
In Defense of Medicine ...................................209
PART II. MEDICINE VERSUS EUTHANASIA
Chapter XVII.
Chapter XVIII.
VOL. 28, NO. 2
Do We Treat All Patients, or May We
Refuse to Help Some of Them? ...................213
Biological Cleansing at the Beginning
of Life.........................................................227
FALL 2012
Chapter XIX.
Chapter XX.
Crypthanasia .................................................232
Dutch Government-Ordered Surveys
of Euthanasia .............................................237
Chapter XXI.
The Philosophy of Euthanasia ........................244
Chapter XXII. Utilitarianism of Bentham-Mill-Singer
and the Philosophy of Euthanasia ..............264
Chapter XXIII. Doctors Who Practice Euthanasia ...................273
Chapter XXIV. At the Bottom .................................................281
Chapter XXV.
The Hippocratic Physician and
the Changing World ...................................285
Chapter XXVI. Staying to the Very End at the Patient’s Side....293
Chapter XXVII. Death in the Gray Zone ..................................298
Chapter XXVIII. American Assisted Suicide ..............................304
Chapter XXIX. The Shaping of Public Opinion ......................318
Chapter XXX. The Society That Has Embraced Euthanasia ...321
Chapter XXXI. Who Is Leading Us There?..............................333
Chapter XXXII. Toward a Killing Society .................................339
APPENDIX I
APPENDIX II
The Nazi Euthanasia .......................................350
Voices From Mensa.........................................358
Preface
This volume of Issues in Law and Medicine presents for the first time in the English language the complete book Other People’s Lives: Reflections on Medicine, Ethics,
and Euthanasia, by Richard Fenigsen, M.D., Ph.D. It is a translation from the original
Polish language version published in 2010 with the title Przysiega Hipokratesa [The
Hippocratic Oath] by Ryszard Fenigsen. As our readers know, we have previously
published all of the book piecemeal since 2008, with the sole exception of the last
two chapters and the appendices which appear here for the first time. Dr. Fenigsen is
a retired cardiologist from the Netherlands, and has observed many changes in ethics
and medical practice, in part due to the acceptance of physician-assisted suicide and
euthanasia there. In the final chapter he discusses the leaders of the pro-euthanasia
movement and where they are leading us, the transformation of society after acceptance
of assisted suicide and euthanasia, and the emerging Killing Society.
Dr. Fenigsen’s book gives us a valuable overview of where we have been and
where we are going. He is a key observer of modern medicine, having been trained as
a traditional clinician, and observing the many changes in medicine on both sides of
the Atlantic. It is a suitable overview of much if not most of what we have published
since the journal’s beginning in 1985.
Barry A. Bostrom, J.D.
EDITOR-IN-CHIEF
Verbatim
Other People’s Lives:
Reflections on Medicine, Ethics,
and Euthanasia
Richard Fenigsen, M.D., Ph.D.*
This book is about the transformation of traditional medicine into the modern “scientific”
variety, and the patients’ and doctors’ adventures on this journey. It is also about losses. The
ethical and intellectual costs of modernization are proving painfully high. The curative powers
of medicine have enormously expanded, but doctors’ clinical skills have suffered, resulting in a
medical practice that is less rational, less beneficial to patients, and more expensive than it need
be. Doctors’ practice and bed side manners have deteriorated, making the medical treatment a
trying experience for many patients. Traditional ethics, to which the profession owed its good
name, is being forcefully challenged.
The losses incurred in the process of modernization are understandable, but such losses
were not necessary. I am convinced that many losses could have been avoided. And I firmly
believe that the doctors’ lost skills and high ethical standards can be restored. To bring this goal
a little closer is the main purpose of the present work.
I shall also try to dispel certain misconceptions. In recent decades, medicine, health care,
and the medical profession have been blessed with the attention of scholars from various domains: lawyers, philosophers, theologians, psychologists, sociologists, and business managers.
A number of “models” of medical practice have been proposed and utilized in the debate. The
genuine physician does not recognize himself in these proposed models. He finds his motives
misread and his reasoning grossly simplified. I shall try, therefore, to throw some light on doctors’ motivation, and that little known subject, the functioning of the medical mind.
The acceptance of euthanasia or physician-assisted suicide would profoundly change
the practice of medicine and the physician’s very calling. I shall try to show that the choice
for euthanasia or assisted suicide is a choice for a medicine, a society, and a world that would
be different from the ones we know. I shall also argue that the legalization of euthanasia will
ultimately require a change in the system of government now prevailing in Western nations.
Part One: In Defense of Medicine
Chapter I. Bioethics Versus Medicine
Lay Adventures in the World of Medicine. What the public thinks of doctors and medicine
is often true, sometimes wrong, and at times touchingly amusing. A lady once told me: “Oh,
This is a translation of the Polish language book entitled Przysiega Hipokratesa [The Hippocratic Oath] by
Ryszard Fenigsen, M.D., Ph.D., published in 2010. Dr. Fenigsen is a retired cardiologist, Willem-Alexander Hospital, ‘s-Hertogenbosch, the Netherlands; M.D., University of Lodz Medical School (Poland), 1951; Ph.D., Medical
Academy, Lodz, 1959.
*
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Issues in Law & Medicine, Volume 28, Number 2, 2012
doctor, you are so marvelously calm, even when I get sick, or when I tell you of the
terrible things that have been happening to me. You have such a soothing influence
on me!” And I thought, “Holy innocence! Were you to know what doubts, tensions,
what boiling anger I stifle inside myself in order to show you that calm face, you’d flee
this place screaming!”
I recall leaving a concert hall on a winter night in the company of R, a musician
who was an acquaintance and a patient of mine, and his wife. Walking a few steps in
the street provoked R’s chest pain, he had to stop, and we all stopped, watching him
and waiting for his pain to subside. A few days later Mrs. R said to me: “Oh, you have
so much empathy, I saw you were suffering when you watched my husband in pain.”
What I really thought when we stopped near that concert hall was that in cold
weather R was getting angina pectoris with the slightest exercise, like walking, but he
never had pain while conducting the orchestra at the opera house, vigorously throwing
his arms about for three or four hours. Apparently the simplifications that had been our
most fruitful approach to coronary heart disease, the “plumber’s view” of pipes clogged
and flow impaired, the imbalance between oxygen demand and oxygen supply, did not
explain everything. Other mechanisms supervened. Some have thought that in cold
air the contraction of blood vessels in the skin increases peripheral resistance to blood
flow, raising the workload —and the oxygen demand—of the heart’s left ventricle, thus
provoking an attack of pain; and I tried to recall whether this was just an educated
guess, or was it a mechanism actually shown in physiological studies. The good lady
believed that I was a better soul that in fact I was.
It is not at all surprising that lay people may have some mistaken ideas concerning
doctors and medicine. The same is true of any profession or trade. When at sixteen I
started my first job, as a lumberjack in the North Russian forest, I quickly learned how
wrong and naive I had been about that trade before entering it.
What about bioethics? While analyzing medical situations bioethicists often display
an admirable command of the subject. But we should not be surprised when it turns out
that the same bioethicists are not aware of basic medical facts and practices. They have
been educated in various fields of knowledge, but not in the one they must now deal.
In 1991, at a committee meeting in Ede, Holland, to which I was invited as the
only physician, we were supposed to discuss a draft statement on ethical principles
of medical care. It was presented by the director of an institute of medical ethics, a
theologian. “When the patient suffers from an incurable disease,” one of the proposed
guidelines read, “it is justified to withhold or discontinue all medical treatment.” The
people attending the meeting gravely nodded in agreement.
“Gentlemen,” I exclaimed, “diabetes, arteriosclerosis, the ordinary form of high
blood pressure, many diseases affecting the joints, and dozens of other common conditions are incurable diseases! And yet doctors spend most of their time treating such
patients, relieving their symptoms, and trying to prolong their lives. Do you really
want to bar these ‘incurables’ from receiving such assistance? Then you can abolish
medicine altogether!”
Other People’s Lives: Reflections on Medicine, Ethics, and Euthanasia
97
The story sounds funny, but isn’t. People equally versed in medical problems
as the members of that committee have drafted living wills, hospital regulations, and
important pieces of legislation.1
At the opening of the international conference2 organized in Prague, Czechoslovakia, by the Hastings Center, an important American institute of bioethics, a middle-aged
man rose from his seat and exposed the primary failing of medicine: Medical specialists,
he said, sought vain glory in spectacular interventions publicized in the media, but
nobody paid attention to the average patient. “What about me?” asked the speaker,
“what if I suffer from some common, unglamourous disease like arthritis or diabetes?
Don’t I deserve the attention of the high priests of medical science?” A large part of the
audience applauded the speech.
I thought the speaker was some embittered patient attending the conference, a
suffering person whose grievances against medicine deserved understanding, and who
was under no obligation to know more about the subject. To my surprise, I learned the
next day that he was Professor B, chair of the department of bioethics at the University
of Pecs, Hungary.
Let’s consider in some detail the professor’s allegations. Diabetes mellitus and
the diseases of the joints are two fields that for many decades have attracted brilliant
researchers and particularly devoted medical practitioners. Owing to their efforts, we
are now able to correctly diagnose degenerative joint disease (osteoarthritis), rheumatoid
arthritis, gout, the involvement of joints in acute rheumatic fever, in collagen diseases,
in sarcoidosis, and some fifty other diseases afflicting the joints. Treatments have been
worked out for many of these. The pharmacological treatment of arthritis has developed
from basic salicylates to steroids, the whole range of non-steroid anti-inflammatory drugs,
and immuno-suppressive therapy. It is supplemented by elaborate physical therapy,
surgical arthroplasty, and total hip and knee replacements.
One hundred and fifty years of research for the causes of diabetes has led from
the discovery of the role of pancreas, identification of insulin-producing islets, to the
isolation of insulin, and later to the crucial distinction between insulin-dependent and
the adult-onset types of diabetes, and the introduction of oral anti-diabetic drugs, to the
studies of diabetic ketoacidosis, and to all consecutive improvements in the treatment
of diabetic coma. The discoveries of Somogyi taught us to avoid excessive dosage of
insulin. Then followed the discovery of non-ketotic, hyperosmolar coma, which is due
to dehydration and must be treated not with insulin, but with water; the introduction
of dozens of insulin preparations to match various blood sugar rhythms; the studies of
insulin resistance, the finding of insulin antibodies, and the introduction of “human”
insulin, obtained by manipulation of bacterial metabolism. These achievements have
resulted in keeping millions of arthritis patients mobile and millions of diabetic patients
alive.
1
2
For a detailed discussion of the subject, see Chapter XXVIII, on “The Oregon Law.”
East-West Bioethics Conference III, Prague, Czechoslovakia, Aug. 29-31, 1991.
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Issues in Law & Medicine, Volume 28, Number 2, 2012
Many medical graduates train in diabetology or pursue several years of study to
specialize in rheumatology, and devote themselves entirely to treating patients with
diabetes or diseases of the joints. Specialized hospital departments and even specialty
hospitals, outpatient clinics, revalidation centers, specialized nurses, dieticians, and
physiotherapists help these patients. Doctors have encouraged and helped the arthritic
and diabetic patients’ associations, the designing and manufacturing of equipment to
assist people with impaired limb mobility, the training of diabetics and their families
in self-controlling the blood glucose levels, in the technique of insulin injections, in
recognizing and combating episodes of hypoglycemia. Instructions, pamphlets, books,
and journals are distributed among patients with diabetes and arthritis. Plays have
been written and staged featuring Princess Insulin in order to make the treatment more
attractive to diabetic children, and Dr. Joslin awarded gold medals to patients who for
twenty-five years strictly adhered to their diet, thereby effectively preventing the complications of diabetes.
Intensive research is being done to find substances that would block the effects of
the protein that damages the diabetic patients’ blood vessels. If this research succeeds,
doctors will be able to prevent those grave complications of diabetes, which are not
warded off by insulin treatment: the damage to blood vessels in the kidneys and the
eyes. A section of Boston’s Joslin Clinic is working on a transplantation project: how to
harvest the insulin-producing islets out of pig and calf pancreases, preserve the vitality
of these fragile cells, increase their longevity, coat them with polymer covers that would
protect them from destruction by the recipient’s immune system, and transplant them
to diabetic patients. If this become feasible, it will be a cure for diabetes.
Yet Professor B says that nobody pays attention to diabetic and arthritic patients,
and the bioethicists applaud. What about the glamorous and spectacular interventions
publicized by the media? Isn’t it the public that perceive these interventions as “spectacular” and the media that make them sensational? The doctor, any genuine doctor, is
preoccupied with a totally different aspect of the event. Cardiopulmonary resuscitation
(raising someone from the dead!) is “spectacular” enough. I have performed the procedure about 400 times, almost 100 times with success. It can be done on a sidewalk or
in a movie theater, but the chances of success are better in a well-equipped office. One
has to train the nurses, keep the equipment in working order, and at regular intervals
check the supplies, the organization, and the skills. When an ambulance arrives with a
patient in cardiac arrest, the protocol must be quickly attended to: good pulse should be
felt in the groin with palpation; the electrocardiogram must be followed on the screen;
ventilation must be heard over both lungs (if it is not, the tube should be pulled an inch
out of the windpipe); the intravenous line must be held open and an additional needle
inserted in another vein because adrenaline must not be injected in the same vein as
bicarbonate; inhaled vomit must be vacuumed out of the airways; all hands must be off
the patient when defibrillation is being done; the position of the hands of the person
doing the massage must be corrected if it threatens to break the ribs; attention must
Other People’s Lives: Reflections on Medicine, Ethics, and Euthanasia
99
be paid to the color of the patient’s skin; and massage must be immediately stopped
whenever the patient’s own pulse is felt on the femoral artery. If among these concerns
the thought dawned on me how spectacular an achievement it would be to raise this
person from the dead, I would be worried about my sanity. And later on? Later on
the event is no longer spoken of. I have never told a resuscitated patient that she had
a cardiac arrest.
I think it is fair to state that Professor B, the chair of a university department
of bioethics, was ignorant of basic medical facts, and had a naive and twisted idea of
physician motivation. But he displayed hostility to doctors and medicine, and was,
therefore, applauded at an international conference of bioethicists.
The Birth of Bioethics. Bioethics is said to be born in the nineteen sixties,3 when
the new technique introduced by Dr. Scribner of Seattle (permanent connection between an artery and a vein on the forearm) made it possible to repeatedly administer
renal dialysis and keep patients alive who were suffering from chronic kidney failure.
At first, the capacity was limited, and not all patients in need of the procedure could
be treated. Since the doctors were not willing to select the patients, a committee of lay
persons was appointed. In their decisions, the members of this body relied upon definite
standards. Married people with children, the employed, churchgoers and those who
volunteered in the community’s activities were the first to be saved. Childless persons,
the unmarried, and the unemployed had little chance of being given access to renal
dialysis, and those considered deviate because of criminal record or a history of mental
disorder were rejected.4
The events received wide publicity and drew the attention of thinkers, moralists,
and morally conscious citizens inside and outside the United States. While some were
appalled by the committee’s proceedings, others believed that important conclusions
could be drawn from the developments in Seattle. A number of debaters seem to have
agreed on the following:
1. Progress in medicine creates moral problems that doctors cannot solve.
2. Therefore, solutions must be sought outside traditional medical ethics and
outside accepted norms and actions that have until now prevailed in medicine.
3. Ethical problems, including those concerning people’s lives and deaths, can
and should be analytically examined, and the conclusions should be based
on sound reasoning.
4. The allocation of scarce resources ought to be guided by justice and fairness.
5. Justice and fairness are owed not only to the actual patient, but to all persons
in need of help, even to those not present, to all persons affected by the decision, and consequently, to society as a whole.
On these assumptions, Bioethics was founded: the learned discipline dealing with ethical
problems that Medicine creates, but is unable to solve.
A. R. JONSEN, THE NEW MEDICINE AND THE OLD ETHICS 17-18 (1990).
S. Alexander, They Decide Who Lives, Who Dies: Medical Miracle Puts a Burden on a Small Committee,
LIFE, Nov. 9, 1962, at 102.
3
4
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Issues in Law & Medicine, Volume 28, Number 2, 2012
The Moral Side of the Decisions of Seattle Lay Persons Committee. Many bioethicists
have long forsworn “the narrow middle-class standards of the Seattle Committee”; others
still defend at least some of these standards.5 We must try to define more clearly the
moral attitudes of the committee members and of persons who condemned the committee’s decisions. The criteria the committee applied are not intrinsically vile. Applying
such standards may be justified when dealing with various community problems, for
example, when selecting candidates for a school committee or a financial institution’s
board of trustees. We would also support the opinion that mentally deficient persons
and those with a criminal record should be barred from joining the police force.
What many people rejected with indignation was using social criteria to decide
who would live and who would die. The criteria of success or social importance are
irrelevant when we face our final destiny. I strongly feel that people are equal in matters
of life and death. We are equal in our ability to suffer, fear, and hope, and equal in our
final necessity to face death and die. Many of us strongly feel that every human being’s
life, beginning with our own, has inestimable value. Therefore, no one’s life should
be judged more or less valuable than someone else’s. No proof of the correctness of
this attitude will be attempted, and none exists, this being no more and no less than a
moral intuition.6
While many people were appalled by the decisions of the Seattle Committee, part
of the public approved the committee’s proceedings, thus revealing the great moral
divide in our time.
Scarcity. It is a tenet of bioethics that moral philosophy, as applied to health care,
must assume an ever present scarcity of medical resources. As the introduction of the
new method of renal dialysis has shown, every new development in medicine creates
a discrepancy between demand for the treatment and the supply. With aging of the
population, the demand for medical facilities increases, while the ability of the economy to cope with the task is shrinking. Scarcity, assert the bioethicists, must, and does,
influence all medical decisions. Lending assistance to a patient always means that some
other person is denied help.7
How Real is the Scarcity Proclaimed by Bioethics? In most of their considerations,
bioethicists do not deal with any concrete situations, but only with a general idea, a
putative scarcity. When concrete examples are discussed, these are often unconvincing.
Let’s consider one of the classic cases cited by bioethicists: the story of Donald and George.
Levine and Veatch8 published, and Kilner9 exhaustively analyzed the extremely unusual
occurrence of two patients suffering cardiac arrest in the same hospital at almost the
same time, at an interval of four minutes. We learn that the patients were very different
J. F. KILNER, WHO LIVES? WHO DIES? ETHICAL CRITERIA IN PATIENT SELECTION 27-74 (1990).
C. TAYLOR, SOURCES OF THE SELF: THE MAKING OF THE MODERN IDENTITY 4-8 (1989).
7
This reasoning has interesting consequences since it leads to the conclusion that all medical actions
and also all acts of helping a person in need are morally wrong.
8
CASES IN BIOETHICS 96 (C. Levine & R. M. Veatch, eds., 1989).
9
KILNER, supra note 5, at 72-74.
5
6
Other People’s Lives: Reflections on Medicine, Ethics, and Euthanasia
101
with regard to their medical condition and social situation. George was thirty-three,
severely retarded, and lived in state institutions since the age of three. His family had
not visited him for over twenty years. Donald, a 48 year old businessman, participating
in community and church activities, married, and the father of four, was admitted to
the hospital because of a minor stroke. When the nearly simultaneous cardiac arrests
(first that of George) occurred, and the hospital resuscitation team arrived, “the team
leader said, ‘first come, first served. Let’s go to work’ . . . the team began to resuscitate
George. Without the emergency aid, Donald died.”
Bioethicists have analyzed all aspects of the team’s decision. Donald had a better
prognosis and a better ability to appreciate the benefits of treatment. George had nobody
that was dependent on him, he himself being a dependent. Donald provided for a wife
and four children. Was Donald “charged with special responsibilities” that would give
him priority in obtaining medical help? It was emphasized that life is almost certainly
denied to another patient whenever any person is helped. Regret was expressed that
no hospital committee had considered the choice beforehand, as such matters are more
appropriately weighed by committees than by individual decision makers. Thus, in the
bioethicists’ view, the story of Donald and George was a particularly striking example
of moral and philosophical problems brought about by scarcity of medical resources.
However honest and inquisitive the bioethicists have been in their analysis, any
person knowledgeable about cardiopulmonary resuscitation and the workings of a
hospital must see their version of the event as misconstrued and their efforts as irrelevant. Indeed, questions must be asked in connection with the George and Donald
story, but not those asked by bioethicists. Why was Donald left to die? Where were the
department’s nurses and the intern on duty? Obviously there was at least one nurse at
Donald’s beside, since his cardiac arrest was promptly diagnosed and reported. Why
didn’t the department’s usual staff start the external cardiac massage; why didn’t they
start ventilating Donald with an Ambu balloon, insert an intravenous line, give him
bicarbonate, fetch a defibrillator? Meanwhile, someone from the Resuscitation Team
(working on George in the adjacent room) could jump in to intubate Donald. No extraordinary measures are described here, just what would have been done in an average
hospital. Why was nothing done and why did all those people present let Donald die
without even trying to do anything?
The answer is clear. Donald had the misfortune of being hospitalized in one of
those unsafe institutions where Organization has supplanted Medicine. In such places
patients are left whole nights without a vital antibiotic because the needle got clogged
and only the I.V. Team has the right to insert a new one; other nurses, however experienced, are discouraged or even forbidden to do it, and after some time unlearn the skill.
Had Donald suffered a cardiac arrest in a shopping mall, he would have a chance
to survive: quite possibly a couple of bystanders would try cardiopulmonary resuscitation and give mouth-to-mouth breaths while someone called the ambulance.There
was no such chance at Donald and George’s hospital: resuscitation was reserved for the
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Issues in Law & Medicine, Volume 28, Number 2, 2012
Resuscitation Team, and no other member of the medical or nursing staff would dare to
resuscitate a 48 year old patient with a sudden cardiac arrest. Thus, the case of Donald
and George revealed a serious problem, but not one of scarcity. The problem was the
hospital’s wrong and thoughtless organization. A peer review would help the management to mend their ways. Instead, three authors plunged into ethical deliberations.
Let’s consider another classical subject of bioethical analysis, the triage: sorting out,
in an overwhelming emergency situation, who should be helped first, who next, and
who not at all. The genuine practicing physician, if he happens to come across some
bioethical writings, is invariably surprised to see how much importance is attributed
to triage. His experience does not confirm that; he knows he does not function that
way. When several ambulances arrive almost simultaneously to his emergency room,
it wouldn’t occur to him to choose which patients should not be helped. He would
quickly order for all patients what is immediately necessary and quickly doable. His
actions would depend on the urgency of their complaints and nothing else. This elderly man who coughs up pink foam apparently has an acute pulmonary edema and
will immediately receive full treatment. That breathless lady with swollen legs will be
propped up on pillows and promised to be taken care of in a short while. The patient
who says he vomited dark blood must have an intravenous line, and his hematocrit and
blood type must be quickly determined.
Intensive care units are presumed to do triage all the time.10 When all beds in a
coronary care unit are taken, should we deny admission to a new patient? Or should
we move a patient from the coronary care unit to the general ward, thereby depriving
him of monitoring and the chance to be promptly resuscitated? And, if so, which one?
The one who is at least risk, or perhaps the one with the least chance of surviving, or
the demented one?
And yet at a coronary care unit the dilemmas can be solved in an entirely different
and simple way. Monitoring systems for a coronary unit of eight beds are routinely
supplied with one or two portable radio transmitters that allow monitoring of the electrocardiograms of patients outside the coronary care unit. If we content ourselves with
that, we may, indeed, sooner or later land in a triage situation. But there is no reason
why the task or the ethical profile of a unit treating sick people should be determined by
the supplier of electronic equipment. We should do what every sensible cardiologist has
been doing since the 1970s: buy not one but ten portable ECG transmitters. Now we
can always make a bed available in the coronary care unit: the patient whom we transfer
stays monitored in an adjacent room, has an I.V. inserted, and virtually the same chance
to get emergency treatment or to be resuscitated as the patients in the coronary care
proper. The bioethicists may correctly object that by creating such “step-down units,”
as these extensions are now called, we have not solved the triage problem in principle.
Indeed, the problem has not been solved; it simply disappears.
10
R. D. Truog, Triage in the ICU, HASTINGS CENTER REP., 22:2, at 13-17 (1992); D. E. Singer et al., Rationing Intensive Care: Physician Responses to Resource Shortage, 309 NEW ENG. J. MED. 1155-60 (1983); P. J.
Strauss et al., Rationing of Intensive Care: An Everyday Occurrence, 255 JAMA 1143-46 (1986).
Other People’s Lives: Reflections on Medicine, Ethics, and Euthanasia
103
I’d like to discuss still another example of scarcity of medical resources. Some
thirty-five years ago I had a conversation with a friend, Dr. J, who specialized in treating
industrial poisoning. He was charged with equipping and opening a department of
toxicology at one of the city’s hospitals, and was almost in despair because his budget
allowed for only two respirators. What if three patients were admitted, all of them in
need of respiratory assistance?
I tried to bring the man to his senses: he still did not have even a single respirator,
and there were as yet no patients exceeding the limits of the facilities. Actually, there were
no patients at all! Shouldn’t he rather equip the department with what was available,
and start doing the work? No, he said, the problem could not be solved, and perhaps
it was better not to buy any respirators!
The Parable of the Good Bioethical Samaritan. The bioethically trained Good Samaritan cannot help being moved by the moans of the man wounded by thieves and
abandoned to die. But he understands that this man just happened to be there. What
about all the others stabbed by thieves, crushed by wagons, and bitten by dogs on all
other roads? We do not see them at the moment, but they all have claim upon our
charity, and should be treated in a fair and reasonable way. Some of them may have a
stronger or more urgent claim upon our charity than this man. Do we have the moral
right to deny our attention and efforts to all these other people, and focus on a single
sufferer just because an accident placed him in our way? No, clearly we do not have
such a right.
And the Good Bioethical Samaritan continued on his way, leaving the wounded
man unattended in the ditch.
The Two Ways of Dealing with Scarcity. We have covered a considerable part of the
scarcity spectrum: scarcity that is only putative, as a general idea; scarcity artificially
created by faulty organization; scarcity imposed by a manufacturer’s shortsighted design
of equipment; and finally, the imaginary scarcity.
What I have tried to prove was that the problem of scarcity has been exaggerated
in bioethics. I am not trying to prove that scarcity of medical resources cannot occur.
It does, incidentally. Moreover, there is a permanent factor that should not be called
“scarcity,” but more correctly, “limitation of resources”: it is the fact that society, quite
reasonably, is willing to spend on health care only a definite fraction of gross national
product.
When an incidental shortage of medical resources is revealed, everyone understands
that something must be done about it. People respond to this situation in two distinctly
different ways. When there was a shortage of dialysis facilities in Seattle, a committee
began selecting patients and determining who was more and who was less valuable
to his family and the community. The “less valuable” people were denied life-saving
treatment. Senators Henry Jackson of Washington and Vance Hartke of Indiana reacted in a different way: they introduced legislation to underwrite the cost of dialysis for
everyone. This program is still providing treatment to all kidney patients in need of it.
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It was a solution on a national scale, but as I have shown in the preceding paragraph,
many instances of scarcity can be remedied locally, and with simple means.
These are the ways of practical-minded people. But the bioethicists who analyzed
the same situations were seeking solutions of a different kind: they tried, in all fairness
and exerting their powers of analysis, to determine which categories of people should
be denied help so that the scarce resources could be used for worthier ones. Bioethicists
have never shown any interest in real, practical solutions that would remedy the problem. I dare say they do not welcome such solutions. In fact, they welcome scarcity. A
prominent bioethicist wrote: “the financial crisis facing the healthcare system provides a
superb . . . occasion to ask some basic questions once again about health and human life.11
Rationing. Living within a limited budget is a necessity. Even further cuts may
sometimes be unavoidable; but all should bear the consequences. Yet most American
attempts to ration health care, influenced as they are by current ideologies (bioethics,
remnants of eugenics and social Darwinism; and unrestrained market forces) deny or
limit medical assistance not to everyone, but to certain groups: the economically or
biologically weakest. Appeals to justice and fairness in allocation of scarce resources
accompany these endeavors. To select people, in particular those that most need our
care, the “85 plussers,” the recipients of Medicaid, infants with disabilities, and others
who are mentally retarded, have dementia, or otherwise gravely ill, and deny them
health care in fighting disease,12 is as morally repugnant as it is illegal.
Attempts to involve doctors in rationing should be vigorously resisted. The proponents of such involvement disregard the special needs and rights of people who are sick
and the specific role of physicians. Patients are people in distress, already weakened in
their fight against the implacable enemy—disease. The last thing they need is another
enemy at their side. Neither do they need an impartial expert who would judge them
and perhaps pass a sentence condemning them. Nor would their lives be safe with an
ambivalent and easily discouraged defender. What sick people need, hope for, and in
a just society have the right to expect, is an unswerving defender who embraces their
interest and no one else’s. Doctors should demand, and fight for, everything that is
medically necessary for their patients. Leave politicians and administrators to look
after the budget. Allocation of resources still result from the clash of these conflicting
forces. It has been this way for a long time, and this is the good way. Any inequities
that may occur will have the excuse of not being intentionally planned, and the chance
to be corrected by the same free play of forces.
J. D. Rothman, Rationing Life, N.Y. REV. OF BOOKS, Mar. 5, 1992, at 33 (quoting D. Callahan, emphasis added).
12
P. T. MENZEL, STRONG MEDICINE: THE ETHICAL RATIONING IN HEALTH CARE (Oxford U. Press, 1991);
Gross et al., Early Management and Decision Making for the Treatment of Meningomyelocele, 72 PEDIATRICS 450
(1983); Health Security Act, S. 1757 & H.R. 3600 (1990-91); Testimony of Hillary Clinton, 8:2 IAETF
UPDATE, Mar.-Spr. 1994; E. Saltus, Silber Attacks Health System, BOSTON GLOBE, Apr. 30, 1991; D. Callahan,
Symbols, Rationality, and Justice, 18 AM. J. L. & MED. 1 (1992).
11
Other People’s Lives: Reflections on Medicine, Ethics, and Euthanasia
105
Plans to refuse medical help to persons above a certain age13 deserve special attention because of the huge numbers of prospective victims, and the clear and immediate
danger to democracy. The issue will be discussed in detail in Chapter XXX.
Toward an Antagonistic Model of Health Care. Uninterested in the dedication of
physicians, focusing on the purported wrongs done to patients, and having introduced
into the discourse the language of rights, which is the language of conflict, bioethicists
have consistently promoted a model of health care based on distrust and antagonism,
a model both nonsensical and impossible.
Early in the campaign, the doctors’ traditional manner of informing the patients
came under assault.14 Court rulings sealed the bioethicists’ victory on this issue. Doctors
can now be sued and punished for non-disclosure. Then, the competence of doctors
to make treatment decisions has been questioned. Of course, in traditional medical
practice the patient’s consent to treatment was required, but it was the doctor who chose
and proposed the treatment. The traditional doctor-patient relationship emphasized
the doctor’s competence and assumed that his intentions were honest and his actions
aimed at the patient’s good.
In bioethics, these assumptions are no longer valid. Instead, the accepted view is
that doctors have advised useless or unproven treatments in the past, and while they
may now propose verified therapies, they should disregard the needs of the individual
patient and ignore his values. Patients are advised to be critical and suspicious, and
are repeatedly told that they, and not the doctors, should decide what treatments to
pursue. Stories are published almost daily in praise of patients who reject the disabling,
mutilating, and foolish therapies proposed by doctors, thoroughly studied their own
problems on the Internet, and chose the treatments they wanted.
Obviously, the bioethicists have not created the movement of public rebellion
against medicine. The rebellion broke out spontaneously, giving voice to grievances
some of which are justified and others irrational.15 But the bioethicists have fanned the
brewing conflict, and did their best to make of it the governing principle of health care.
Their efforts, and the American public’s propensity for litigation, are transforming the
doctor-patient relationship into one of enmity, distrust, and mutual suspicions.
Fortunately, most encounters between doctors and patients still pass in an atmosphere of trust and benevolence. But antagonistic attitudes are becoming more frequent.
To avoid accusations of negligence, doctors practicing “defensive medicine” order more
tests than necessary. The patients are left exhausted, often no sensible diagnosis can be
made, and the costs are soaring. Threatened with potential lawsuits for non-disclosure,
W. Slater, Latest Lamm Remark Angers the Elderly, ARIZ. DAILY STAR, Mar. 29, 1984, at 1; J. Paterson,
Something Needs to be Done About the Quality of Dying, INT’L HERALD TRIB., Jan. 15, 1988; Saltus, supra note
12; D. CALLAHAN, SETTING LIMITS: MEDICAL GOALS IN AN AGING SOCIETY (1987); D. CALLAHAN, WHAT KIND OF LIFE:
THE LIMITS OF MEDICAL PROGRESS (1990). Contra, R. Fenigsen, Most of Them Would Rather Live, INT’L HERALD
TRIB., Jan. 29, 1988.
14
See Chapter VI, infra at 128.
15
See Chapter III, infra at 110.
13
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Issues in Law & Medicine, Volume 28, Number 2, 2012
the intellectually inferior or emotionally unstable doctors respond with a vengeance,
heaping upon the patients gloomy predictions and sadistic details, breaking the patients’
will to live and provoking requests for assistance in suicide.
An increasing number of patients, firmly convinced that treatment decisions
should never be the doctor’s, maintain that the role of physicians is to execute the patients’ orders. If this becomes the rule, it will be the end of medicine as a profession
and learned calling.
In the natural course of events, the doctor-patient relationship is a uniquely fortunate arrangement because the interests of the two parties fully coincide. To transform
this relationship into a conflict is not impossible; but it takes a good deal of ill-will and
stupidity. If this bizarre endeavor succeeds, sick people will still be here, but there won’t
be any doctors willing to treat them or knowing how.
Evaluation of Bioethics. The bioethicists have brought to the debate the sharp reasoning of analytical philosophy. They have induced the physicians to sober reflection,
confronting them with critical opinions held by the laity. They put a limit on medical
paternalism, pointing out that good intentions do not justify every action.
Yet the result of thirty-five years of bioethics is as negative as its founding assumptions. Bioethics purports to be the antithesis of medicine: Medicine is the problem,
bioethics is the solution. Having no real knowledge in the domain in which they
intervene, the bioethicists make mistakes resulting in grave harm (e.g., faulty “living
wills” and hospital regulations, unsound legislation). They promote a nonsensical and
antagonistic model of health care. Bioethicists try to stir up the patients’ anti-medical
rebellion in countries where such conflict does not exist.16 In their zeal to disprove and
reverse all classical tenets of medicine, the bioethicists have rejected the ethics that for
twenty-five centuries protected patients from harm. Intervening in an ethical process
they have never experienced and do not understand, they urge the doctor to renounce
his absolute loyalty to the patient, to side with the society against the individual, to
weigh the value of lives of various persons, and to serve not every suffering human,
but only those whose social or biological condition they approve. They encourage the
doctor to judge his patients, and should such be the case, condemn, punish, and even
abandon them (e.g., arbitrarily denying life-saving help to an alcoholic17 or a smoker18).
American bioethicists are attempting to stir up the anti-medical rebellion in countries where this
conflict does not exist. Eastern Europe is still one such happy region: in Polish opinion polls of the 1990s,
much the same as in the 1960s and 1970s, eighty percent of respondents named the physician as the
most respected profession. But in recent decades the American bioethic think tank, the Hastings Center,
organized a number of “East-West Bioethics Conferences” at which they have acquainted the Eastern
Europeans with the American criticism of medicine and distrust of doctors. At the August, 1991, Prague
conference which I attended, the pronouncements of American bioethicists caused a good deal of bewilderment among the East German, Polish, Czech, Bulgarian, and Rumanian delegates.
17
Saltus, supra note 12 (quoting J. Silber).
18
Bij eigen schuld gaat andere patiënt voor [trans.: When the patient (himself) is to blame (for his condition), another patient will have precedence], BRABANTS DAGBLAD, Nov. 2, 1990 (interview with professor
Helen Dupuis).
16
Other People’s Lives: Reflections on Medicine, Ethics, and Euthanasia
107
By assuming the right to decide that other people should die, the bioethicists have sided
with anti-humanitarian currents in our civilization.
Quixotic as this assault on the huge modern bioethics enterprise may appear, I
appeal to people of good will to start deconstructing the multimillion dollar bioethics
industry. Let’s begin by withholding our donations.
Chapter II. On the Ethics of Physicians19
Attempts to incorporate medical ethics in a universally valid ethical system are
certainly justified, but have not been entirely successful. When considering contemporary ethical systems, many physicians do not find the reflection of their own ethical
experience, of the emotionally tense, strongly interactive ethical process in which they
are involved while practicing medicine.
Renouncing that, the traditionally educated physician might agree with one of the
religious systems of ethics, in particular with the Judaic or Christian ethical heritage. He
shares with them the belief that human life is inviolable, and the conviction that the lives
of all people are of equal and of inestimable value; the commitment to the individual,
and to the weakest and most vulnerable among us. However, religious ethics are linked
to assumptions that not all doctors are prepared to make.
Much deeper disagreement exists with the ethical systems said to be based on
reason, of which utilitarianism is the main representative.20 Starting from rational and
apparently humane assumptions, and driven by impeccable logic, the utilitarian ethics
would ultimately lead the physician to do everything he has traditionally, intuitively, and
rationally rejected: finding some lives less valuable than others, deciding who should die,
siding with the majority of healthy persons against those who are weak and vulnerable,
and with societal interests against the individual.
To What Extent Can Ethics Be Formulated. Ludwig Wittgenstein wrote that ethics
should not and could not be expressed in words.21 Quite a few physicians might subscribe to this statement. Oversimplification seems inherent to written ethical rules.
Moreover, purged as they are of emotional content, written rules lack that human quality
that would make them humane. And no written rule explains, or has the power to
command, the devotion or the creative efforts of dedicated physicians.
I and Thou. The debate on medical ethics has seldom discussed how, in reality,
physicians of the traditional school attain their ethical views. Their basic ethical attitude,
like that of most young men and women, has already been formed in their childhood
and youth. As young physicians, they embark on their journey with a few ethical
aphorisms, usually conveyed to them by a master. These maxims represent the shared
experience and wisdom of the profession.
19
20
21
6.421.
The subject of medical ethics is further touched on in Chapter VI and discussed in Chapter XVI.
P. SINGER, PRACTICAL ETHICS 13, 90-91, 102-05, 172-73 (2nd ed.1993).
L. WITTGENSTEIN, NOTEBOOKS 1914-1918 (2nd ed. 1979) (entry for July 30, 1916); see also TRACTATUS
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Then, the bedside closeness to the patient, and an interactive “I and Thou” emotionally charged ethical process play a crucial role in shaping the conduct of a physician.
It is this process that enables the physician to grasp in full the complexity and the dynamics of the patient’s situation, the richness of his life and spirit, even when nearing
the end, and the horror that deliberate destruction of such life would be.
The interaction is not limited to verbal exchange. The traditional physician will
stand in awe before the patient who cannot communicate, respecting in the newborn
his potential and promise, and in the protractedly unconscious all that he has been,
that he perhaps still is, and cherishing whatever hope there is that he might recover.
Distance from the patient imposed by a new technical and overly organized medicine is dangerous because it creates an empty ethical and emotional space.
On the Ethics of Physicians. The coronary care nurses in Den Bosch besieged me
with demands to prescribe large doses of Valium to a very anxious patient. A tall, trim,
very handsome man of 46, who “had never been sick,” was admitted with a particularly
bad myocardial infarction. The very high blood levels of creatine phosphokinase, in the
thousands, witnessed of a tremendous loss of heart muscle. The dismally low blood
pressure and the quickly increasing congestion of the lungs indicated that the pump
function of the heart was severely compromised. On the first day the patient’s condition
improved slightly; but he confessed to the nurses how much he was afraid of dying.
Unfortunately, his fear was well grounded. Yet I was reluctant to use pharmacological sedation, fearing that in this patient, already “on the edge,” it could lead to
hypoventilation and hypoxic cardiac arrest. I keenly wanted to alleviate the patient’s
mental suffering, but rejected the means that could hasten the very outcome the patient
was afraid of.
I spent some time talking to the patient, and told him that his fears were understood,
and to some extent shared; but I wanted him also to share our hope, which we certainly
still had. I couldn’t tell if the patient was thus reassured; perhaps he felt less lonely.
His wife and children had been informed of the gravity of the situation. I considered calling them to come, but refrained from doing so on my own initiative, because
this would have frightened the patient even more. He died the same night. Now, fifteen
years after that event, I still don’t know if my decision was right or wrong. I only know
that I could not act otherwise.
A lady of 78, with adult-onset diabetes, was admitted with high fever, 104° F, due
to a urinary infection. The bacterium found in both urine and blood was an E. coli,
susceptible, at least in the culture dish, to two antibiotics: a cephalosporin, and gentamycin. Unfortunately, the patient’s kidney function was impaired, and both antibiotics
carried some risk of further damaging the kidneys. The danger was much less with
cephalosporin, and this was, therefore, chosen. But it did not work: after twenty-four
hours, the patient’s body temperature did not drop, in fact, it rose to 105.8°. Verbal
contact with the patient was lost. She was raving and made constant aimless movements
with her arms and hands.
Other People’s Lives: Reflections on Medicine, Ethics, and Euthanasia
109
“Actually, it would be better if she died of her disease and not as a result of our
treatment, of kidney failure caused by gentamycin,” said a resident known for his
propensity to utter feelings that others would suppress. “Better for whom?” asked the
doctor. Cephalosporin was stopped and gentamycin started, with due precautions.
During the next three hours, the patient four times pulled out the intravenous line
through which the antibiotic and the fluids were administered. An intern said that such
persistent struggle should perhaps be interpreted as refusal of treatment, and respected.
This the doctor immediately refuted: the patient did not know what she was doing.
Restraining cuffs were put on the patient’s wrists, and fastened to the frame of
the bed. This was repugnant to the doctor and the nurses; worse still, the constraint
aggravated the patient’s unrest. The doctor asked himself whether the uncertain hope
for improvement justified the violence done to the patient.
Meanwhile, the fever dropped to 99.6°, and the patient regained consciousness.
It took another ten days, and the help of a urologist, to ensure the flow of urine from
the left kidney, crushing an obstructing stone, and eradicating the infection.
The basic rules, rather imbibed by experience than remembered by rote, have
shaped the doctor’s ethical views, but it is the patient’s quickly changing medical situation and his or her silent or vocal claim that determine the doctor’s actual conduct.
Knowing that, I wonder how much bioethicists can contribute to medical ethics. Many
have never been part of this interactive process.
Whom Does the Doctor Owe His Loyalty? Absolute loyalty of the physician toward his
patient has been firmly established in the Hippocratic medical tradition, and is formally
required by the International Code of Medical Ethics, which states: “A physician shall
owe his patients complete loyalty and all the resources of his science.”22
It is understandable that the medical profession has taken such an unequivocal
stand. Medicine has not come into being to take care of states, societies, or even families;
its primary purpose, its reason for being, is to help the individual who is ill. Remarkably,
the general public, the legislatures, and the governments have respected and supported
doctors’ exclusive commitment to their patients.
At present, however, administrators, bioethicists, and utilitarian philosophers
maintain that the doctor’s loyalty to larger groups of persons in need, to the society as a
whole, or even to health care organizations, should take precedence. Justice and fairness
in the allocation of scarce medical resources, corporate or societal source of payment,
and ownership of facilities have been cited as justifications.
Most of these arguments are discussed elsewhere in this work. As for the payments,
the theorists seem to forget that ultimately it is the patient who pays for all health care
22
INTERNATIONAL CODE OF MEDICAL ETHICS (1983) (adopted at the Third Assembly of the World Medical
Association, London, Oct. 1949; amended at the Twenty-Second Assembly, Sydney, Aug. 1968, and the
Thirty-Fifth Assembly, Venice, Oct. 1983).
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services, facilities, and equipment.23 The consequences of such a change in doctors’
loyalties expand far beyond the wrongs done to an individual patient. Doctors’ activities
place them at the crossing of the most humane and the ominously anti-human trends in
society. Significantly, the present American campaign to change the doctors’ allegiances
can claim only one historical precedent: the adherence of some British, American, and
German doctors to the eugenic movement. The good of society (or nation, or race, as
the case may be) was adopted by these doctors as the aim of medical practice. They
thought that sacrificing the well-being or the lives of some individuals for that “higher”
goal was justified. This change in the aims of medicine was most clearly proclaimed
when in 1934 the Nazi authorities relieved German doctors from their allegiance to
individual patients, and appointed them “Healers of the German Volk.”24
It has been an immortal service rendered by Hippocratic ethics that it has kept
medicine firmly on the side of the individual patient. The moment this ethic is abandoned, and doctors begin to sacrifice some individuals for the higher good, the door is
opened to medical elimination of groups considered a burden or an eyesore to society.
Empty threats? Who knows? In the United States, medical extermination of whole
groups of the population would seem unthinkable. And yet, in the last three quarters
of a century such yearnings have been repeatedly expressed in some influential circles.25
Chapter III. The Attack on Medicine
The doctor, looking grave and solemn, began his examination. He took the patient’s
pulse rate and body temperature, and proceeded to the percussion and auscultation.
With a certainty that left no room for doubt, Ivan Ilyich knew that all this was rubbish
and fraud.26
Leo Tolstoy
Ivan Illich.27 The hero of this story is the near namesake of Tolstoy’s Ivan Ilyich,
professor Ivan Illich of Cuernavaca, Mexico. Illich, the Vienna-born quadruple graduate
of European universities, and one time parish priest ministering to Manhattan’s poor,
has become the theorist and ardent advocate of rebellion against Western industrialized
civilization. The grave moral failures of our civilization certainly have fed this movement,
but some of its ideas can be traced to earlier sources, to the anarchism of Proudhon and
Kropotkin, early 19th century’s romanticism, the views of J. J. Rousseau, and to the even
earlier myth of the Happy Savage. Illich’s anti-industrialism writings often surprise by
their vehemence, uncompromising thoroughness, and unexpected targets of assault.
E.g., as a buyer of health insurance, as an employee whose work was valuable enough for the employer to pay for a health plan, as a life-long taxpayer or dependent of one, and even as an indigent helped
by fellow Americans out of human solidarity.
24
R. J. LIFTON, THE NAZI DOCTORS: MEDICAL KILLING AND THE PSYCHOLOGY OF GENOCIDE 30 (1986).
25
See, e.g., Editorial, A New Ethic for Medicine and Society, 113 CAL. MED. 67-68 (1970) (official journal
of the California Medical Association).
26
LEO TOLSTOY, 9 SMYERT’ IVANA ILYICHA [The Death of Ivan Ilyich] 102 (Sobranye Khudozhestvennykh
Proizvedeniy, Moscow: Prawda Pub. House, 1948).
27
IVAN ILLICH, THE MEDICAL NEMESIS: THE EXPROPRIATION OF HEALTH (1976); and IVAN ILLICH, TOWARD A
HISTORY OF NEEDS (1980).
23
Other People’s Lives: Reflections on Medicine, Ethics, and Euthanasia
111
In Illich’s view, the expanding technology very soon reaches the point beyond which it
inevitably turns against people.
***
In the 1970s, Illich was widely acclaimed in the intellectual and professional circles of Western Europe and North America as the prophet who told us the truth about
ourselves. Illich’s teachings on the sinister activities of the medical Mafia not only supplied arguments for the Western European and, in particular, Holland’s anti-medical
campaign of the 1970s and 1980s, but, surprisingly, met with an enthusiastic response
from many doctors. At the assembly of the British Medical Association in Edinburgh,
Illich was given a standing ovation. Prominent physicians declared that when they read
Illich’s works, scales fell from their eyes. Apparently, the disappointment of “modern”
physicians with their role, and with medicine in general, made them receptive to Illich’s
ideas. His name may now be almost forgotten, but this man has substantially contributed to the present crisis of medicine.
Several features of Illich’s writings contributed to the powerful impact these publications had at the time. Their subject matter was of vital importance: it was the heavy
price mankind was paying for industrialization, man’s entanglement in the complexities
of societal structure, the abysmal contrast between the First and the Third World. Illich’s
onslaught on institutions people had considered friendly (e.g., formal educational institutions), attested to the originality of the author’s thought and his intellectual courage.
The solution he proposed—no less than a total destruction of our civilization—showed
Illich as a thorough thinker who wouldn’t content himself with half-measures.
Yet Illich’s success among intellectuals of the 1970s is an astonishing story. His
allegations were, to put it mildly, biased and unreasonable, and his propositions radical
and absurd. In his view, the school, for instance, was not a teaching institution with some
faults and negative aspects; it was a criminal conspiracy to create social inequalities, and
nothing else. This is patently untrue. It is also worth pointing out that without formal
education nobody would be able to raise or debate the issues of Illich’s writings. Neither
could prof. Illich’s favorite bike be designed or produced by uneducated workers. The
village blacksmith wouldn’t be able to make the lightweight metal frame, the precision
bearing or the rubber tires, all of which require formal education in the sciences and
engineering principles.
In Illich’s view, the only aim of professional groups is power, and enslavement of
other people. . . . Medicine is the area of Illich’s particular interest. The doctors, he
asserts, do not provide any useful services, but only seek to enhance their own wealth
and power over the people. This is not true. Any man who once experienced the
excruciating pain and pressure of urinary retention, and the wonderful relief provided
by inserting a catheter, will refute Illich’s absurd statement. A multitude of similar
examples could be cited.
But a few points in Illich’s “medical” writings deserve our attention. First of all,
the myth of the medical Mafia. To prove its existence Illich cites “the conspiracy set up
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2500 years ago on the island of Kos,” that is, the Hippocratic school and the Oath of
Hippocrates. But the Hippocratic Oath ranks among the most beautiful documents in
human history. In order to present it as evidence of criminal conspiracy, Illich had to
“adjust” the Oath’s contents. Taking the Oath the physician vows not to divulge secrets
he may learn upon entering the sick person’s house. He also vows to revere the master
who taught him the Art, and, if the master’s children wish to learn, to teach them without
a fee. In Illich’s interpretation, however, the physician swore not to disclose the secrets
of their trade to anyone but fellow physicians and their children, thereby setting up a
“criminal family” bound by a code of silence, i.e., a Mafia.
In the industrial era, the medical Mafia has expanded and consolidated their power
by gaining access to government and its means of enforcement. In Illich’s view, the mandatory vaccinations (common in the European countries), and the legislation regulating
the practice of medicine are but means to increase the Mafia’s power and protect doctors’
monopoly. It is twisted thinking to consider vaccinations a source of “power” (which
no doctor is seeking). Why not look at what the vaccinations really are and what they
do? Smallpox, the scourge that killed hundreds of thousands in Europe, and disfigured
many millions, is now eradicated on our planet due to mandatory vaccinations carried
out in most countries. Undoubtedly, the vaccinations against diphtheria, tetanus, and
poliomyelitis prevented much suffering and saved many lives. A disease prevented, or
eradicated, diminishes rather than enhances the power of doctors.
Illich suggests that government regulation of medical practice serves only to protect
the doctors’ monopoly on health care. Therapeutic interventions carry some risk, and
quackery is by no means risk-free. There have been case reports of lungs collapsed due
to acupuncture, and massive deep bleeding caused by this procedure. The fact that the
“healer” had no knowledge of human anatomy and did not know what he was doing is
no excuse. Society needs laws to determine the responsibility of medical practitioners
for bodily injuries they may inflict, and laws that prevent the worst disasters by barring
ignorant individuals from performing invasive procedures.
***
The American and Dutch Attack on Medicine. Bioethics28 should be seen as the scientifically equipped, institutionalized manifestation of a much broader popular anti-medical
wave.29 The other causes seem to have been the post-World War II anti-establishment,
anti-intellectual, and anti-technology rebellion (and the reverse grievance: that medicine
is not as infallibly effective as engineering); patients’ repugnance of medical invasions
of their bodies; democratic resentment of doctors who wield so much power though
no one had elected them; the popular media’s education of the public on health issues;
and sado-masochistic musing involving doctors and nurses. The attack on medical
practice includes a narrower current of discriminatory eugenics, the abhorrence of
See Ch. I, supra.
This subject will be discussed in Chapters VI, Speaking the Truth, XI, On Therapy, XII, The Lost Skills,
The Bad Habits, and XV, Is Medicine Still for the Patient’s Benefit?
28
29
Other People’s Lives: Reflections on Medicine, Ethics, and Euthanasia
113
anyone who is congenitally disabled, crippled or disfigured, and resentment of doctors
who keep them alive.
In the United States, the rebellion against medical paternalism has converted the
principle of patient consent into the postulate that doctors should carry out the patient’s orders. Putting this postulate into full effect would mean the end of medicine.
Addressing the doctors in an uncivil or brutal way is becoming a fashion in letters to
editors and in other media. In the face of the tragedy of breast cancer, the wrath turns
against the doctors who have advised radical mastectomies.
In Holland, the attack reached its climax in the 1970s and 1980s when the government, the body politic, the media, and a large part of the public joined the campaign. Members of parliament were elected, cabinet ministers secured their positions,
television networks improved their ratings, and newspapers increased their circulation
by assaulting the medical profession. The Parliament and the media extolled the “alternative medicine” while “university medicine” was derided and its total failure presented
as a foregone conclusion. The “big money” earned by medical specialists was loudly
decried. No one explained that of this gross income a large part was spent on salaries
of secretaries and assistants, social security payments, and the lease of hospital facilities,
while up to 70% of the remaining sum paid taxes. Greed was the only motivation ever
mentioned and the only one accepted by the public. When the medical profession did
not rush to adopt the nonsensical “alterative method of treating cancer with diet,” Mrs.
Ria Beckers, leader of the leftist political party, shouted in the Parliament that doctors
were burying this excellent method because applying it would reduce the their income.
***
People who publicly attacked the medical profession were never required to
substantiate their claims. Even entirely implausible allegations were accepted and
immediately published. An indignant letter to the Brabants Dagblad, a large circulation
Dutch daily newspaper, stated that family doctors, afraid of losing their income, did
not join group practices, and as a result young people unnecessarily died! Group practices had no influence whatsoever on doctors’ income or young people’s mortality; but
no correction appeared. No accusation was ever refuted, not only because the editors
wouldn’t have printed it, but, first of all, because the Dutch doctors ducked for cover
and tried to make as little noise as possible.
***
Patient Privacy, the Attack on Medicine, and the Quality of Medical Care. I’m quite
sure that in the past we better protected patient privacy than now. We sincerely believed
in our special calling and the purity of our intentions, and therefore had no qualms
about approaching the patients’ bodies. We used to let the patient undress for physical
examination, not allowing garments to be in the way. Abnormal coloration of the skin,
pulsation of the veins and arteries on the neck, chest pulsation due to heart enlargement,
recoil chest movements of patients with severe incompetence of tricuspid valve, large
abdomens containing excessive fluid, dilated veins around the navel, edema at the small
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of the back could be promptly noticed. The access to the heart area and the lungs was
unhindered, the heart sounds and murmurs were listened to under optimal circumstances. No friction of a bra against the skin could simulate a pericardial friction rub.
Over the lungs, the normal respiration and all kinds of pathological sounds could be
faultlessly identified. We could palpate the abdomen as it should be done, placing the
examining hand flat on the belly, finding the painful spots, feeling muscular resistance,
if any, feeling the organs moving with respiration, tracing the edge of the liver, feeling
the round shape of a distended gall bladder, indented edge of the spleen, palpating the
lower poles of the kidneys and checking their ballottement, detecting tumors, feeling an
infiltrate around the appendix, an aneurysm of the abdominal aorta, an enlarged uterus,
or an overfilled bladder. We could inspect the legs, palpate them for edema and feel
the pulsation of the arteries. Patients of both sexes were asked to keep their briefs or
slips on during the examination, and we could slightly move the hem and palpate the
femoral artery and the lymph nodes in the groin.
From our early years we were trained to proceed according to the rules of the
art, to focus on what was relevant and dismiss everything else. Never in my life did a
patient say a word or make a gesture showing that she, or he, suspected me of doing
something improper. Doctors should have preserved the traditional attitude, and with
it the self-confidence, the confidence of the patients, and the public recognition of doctors’ special calling. Instead, American doctors have capitulated to the propaganda and
prejudice fostered against them. The specter of distrust and possible enmity between
the patient and the doctor, and the modern doctors’ neglect of clinical medicine have
converged to produce a curious twist in American medical practice: doctors do not
ask patients to undress for physical examination, listen to a patient’s heart and lungs
placing the stethoscope on whatever piece of clothing the patient is wearing, and even
“examine” the abdomen of a fully dressed patient sitting on a chair. By doing so, they
“protect the privacy of the patients,” and above all, protect themselves against accusations
of indecent conduct, voyeurism, or sexual assault. By the way, precious time is spared
and the doctor’s effort minimized.
I was shocked in the late 1980s when I first saw American doctors examining
patients this way. I have a special interest in clinical methods of examination, having
spent eighteen years teaching the subject to medical students and graduates. I am the
author of a textbook on cardiac auscultation published in 1968.30 I have studied the
excellent treatises on auscultation of the heart published in America by Samuel Levine,31
Ongley, Sprague, and Rappaport,32 and Victor McKusick.33 With the appearance of these
30
R. FENIGSEN, OSLUCHIWANIE SERCA [Auscultation of the Heart] (PZWL Pubs., Warsaw, Polland 1968).
During my visit to Polland in 1997, I was pleased to see that this textbook was still being used for the
training of Polish cardiologists.
31
S. A. LEVINE & W. P. HARVEY, CLINICAL AUSCULTATION OF THE HEART (2nd ed. 1959).
32
P. A. ONGLEY ET AL., HEART SOUNDS AND MURMURS: A CLINICAL AND PHONOCARDIOGRAPHIC STUDY (1960).
33
V. A. MCKUSICK, CARDIOVASCULAR SOUND IN HEALTH AND DISEASE (1958).
Other People’s Lives: Reflections on Medicine, Ethics, and Euthanasia
115
great works the homeland of cardiac auscultation moved from Laënnec’s, Bouillaud’s,
Potain’s, and Huchard’s France to the United States.
What I now saw seemed a mockery of medical practice. But I told myself to keep
an open mind. This country has set high standards of proficiency in almost every field,
and if American doctors applied this method of auscultation, there could be something
to it. For a century and a half patients were required to undress for examination, but
perhaps it was unnecessary.
I decided to test the “new method.” During three months in 1989 I compared my
findings from auscultation done in the usual way with those obtained by examination
through a garment. My patients in Den Bosch were baffled, but I explained to them
what I was doing.
The heart is a mechanical device of very high quality: it accomplishes a great task
making very little noise.34 Many cardiac sound and murmurs are barely audible, being
three times softer than a whisper.35 I found that auscultation through a shirt or a pajama further dampened the heart sounds. Some sounds (the atrial sound and the third
heart sound), the dynamic phenomena (movable splitting of a second heart sound),
and all softer murmurs, in particular, the murmurs in most cases of aortic or pulmonic
valvular incompetence, were completely eliminated. About 60 percent of information
obtainable from auscultation was lost.
The doctors who in this way “protect patient privacy” go through the motions of
a medical examination, but miss important diagnostic signs. What they do is hardly
a diagnostic procedure, rather it is akin to the gestures performed by a medicine man.
Chapter IV. The Responsibility and the Morale of Physicians
Doing More Than Required. One of 20th century’s most talented Polish poets was
admitted to the Omega Clinic, Warsaw’s fashionable medical center, with vague abdominal complaints. Nothing particular was found upon routine examination. Gastroscopy
and X-rays were scheduled for the next two days. Meanwhile, the nurse observed the
patient’s condition at her rounds, that is, every hour.
However, my friend Dr. Jakub Winer somehow could not set his mind to rest. He
wasn’t even the patient’s attending physician, just the director of the hospital; but he
came to see the patient several times. He apparently sensed something unaccountable
in the poet’s condition. When he came again at 11:30 p.m., between the nurse’s visits,
he found the patient collapsing from a huge stomach bleed. The man could not even
reach the bell. Surgery for the bleeding ulcer was immediately done and saved the
patient’s life.
One might observe that the doctor’s alertness and diligence may have been heightened by his admiration for the patient’s poetry and because the patient was a celebrity.
That is probably true. But it is also true that Dr. Winer only did what good doctors
34
J. W. Hurst & R. C. Schlant, Introduction and Principles of Auscultation, in THE HEART, ARTERIES
VEINS 219-38 (J. W. Hurst & R. B. Logue, eds. 1970).
35
FENIGSEN, supra note 30, at 20.
AND
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in hundreds of hospitals are doing every day and every night for patients who are not
celebrities.
They do it, not necessarily for lofty reasons. A doctor may do it out of a sense
of duty, but he may also be moved by ambition, or he may be living up to his own
obsessive personality. Most doctors who exert themselves without limits are simply
compelled to do so by the logic of this work. In Den Bosch, after typical work hours
the hospital doctors returned to their houses and were supposed to be on call. This
was not good enough in some cases; in particular, to tend to patients whose condition
might change within seconds, as with life-threatening disturbances in heart rhythm, or
who may irreversibly deteriorate within minutes, as in cardiogenic shock, pulmonary
edema, or large myocardial infarction in young men. Therefore, I put my hospital office
in a room situated eight feet from the coronary care unit, and whenever such a “brittle”
case was admitted I would spend a night or two on a couch in the office, getting up
every half-hour to look at the patient, and darting off at every signal from the nurses.
I was physically fit, able to take advantage of ten minutes of sleep, and to wake up in a
second to full consciousness. Thus, these nights were not taking too heavy a toll on me.
Neither was I much bothered by the displeasure of some other doctors who thought that
I was setting unreasonable standards which they did not intend to adopt. Was it worth
while? I happen to know the answer, and I owe it to the Central Bureau of Statistics from
which every medical specialist in Holland received computerized statements showing
the number of patients he treated, their diagnoses, as well as other data, including the
mortality rate compared with the national average. As long as I alone was leading the
department (1976-1981), the Central Bureau of Statistics statements showed, year in
and year out, a thirteen percent mortality rate among my patients while the average
national mortality rate of patients with the same diseases and in the same age groups
held constant at seventeen percent.
Fighting Good Fights for the Patients’ Sake. Doctor Ignaz Philip Semmelweis (18181865) has long been, and remains, our worthy example. He divined that puerperal
fever (fever that follows childbirth), of which so many young mothers died, was an
infection, and that at the University of Vienna department of obstetrics it was brought
over from the dissecting-room on the unwashed hands and aprons of doctors and medical students.36 Semmelweis was almost destroyed by the enmity of his incredulous and
indignant colleagues, but he carried on through all difficulties his postulates of cleanness
and antisepsis, and the epidemic was stopped.
Well, many of us have to fight battles on a larger or smaller scale. In 1963, when
I was appointed head of a hospital department in Lodz, I clearly saw that I had to
protect the patients under my care against two scourges that plagued the Polish health
care system at that time: the inoculated hepatitis and the excessive exposure to X-rays.
An inordinately high percentage of hospitalized patients (and quite a few out-patients as well) contracted jaundice due to viral hepatitis. The virus was transmitted
36
R. PORTER, THE GREATEST BENEFIT TO MANKIND: A MEDICAL HISTORY OF HUMANITY 370 (1998).
Other People’s Lives: Reflections on Medicine, Ethics, and Euthanasia
117
by multiple-use needles, syringes, and transfusion or infusion bottles and tubes. All
these were sterilized in autoclaves or by simple boiling, but neither method killed all
the viruses.
The other scourge was the unnecessary irradiation. The handling of the X-rays was
no more as carefree as in the forties (in 1947, an elegant Lodz shoe shop had still been
using a German shoemaker’s X-ray device to check if the shoe fit the customer’s foot),
but roentgenograms were sparsely used and the basic method of X-ray examination of
the chest, stomach, and colon was radioscopy at which both the patient and the doctor
were exposed to large doses of X-rays (TV appliances which reduce the irradiation were
not yet available). The X-rays may damage people’s bone marrow and reproductive
cells, and may cause cancer.
So when I took over the department I declared that no radioscopy would be done
on my patients, only roentgenograms (involving much less exposure to X-rays); and
that sampling of blood, injections, infusions and blood transfusions would only be done
with single-use disposable needles, syringes, plastic bottles and tubes.
This was an outrage. I refused to do what everybody was doing since time immemorial. Moreover, X-ray films were expensive and the disposable needles, syringes and
bottles were not only expensive but also in short supply. The hospital’s administration
and the City’s health authorities flatly refused my requests. I was adamant, too. No
films? No X-ray examinations. No disposable needles? No injections!
But Poland is a “soft” country where good ideas are seldom put into practice, but
neither are evil schemes; and the forces that oppose good initiatives lack the callousness needed to put up effective resistance. I won after a stalemate that lasted only 48
hours. With time, some other doctors joined my protest, and even some institutions;
but it took years before the two scourges were more or less eradicated in the country.
When I opened the first intensive care unit in Lodz in 1966, my expenses on antibiotics soared. To the managers’ outcry I answered that I could not do otherwise, and
added that I was always prepared to go to jail for a good cause. This was just a joke;
but threats that I would have to pay for the medicines could have been real. I didn’t
even consider giving in because this would have meant giving up gravely ill patients.
After a fortnight’s tug-of-war the drug budget for my intensive beds was officially raised
to 425% of the usual budget.
From Den Bosch I remember a Mr. N, a man of 49 who had suffered a myocardial
infarction and the catheterization showed that besides the narrowed arteries requiring a
triple bypass, the left ventricle of his heart was so badly mauled by the infarction that it
had to be surgically “trimmed” by cutting off the weakest parts and sewing up the good
ones. This would have been a huge and difficult intervention, no longer experimental
in 1987, but with uncertain outcome. I agreed with Dr. Claessens who catheterized this
patient that we should refer him to a surgeon with special skills, and to a department
known for doing this kind of surgery with good results. We referred Mr. N to Dr. W.
Dudley Johnson in Milwaukee, Wisconsin. But Milwaukee was outside the admissible
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range of referrals, which was limited to the nine Dutch departments of cardiac surgery
and three hospitals abroad. The Dutch Public Insurance Fund refused to pay for Mr.
N’s trip and treatment. Their chief medical adviser stated that our request was unheard
of and unfounded. He questioned whether we were acting for the good of the patient
and alleged that we were seeking publicity (no journalist was ever informed of the case).
We had to fight a battle involving multiple phone calls, long letters, and even a trip to
the Fund’s headquarters; and we won. Dr. Johnson did the surgery with excellent result
and the patient has been doing well for many years afterwards.
Why Do Doctors Take Personal Risks? Dr. Bernard Lown gives in his book a vivid
description of the dilemma he faced in 1959 when all usual methods failed to stop a
patient’s life-threatening rapid heart beat, the ventricular tachycardia.37 It then occurred
to Dr. Lown to try an electric shock. Electric defibrillators had just been introduced to
stop ventricular fibrillation, the chaotic electrical activity that equals clinical death. The
device had never been used on a patient whose heart was still beating. The technique
of using it on a beating heart, to stop a ventricular tachycardia, the voltage needed,
the dosage of energy, the need for anesthesia—all that was unknown. But the patient’s
situation was becoming desperate. “I threw caution to the wind,” writes Dr. Lown.
“As Mr. C was about to be anesthetized, the director of medical services barged in and
stopped the procedure . . . (He) asked whether I understood that if the patient died
the hospital would be legally liable . . . When I remained nonplussed, he insisted that
I obtain clearance from the hospital’s attorney. I refused, but as a compromise noted in
the patient’s chart my sole and exclusive responsibility, and acknowledged the hospital’s
opposition . . . Mr. C was anesthetized. We then applied large plate electrodes on . . .
his chest . . . I delivered an electric jolt.” It worked.
With normal heart beat restored, Mr. C quickly improved; but this is only part of
the story. Doctor Lown’s daring gamble opened an entirely new chapter in cardiology
and in the history of medicine. After two subsequent great improvements, both made
by Lown, the replacement of alternate current defibrillators with direct current, and
synchronizing the discharge with the patient’s electrocardiogram, the therapeutic electric
shock, “the cardioversion,” became a safe and effective method of restoring normal heart
rhythm, now widely used all over the world.
Due to Polish limitations of hard-currency imports, resulting in a four year gap
between the availability of equipment in the United States and Poland, I had to experiment and solve the problem that had already, and better, been solved by Dr. Lown, and
stage again the drama of a risky decision. In 1966, a 73 year old man was admitted to
my department in Lodz with an attack of ventricular tachycardia. It turned out that
he had an aneurysm of the left ventricle, a bulge of the heart wall at the spot that had
been weakened by an infarction. At that time, surgery for a heart aneurysm was not yet
feasible. Mr. G’s aneurysm—or the electrically unstable zone at its edge—repeatedly
triggered attacks of ventricular tachycardia. The patient produced (and, with some help
37
B. LOWN, THE LOST ART OF HEALING 191-95 (1996).
Other People’s Lives: Reflections on Medicine, Ethics, and Euthanasia
119
from us, survived) quite a prodigious number of such attacks (145 in all).38 With time,
stopping the tachycardia with drugs became more and more difficult, and the drug
toxicity became worrisome. In 1967 I was to obtain the cardioverter I had ordered,
the safe device that stops ventricular tachycardia and other forms of abnormally quick
heart beat with an electric impulse that is synchronized with the patient’s ECG so as
to avoid the T-wave (hitting this “vulnerable phase” might induce ventricular fibrillation). But this was 1966, there was no cardioverter in Lodz and none in the country. I
phoned two experts I knew, Dr. Brunet at Hôspital Lariboisière in Paris and Dr. Peleška
at the Institute of Cardiology in Prague. They both recommended an experimental
technique that Peleška had developed: he connected a DC-defibrillator with a coil of
wire representing an inductive resistance of 0.23 Henry / 31 Ohm. While led through
this appliance, the direct current impulse from the defibrillator was transformed into a
waning oscillatory discharge. In extensive animal experiments Peleška had found that
an impulse of this form was almost as safe as a synchronized one. Together with Mr.
Witold Chrust, an electrical engineer, we constructed the device according to Peleška’s
specifications, and tested it in experiments.39 I still did not dare to use it on a human
being. But then Mr. G suffered an attack of ventricular tachycardia that lasted four days
and did not respond to medication. The patient was ready to try anything, and his
son, a physician, trusted my judgment, but the patient’s daughter-in-law, also a doctor,
opposed “experimenting on her father,” and hinted at grave consequences. But this was
the fifth day of incessant ventricular tachycardia, Mr. G’s blood pressure was falling, he
produced no urine, and his lungs were increasingly congested; the electric shock was our
only hope. We anesthetized Mr. G, applied the electrodes to his chest, and discharged
the defibrillator through Peleška’s device. The ventricular tachycardia was stopped at
once, and the heart resumed beating at a normal rhythm. In the months to come, Mr.
G had 37 more attacks and every time we cut short the tachycardia with our oscillatory
electric discharge. We also succeeded with other patients. I stopped using the device
only when at long last my synchronized cardioverter arrived.
The Physician and the Patients’ Rights. In the last thirty years a powerful movement
has risen in defense of patients’ rights.40 Remarkably, doctors who provide the most
dedicated and insightful care to patients seem to be unaware of patients’ rights. Do
patients have a right to doctors’ special dedication, personal sacrifices, creative efforts,
or insights? Certainly not a right that can be claimed, fought for, or secured by legal
process.
E. Chetkowska, E. Spolinska, K. Ballandowicz, & R. Fenigsen, 145 napadow czestoskurcu komorowego [145 attacks of ventricular tachycardia], 8 KARDIOLOGIA POLSKA 69 (1968).
39
R. Fenigsen, K. Ballandowicz, W. Chrust, & E. Spolinska, Kardiowersja w czestoskurcu komorowym
[Cardioversion in ventricular tachycardia], 8 KARDIOLOGIA POLSKA 209 (1966).
40
I fully support the (recently proclaimed) right of patients to sue their HMOs for failure to provide
due care. It is not this right that is the subject of the present paragraph, but the rights purported to protect
patients from being wronged by their doctors. Promoted by the so-called patient’s rights movement, these
“rights” have become an important argument in the fight against medical paternalism.
38
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Issues in Law & Medicine, Volume 28, Number 2, 2012
The final victory of the patient’s rights movement may not be that far off. When
this happens, patients will be treated strictly according to their rights. This will be the
end of all hope for those patients whose lives can only be saved by an extraordinary
effort, by sudden insight, or a special creative solution.
Making the Decisions. Twenty-three years ago America’s leading gastroenterologist,
Dr. Franz J. Ingelfinger, delivered a remarkable lecture at Harvard Medical School.41
He reported his own case: he himself had become a patient, and his disease was one
on which he was a world-class expert—cancer of the stomach. Unfortunately, not just
any stomach cancer, but “the crux of gastroenterology,” the cancer located high in the
stomach, near the esophagus. Dr. Ingelfinger had surgery and the tumor was removed
(together with most of his stomach), but some probably afflicted lymph nodes could
not be reached. The gastroenterologists and radiotherapists involved in the case had
discussed all aspects of the problem: the high probability (but no certainty) that some
lymph nodes containing malignant cells had been left, the very limited gains that could
be expected from radiotherapy, and the serious side-effects of the treatment. Point by
point, all considerations were presented to the patient. Nobody was making a decision,
apparently this was left to the patient himself.
But the patient, with his expert knowledge of the subject, and excellent grasp of all
the details of the situation, was unable to decide. He was left in a state of incertitude,
hesitation, and torment.
And then a friend told him, “What you need is a doctor.” A family physician
was approached, an old acquaintance whom Dr. Ingelfinger trusted. He examined the
patient, heard all the arguments, and decided, “No radiotherapy.”
So much for Dr. Ingelfinger’s story. I think it shows quite clearly how inadequate
the prevailing view on decision making has become. The courts, the bioethicists, and a
large segment of the public now believe that the role of the doctor is to present the facts
and perhaps propose a treatment. Ultimately, it is the patient who decides.
There are, indeed, situations in which such an arrangement is appropriate. For
instance, when cosmetic surgery is considered, or the replacement of a knee joint in a
case of osteoarthrosis. Sometimes even in much more dramatic situations the decision
is, and should be, the patient’s alone. A friend of mine, an experienced surgeon, a lucid
and emotionally balanced individual, a man of considerable physical strength and courage and all his life a fervent hunter, in his late sixties was stricken with a cancer of the
rectum. While asking a colleague to perform the surgery he said that he agreed to the
resection of the intestine if his own anus and sphincter could be preserved; but if this
could not be done, and an artificial anus had to be made on his abdomen, he required
the bowels to be left untouched because he would not accept living with a plastic bag
for excrement on his belly. There was no discussion possible, his decision had already
been made. Fortunately the operating surgeon was able to excise the tumor and connect
the bowel stumps end-to-end.
41
F.J. Ingelfinger, Arrogance, 303 NEW ENG. J. MED. 1507 (1980).
Other People’s Lives: Reflections on Medicine, Ethics, and Euthanasia
121
I could cite more of such examples; but there also are many medical situations in
which expecting the patient to decide will not and cannot work. What good will it do
to a frightened and distraught young woman with a tight narrowing of a heart valve if
I tell her that surgery carries a 1.5% risk of death and a 0.3% chance of developing a
severe valve leak,42 and that there is a 10 to 40% risk of painful post-pericardiotomy
pericarditis,43 but if she does not consent to surgery her chances to survive five years
are only 15%?44 And then to tell her that it is up to her to decide? She would be left
confused and terrified. On the part of the doctor, such course of action would be a
cowardly attempt to shun his own responsibility and lay the burden on the weakest
party, the gravely ill patient.
When a man is brought to the emergency room because of a sudden stabbing
pain in the abdomen and I find a hard “defense” of the abdominal muscles, no audible
sounds of intestinal movement, and a dry tongue, and X-rays show a layer of air under
the diaphragm, confirming that a perforation of an ulcer has occurred, should I present
to him surgery as an option? That’s no option, that is life, while waiting, not operating,
means death. In these situations, the most important ones that medicine knows, the
doctor has no right to “present options.” He must influence, encourage, and quickly
prevail upon the patient to choose the salutary course of action.
The habit of assuming responsibility, the courage to make the decision, the steadiness resulting from certainty that you are doing the right thing have always been the
high qualities of a traditionally educated physician. These virtues are now condemned
as inadmissible paternalism.
Physicians Facing Their Own Illnesses and Death. Physicians in War. Why are some
doctors reluctant to tell a patient he is dying? Jay Katz knows the answer: physicians
may fear death even more than their patients; they use silence to avoid the subject of
their own fears.45 Andrew Solomon further expands on the theme of doctors’ cowardice,
“The doctors who resist euthanasia are in many instances people who entered medicine to
conquer their own fear of disease and death.”46 This rancorous statement misrepresents
the motives of people who choose a medical career; curiously, it also contains some truth,
unintended by the author. Indeed, studying, and, in particular, practicing medicine
seems to immunize people against excessive fear of death and disease. Confronted with
the possibility of his own demise, a physician worthy of the name tends to view it with
more interest than fear, watching his symptoms and trying to establish the diagnosis.
One of my teachers in neurology, a Dr. K, having suffered what at first seemed to be a
minor stroke, wrote on a sheet of paper, “Can’t speak + can’t swallow ‘ bulbar palsy.” I
S. John et al., Closed Mitral Valvotomy: Early Results and Long-term Follow-up of 3724 Consecutive
Patients, 68 CIRCULATION 891 (1983).
43
B.H. Lorell & E. Braunwald, Pericardial Disease, in HEART DISEASE 1522 (E. Braunwald, ed., 3rd ed.,
1988).
44
K.H. Olesen, The Natural History of 271 Patients With Mitral Stenosis Under Medical Treatment, 24
BRIT. HEART J. 439 (1962).
45
J. KATZ, THE SILENT WORLD OF DOCTOR AND PATIENT 219 (1984).
46
A. Solomon, A Death of One’s Own, NEW YORKER, May 22, 1995, at 68.
42
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saw this note. K’s penmanship was, as always, impeccable. He knew, of course, that
bulbar palsy was a life-threatening condition. It killed him within a few weeks.
In bed after a myocardial infarction, an acquaintance of mine, professor Marceli
L., an internist, reflected upon his repeated episodes of quick heart beat, palpated his
own chest, and said, “I have a post-infarction aneurysm which apparently is causing
attacks of ventricular tachycardia.” This was in the fifties when surgery to repair the
aneurysm was not yet feasible, and antiarrhythmic drugs did not do much good for Dr.
L. He died within a month from his diagnosis.
The Moscow surgeon Petrovskiy, author of a book on pulmonary embolism, once
explained to me his life-long interest in the subject.47 In the summer of 1911, as a
medical student, he was assisting his father, a surgeon at a country hospital. The father
inadvertently cut his own finger while operating on a patient’s abscess. Two weeks later,
when his fever subsided and the swelling and the purple streak disappeared from his
arm, Petrovskiy Sr. got out of bed and walked into the study, talking to his son. Suddenly he fell, and said, “I’m dying of pulmonary embolism,” and died. At the autopsy,
the main pulmonary artery was obstructed by a large clot descended from the axillary
vein. All my life these three doctors have been my models.
Not everyone is given the chance to demonstrate his stoicism and diagnostic skills
in such a dramatic way; but very many doctors whom I watched during grave illnesses,
as their friend or attending physician, in one way or another showed such calm and
courageous attitude, and I always greatly appreciated it. My good friend Dr. T, a surgeon
and an enthusiastic hunter (the same whose case was mentioned in a previous paragraph),
noticed an unfamiliar weakness while carrying, with three other men, a moose he had
shot. He did not give up and carried the load to the truck. Back home in Toronto he
looked in the mirror, saw that he was pale, examined himself, found bleeding from a
rectal tumor, called a colleague, and had an immediate surgery. He was cured.
My close friend Dr. Alexander A., knowing that surgery to remove his stomach
cancer had not cured him, and had left a number of affected lymph nodes around the
aorta, displayed in the last year of his life admirable strength and courage, doing microscopy for a few hours every day (he was a pathologist), enjoying concerts, excursions to
the countryside and visits to museums, seeing scores of people, taking interest in their
lives—and it was he who comforted his visitors.
My own illnesses struck at the most inconvenient times and places on the globe.
I got pneumonia on the Trans-Siberian Express train, a phlebitis in Angkor Vat in
Cambodia, a chest pain, due to a diaphragmatic hernia, while driving on a highway, an
alarming heart arrhythmia, the paroxysmal atrial fibrillation, once on an airplane, once
in a hotel 4,000 miles from home, and once on a boat cruising the Caribbean. An acute
prostatitis with shaking shivers befell me on the Stockholm ferry bound for Tallin; and
under a cool shower on a very hot day in Nanning in South China, I got a spasm of the
right external oblique abdominal muscle that closely mimicked an acutely distended gall
47
Clots that originate in the veins and travel through the heart to the main lung artery or its branches.
Other People’s Lives: Reflections on Medicine, Ethics, and Euthanasia
123
bladder. Every time I established the diagnosis, and treated myself, or refrained from
treatment, just as I would have done with any other patient. There is no great merit in
this, it’s just how it should be. In Indochina in 1955, when I was vaccinating people
during an outbreak of plague in Svay Rieng, by accident a dose of vaccine burst in my
face and I inhaled a good deal. It contained weakened, but live, plague Yersinias that
could become virulent due to the passage through the lungs. A plague specialist from
the World Health Organization, who happened to be there waiting for her turn to be
vaccinated, advised me to immediately start a course of streptomycin and sulphadiazine.
If I had done that, I would have had no certainty whether I contracted the plague for
weeks, not cured, but only suppressed by treatment. I therefore started no treatment,
and for ten days took my body temperature twice daily. It was normal.
When we met in Amsterdam to honor Dr. Richard Langendorf, the famous Chicago
specialist in cardiac arrhythmias, Dr. Leo Schamroth of Johannesburg told us the story
of Langendorf the patient. He underwent cardiac surgery and was already awake in the
recovery room, but still assisted by a respirator, and patiently suffered the tube stuck in
his windpipe. Suddenly he started to gesticulate and protest with his whole body. The
tube was promptly removed and Langendorf, now able to speak, pointed to the screen
on which the ECG of the patient on the next bed was displayed, and said, “Look at his
rhythm! Why don’t you do something about it?!”
Now let us not forget the thousands of quiet heroes, doctors who attended to
patients with infectious (and highly contagious) diseases for which there was no cure.
They knew the risks, but did not abandon their patients. Dr. Matthew Lokwiya, who
led the fight against the deadly Ebola virus as head of one of Northern Uganda’s best
hospitals, caught the virus from his patients and died in 2006.
Let us also not forget doctors who experimented on themselves. Strzyzowski who
during his lecture in Lausanne drank a deadly dose of sublimate, and then a solution
of sulfuretted hydrogen, to prove his theory that the latter was an effective antidote to
heavy metals poisoning; old Brumpt, the great parasitologist, who in North Africa implanted in his own leg the giant worm, Wucchereria Bancrofti, that causes elephantiasis,
to bring it alive to Paris; Werner Forssmann from Eberswalde, who in 1928, looking at
a fluoroscopic screen in a mirror, as the first man in the world pushed a catheter into
a human heart, his own, and then climbed the stairs to the X-ray department to make
the historical roentgenogram; or Jonas Salk who first tried his polio vaccine on himself.
Well, are doctors, in particular those “who resist euthanasia” or “don’t tell the
truth,” reformed cowards? Have we undertaken the study and practice of medicine to
get rid of our pathological fears? Honestly, as I try to examine my own past and that
of medical people close to me, I cannot confirm Solomon’s (or Jay Katz’s) assertions. I
recall quite well the thoughts and feelings I had when as a high school student I decided
to major in biology, and then study medicine. They were not those suggested by Katz
and Solomon.
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Was there, underneath, an unconscious but terrible fear of death? Were there such
fear, I’m sure it would surface shortly afterwards, during my seventeen months at the
front in World War II, but I conducted myself no worse than other men.
My friend Dr. Marek Edelman, an active opponent of euthanasia,48 as a teenager
during the Second World War was active in the clandestine Bund organization in the
Warsaw ghetto, exposing himself to frequent brushes with the SS-men. “He was utterly
without fear,” as one of the leaders of the Bund wrote of him.49 Marek co-founded the
Jewish Fighting Organization in the ghetto, fought the SS troops in the victorious street
battle of January 18, 1943, was one of the leaders of the ghetto uprising in April-May
of 1943, and when this battle was lost, escaped with his fighters’ group through the
sewers, only to fight again, in the Polish uprising of August-September of 1944. In
October 1945, he entered the University of Lodz Medical School.
In 1935, as a second-year medical student, my friend Victor Taubenfligel was
relegated from Prague University for engaging in fist fights with the Nazi squads. He
graduated as an M.D. from University of Padua and immediately volunteered as a physician with the International Brigades fighting in the Spanish Civil War. After republican
defeat, he was recruited for a surgeon’s work with the Kuomintang Army in China, and
spent the last war years as contract surgeon to the U.S. Army in Burma. His superior at
the time, Lt. Col. Gordon S. Seagrave, M.D., devoted to Victor several heart-warming
pages in his book “Burma Surgeon Returns,” published after the war.50
Victor’s certificates from the U.S. Army make a remarkable reading:
“Doctor Taubenfligel . . . displayed unusual initiative . . . outstanding attention to
duty, and a high degree of professional ability . . . Dr. Taubenfligel assisted materially
in establishing a high respect for the United States Army Medical Department among
Chinese units . . . By command of General Stilwell: Frank Milani, Colonel.”51
“Dr. Taubenfligel has performed his duties at a variety of assignments, including
combat, in a highly commendable manner . . . His character is excellent and he is a
thoroughly reliable and loyal individual . . . For the Commanding General: L. J. Bullis,
Jr., Lt. Col.”52
“Dr. Taubenfligel was in combat service enduring indescribable hardships with
American and Chinese troops, in constant danger from the enemy, yet throughout has
been extremely active and capable in his work. In this unit his service has been most
superior and his loyalty to the unit and its army assignments most trustworthy. He has
done excellent surgery, yet does not shun the meaner, more difficult tasks . . . He is a
48
M. Edelman, To, co dobre, jest slabe [The weakness of the good], TYGODNIK POWSZECHNY (Cracow),
Dec. 4, 1994 (No. 49).
49
B. GOLDSTEIN, THE STARS BEAR WITNESS 160-61 (1949).
50
G.S. SEAGRAVE, BURMA SURGEON RETURNS 105, 210, 212 (1946).
51
Headquarters, United States Army Forces China-Burma-India, A.P.O. 885, 25 Oct. 1944. Subject:
Award of the Emblem of Meritorious Civilian Service to Dr. Viktor Taubenfligel (courtesy of Taubenfligel
family).
52
Headquarters, Northern Combat Area Command. A.P.O. 218. VWP/cjj, 11 June 1945 (courtesy of
Taubenfligel family).
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superb leader and his incredibly high morale has been a constant source of inspiration
to the officers and men of this unit whether American, British, Burmese, or Chinese.
(Sgd) Gordon S. Seagrave, Lt. Col. MC.”53
I wish to mention the doctors of Medical Company, 3rd infantry division, and of
nd
2 Mobile Field Hospital, 1st Polish Army of Europe’s Eastern Front; all of them middle-aged civilians in uniform, surgeons by profession, or, as Dr. Rak, gynecologists who
in the military re-qualified as general surgeons. In 1944-45, as a young soldier, I met
them now and again, and invariably was impressed by their cheerfulness, composure,
and imperturbability at work. Seeing them strengthened my youthful decision to study
medicine. I saw I was right choosing a career that gave one such steadiness, calm, and
obliviousness to danger.
Chapter V. The Motivation of Physicians
During the twenty years of the attack on medicine that I witnessed in Holland,
the media, politicians, and “people in the street” expressed the opinion that doctors’
sole reason to do their work was the big money they were making. The anti-medical
prophet Ivan Illich, much quoted at the time, disagreed, he knew that what motivated
the doctors to work was the greed for power.
On the other extreme, the Polish school of medical ethics, and in particular one
of its founders, Dr. Teodor Heiman, asserted that love of suffering mankind, and nothing else, should be the doctor’s motive to practice medicine.54 When I was a student
at the Medical School, this statement by Heiman worried me a lot. Much as I tried, I
could not find in my soul any genuine love of mankind, suffering or not. Further in
this chapter, I shall describe what I used to feel coming to see a patient. It was quite a
mixture of emotions, but love was not one of them. I had, therefore, serious doubts;
perhaps I was unfit to become a doctor?
My first sobering reflections came after my first encounters with unpleasant patients.
At times one comes across an obnoxious, abrasive individual, or a hostile psychopath.
We certainly did not love such persons. But we paid no attention to their outbursts,
and treated them the same as all other patients. If love were the doctor’s motive to help
patients, these people would be left without medical assistance.
Is money the incentive? I recall an elderly gentleman who on a Sunday evening
fifteen times lost consciousness due to an intermittent heart blockage. Fortunately,
every time he responded to a thump on the chest, and this was what I was doing waiting for the surgical team to gather. It was in the early days of pacemakers, before the
invention of transvenous electrodes. Effective temporary pacemakers did not exist,
and implanting a pacemaker was a huge affair; one had to open the patient’s chest, cut
the pericardium, and sew two button-like electrodes to the surface of the heart. In
Seagrave Hospital Unit. 896th Clearing Co., U.S. Army. Certificate, 5 June 1945 (courtesy of
Taubenfligel family).
54
T. HEIMAN, ETYKA LEKARSKA I OBOWIAZKI LEKARZA [Medical ethics and the duties of physician] (Gebethner & Wolf, Warsaw, 1917).
53
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the meantime, an incision was made on the abdomen in order to implant the battery.
Two thoracic surgeons (one of them the head of the department), a general surgeon, a
surgical resident, and an anesthetist were working on the patient, while I was following
his heart rhythm. I looked around the operating theater, and it occurred to me that
if this were to be done for money, my patient wouldn’t survive. I simply wouldn’t be
able to assemble such a team on a Saturday night. The hospital’s two surgeons on duty
were operating on emergency patients in other theaters. The doctors working on my
patient were not on duty. They canceled whatever plans they had for that Saturday
evening, and rushed to the hospital. On duty or not, they could not refuse assistance
when someone’s life depended on it. They would not do that for a fee. They did not
grumble, and, on the contrary, felt rewarded because the novelty of the procedure made
it particularly interesting.
In Polish hospitals where I spent the first half of my professional life, I was earning
decent money doing private practice and collecting my salary as head of the department and outpatient clinic, but other members of the team, some of them experienced
physicians, were sadly underpaid. As in any team, a few were nice but undistinguished
people; others, receiving the same miserable salaries, impressed and inspired me by
their dedication, mental concentration, persistence in thinking of a patient, and constant
desire to improve their knowledge and skills. I learned a lot from them.
I think of the consultants I met in 1961-62 at Hammersmith Hospital in London,
and Oxford’s Radcliffe Infirmary. They were doing excellent research, simple, rigorously
controlled, and purposeful, and very good teaching, and provided prudent, effective,
high-quality patient care. At that time, they were paid little more than 200 pounds a
month while their counterparts in continental Europe earned thrice that much in salaries, in addition to lucrative private practice.
I would also like to mention my grand-uncle Dr. Oskar Pomper, the internist
who made some original contributions to gastroenterology. He opened his practice in
Warsaw around 1890, and the news quickly spread that he did not accept fees from
poor patients. Quite often he gave to a patient’s family the money to buy the medicine
he prescribed. Soon he had almost no other patients but the poor, and this kind of
practice continued for more than forty years.
And I think of all those European doctors who volunteer to work for no pay in
difficult and often dangerous places where Physicians Without Borders open a hospital
or a post to help the victims of war or calamity.
I am not trying to prove that money is not an incentive to practice medicine. It
often is. What I’m trying to say is that money is not the necessary incentive: many
doctors practice medicine with great dedication even though they are paid very little
or not at all. Medicine is a self-rewarding activity.
What is, then, the motivation of physicians? The only way I can contribute to the
understanding of a physicians’ motives is to describe my own. My decision to become a
doctor was made when I was a high school student. I was interested in biology, enthralled
Other People’s Lives: Reflections on Medicine, Ethics, and Euthanasia
127
with living beings, and awed by their complexity. And medicine was biology aimed at
helping people; it seemed an exciting way to make a living. Also, as a teenager I coveted
the respect doctors I knew enjoyed, and the attentive way they were listened to. And
in the turbulent Europe of that time (1938), with my people under assault, I wanted
to pursue a career which in my naïveté I believed least likely to arouse people’s hate.
When I think of my later incentives to practice medicine, I see a multitude of intertwined motives, most of which were selfish. A few were not. When coming to see a
new patient I felt excitement at the prospect of finding out what was wrong with him.
This was, every time, a great intellectual adventure. At the same time, I was warmly
grateful to the patient for trusting me. Also, I hoped to be able to help the patient in
some way, and anticipated the recognition I would receive. I often felt compassion, its
intensity varying, though, from case to case.
Taking patient histories were very time consuming and a tremendous challenge,
but it had great rewards. When the difficulties (and, often, the patient’s resistance) were
overcome, a true catharsis was reached.
The physical examination has always been an emotionally stimulating procedure.
Being a traditionally trained doctor I did many more physical examinations than a
“modern” doctor does. I enjoyed exerting my skills, the trustful cooperation of the
patient, and the very act of touching my fellow humans in an amiable, purposeful, and
totally asexual way. For many years these bodily contacts have helped a good deal to
keep me on friendly terms with humankind.
I excelled in manual interventions that have been part of classical internal medicine, the carotid sinus pressure, the pleural, abdominal and pericardial punctures, the
lumbar puncture, the surgical exposure, ligation and incision of veins, and the most
trivial and most often botched of them all, the puncture of difficult veins. In my forties
I did my best to acquire new manual skills, those of cardiac catheterization and insertion
of pacing electrodes. Every time I performed these procedures I derived the kind of
satisfaction and pride only handwork can provide.
With time, I have taken a special liking to certain groups of patients, actually, to
most of them. I liked hospital patients in general: their patience, tenacity and courage,
the understanding they showed when the doctor had to attend to others, their ability
to maintain hope in spite of setbacks.
In Lodz I liked the working class patients, factual and precise in watching their
symptoms, and able to tell me their complaints in one or two minutes’ time and in such
a detailed and straightforward way that I immediately knew the diagnosis. Their ways
were very different from those of some intellectuals who divagated for half an hour,
providing me with no information at all, and then, still talking, managed to answer
none of my questions.
I immensely liked patients from the Protestant towns and villages around Den
Bosch, so modest, so reasonable, so orderly, courteous, and dependable, so calm when
facing the vicissitudes of age and disease.
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When a doctor has worked for a long enough time at the same place, not only
following the individual patients but watching what happens to families, to generations,
to whole communities, he begins to embrace a broader panorama, a vision of the kind
that also artists tend to have in their mature years—or perhaps most people have, but
artists give such visions an expression: Gauguin in his “Where do we come from? What
are we? Whither we go?” painting, Vigeland in his (so starkly Germanic) sculpture park
in Oslo, Stanley Spencer in his strangely moving “Last Judgment.”
I saw daughters, themselves frail in their middle age, coming back crushed from
the burials of parents; a tight-lipped mother at the bedside of her teenage son already
paralyzed by brain hemorrhage and bleeding from all openings of his body; a wife who
restrained her sobbing over the husband’s torso, so muscular, so handsome, so desirable, yet dead, dead due to a stupid accident in some obscure blood vessel; an elderly
couple so beautiful, so noble, so much in love, dying in one night as the lady suffered a
pulmonary edema at the sight of the husband’s heart attack; old men who in the wake of
the spouses’ burials developed devastating temporal arteritis. My vision that arose and
kept recurring was that of a procession in which all of them, mothers leading children
by hand, married couples looking in each other’s eyes, elderly husbands supporting their
wives, marched steadily, patiently, never despairing, into the twilight, over the slightly
curved earth’s surface, toward the huge black pit dug for us on the horizon. And I conceived, so late in my professional life, a deep sympathy with all of us, our failures, our
disenchantments, our innocent sufferings, our undeserved deaths. A wave of rebellion
rose from my heart, and has not ebbed ever since.
***
Chapter VI. Speaking the Truth
“Falsehood is in itself bad and reprehensible,” states Aristotle in The Nicomachean
Ethics, “while the truth is a fine and praiseworthy thing.”55 He does not say why. There
seem to be important reasons to respect and value the truth. We need some amount
of truthful knowledge of the world to move around and perform our tasks (though we
mostly achieve these goals with a mixture of truth, error, ignorance, emotional drive,
and automatism, in varying proportions). We should respect the truth as the quest of
everyone’s mind.56 And we should value it for its concordance with the state and course
of the universe, its “beauty,” as Einstein would have it.
But assuming that we sometimes know the truth, should we always tell it? Instances in which we shouldn’t come to mind as soon as this question is posed. It may
be a morally laudable and heroic act not to reveal the truth, as when a captive of the
Gestapo refused under torture to name the members of an underground organization.
Priests, lawyers, and doctors must not divulge what they have learned in the confessional
or office. It is a bad employee who informs competitors of his firm’s trade secrets. We
do not approach a person to tell him we don’t like his looks. Thus, we do not tell the
55
56
ARISTOTLE, THE NICOMACHEAN ETHICS 165 (J.A.K. Thomson, trans., 1983).
Id. at 205.
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truth if by doing so we would damage values which we place higher than veracity. In
the language of W. D. Ross’s philosophy, telling the truth may be our “prima facie duty,”
but not necessarily our “duty proper.”57
Should We Tell The Patient That He Is Dying?58
The word Truth stands in the center of your emblem. But there is something more
important than Truth: It is Life.59
Rabbi Adin Steinsaltz
In the 1960-1970s the traditional doctor/patient relationship and method of
informing patients about their medical condition came under assault. Philosophers,
theologians, some patients, and the courts rose against medical deceit and asserted the
patients’ right to be correctly and fully informed of their diagnosis, prognosis, treatment
alternatives, and/or imminent death. A doctor owed his patient the truth, they said,
because, in the spirit of Kantian ethics, he should respect the patient as an autonomous
rational being,60 and provide him with truthful information needed to make rational
decisions. The fiduciary relationship required that the patients’ trust be rewarded with
truthful information.61 Patients were entitled to knowing the truth not so much because
it concerned their own bodies, but because it concerned their own lives.62 Not doctors,
but patients and the courts should determine the extent of information patients received.63
Dying persons needed to know the truth in order to settle family and money matters.64
Informing the patient of his imminent death would induce him to renounce expensive
treatments, thereby limiting the costs of health care and helping the national economy.65
There have been, and still are, strong arguments in favor of the traditional way of
giving information, though it follows the principle of beneficence rather than autonomy.
Informing patients is part of medical practice and is, therefore, subject to the rule of
doing no harm. Not only the tissues of a patient’s body, but also his psyche, should be
handled with care. Diagnoses are fallible and prognoses notoriously unreliable, thus,
part of the information given to patients is bound to prove untrue: one more reason to
restrain it. And the traditional medical rule of never taking away hope is based on the
knowledge of wishes and reactions of patients who are gravely ill, i.e., the very group
concerned.
J. Dancy, An Ethics of Prima Facie Duties, in A COMPANION TO ETHICS 219-23 (P. Singer, ed., 1994).
The concept of informed consent is in many ways related to the subject of this chapter, but is not
discussed here.
59
From Rabbi Adin Steinsaltz’s speech upon receiving an honorary doctorate, Commencement,
Brandeis University, May 1999.
60
N. A. Davis, Contemporary Deontology, in A COMPANION TO ETHICS 211 (P. Singer, ed., 1994).
61
Cobbs v. Grant, 8 Cal. 3d 229, 502 P.2d 1, 104 Cal. Rptr. 505 (Cal. 1972).
62
A. Capron, Duty, Truth, and Whole Human Beings, HASTINGS CENTER REP., vol. 23, 1993, at 13-14.
63
J. G. Annas & F. H. Miller, The Empire of Death: How Culture and Economics Affect Informed Consent in
the U.S., the U.K., and Japan, 20 AM. J. L. & MED. 379, n.6 (1994); see also Canterbury v. Spence, 464 F.2d
772 (D.C. Cir. 1972), cert. denied, 409 U.S. 1064 (1972).
64
Arato v. Avedon, 13 Cal. App.4th 1325, 11 Cal. Rptr.2d 169 (1992).
65
Annas & Miller, supra note 63, at 390.
57
58
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Some people know they are dying. When a patient does not know that, that is,
still believes he will live, I won’t tell him he will soon die. For one thing, doctors can
seldom predict that with certainty. But, most importantly, why should I kill his spirit
while he is living? Why should I inflict such pain? I am a doctor and everything I do
must be aimed at relieving suffering. I must have no other business. I should never
do the opposite.
Important matters may be involved: the future of the family, decisions concerning
money. But in my mind, medical considerations must prevail over all others. If I am
not faithful to this principle, I have no business being a doctor.
I belong to the generation of physicians who used to be very cautious while talking
to patients. Experience taught us that the more we talked, the worse were the misunderstandings: not because of the patients’ lack of medical knowledge, but because of
their anxiety. Hence the old clinical adage: “SAY ONLY WHAT IS ABSOLUTELY NECESSARY.” It has been attributed to Hippocrates, but I could not find it in his writings.
Whoever the author, I know the advice is sound.
We used to be very earnest and literal in observing the injunction “PRIMUM NON
NOCERE,” first of all, do no harm; and it has always been obvious to us that suffering
could be inflicted and harm done not only with ill-performed procedures, or ill-judged
prescriptions, but also with imprudent words. And we tried not to frighten, depress,
or traumatize the patients by choice of words, tone of voice, facial expression, or body
language. When it was necessary to break bad news, we would also point out some good
aspect of the situation, a chance of improvement, or something that could be done, even
if it was the hope that a lesser complaint could be relieved: “THE PATIENT MAY LOSE
HIS LIFE, BUT NEVER HOPE.” This old clinical proverb is not cynical. It reminds
us of our ultimate powerlessness; and that we should be supportive to the very end.
The traditional way of informing patients had its shortcomings. Not only the
bioethicists but also some medical practitioners voiced criticism. These doctors argued
that while most patients in declining health avidly accepted words of promise and
hope, others became critical and ultimately distrusted the doctor. Further, unbearable
tension and falsity could be created between the family members who knew, and the
hopelessly ill person, who did not. Some doctors also admitted that there might be a
mixed motivation behind the policy of not informing the patient of his demise. Doctors
who pursue such a policy in order to protect the patient soon discover that it is also
protecting themselves. It allows the doctor to avoid the painful difficulty of speaking
to the patient on the subject of his death and facing him afterwards.
The debate might have led to an improved manner of informing the patients,66
but was solved in the least appropriate way, by court rulings.
The Lethal Avalanche. Whatever the weaknesses of the traditional way of informing
patients, it did promote doctors’ good qualities: caution and gentleness.
66
Donald S. Kornfeld, Doctor’s Dilemma: What Truth for What Patient at What Time? N.Y. TIMES, May
16, 1978; A. Piper, Jr., Truce on the Battlefield: A Proposal for a Different Approach to Medical Informed Consent, 22 J.L. MED. & ETHICS 301 (1994).
Other People’s Lives: Reflections on Medicine, Ethics, and Euthanasia
131
The information revolution produced the opposite effect. The intellectual mediocrities and the emotionally unstable individuals in the medical profession started to
assail the patients and the families with cruel, thoughtless, and often erroneous information. The court rulings that only “material” information should be disclosed,67 and
that patients had the right to waive information,68 have been sweepingly disregarded.
There has been no reckoning with the obvious fact that patients belonging to certain
ethnic and cultural groups did not want and could not tolerate medical death sentences.
The new manner of informing the patients has quickly spread throughout English-speaking countries and is even making inroads in Central Europe and the Mediterranean. In Holland, prof. Jongkees, the long-time editor of The Netherlands Journal of
Medicine, published an article warning against the medical explosion of verbal cruelty.69
In one of the cases he cited, the patient recovering after a serious operation received a
special visit from a doctor in whose opinion the surgeon in charge had not provided the
patient with sufficient information. He explained to the patient that his condition was
much worse than he thought, and, in fact, hopeless. “A couple of days later the patient
died of a massive myocardial infarction,” wrote Jongkees; and added: “I don’t want to
say that this was directly caused by that truth-loving doctor’s words.”70
I had just twice defibrillated a young woman with a myocardial infarction, and no
sooner had she opened her eyes than a nurse hastened to tell her: “Madam, in the last
few minutes you died twice.” I know a young woman who went to her family physician
because of a low-abdominal pain and immediately heard from him that “this could be
cancer.” Two weeks later this was determined not to be cancer, but the patient had not
slept one night in the meantime, and had already bid farewell to her friends, and to
life. People diagnosed with cancer not only must hear about the metastases that have
been found, but also about those which might appear in the future: in the spine, the
heart, the brain! With good reason Jongkees queried the real motive of “speaking the
truth”: honesty or sadism?71
He forgot to mention stupidity. When someone in my family was diagnosed with
multiple myeloma (a bone marrow malignancy), professor B at a hospital in Geneva
limited himself to stating, “Vous etes incurable,” but the associate professor, Dr. S, said to
the patient: “Oh, how I pity you! You’ll be dying in infernal pain.” The horrible pains
somehow failed to appear, but after receiving that information the patient attempted
suicide twice.
And what if the “truth” the patient has been told proves untrue? In a university
hospital in Holland, I witnessed a conversation between a young doctor and a female
patient who, despite the implantation of two prosthetic heart valves, wasn’t doing well,
Cobbs v. Grant, 8 Cal. 3d 229, 502 P.2d 1, 104 Cal. Rptr. 505 (Cal. 1972).
Annas & Miller, supra note 63, at 379, n.6 & 390.
69
L. B. W. Jongkees, Over het spreken van waarheid: Eerlijkheid of sadisme? [On speaking the truth:
honesty or sadism?], 122 NEDERL. TIJDSCHRIFT V. GENEESKUNDE 921 (1978).
70
Id.
71
Id.
67
68
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and moreover, had a complication of anesthesia: a tracheal narrowing due to intubation.
Weeping, the patient told the doctor that she would not be able to withstand another
procedure as painful as the one that day (an attempt to widen the trachea). “Oh yes you
will,” said the doctor, “this is a series of twelve procedures, and we’ll be doing it eleven
times again.” Then he left the patient who was sobbing disconsolately. She had to know
the truth and accept it. But this was not the truth, the woman died the same night, and
the eleven planned procedures were never performed. The truth-loving doctor had,
however, succeeded in poisoning the final hours of that woman’s life.
My American experiences tend to complete the sad picture. Often it is not even
the contents of the information, but the way it is presented, that drives the patient to
despair. For some years now, I have been watching two patients in Boston, both with
chronic conditions. Mr. A is 72 years of age, has adult-onset diabetes, a clogged artery in one leg, and two coronary bypasses that unfortunately were closed with clots
less than a year after surgery. I previously had quite a few patients like him, and most
of them did fairly well for a long time. Their diabetes and high blood pressure were
treated, the artery in the leg either opened up with a balloon catheter, or replaced with
a Teflon tube, or else they were taught to walk a lot, slowly as not to provoke calf pain,
but as far a distance as possible, and told this might help them develop some collateral
circulation. They received beta-blocking drugs carefully chosen and dosed, and nitroglycerin as needed. I expressed satisfaction at every small progress they made, and also
when they simply avoided deterioration. These people attended opera performances,
traveled to sunny islands for holidays, and were, in general, fairly content with their
lives. Not so for Mr. A of Brookline, Massachusetts. Once every two months he goes
to see his cardiologist, awaits the day with trepidation, and comes back devastated.
The information he receives is the same he would hear from me, but the delivery, the
emphasis, the repeated somber predictions, the omission of any encouraging news or
opinions, the scoffing at every chance of improvement seemed calculated to finish the
patient off. Every time he hears that surgery is the only solution, but cannot and will
not be done; that he is incurable; and that medicines do nothing, NOTHING! to cure
his afflictions. For several years now, Mr. A has been living in gloom and despair. The
man sees his life as senseless and reduced to waiting for death.
The other patient I am watching is now a 70 year old lady, Mrs. S, beautiful, sophisticated, and capable of enjoying everything that is worth while in life. Four years
ago, feeling quite healthy, she went for a routine check-up and was found to have too
much alkaline phosphatase in her blood. A special test, the endoscopic retrograde
cholangiopancreatography, showed multiple narrowings in the bile ducts, typical of
sclerosing cholangitis, a progressing disease causing obstruction to the bile flow, secondary infections, and, in the long run, cirrhosis of the liver.
The medical assistance the patient received has been almost perfect. The very
first step, the faultlessly performed test and the prompt diagnosis witnessed the doctors’
excellent skills. Treatment with methotrexate, an immunosuppressive drug, did not
Other People’s Lives: Reflections on Medicine, Ethics, and Euthanasia
133
inhibit the progress of the disease, and was stopped. Two bouts of infectious cholangitis
were adequately treated with antibiotics. One year later, a timely decision was made to
perform a transhepatic cholangiography. It showed that the most important narrowing
was the one outside the liver, in the common bile duct. The obstacle was surgically
removed, and with the main outflow of bile now secured and long-term antibacterial
treatment implemented, the infections did not recur. When some increase in the blood
level of bile dye was discovered, a new transhepatic cholangiography was done, and,
manipulating through the same catheter, and using inflatable balloons, the radiologist
opened up a number of narrowing bile ducts inside the liver.
Admiring what the doctors did, I was appalled at what they said. A patient with
this disease, at the early stage in which Mrs. S was, would be adequately informed if
told that hers was a chronic ailment, that there was no cure, but—depending on the
circumstances—much could be done to improve her condition, combat infections,
remove the narrowings, etc.; and that she did not need a liver transplant at this time,
and probably would never need it. Mrs. S’s two doctors chose a different manner of
presenting the truth. They hammered into the patient’s head the incurability of the
disease, its inexorable progress, and deadly outcome. This threw her into a chronic
depression. Only when Mrs. S chose to stay under the care of the surgeon who had
operated on her bile duct, a young man whose ways were surprisingly “traditional,” did
she regain her normal mood. Even then she still had to endure the chief radiologist.
The procedure this man performed—the balloon-widening of the bile ducts inside the
liver—was done masterfully and with good result, but during the procedure the radiologist, speaking to his assistant, all the time cursed “this terrible mess of a liver” inside
which he had to work. “Again a narrowing? Isn’t there a single decent bile duct in the
whole liver? One cannot expect me to dilate all these muddy tubes!” All this time the
patient, fully awake, attentively listened to the doctor’s words. The Kantian injunction
to respect every person as a rational autonomous agent had little impact on this doctor.
He treated his patient as no person at all, insensate, or simply not present.
Mrs. Z, a 35 year old university graduate, was in the fifth month of her first pregnancy, went for a check-up to a maternity clinic in Brighton, Massachusetts, and was
seen by a resident obstetrician. She was feeling wonderful, and was happily preparing
herself for the great event. The doctor did his best to disabuse her of her foolish expectations. Didn’t she know that a first pregnancy at her age carried an exceedingly high
risk of Down Syndrome for the child, and of grave complications before and during
birth? She might develop toxemia causing convulsions and blindness; there might be a
placenta previa or an atonic uterus, both of which would lead to deadly hemorrhages; it
might prove necessary to crush the child’s skull and suck out the brain with a vacuum
pump—the woman’s attempts to stop the doctor’s recitation were of no avail—or the
child might get strangled to death by the umbilical cord. She had, however, the legal
option of abortion. While telling me the story the young woman expressed only con-
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tempt for her tormentor, but ladies emotionally less stable and not as well intellectually
equipped would certainly panic or be severely depressed.
Mrs. P, a university professor who had been born in Eastern Europe and immigrated
to the United States in her forties, struggled for three years with a malignancy involving
several organs. All therapies were tried, and the patient had spells of a certain well-being
and even hope. However, every time a shadow was discovered on the X-rays, a “tumor
marker” in her blood increased, or white blood cell count dipped, the doctors hurried
to her bedside to crush her with the news. Many times the patient begged them not to
tell her, to spare her the distress. Her close friend, a member of the same faculty, Mrs. E,
repeatedly tried to explain that the patient, raised in a different culture, did not want to
hear the bad news and was truly unable to cope with it. All requests and explanations
were rejected by the physicians.
The following story should be given a prominent place in the annals of medical
idiocy. A happily married woman, the mother of a marvelous two year old girl, and
four months into her second pregnancy (a boy, according to the ultrasound), was in the
best possible mood when she answered the phone on a winter day in 1998. Somewhat
to her surprise, it was the substitute family physician calling. Yes, she knew that her
husband recently consulted this doctor because of a urinary infection. But did she know
that the husband’s father died of pancreatic cancer at the age of 65? Yes, she knew that
too. Did she realize that cancer of the pancreas was a most terrible, extremely painful,
and always deadly disease? Wasn’t she worried? Did she understand what the disease
of her father-in-law meant for the future of her family?
“Thank you for calling,” said the woman and hung up. But it would be interesting
to know the truth-loving doctor’s intention. Did he want to cause the lady’s nervous
breakdown? Did he want her to divorce her husband, or commit suicide? I don’t really
suspect him of such malice; rather, of bottomless stupidity. By the way, nothing indicated that the father-in-law’s case belonged to the small group of genetically determined
pancreatic cancers; outside of this category, cancer of the pancreas is not a disease that
is known to reoccur in families.72
Kowlessar O. Dhodanand, Diseases of the Pancreas, in CECIL-LOEB TEXTBOOK OF MEDICINE, 13th ed.
1313-27 (P.B. Beeson & W. McDermott, eds., 1971); J. P. Cello, Carcinoma of the Pancreas, in CECIL TEXTBOOK OF MEDICINE, 17th ed., 777-80 (J. B. Wijngaarden & L. H. Smith, Jr., eds., 1985); and R. J. Mayer,
Pancreatic Cancer, in HARRISON’S PRINCIPLES OF INTERNAL MEDICINE, 12th ed. 1383-86 (J. D. Wilson et al., eds.,
1991).
72
Other People’s Lives: Reflections on Medicine, Ethics, and Euthanasia
135
Predicting How Long a Patient Will Live. Predicting how long a patient will live
constitutes a separate class of obnoxious medical nonsense.73 Press reports on faulty
medical predictions of death have no end.74
Who Wants It? “What’s the point of truth if people suffer from it?”75 Do the patients
want “the whole truth”? A grave error is committed when conclusions about patients’
desires are drawn from opinion polls. A survey76 showed in 1982 that 85 percent of
Americans “would want their physicians to give them a realistic estimate of how long
they had to live if they had a type of cancer that usually leads to death in less than a
year.” Of course; the respondents (and the researchers who had phrased the questions)
have grossly overestimated the physicians’ ability to make such exact predictions. But,
more importantly, we should realize that in this study, as in all of this kind, the wrong
group was surveyed: the general public. A great majority of such a group are healthy
people. These are not the people doctors will have to inform about their condition.
If we want to know what kind of information doctors should give to sick people, we
should study the desires of people who are sick. It is common knowledge, and has
been confirmed in well-documented studies,77 that, in matters of life, death, and medical decisions, the opinions of healthy people differ from the opinions of patients with
life-threatening disease. Healthy people are inclined to bravado, while the gravely ill
tend to cling to life and hope.
Over the years I have heard some patients express their views on the subject. I
remember at least half a dozen female patients who used to say, “If the truth is bad, I
want to be told a lie.” It takes courage to make such a statement that openly admits
one’s weakness.
I also recall two male patients who stated that they wanted to know the truth no
matter how bad. But it was apparently not what one of them really wanted. When a
doctor finally told him that the pus in his left pleura had originated from a decaying,
73
In chapter XXVIII, section on “The Oregon Law,” I discuss in detail the reasons why predicting how
long a person will live is a very inexact science.
74
Editorial, The Problematic Death Certificate, 313 NEW ENG. J. MED. 1285-86 (1985); T. Kircher, et al.,
The Autopsy as a Measure of Accuracy of the Death Certificate, 313 NEW ENG. J. MED. 1263-69 (1985); R. E.
Anderson & Ch. R. Key, The Sensitivity and Specificity of Clinical Diagnositcs During Five Decades: Toward an
Understanding of Necessary Fallibility, 261 JAMA 1610 (1989); L. Goldman et al., The Value of the Autopsy in
Three Medical Eras, 308 NEW ENG. J. MED. 1000 (1983); M. Boers, Obduceren is vooruitzein: De toekomst van
obductie [Performing autopsies means looking ahead: The future of the post-mortem], 134 NED. TIDJSCHRIFT
V. GENEESKUNDE 1346 (1990); E. Wubeke et al., Obducties in een verpleeghuis [Autopsies in a nursing home],
133 NED. TIDJSCHRIFT V. GENEESKUNDE 765 (1989); W. D. Rees et al., “Patients with Terminal Cancer” Who
Have Neither Terminal Illness Nor Cancer, 1987 BRIT. MED. J. (Dutch ed.) 488-89.
75
ISAAC BASHEVIS SINGER, THE DEATH OF METHUSELAH 128 (1989).
76
2 PRESIDENT’S COMMISSION FOR THE STUDY OF ETHICAL PROBLEMS IN MEDICINE AND BIOMEDICAL AND BEHAVIORAL RESEARCH 221-24, 245 (1992) (Appendices: Empirical Studies of Informed Consent).
77
M. L. Slevin et al., Attitudes to Chemotherapy: Comparing Views of Patients With Cancer With Those of
Doctors, Nurses, and General Public, 300 BRIT. MED. J. 1458 (1990); D. E. Patterson et al., When Life Support is Questioned Early in the Care of Patients With Cervical-Level Quadriplegia, 328 NEW ENG. J. MED. 508
(1993); John H. Hess, Looking for Traction on the Slippery Slope: A Discussion of the Michael Martin Case, 11
ISSUES IN LAW & MED. 105, 114-15 (1995).
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infected, inoperable cancer of the colon, the patient reacted with totally deranged behavior. He spent the rest of his life screaming, abusing the doctors, upsetting teapots
and bedpans, and throwing his slippers at the cleaning personnel.
Obtaining from patients an entirely sincere answer to the question of how they
wish to be informed, an answer unconstrained by macho feelings, shame, or social rules
of conduct, may not be as simple as it seems.
Stories are published of patients who, having been told that they must soon die,
made the most of every remaining week and day, and achieved with their families and
friends a spiritual communion they had never known before.78 I personally know such
examples. Meanwhile, other patients, facing their own imminent annihilation, and
seeing all hope, interest, and meaning taken away, regret having ever entered a doctor’s
office. Many feel that suicide or euthanasia are the only sensible solutions. There is no
doubt in my mind that the doctors’ new manner of informing patients has become one
of the causes of the rush to euthanasia.
And as if Truth were not deadly enough, unfounded suspicions, false predictions,
and unnecessary horrors are heaped upon the patients’ heads. The intellectually inferior, internally insecure, and embittered members of the profession have now found
the opportunity to unleash their aggression.
Among this mayhem, good and wise men and women, of whom there are many
in the medical profession, still find ways to protect patients. As long as there are still
physicians worthy of the name, they will choose, carefully and compassionately, what
truth to tell which patient at what time.79
What Shall We Tell The Patient? I recommend a truthful, discerning, and restrained
manner of informing patients about their medical condition. Answering questions is
preferable to volunteering information. Information given to the family should be identical with that given to the patient. Details should be avoided: they do not enlighten,
but horrify. Good aspects of the situation, and the ways of bringing relief, should be
emphasized.
The prospect of a patient’s death should only be discussed at the patient’s insistence.
It is advisable to place this subject in the context of fears, hopes, and uncertainties shared
by all people. Attempts to predict the proximity of a patient’s death are particularly
traumatic, scientifically untenable, lead to spectacular blunders, and cannot be part of
information given to patients by a medical doctor.
78
J. Thomas, A Professor’s Final Course: His Own Death: Facing a Fatal Disease, Morris Schwartz Teaches
How to Live Until the Last Moment, BOSTON GLOBE, Mar. 9, 1995.
79
Korenfeld, supra note 66.
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Chapter VII. The Medical Mind
Learning Medicine From a Master. In 1997, Dr. Joseph Stanton invited me to address the students and recent graduates of Harvard Medical School who were taking
the restated Hippocratic Oath. Here is what I said:80
Dear Friends, I want to draw your attention to a sentence in the original Oath,
which reads: I will pay the same respect to my master in the Science as to my parents. It is
not so much a matter of respect any more, the forms of respect change with time and I
think the present-day masters like to be treated as fellow students of medicine, and of
course that’s what we all are. But what in my opinion is still important, and what the
Oath took for granted, is learning medicine from a master.
Let me tell you a story that my teacher, Dr. Jakubowski, told me many years ago.
In 1915, as a young military doctor with the Russian army during World War I, he stayed
with his regiment in a provincial town in Central Russia. While there, he was called
to see a very sick twelve-year old girl who was running a fever of 40° C (104° F). Two
doctors had seen her and couldn’t find the cause. After a meticulous routine examination, neither could Dr. Jakubowski. But he remembered a lesson from his Paris student
years, something his teacher in surgery had told him: “If a child comes back from school
and does not complain of anything, but the next day falls ill with high fever, tap with
your finger all long bones. Children are kicked by playmates at ball games, don’t pay
attention to the injury, and forget about it. Meanwhile, bacteria from the child’s throat
or teeth may settle in the injured bone and osteomyelitis develops.”81
Dr. Jakubowski percussed the girl’s bones inch by inch and found a very painful
spot in the left shin. Within hours the surgeon at the local hospital chiseled out the
infected piece of bone, and the child was cured. Tearful parents came to thank Dr.
Jakubowski, and the father said: “Boh vas poslal” (“God has sent you”). Agnostic as he was,
Jakubowski must have been moved by these words because I could see that even forty
years after the event he had to subdue some emotion while telling this part of the story.
Since the day I heard it, I have inquired about possible trauma and percussed the
bones in every case of unexplained fever. It paid off two years later, in a quite exceptional, I would even say, unheard of case. A distant relative of mine, Mr. S, was rushed
150 miles to my hospital in Lodz, Poland, with a fever of 103°-104° F. He had been
doing some repairs and fell from the roof of his house. He didn’t break any bones and
hurt nowhere, but two days after the fall the fever began.
Percussing his bones, I found in the right shin a spot that not only was painful,
but there was even fluctuation indicating the presence of fluid. An area of rarefied bone
was seen on the X-rays. I punctured the affected spot and drew thick green pus. The
patient was transferred to the department of the excellent bone surgeon Dr. WroblewsThis is a shortened version of my lecture delivered at the Ceremony of Restating the Hippocratic
Oath, Vanderbilt Hall, Harvard Medical School, May 10, 1997.
81
“Osteomyelitis” means a bacterial infection involving a bone and the bone marrow. “Septicemia” is
a suppurative infection spreading by the blood stream to various organs.
80
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ki. Meanwhile, sensational news came from the lab: the pus swarmed with Salmonella
typhi, the causative agent of typhoid fever!
The patient had typhoid fever during World War II. It turned out that he still
was a carrier of the bacilli, stored in his gall bladder. Bone surgery had to be combined
with a chloramphenicol cure.
About a year later, at a military hospital in Lodz, I saw a pale, sick lady of 34. She
ran a hectic fever that alternated with profuse sweating. The patient’s left forearm was
swollen, and her spleen was palpable, soft on touch. Her white blood cell count was
elevated to 32,000. It had been four days since her admission and she didn’t have a
diagnosis. The head of the department, Dr. H, a laboratory-minded theorist who was
out of touch with clinical practice, never once examined the patient, but kept firing
away disparate and improbable diagnoses that had no connection with the patient’s
problem. Carefully examining the forearm, I found fluctuation. Puncture revealed
pus. I proceeded to percuss the bones, and found in the right shin the area of osteomyelitis that was the source of the patient’s septicemia. In the culture of the pus from
the forearm there was abundant growth of staphylococci. A sequestered piece of dead
infected bone was removed by surgery, and an intensive antibiotic treatment eliminated
the distant foci of infection.
I kept applying in my practice this method that was never mentioned in the textbooks, but in the following thirty years found no more cases of osteomyelitis. Indeed, my
gradual, and then definitive switching from internal medicine to cardiology reduced my
chances of seeing these cases. I leave it to you to judge whether the diagnostic method
that my master handed down to me, and he himself had inherited from his teacher, is
cost-effective enough to be recommended.
Listening to what the master says is an important part of the young physician’s
education. Usually the teacher will say it in connection with a patient they have just seen
together, which gives his remarks a vivid, specific, and memorable quality. Moreover,
the master wouldn’t bother to tell you what can be found in textbooks, he will expand
beyond that.
Is there anything else? Yes indeed. Textbooks, monographs, and the top medical
journals contain the best established information. This is the canon of medical knowledge. It cannot encompass the infinite multitude and variety of phenomena in health
and disease, nor the enormous variety of ways in which facts present themselves to our
mind under varying circumstances.
The canon does not even encompass the totality of observations made by those
astute nature watchers, the practicing physicians. Doctors do not publish everything
they notice. As legend will have it, Gallavardin, the prominent Lyon cardiologist, never
published his observation that atrial flutter (an important disturbance in heart rhythm)
can be diagnosed without electrocardiogram, just by watching the quick regular pulsation of the neck veins; but he used to demonstrate this excellent diagnostic method to
his students at the bedside.
Other People’s Lives: Reflections on Medicine, Ethics, and Euthanasia
139
Dr. Jean Lengre had traditional medical education in mind when he formulated
his maxim, “Seul un medecin peut former des autres medecins” (“only a physician can make
other physicians”).
Learning from a master involves now outmoded attitudes and qualities: faith in
the master’s knowledge and wisdom, an unavoidable emotional link of admiration and
gratitude, and some humility. The present-day student sets a higher value on his own
dignity and independence, and on the right to critical judgment, and prefers to preserve
an impersonal distance from teachers and other business acquaintances. Medicine is
still being learned from masters, but, to my regret, less and less so. The results are, to
put it cautiously, mixed. Old nonsense that was only taught because it was never critically examined, is being scrapped. On the other hand, many doctors of the younger
generation never learn important skills.
In following in the steps of the master, one learns bedside manners, which can calm
the sick and inspire confidence. And such is the bearing of a genuine clinician, that
along with the distress of a sudden illness, the very arrival of the doctor brings relief,
the feeling that somebody cares and assumes responsibility.
From a master one learns the most difficult art of taking history: how to be exacting and critical, how to pursue promising tracks but avoid imposing one’s own ideas
on the patient; how to persevere and “fight and win this duel in the best interest of the
other party.”
And the important art of palpating the abdomen can only be properly learned
under a master’s guidance. Please do not say, “why should we waste our time on these
subtleties now that a CAT-scan will show it all and more, and with more precision.”
It will. But please, first use the wonderful abilities of your own senses and your own
mind. The knowledge of the case you will gain in this way may instantly reveal the
diagnosis. If not, it will guide your further quest and tell you which tests to order as
well as clarify your conclusions.
Fortuity. The famous 19th century Swiss surgeon, Dr. Emil Kocher had a patient
who was being prepared for thyroid surgery. Unexpectedly, her enlarged and hyperactive thyroid gland decreased in size. At the same time, the patient’s symptoms, anxiety,
palpitations, and trembling, markedly decreased. Kocher wondered how this improvement was produced. He checked all circumstances in great detail, and discovered that
the lady had mixed up two bottles of medicines: she smeared the infected spot on her
skin with a sedative, and swallowed the solution of iodine. Kocher then tried iodine
on other patients as well and so began the new and largely effective treatment for hyperthyroidism. Other therapies are now used, but the treatment with non-radioactive
iodine has been beneficial to many patients for almost a century, is still used in cases of
life-threatening thyroid crisis, and, moreover, has enormously helped our understanding
of the function of the thyroid gland and the thyroid hormone synthesis. All this progress
was triggered by a patient’s mistake.
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When Dr. Karel Wenckebach, later the famous cardiologist in Vienna, worked as
a general practitioner on the island of Java, in what was then the Dutch East Indies,
malaria was the most common complaint among his patients. Once a patient told him:
“You know, doctor, when I cure with quinine for my malaria, I do not have my attacks of
palpitation.” Wenckebach could have dismissed the remark as “another nonsense,” but
he did not. He was a keen listener to what the patients were saying, and had an insatiable curiosity about nature’s phenomena. He started to experiment with the drug, and it
proved effective not only in preventing that patient’s paroxysmal atrial fibrillation, but
also a number of other troubles in heart rhythm. For many years since, quinidine, a drug
closely related to quinine, has been the primary medicine used for cardiac arrhythmia.
In Den Bosch, one of our hospital’s internists called me to see his patient, Mr. M,
age 44, admitted with a severe and unexplained congestive heart failure. The man was
breathless, unable to climb even half a flight of stairs, his legs were swollen, and there
were large quantities of fluid behind both his lungs and in the abdomen. The cause of
the heart failure was a mystery. The common heart diseases had been ruled out. The
patient owned a restaurant, and a suspicion arose that perhaps he drank more than he
admitted, and could have developed the alcohol-induced B-1 vitamin deficiency, “the
wet form of beri-beri.” But this was not the case, his blood contained normal amounts
of B-1 vitamin. Fortunately the patient responded well to vigorous diuretic treatment,
and we gained some time to continue the diagnostic quest. And then, during my second or third conversation with the patient, I saw that his left middle finger suddenly
became dead white.
Eureka! This was “Raynaud phenomenon,” which often accompanies collagen
diseases, systemic diseases of the connective tissue, some of which involve the heart
impairing its function. Scleroderma is the typical collagen disease that may cause heart
failure; but Mr. M did not have scleroderma. Then I tested his blood for antibodies
against ribonuclear antigen, and, indeed, high titers of these antibodies were found. This
showed that M had a less common collagen disorder called “mixed connective tissue
disease”: an important diagnosis because the patients with this disease may improve
with prednisone treatment.
Raynaud’s “dead fingers” are a fleeting phenomenon that usually disappears after a
few minutes, leaving no trace. Mr. M previously had it several times, but did not know
it might be important and never mentioned it to the doctors. By sheer happenstance I
witnessed his “dead finger” episode which provided the clue to the diagnosis.
But, as Louis Pasteur one said, “le hasard n’aide que les gens avisés,” “only people
versed in the subject draw advantage from fortuity.” And sometimes it takes more: an
open mind, and a sense of humor. Dr. Kocher must have been an ironic observer of
nature and people, since in the mixed-up medicine bottles he saw a chance for scientific
discovery and therapeutic progress.
The Importance of Doctor’s Hobbies. I remember a young woman of 20 who fainted
ten or twelve times, falling on the floor or the pavement. Every time she spontaneously
Other People’s Lives: Reflections on Medicine, Ethics, and Euthanasia
141
regained consciousness after a short time. The family physician referred her to a cardiologist who did not find the cause: on the patient’s ultrasound there were no signs of
cardiac muscle abnormality (cardiomyopathy), and the 24 hours’ Holter electrocardiogram, three times repeated, failed to show any disturbance in heart rhythm that would
explain the fainting. Then the patient underwent a complete neurological evaluation,
which included an MRI scan of the head and an electroencephalogram with a hyperventilation test. The suspicion of epilepsy was not confirmed. Anyway, after eleven
weeks of investigation and having used about 7,000 guilders of the Public Insurance
Fund’s, the patient still had no diagnosis, and, consequently, did not know how to avoid
fainting. Then she fainted in the street in Den Bosch and was brought to our emergency
room. I asked her several questions, and learned that she repeatedly became dizzy and
fainted at the bus stop, but never when seated or in bed. I asked her these questions
because postural hypotension, fainting due to the fall in blood pressure in upright
posture, happened to be my hobby since the time of my work with ganglion-blocking
drugs in the fifties.82 This patient’s blood pressure was 115/80 when she was lying
on the stretcher. On standing up the girl became dizzy and her blood pressure fell to
70/40. The diagnosis of postural hypotension was established within ten minutes of
the patient’s arrival, and at the cost of 130 guilders.
Over the years, my “postural hobby” enabled me to correctly diagnose scores of
cases. Many of these patients were young, but some were in their eighties, like Judge
B in Lodz, who repeatedly fainted while buying his newspaper in the morning, when
there were several people before him at the newsstand. The medical advice this patient
was given? “Subscribe to your newspaper and you will receive it in your mailbox.”
A monomaniac with a single diagnostic hobby horse is a nuisance and sometimes
a danger to his patients, but a doctor who has twenty or thirty hobbies—favorite topics
for investigation—is a good diagnostician. My own hobby count is seventeen.
Sudden Insights. A doctor’s sound knowledge, systematic approach and straightforward reasoning very often lead to correct diagnosis, but in other cases solving the
puzzle, or solving it quickly enough to save a life, takes something special, an unusual turn
of a doctor’s mind, a genuine burst of insight.
One morning in Nakskov, I was called by a nurse who said that the intern on duty
was resuscitating Mr. E. Running to the ward I wondered what had happened. The patient
was a man of 46 who had gallstones. We were “cooling” his gallbladder infection with
antibiotics, in preparation for surgery. There really was no reason why this man should
have a cardiac arrest! When I arrived, the resuscitation— including cardiac massage
and ventilation with a balloon—was in full swing. The patient’s heart was in virtual
standstill; the screen showed long periods when the patient’s ECG was a straight line.
R. Fenigsen, Ganglion-Blocking Drugs in Cardiac Asthma a. Pulmonary Edema, 1 KARDIOLOGIA POLS149 (1958); R. Fenigsen, Treatment of Hypertensive Heart Failure, 3 KARKIOLOGIA POLSKA 59 (1960); R.
Fenigsen, Treatment of Severe a. Malignant Hypertension, in PROBLEMY KARDKIOLOGICZNE 57-59 (A. Askansas,
ed., 1964); R. Fenigsen & K. Ballandowicz, The Solved and Unsolved Problems of Blood Pressure-Lowering
Therapy, in PROBLEMY KARDIOLOGICZNE 187-89.
82
KA
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But the patient looked peculiar: his skin was pale gray, and wet! There were drops of
sweat on his face and even a small pool above the collarbone. This was incongruous;
patients in cardiac arrest do not sweat. Suddenly I was struck by the thought that this
man was dying of hypoglycemia! Why should he have it? The pancreas is often affected
in patients with gallstones, but could this provoke such a huge discharge of insulin? Or
had the patient received an injection of insulin by a nurse’s mistake? Never mind the
cause, my impression of hypoglycemia was so strong that I had to act on it. Without
interrupting the cardiac massage I drew from a vein a sample of blood to be examined
later, and injected 50 cc of 40 percent glucose.
The patient’s heart resumed beating and he regained consciousness even before
the injection was completed. The glucose content in the patient’s blood sampled before
the injection was 18 mg per 100 cc, which is extremely low. The patient fully recovered
and later had surgery for his gallbladder. The cause of that hypoglycemia has never
been found.
Dissecting aneurysm of the thoracic aorta is a disease often diagnosed by sudden
insight. In this condition blood gushes through the torn inner layer into the wall of
the body’s main artery. Patients with this disease usually experience an excruciating
chest pain, and arrive at the coronary care unit with a general practitioner’s presumptive
diagnosis of myocardial infarction. I remember Mr. Z, a traveling salesman dealing in
perfumes, who within ten days was admitted to two hospitals, one in Belgium and one
in Holland, and each time was discharged with the pronouncement that “myocardial
infarction was ruled out.” A vague movement of the patient’s hand toward his throat
while he was telling me of his pain gave my thoughts the right direction. Ultrasound
and aortography confirmed the dissecting aneurysm of the operable type, and surgery
immediately followed.
I recall a similar sharp turn in my thoughts in virtually all cases of this disease
that I saw. It always was triggered by a single detail: an aorta that was a bit too broad
on the X-rays, a murmur heard at the base of the neck.
There is still another, much larger category of cases in which the diagnosis is
often due to a doctor’s sudden insight: the patients with pulmonary embolism, blood
clots that travel to the lungs. In the last fifty years great progress has been made in
handling this problem. We now fully appreciate the frequency of embolism in patients
immobilized after surgery, and, accordingly, preventive measures, early mobilization,
supportive stockings, administration of anticoagulants (medicines that prevent clotting) have become the rule. They are largely effective. However, cases of pulmonary
embolism still do occur, and often cannot be diagnosed in a simple and obvious way.
From some obscure vein, deep in the leg or in the pelvis, a clot was lurking and breaks
off. It noiselessly travels with the blood stream to the right ventricle of the heart and
then to a site deep in the chest: a branch of the pulmonary artery. In many cases we
can guess what happened only from indirect hints. The discovery of the hidden reality
is often experienced as a sudden inspiration: instantly it dawns on you that a patient’s
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abrupt “anxieties,” accompanied every time by acceleration of the heart beat, can be
due to pulmonary embolisms. Confirmation by lung scan or pulmonary angiography
takes a few hours, but in the meantime, anti-clot treatment may be instituted warding
off further damage and danger.
Very large clots choke up the main lung artery and this means sudden death. Massive but incomplete clogging produces a dramatic picture, but rescue is still possible.
A delay, however, would be deadly, even a few minutes count. That is when diagnosis
by sudden insight shows its advantages over systematic exploration of all possibilities.
I recall Mr. C, whom the family doctor sent to my coronary care unit in Den Bosch as
a case of myocardial infarction. “He is in very bad shape,” added the doctor on the
phone, “I would say his is dying.” The patient had felt sudden chest pain, almost fainted,
and was gasping for breath. His cheeks, lips, nose, and fingernails were blue and his
blood pressure was dismally low: 70/50. There were no signs of myocardial infarction
on the ECG. The chest X-rays revealed no “clouds” or stripes one would expect with
congestion of the lungs due to heart failure. On the contrary, the lungs were unusually
translucent! The network of blood vessels all but disappeared from the lung fields. I
was struck by the thought that something was blocking the inflow of blood to the lungs
whence the entire blood circulation in the body was reduced to a trickle. This man’s
main pulmonary artery must be clogged! A few additional questions revealed that six
weeks earlier the patient had knee surgery and that the post-operative anti-coagulant
treatment was stopped three weeks ago. That’s when a clot must have formed somewhere
in the veins! I diagnosed massive embolism of the pulmonary artery. At surgery the
clot that obstructed 80-90 percent of the main pulmonary artery and both its branches
was removed and the patient saved.
In every one of these cases the sudden insight was triggered by a detail of external
reality. But sometimes the mental explosion occurs entirely within the mind like those
flashes of lighting that do not strike the earth but span the gap between two clouds. Mrs.
Van H, 62, whom I was seeing at regular intervals at the outpatient clinic in Den Bosch,
was being treated for rather severe congestive heart failure. Treatment with large doses
of diuretics was successful enough: the patient could soon breathe freely, her legs were
no longer swollen, there was hardly any excessive fluid in her body, and she was able to
do moderate exercise. One day, accompanied by her worried husband, she appeared for
an unscheduled visit. She was strikingly changed: frightened, confused, did not seem
to understand my questions, and made strange and unnecessary movements with her
head and arms; her speech was slurred and made little sense. Her lips were parched
and the tongue dry, but simple dehydration could not explain such mental confusion.
Unless—unless Mrs. Van H’s blood was so concentrated, contained so many molecules
in every cubic millimeter, that by osmosis it drew fluid from all tissues of the body,
and the patient was falling into so called hyperosmolality coma! But for that she must
have vast amounts of glucose in her blood—only in this way can such a high molecule
count be achieved, however, she had never before been diabetic. But since her last visit
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she may have developed diabetes mellitus as a side effect of thiazide diuretics! And she
would now be in “hyperosmolality pre-coma”! (a term I instantly coined to describe
Mrs. Van H’s condition).
Indeed, her blood contained over 500 mg of glucose per 100 ml., which is a very
high figure, and the levels of sodium and creatinine were extremely high. Fifteen liters
of water were given intravenously within 48 hours, but after the first four or five liters,
Mrs. Van H had already reverted to her normal mien.
Clinical Thinking. “Think the clinical way” was the summons that a medical trainee
of the 1920s, 30s, 40s, and 50s used to hear from his tutors, particularly in European
continental hospitals influenced by Paris or Vienna. It meant: be guided by the facts
of the case, not by theoretical speculations. Having examined a patient, and found a
palpable spleen, a young medico would call to mind the list of twenty-seven possible
causes of splenomegaly (spleen enlargement), and plan to investigate the patient for all
of these. A senior doctor would call him to order: “Think the clinical way! This list
includes a number of diseases your patient certainly does not have: all those in which
the spleen is hard and very large. Your patient’s spleen is just palpable, and soft on
touch. Therefore, think of an infectious disease. The patient has a fever, sore throat,
white patches on the tonsils, and palpable lymph nodes on his neck, in the armpits
and groin. I would say he’s got infectious mononucleosis. Let’s examine his blood for
atypical lymphocytes, and we shall see if this is indeed the case.”
Thus instilled by teachers, “clinical thinking” became a habit with doctors of the
traditional cast. Not with “modern” ones. The results are often bizarre. My daughter
consulted her family physician in Copenhagen complaining of fever, and pain and
swelling of several joints. The doctor said he suspected gout and ordered a blood test
for uric acid. Well, gout may start with pain in many joints, but within hours it will be
confined to a single one. Persisting pain in many joints is not a feature of acute gout.
And, first of all, gout was extremely unlikely in a young female who had none of the
specific causes of gout (such as chronic myeloid leukemia, polycytemia, or the use of
thiazide diuretics). A doctor who was fixing his mind on such an improbable concept,
and did not even consider diseases that are common in young women, was a bizarre kind
of doctor. I had to bring the patient urgently to Den Bosch. She had acute rheumatic
fever due to streptococcal infection.
The inability to think the “clinical way” may have tragic consequences. In 1971,
a gravely ill young woman was admitted to our department of cardiology in Aalborg,
Denmark. She had a very tight mitral stenosis, a condition resulting from rheumatic
heart disease. In these patients the opening between the two chambers of the heart,
the left atrium and the left ventricle, is severely narrowed, impeding the blood flow.
Blood accumulates above the barrier, notably in the lungs where small blood vessels
get distended, and plasma starts to seep through the vessels’ walls into the lung alveoli. This is pulmonary edema, or “wet lung”—the patient suffocates because her lungs
fill with liquid and foam, and absorption of oxygen is severely compromised. In the
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first four days of her stay in the department our patient suffered three attacks of acute
pulmonary edema, each of which could have been fatal. Emergency surgery had to be
done, splitting the leaflets of the mitral valve. Surgery was scheduled for the afternoon.
Meanwhile, I was tapping the patient’s pleural effusion, the fluid around her right lung.
It proved intensely pink-colored. A doctor in the habit of thinking “the clinical way”
would immediately connect this finding with the patient’s condition: as a rule, in patients with valvular heart disease and totally irregular heart beat, a bloody pleural fluid
results from pulmonary embolism. Clots form in their “fibrillating,” not contracting
atria, and from the right atrium travel to the heart’s right ventricle and then to the lungs.
If the lung damage reaches the pleura, the resulting exudate is usually colored by an
admixture of blood.
Unfortunately, the head of the department, Dr. PS, a man who never acquired the
habit of clinical thinking, entered the room and saw the tapped pleural fluid. “Hemorrhagic fluid!” he exclaimed. “This can be cancer. We have to postpone heart surgery,
and await the cytologic examination of the fluid.”
I listened with a sinking heart. Should this patient, who could be rescued so
perfectly, be lost due to this man’s mental aberration? Cytology was being done at the
university hospital in Aarhus, 65 miles away. Sending the samples and waiting for the
work-out would take two days, meanwhile, any minute a new pulmonary edema could
kill the patient.
But could it be a cancer? Well, anything could be; but the odds of a 34 year old
woman to be stricken simultaneously with two deadly diseases were so infinitely small
as to be nonexistent. Alas, all my remonstrations were of no avail. Surgery was postponed. The next day the patient died in acute pulmonary edema. At post-mortem, the
hemorrhagic pleural fluid was found to be due to lung embolism.
The Pitfalls of Clinical Thinking. With a seemingly small shift in the meaning, the
postulate “think the clinical way” may be transformed into the maxim “don’t look for
what is theoretically possible, look for what is likely.”
Some doctors, mindful of “the rule to think of what is likely,” dismiss beforehand
all less-than-common diseases, such as coarctation of the aorta. It is a congenital
malformation in which the body’s main artery is severely narrowed high in the chest.
Coarctation is a rare abnormality: out of 100,000 newborns only about 55 (mostly males)
will have it. In individuals who have the coarctation and survive the early childhood,
the arteries of the upper part of the body vigorously pulsate and the blood pressure
measured on the arms is high, while in the lower half of the body the arteries’ pulse
is weak or they do not pulsate at all. These patients, if untreated, are prone to serious
complications at a relatively young age, while timely diagnosis and surgery can cure
them, or at least greatly improve their outlook. The diagnosis of coarctation should
immediately become obvious to a doctor who examines an adolescent with high blood
pressure, places his finger on the patient’s groin, and finds no pulse of the femoral artery.
The point is that doctors who do not look for the “unlikely” just don’t put their fingers on
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the femoral arteries of young patients. In the minds of these doctors, coarctation of the
aorta is something that can be found in small-print sections of the textbooks, but not
in real life. In 1960, I created a sensation at a conference in Lodz, demonstrating eight
patients with coarctation to 300 doctors who had never diagnosed one. Till 1968, the
number of cases detected by myself and my team increased to fifteen.83 This was, to
my knowledge, the largest series ever published outside the United States. People who
suffer from uncommon, “unlikely” diseases have the same right to correct diagnosis and
adequate treatment as all other patients!
The year was 1957 and with several of my colleagues, I attended a meeting of
the Polish Society of Internal Medicine, in Lodz, at which our good friend and senior
physician Dr. Z was reading a paper on “Difficulties in Digitalis Therapy.” One of the
points he made was that cases of congestive heart failure that did not respond well to
preparations of purple foxglove (the heart medicine then in common use on the Continent), could be treated with good effect with the active substance obtained from another
subspecies of foxglove, Digitalis lanata. He cited the case of a 22 year old woman with
heart failure due to valvular heart disease; the very large accumulation of fluid in her
abdomen significantly decreased when her Digitalis drug was changed.
Then Dr. Ch. took the floor, a rather dull but erudite man. Visibly amused, Dr.
Ch. declared that this patient kept appointments at two hospitals, and if there was any
improvement, she owed it not so much to the digoxin prescribed by Dr. Z as to the special
diuretic regimen administered by himself. The audience responded with some hilarity.
My friend Dr. Marek Edelman and I looked at each other; we too were amused.
From Z’s description we recognized the patient: it was Klara, a nice, bright, working-class
girl who in the meantime had come under our care. Now we were watching a comedy
in which The Error tried to correct The Mistake. Klara had no valvular heart disease.
The two respected internists contended themselves with this diagnosis because the
auscultatory signs seemed at least partly compatible with it, and because in the 1950s,
in Central Europe, the disease of mitral valve was the most common—thus, the most
likely!—cause of congestive heart failure in young females. But when I had examined
Klara, I noticed that the clinical picture did not quite fit that of heart failure due to
valvular disease. There was a large congested liver and much fluid in the abdomen, but
the patient was not breathless, there was no congestion of the lungs. Then, carefully
examining Klara’s chest, I found that her palpable heart beat, the “apical impulse,” was
reversed: not pushing out with every heart contraction, but pulling in! This is a sure
sign of adhesions between the two layers of the pericardium, the membranous bag
surrounding the heart. Thus, the click after Klara’s second heart sound was not an
“opening snap” of narrowed mitral valve, it was the “early diastolic pericardial sound”
described by Potain 140 years ago. Klara was sick with constrictive pericarditis! In
this post-inflammatory condition, the thickened, ingrown pericardium constrains the
83
OLOGIA
R. Fenigsen et al., Clinical Symptomatology of Coarctation of the Aorta in Adolescents a. Adults, 3 KARDIPOLSKA 241 (1960); R. FENIGSEN, AUSCULTATION OF THE HEART 51-53, 55-57 (1968) (in Polish).
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movements of the heart and interferes with its filling and its pumping function. To find
out what was wrong with Klara, one had to look for the “somewhat less likely.”
A quick cardiac catheterization confirmed my diagnosis. At the time of that Internists Society’s meeting, Klara was recovering from surgery. Ten days earlier I had referred
her to our hospital’s thoracic surgeon, professor Jan Moll, who excised a window in
her pericardium and, patiently separating the rest of it from the heart muscle, liberated
the heart from the constraining “armor.” Dr. Z’s mastery in using digitalis and Dr. Ch.’s
sophisticated diuretic regime were admirable, but irrelevant.
We did not say a word at that meeting. There were already too many theatrical
disclosures for a single evening.
Klara was cured. Witty girl, she teased us saying: “What have I gained by that
surgery? When there was still so much water in my belly, people were taking me for a
pregnant lady, and I was allowed to enter the streetcars through the front door. Now I
have to use the rear door and squeeze myself in with the crowd!”
Thoroughness. Can a valid lesson be learned from an exceedingly rare, exceptional
case? Perhaps. Let me tell you the story of a robust, 37 year old lady, the mother of two,
who was referred to me in Lodz because the family physician had treated her for eight
years and never been able to control her high blood pressure. “Sometimes a medicine
works beautifully, and sometimes with the same treatment I find a blood pressure of
240/140!” he complained in his letter.
When the patient undressed, I saw that on the skin of her left arm, shoulder, and
the left upper part of the torso there were dozens of crimson-red clusters of dilated
blood vessels, the multiple skin hemangioma known as Klippel-Trenaunay syndrome.
Quite peculiarly, it was confined to one side of the patient’s body, the left side. But it
was just a presage of more important asymmetries to come.
Vigorous pulsation of arteries was visible and palpable at the patient’s right wrist,
right elbow, over the right collarbone, and on the right side of the neck. On the left
side, on the neck and arm, there was no pulse at all. The blood pressure was 240/150
on the right arm and 115/80 on the left arm. A very weak pulse of the femoral arteries
could be felt in the groins. The blood pressure in the legs was 130/80. Pulsation of
dilated arteries could be seen and felt under every rib on the patient’s back—but only
on the right side.
The diagnosis was obvious after a few minutes’ examination: the body’s main artery
was interrupted where it arches high in the chest.84 This congenital malformation is
called interruption of the aortic arch. The arterial trunk originating above the obstruction,
and its branches running on the right side of the neck and to the right arm received
all blood pumped by the heart. The arterial system beyond the obstruction received
none. The patient was one of the very, very few survivors born with this abnormality.
Life was only possible due to collateral circulation, minor arteries, which in this patient
84
R. Fenigsen & K. Zrobkowa, Right-Sided Collateral Circulation in Coarctation of the Aortic Arch, 2
POLISH MED. J. 218 (1963).
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considerably widened and led blood to the lower half of the body and, by circuitous
way, to the left side. I did an angiography which showed that an enormously dilated
artery to the right breast, the internal mammary, was the main route.
What an unusual anomaly! What a diagnosis! And to be sure, it was not due to a
sudden insight or mysterious intuition, but simply the result of a thorough examination.
I have always had an absolute routine to inspect and palpate all accessible arteries: on
both sides of the neck, above the collarbones, at both elbows, wrists, groins, behind the
knees, at the ankles and on the feet. I also always placed my stethoscope on the arteries
in the neck, above the clavicles, and in the groins, and in every new patient I took the
blood pressure on both arms. Not just a rarity such as an interrupted aortic arch, but
a whole gamut of more common abnormalities are discovered in this way.
The family physician may have been an assiduous therapist—he tried various
combinations of blood pressure-lowering drugs—but to put it mildly, he was not a very
thorough examiner. The means to make the diagnosis—his eyes and two hands—were
fully at his disposal, but I wonder if he ever asked the patient to undress. Every time
he took the blood pressure on this patient’s left arm he concluded that the “medicines
worked wonderfully,” but when he happened to measure the blood pressure on the right
arm he was badly disappointed. It sounds funny, but isn’t.
Intuition. It is often assumed, and I think quite rightly, that intuition plays an
important part in the diagnostic process. Intuition is what the doctor knows quite well,
but would have a hard time trying to explain how he comes to know it. What is this
mysterious source of knowledge? How can it be explained?
I once tried to analyze the intuitive component in diagnosing a very rare disease:
the pheochromocytoma. It is a tumor composed of the so-called chromaffin cells that
produce large quantities of adrenaline.
When a large amount of the tumor’s secretion enters the bloodstream, the patient’s
whole body is shaken by a violent adrenaline storm. Pale, trembling, with a powerfully
beating heart, dry mouth, dilated pupils, goose flesh on her arms, the patient has a feeling
of impending disaster. During such attacks, the blood pressure may rise to 240/130,
even 300/150, as I found in one of my patients.85 A few minutes or a quarter of an hour
later, the patient calms down and her blood pressure returns to normal.
Thus, the typical clinical picture of pheochromocytoma is one of a paroxysmal disease. However, in some cases the attacks are muted or absent, and the blood pressure
is elevated all the time.
It is vitally important that the diagnosis be made as quickly as possible. Most of
them can be cured with surgery. The tumor, situated in the adrenal medulla, often the
right one, or sometimes outside the adrenal glands, is usually not malignant, can be
S. Adamski, R. Fenigsen & W. Januszewicz, Pheochromocytoma: Confrontation of Clinical Features
With the Urinary Output of Catecholamines, 2 KARDIOLOGIA POLSKA 17 (1959); R. Fenigsen, Pheochromocytoma, in J. JAKUBOWSKI & R. FENIGSEN, AKTYWNA TERAPIA NADCISNIENIA [Active treatment of arterial hypertension] 95-106 (1962).
85
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removed, and does not recur. On the other hand, untreated patients may die in their
forties, or earlier, of pulmonary edema, cardiac arrhythmia, adrenaline shock, or stroke.
Yet making the diagnosis of pheochromocytoma is quite challenging. The chances are good if the patient is hospitalized and her blood pressure monitored; or if an
alert doctor happens to witness the attack. Otherwise, the patient’s complaints may be
mistakenly interpreted as panic attacks, hyperventilation, or the like, and the disease
remains undiagnosed.
Screening is a possible approach. One can determine the amount of an adrenaline
metabolite in the urine of all patients with high blood pressure, and closely examine
patients who excrete too much. This may be done, but it is a vast undertaking; moreover,
it leaves several loopholes. Between the attacks some patients with pheochromocytoma
do not excrete abnormal amounts of adrenaline or its metabolites. Such cases would
be missed. And screening all patients of a hypertension clinic does not include persons
who may have pheochromocytoma, but are not known to have high blood pressure.
The other, clinical approach is to investigate those patients in whom we for some
reason suspect pheochromocytoma. But how does such suspicion arise?
When asked why it occurred to them that the patient might have the adrenaline-producing tumor, doctors would say: “I had a vague impression that this was not
your usual case of high blood pressure,” or “I don’t know why it seemed to me that
something was working this person.”
Having reviewed all my cases of pheochromocytoma, two cases diagnosed by my
colleagues, and the few publications in which the search for the diagnosis was reported
in detail, I found that a vague impression, or intuition, was indeed a fair description of the
doctors’ subjective experience.
But the source of such intuition could be further traced to some facts the doctor
had noticed. It could be a patient’s cool and moist skin, or her hands and wrists turning
white, or fleeting goose flesh, slightly elevated body temperature, or perhaps a blood
test that showed an elevated white blood cell count (all these signs are just various
manifestations of the excess of circulating adrenaline). Like those premonitions and
prophetic dreams which Freud analyzed in his “psycho-pathology of everyday life,”
diagnostic intuitions did not arise from nowhere, but were triggered by perceptions of
reality, perceptions that had been fleeting, or seemingly unimportant, or forgotten. With
some sleuth’s work, every “diagnostic intuition” can be explained.
A neurologist, a good acquaintance of mine and a senior physician, asked me to
take over the treatment of a 46 year old lady who had high blood pressure and “never
responded to medicines.” “She also has,” the doctor added in his letter, “a peculiar skin
condition on her hands, the Herxheimer-Pick disease. Please forgive me this excursion
into the domain of dermatology.” Forgiveness was granted; but what was actually wrong
with the patient?
Her blood pressure was 180/130, and did not change much with repeated measurements. Her hands and wrists were cold and presented a geographic map of white
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and purple areas. There was some movement, parts of the purple spots were turning
white and vice versa. Goose flesh appeared on the patient’s arms and forearms, and
then disappeared while I was watching. “Let’s see if she has pheochromocytoma,” I
said to myself.
She had it. After surgery her blood pressure returned to normal, and the “peculiar
skin condition” disappeared. She was my third case of pheochromocytoma. Six more
cases followed.
The Beauty of It. That a doctor can find esthetic pleasure in his findings seems
incredible but is nevertheless true.
Dermatologists are known for appreciating the esthetic potential of their specialty.
Disfiguring skin disease precludes such perception but many other strike the eye with
complex patterns, the three-dimensional plasticity of eruptions, and a gamut of subtle
color shades. When I saw the painting by Jan Cybis at Warsaw’s National Museum, I
immediately bought an album of reproductions for my friend Dr. Isaac van der Sluis
in Amsterdam. I knew that being a dermatologist he would appreciate the particularly
rich texture of canvas fibers and thick stripes of color in this painter’s work.
In his “Stethoscope Song” (1864), Oliver Wendell Holmes satirically described
the joys of auscultation:
The bruit de rape, and bruit de scie,
And bruit de diable are all combined;
How happy Bouillaud would be
If he such a case could find!
Satire apart, pleasures with an esthetic component are common on cardiac auscultation.
The musical quality of some of the sounds, the complex, distinctive sequences, the
harmony between nature’s phenomenon and the mental conclusion, and the suddenly
found explanation of a patient’s problem form an experience both emotional and esthetic.
Occasionally nature succeeds in imitating genuine art. I observed for some time a
young patient with double valvular heart disease, auscultatory features of juvenile heart,
and a very pronounced first degree atrio-ventricular block. The resulting “melody”
closely resembled the initial chords of Rachmaninoff’s third piano concerto in D minor.86
The seat of the government of the Province of North Brabant is a high-rise edifice,
the only such building in the whole East of the Netherlands. “I chaired the committee
appointed to assess that project,” said Mr. W, an old architect of some renown, and my
patient, “and everybody was very cautious because of the high cost, the high profile of
the project, and the publicity around it. And, you know, everything depends on the
conduct of the metallic framework. If there is any error in the calculations concerning this frame, on a windy day the building will sway to and fro, chandeliers will get
swinging, and water will spurt out of the bathtubs. But I studied the project, and was
struck by the sheer beauty of the mathematical work. I had no doubt: this building
must be good; and I prevailed upon the committee members to approve the project.”
86
R. FENIGSEN, AUSCULTATION OF THE HEART 161-62 (1968).
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“What you say strikes a responsive chord in me,” I said. “This is the way I sometimes gain confidence in presumptive diagnosis. And do you know that on a higher
level of intellectual quest, Einstein felt the same way about hypotheses in theoretical
physics? When a reasoning impressed him as beautiful, he knew it was correct.” “No,
I didn’t know that,” said W, “How interesting! But indeed, perhaps we perceive an
intellectual operation as beautiful when we feel that it is in harmony with the structure
or rhythm of the universe.”
Chapter VIII. More on the Medical Mind
In Praise of Anecdotal Evidence. In this book I report a number of case histories,
and I am often using these to make a point. Some scientific-minded readers may tend
to dismiss these stories as merely anecdotal evidence. Please don’t do that. Properly
designed studies and controlled trials are not the only way to know reality. The bulk of
knowledge humankind has accumulated in its history has not been derived from controlled trials. People found that Britain was an island, and how to bake bread, though
no properly designed studies on these subjects had been conducted. Medical knowledge
begins with case histories, that is, anecdotal evidence. Basic discoveries in medicine:
that measles were contagious but left a life-long immunity; that black stools indicated
a bleeding from the upper part of the digestive tract; that acute rheumatic fever led to
valvular heart disease, and many hundreds of equally important observations, were all
based on anecdotal evidence. It was on grounds of purely anecdotal evidence that Dr.
Edward Jenner introduced in 1796 his cowpox vaccine, and Dr. William Withering his
foxglove therapy (1785); yet Jenner’s vaccine saved many millions of lives, and ultimately
eradicated smallpox on this planet; and Withering’s digitalis has relieved hundreds of
thousands of people suffering from heart failure. It is not true that such discoveries
could only be made in the 18th century, but are impossible now. We are still able to
observe facts. Properly designed studies and controlled trials serve to deepen and verify
our knowledge, not to make us blind to what is happening around us.
How Scientific Medicine Has Become. The notion that medicine is being transformed
from old guesswork and empiricism into an exact science of “hard facts,” laboratory
measurement, and statistically significant findings, is partly true and partly based on
a mistaken understanding. There has been an abundance of hard facts in traditional
clinical medicine, and by no means are all assertions of the new “scientific” medicine
hard facts or objective truths. If listening to a patient’s heart we hear a very loud first
heart sound preceded by a coarse murmur, and the second heart sound is followed by
an additional “snap,” so that the whole tune resembles a quail’s call, we know that the
patient has a valvular heart disease, namely, a narrowing of the orifice between the left
atrium and the left ventricle (mitral stenosis), and this is a harder fact than the “scientific”
measurement of the orifice’s surface based on catheterization data since the latter method
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has many pitfalls: low flow, leaking valve, beat-to-beat variation, or failure to wedge the
catheter into a small pulmonary blood vessel, all introduce errors to this determination.87
The new scientific medicine is not even free of some patent nonsense. The electrocardiographic diagnosis of “anterior” myocardial infarction is still based on the ingenious
but mistaken “electrical window” theory. As a result, the localization and extension of
the infarction, as determined from the ECG, prove wrong at the post-mortem in more
than half the cases.88
What is a “Hard Fact”? The noted Polish-Jewish serologist Dr. Ludwig Fleck published in the 1930s a book in German on “The origins and development of a scientific
fact.” Many years later his theories gained some popularity among American historians of science.89 Fleck, indeed, was a precursor of present day “post-modernism.” In
his view, a “scientific fact” was the result of a gradual process during which the circles
having a say in science developed a conceptual apparatus and a vocabulary needed to
formulate the new truth. I do not subscribe to Fleck’s view and think that his use of
language confused a natural phenomenon with its discovery and its acknowledgment
by the scientific community. But I do find the uncritical faith in the self-contained
existence of “hard scientific facts” a bit naive.
Hard as a Fact May Be, It Takes a Human Being to Perceive It. A curious and ominous
disturbance in bio-electrical activity of the heart, described in 1965, is a good example.
That year during my stay at Paris’ Hospital Lariboisiere I spent some time at the graphic
lab, which was the domain of Dr. Dessertenne, a tall, taciturn, collected man. He showed
me a peculiar electrocardiographic finding he had recently published: the torsades des
pointes, an extremely fast electrical activity of the heart’s ventricles, conspicuous by
gradual turning of the peaks of ECG waves which alternately pointed up for a couple
of seconds and then for a similar period turned down, and this sequence of events repeated itself again and again. During this disturbance the heart does not contract and
W. Grossman & W. H. Barry, Cardiac Catheterization, in BRAUNWALD’S HEART DISEASE, 3rd ed. 258 (E.
Braunwald, ed., 1988).
88
In spite of a dismal confirmation rate, mainly due to the inability to detect the infarctions of interventricular septum, the diagnostics based on the “electrical window” theory remain in general use.
Meanwhile, Dr. Demetrio Sodi-Pallares of the Mexican Institute of Cardiology has developed a different
system of electrocardiographic diagnosis. D. Sodi-Pallares et al., The Reliability of the Electrocardiogram in
the Diagnosis of Myocardial Infarction, in CORONARY HEART DISEASE 278 (W. Likoff & J. H. Moyer, eds., 1963).
This method is not concerned with the hypothetical “hole” through which the electrical potentials of the
interior of the heart are supposed to be recorded, but asks a different question: “which bioelectrical forces
disappear when the heart muscle is damaged by infarction.” Diagnoses based on Sodi-Pallares criteria are
in remarkable agreement with post-mortem findings. Cf., R. Fenigsen, Samenhang tussen ECG en lokalisatie
van hartinfarkt [Correlation between the ECG and the localization of myocardial infarction], 119 NEDERLANDS TIJDSCHRIFT V. GENEESKUNDE 729 (1975); and R. Fenigsen, The Reliability of D. Sodi-Pallares’ Diagnostic
Criteria in Myocardial Infarction: A Prospective Study, 1966-1984, in ELECTROCARDIOLOGY: PROCEEDINGS OF THE
INTERNATIONAL SYMPOSIUM ON ELECTROCARDIOLOGY 269 (E. Piccolo & A. Raviele, eds, Venice, 1986).
89
F. L. Holmes, Argument and Narrative in Scientific Writing, in THE LITERARY STRUCTURE OF SCIENTIFIC
ARGUMENT 178 (P. Dear, ed., 1991); Fleck’s book appeared in English translation as LUDWIG FLECK, GENESIS
AND DEVELOPMENT OF A SCIENTIFIC FACT (1979).
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pumps no blood. Most often the torsades spontaneously cease after some seconds, but
if the disturbance persists, the patient loses consciousness and ultimately dies. Before
Dessertenne, bouts of this strange and ominous cardiac arrhythmia had been recorded
by electrocardiographers all over the world but nobody paid attention; or sometimes
this ECG pattern was misinterpreted as “ventricular fibrillation with large waves.”
Dessertenne noticed that it was something else and specific, and most importantly,
found out when, how, and why the torsades occurred: it happened if during normal
heart rhythm the electric cycle of every heart beat (the Q-T interval of the ECG) was
considerably prolonged. This discovery immediately opened the way to prevention
and effective treatment: to suppress the torsades one had to shorten the Q-T interval.
It could be achieved by removing the cause, quickening the heart rate, or injecting
magnesium sulphate. The problem has considerable practical importance, because the
cases are there: patients with long Q-T due to alcohol-induced potassium deficiency,
inborn abnormality, side-effects of anti-arrhythmic drugs (amiodarone), or side-effects
of chemotherapy. For these reasons, quite a few people develop the life-threatening
torsades des pointes.
But even after the publication of Dessertenne’s work the torsades were still a long
way from being universally recognized as a “fact of science.” They are recognized now;
but the delay was considerable. Articles published in English reach all corners of the
world, but those published in French, in the Archives des Maladies du Coeur et des Vaisseaux, do not easily cross the Channel, let alone the Atlantic Ocean. Even in Leiden,
Holland, I had the dubious satisfaction of introducing as “novelty” the torsades that had
been discovered eleven years earlier by that quiet Frenchman.
“Medical Diagnosis is a Job Like Any Other.” No it isn’t. More often than not, appearances are misleading, and we are groping around a hidden reality.
Should one order a chest X-ray when the patient complains of pain along one
arm? Yes, if the pain is severe; the patient may in fact have cancer of the lung (the
Tobias-Pancoast syndrome). What struck me was that the patient appeared to be so
sick and so heavily oppressed by the pain. Immediate chest X-ray revealed a tumor’s
shadow at the very top of the left lung’s upper lobe.
Our hospital’s lab technician brought in her mother, age 45, who in the last few
weeks was becoming breathless at the slightest exercise. The ladies sought the help of
a cardiologist assuming that shortness of breath must be due to heart weakness. But
the mother was strikingly pale. Examining her abdomen, I felt a tumor the size of a
tennis ball. She was severely anemic due to a bleeding cancer of the colon, fortunately,
operable. The patient’s shortness of breath was due to anemia.
I remember a girl of twelve whom the family physician diagnosed as having acute
appendicitis and referred for immediate surgery. What she really had was a pneumonia
of the lower lobe of the right lung. The involvement of diaphragmatic pleura caused a
painful tension of the abdominal muscles, which mislead the poor doctor.
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A worker employed at the production of viscose was brought to my emergency
room in Lodz by a doctor who found him acutely psychotic and suspected a poisoning
with carbon bisulphide. The man screamed, fought the medics, and shouted obscenities. He died before anything could be done. Autopsy revealed a burst thoracic aorta.
The patient’s “mental illness” had been due to the sudden insufficient blood supply to
the brain.
Eight hours after surgery to remove a clot obstructing her femoral artery, the 48
year old lady with valvular heart disease suddenly began to scream, complaining of an
excruciating pain in her chest. The surgeon, certain that she was having a myocardial
infarction, called the cardiologist. But one had only to pull off her blanket to see what
was wrong with her: there was a profuse post-surgery bleeding from the femoral artery
into the thigh. This caused such a precipitous fall in blood pressure that the blood
flow in the coronary arteries of the heart was critically reduced resulting in severe pain
of angina pectoris. A quick blood transfusion and repair of the artery’s suture solved
the problem.
A man of 46 suddenly became sick in his living room and felt that he was dying.
The family physician told me on the phone: “He seems indeed to be dying and I don’t
know why.” The patient was in awful shape, ghastly pale, sweating and shaky. His
pulse and blood pressure were normal. Which illness could make the patient feel so
terrible, even feel “he would rather die,” when there was no real danger of death? There
is such a condition: acute vestibular dysfunction, as in severe motion sickness or the
syndrome of Menière. I recall the amazement of a medical student who was with me in
the emergency room, when the first question I asked the presumably dying patient was,
“have you ever had an ear infection?” He had, indeed, a long history of otitis media,
left ear drum perforations, pus flowing out, and hearing loss. I could assure him right
away that he would not die from the inner ear affliction that had caused his terrible
vertigo, nausea, and the feeling that life was slipping away.
Hodgkin’s disease, a malignancy of lymph nodes, may first manifest itself as
pericarditis, an inflammation of the membranous sac around the heart, leading the
diagnostic quest astray. The doctor becomes preoccupied, as he should be, with the
manifestations of pericarditis, the pain, the audible friction rub, the electrocardographic
changes. Large quantities of fluid accumulate in the pericardial sac and warrant needle
puncture to relieve the heart from the constraint. Prednisone treatment is tried as a
attempt to stop the accumulation of fluid. One tries to find the cause of the disease, of
course considering first the usual causes of pericarditis: rheumatic fever, viral infection,
and tuberculosis. Weeks elapse, and among all those preoccupations the doctor does
not pay enough attention to the first warning from the radiologist that “a poly-cyclic
shadow” in the middle of the chest appeared on some X-rays, suggestive of enlarged
lymph nodes. Only the second such warning awakes you, and the idea dawns on you
that the pericarditis had been a manifestation of an underlying malignant disease; that it
must have been the malignantly transformed lymph nodes deep within the chest which
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grew into the heart sac; and since this is the only detectable cluster of diseased lymph
nodes, these may be surgically removed, the site irradiated, and the patient cured. He
was a 28 year old truck driver, and the delay of the diagnosis I just described was my
mistake. An understandable mistake—yet unforgivable.
In Lodz, a 56 year old hitherto quite healthy man came to my office accompanied
by a worried wife and two grown-up children. For two days he had been gasping for
breath while climbing stairs. Now the public knows that shortness of breath may be
due to heart weakness; that’s why the man came to see the cardiologist. The patient’s
pulse and blood pressure were normal and further physical examination did not reveal
anything remarkable. But he looked pale and straw-colored. It was late afternoon on
a winter day, and neither in the electric light nor in the faint daylight when the lamp
was switched off, could I make out for sure if his eye whites were yellow.
The man was healthy until two days ago; something suddenly happened that made
him short of breath, pale, and perhaps yellow. One thing that could cause all that at once
would be an acute massive destruction of red blood cells. “Have you noticed anything
peculiar about the color of your urine?” “Yes, since yesterday it has been very dark.
How did you know that?!”
My diagnosis of acute hemolytic anemia was immediately confirmed in the lab.
Prednisone treatment to prevent the destruction of patient’s remaining red blood cells
was started the same evening.
The reasoning leading to such diagnosis is not unlike a motorist’s who is driving
a European car and sees, all of a sudden, that the red lamp is aglow showing that the
battery is not being charged, and at the same time the engine is rapidly overheating.
What single event would suddenly cause these disparate effects? A snapped fan belt, of
course! Now, what would suddenly make a man pale, yellow, and breathless? A massive
destruction of red blood cells (acute hemolytic anemia) is a single event that would
explain all these effects at once. When the red blood cells are destroyed by antibodies,
and release hemoglobin, the oxygen-carrying red dye, too little oxygen is transported to
the tissues which makes the patient breathless, red blood no longer contributes to the
coloration of the skin, lips, etc. making the patient pale, and hemoglobin released into
the blood stream is converted into bilirubin causing jaundice. The excess of bilirubin
in the blood is then filtered through the kidneys, making the urine dark.
How Complex is the Statement: For Patient’s Swollen Legs, the Doctor Prescribed a Diuretic? Let’s try to reproduce the doctor’s considerations. “I wonder why she’s got this
edema of the legs. She is not breathless, the neck veins are not overfilled, the auscultation
of the lungs and of the heart reveals nothing abnormal, and the liver is not enlarged,
thus, she is not in heart failure. Her urine contains no albumin and the serum albumin
is normal, so this is not a nephrotic syndrome. She recently had a full gynecological
check-up, therefore, thank goodness, we don’t need to worry about a malignancy in
that area. This edema must be of ‘local’ origin.”
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There are other edema-producing conditions which the doctor does not even
mention is his monologue. The patient has not traveled in the last week, so there is no
reason to think of edema due to air travelers’ leg immobility. The lady’s smooth skin,
vivid facial expression, and quick pulse allow the doctor to skip the possibility of thyroid
insufficiency. There is no history of sore throat, no subfebrile body temperature, no facial
or eyelids’ edema, thus, nothing that would cause the doctor to think of inflammation
of kidney’s glomeruli (acute glomerulonephritis). Jaundice, enlarged spleen, abdomen
distended by fluid, purple “spiders” on the skin would make the doctor think of edema
due to cirrhosis of the liver. The possibility does not even occur to him because none
of these signs are present. Some drugs may produce edema, but the patient has not
taken any medicines. Hunger edema is not exactly a condition that must be considered
in a middle-class lady in Cambridge, Massachusetts, in 2001. Edema of only one leg
would suggest thrombophlebitis, and in a person who just came back from Northern
or Central Africa it would raise the suspicion of filariasis, infestation with a worm called
Wuchereria Bancrofti, but both legs are swollen and the lady has not been to Africa.
As I said, all these possibilities are not even mentioned in the doctor’s internal
monologue; but this does not mean that no work has been done on them. The doctor
did inquire about the patient’s travels and circumstances, recent and previous illnesses,
intake of medicines; he did watch her face, movements, skin color, he examined the
abdomen, palpated the liver, tried to palpate the spleen, etc. Thus, it is not that the
conditions just listed did not occur to him: the doctor has surveyed the terrain for signs
that could have triggered the quest for these ailments, found none, and suppressed the
thought.
Let’s return to his monologue: “It must be local though she’s hardly got any varicose
veins, and while I don’t like the arch of her foot, or the shape of her ankles, I don’t really
know how this can produce edema. Giving her a diuretic is not the most logical thing
to do, but I won’t start with support hose, not now in summer time. I do feel like giving
her a diuretic because it would be nice to get some quick effect; moreover, there are these
unpleasant reddish spots on her skin, perhaps an incipient capillary lymphangitis, so it’s
better to remove the edema rather soon. Mrs. T was her aunt, and she had adult-onset
diabetes, therefore, I won’t give her thiazide diuretics. I’ll give her furosemide which
is said to be somewhat less diabetogenic. Let’s say, 40 mg daily for a week. We shall
check her blood potassium, and if she needs the diuretic longer than two weeks, also
her blood glucose.” And he said: “This has nothing to do with your heart. It’s only a
trouble of circulation in your legs. Please avoid garters. Avoid standing for a long time,
and while seated try to keep your legs up on another chair. Quick walking is better than
slow. You may cook with the usual amount of salt, but don’t use the salt-cellar at the
table. And here is a prescription for tablets that will expel excessive water from your
body. Take one such tablet every morning at least twenty minutes before breakfast.”
How would the patient’s friend, or bio-ethicist, relate the story? “For her swollen
legs the doctor prescribed a diuretic.”
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Less is More, and Simple is Better. If the outsiders underestimate the complexity of
medical thinking, they tend to make the opposite error in evaluating medical actions.
TV images of seven green-clad, masked individuals doing some complex surgery represent the highest achievements of medicine in the public mind. Not in the doctor’s.
It is a good rule not to prescribe a new treatment if the complaint can be cured by
withdrawing one. Instead of doing prostatic surgery, first stop the patient’s disopyramide
capsules: they may be good for his irregular heart beat but impair urination. Before you
prescribe a diuretic for a patient’s swollen legs, first stop the indomethacin she is taking
for arthritis. This drug causes retention of water in the body, and there is a good chance
that after stopping indomethacin, the edema will clear without a diuretic. Indomethacin
will then be replaced by aspirin, which does not cause edema. Do not hurry to start
oral antidiabetic drugs or insulin if the patient has been taking hydrochlorothiazide for
his high blood pressure. This drug may cause diabetes in predisposed persons. You
should stop it and try to control the blood pressure with other medicines. Neither
should gout in patients taking thiazide diuretics be immediately treated with anti-gout
medicines; gout, too, may be a side-effect of the thiazide.
No physician with some common sense would choose a large intervention if a
lesser one would do, and we always prefer the simple to the complex. Moments of
pure joy and genuine hilarity occur in medical practice when a patient recovers without any treatment. We have even more fun when a self-cure occurs before we could
make a diagnosis! We wouldn’t use drugs if the complaint can be cured by changing
the patient’s body position. My grand-uncle, Dr. Oskar Pomper, used to advise (and
probably discovered) a simple method to relieve heart-burn: turning to one’s left side.
Try it, and you’ll see that it works. Upholding the supine patient’s legs can do wonders
in cases of fainting due to a fall in blood pressure. There is a curious, very uncommon,
but interesting condition occurring in late pregnancy: fainting in supine position. It is
caused by the large uterus compressing the lower body’s main vein, the interior vena
cava, thus cutting off the return of venous blood to the heart. The patient immediately
regains consciousness when turned on her side.
While working in Lodz in the 1950s I was dismayed by the condition in which
patients with breathing difficulties due to heart disease, and in particular those with
pulmonary edema (“wet lung”), arrived at the emergency room. Small ambulances
were in use, with space only for a medic’s seat and a stretcher on which the patient laid
supine. The latter posture is harmful for a person with congestion of the lungs: the
patient arrived at the hospital dark blue, with utterly distended neck veins, and almost
suffocating. In 1961, when I was appointed consulting cardiologist to the City of Lodz
health department, my first act was to issue a new directive to the ambulance services:
patients with breathing difficulties were to be transported seated in the medic’s seat.
The condition of these patients on admission visibly improved.
Premature heart beats (often called “missed beats” because of the longer pause
that follows) can be quite vexing. Various drugs may help, but patients who get the
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premature beats while in bed, when their pulse is rather slow, can get rid of irregularity
by getting up and walking around the room.
When someone’s heart suddenly starts beating 180, 200, or even 240 times per
minute, there is an array of methods that can be used to stop such an attack: drugs
taken by mouth or injected, or cardioversion, which is applying an electric shock to
the patient’s chest with a device synchronized with the electrocardiogram. However, a
common form of inordinately quick heart beat, the paroxysmal atrial tachycardia, often
can be stopped by the patient herself: taking a deep breath, holding it, and attempting
a forceful expiration against closed glottis and compressed nostrils. If this procedure,
called the Valsalva maneuver, does not work, in many cases the doctor can stop the
attack by pressing with his thumb on a particular spot on the patient’s neck: the carotid
artery just above the upper edge of the thyroid cartilage. This is the simplest, cheapest,
quickest, and most elegant method. These are the treatments we like best.
Using the Means at Hand. In 1936, my native town’s best surgeon, Dr. Kleinberger,
was called from a bridge game to an apartment next door: a child was suffocating. Dr.
Kleinberger saw croup membranes that almost entirely obstructed the child’s throat, did a
tracheotomy with a penknife sterilized by candle flame, and inserted an unused cigarette
holder as the tubing. The boy recovered from the diphtheria, and the incision healed
“per primam,” that is, without inflammation or infection, and left a barely visible scar.
In Lodz, I was called out from a medical board’s office to see a patient of mine
who had syphlitic aortitis, lived nearby, and was in acute distress. He was coughing up
quantities of dark-pink foam, and his lungs were full of wet rales: it was a life-threatening
pulmonary edema. I kept him seated on a chair, put his feet to a wash-basin with hot
water, found the house enema-apparatus in the bathroom, cut the rubber tubing into
parts, applied tourniquets on his four limbs, and sent his daughter to fetch shots of a
diuretic and morphine from the pharmacy. The patient recovered before she returned.
One day, at the University Hospital in Leiden, Holland, while standing with the
head of the Coronary Care Unit, Dr. Oudhof and several residents and nurses at the bed
of a patient with a runaway pacemaker, I suddenly saw on the ECG screen the onset
of a deadly ventricular fibrillation. I jumped to the patient, said “sorry,” forcefully hit
his breastbone with the side of my fist, and looked up at the screen. The fibrillation
stopped. I became the object of some jokes because of that courteous “sorry,” but I
had said this only to reassure the patient that he was not being assaulted by a madman.
***
Common Sense. Now and again an incompatibility is revealed between the perfect
constructs of science and imperfect human beings. The doctor’s common sense must
then intervene to protect the patients from harm.
The participation of patients with coronary heart disease in exercise programs is a
good example. Several studies suggested that only maximal exercise, at which the heart
rate accelerated to 160-180 beats per minute, improved the condition of cardiac patients
and prolonged their lives. Later these studies were disavowed by other investigators,
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but for some years credulous doctors and patients were going to extremes in advising
and performing maximal exercise.
Recently, in Florida, I found my circle of friends downcast after the sudden death
of one of them, a brilliant and much liked man. A doctor friend told me about the final
weeks of the deceased. After his myocardial infarction, he followed and sometimes
exceeded the advice he had been given at the hospital. Dismissing repeated warnings
of my informant, he ran at top speed along the beach where everyone else walked. He
checked his own pulse rate, and when it fell short of 170 beats per minute, he increased
his running distance and speed. There is no doubt in my mind that with moderate
exercise, such as brisk walking, and a beta-blocker tablet (which, incidentally, would
keep his pulse rate around 60 beats per minute at rest, and below 120 when exercising),
the man would have had a better chance of staying alive. I don’t know whether exercise
killed him; he might have died anyway. But with a little common sense he would have
known that the sensational results of scientific studies should be reviewed with some
skepticism; that, as a general rule, moderation is better than going to the extremes;
and that when a person’s heart is damaged by disease, moderation may be particularly
advisable. I very much regret his death.
Regular exercise, at a level fitting the individual’s ability, is the best advice we can
give to cardiac patients in stable condition, and to healthy persons as well. This is not
a recent discovery, to some extent this truth has always been known. But in the last
twenty years it has been corroborated by extensive statistics, explained in physiological
studies, and broadly accepted in medical and social practice. It even became a fad; and
that’s where the disadvantages appear: excesses, and the reluctance to make exceptions.
While riding my bike along the Charles River from Cambridge to Watertown, at
my own rate of speed, I regularly come across middle-aged joggers and runners. Some
of them look quite happy. Others, pale and sweating, are running with an expression
of suffering on their faces. They are in such visible distress that it is clear they are not
doing what is good for them.
From Den Bosch, I recall a 78 year old lady, who was recovering from a myocardial
infarction. A cardiologist was testing her condition by exercising her forcefully on a
stationary bike. Before her sickness, she had never done any great amount of exercise.
Never mind medical theory: with some common sense, the doctor would have seen that
what the patient needed was to be able to resume her usual way of life. This included
cleaning her small apartment, shopping, and climbing a flight of stairs. Was a heart attack at 78 a good reason, or the right time, to make her the athlete she had never been?
The Doctor’s Most Important Quality. If I were to name a single crucial quality, one
that makes a good doctor and the lack of which disqualifies him, it would be the habit,
and the talent, of complete mental concentration. That the doctor should fully concentrate on the patient he is seeing may seem an obvious requirement, but is not easy to
meet. The hospital and the whole world conspire to distract the doctor. Worse still, the
tiredness, or the weakness of his will, may discourage him from the required effort, and
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encourage the easy way of routine and automatism. The problems of twenty patients
linger at the edge of the doctor’s conscience, and he is unpleasantly aware of the day’s
tightly packed schedule. He is not even half way into his ward round, there is a staff
meeting to attend, the outpatient clinic, a heart catherization, and nurses’ training in
CPR, with possible emergencies in-between. The application for a research grant is not
yet written, the deadline is approaching, $25,000 will be lost, and the project stopped.
But all that must be discarded when I come to see this boy! He has had a rather severe
diphtheria, was discharged from pediatric department of infectious diseases, and obstinately refuses to go to school. We have examined him thoroughly, haven’t we, and
couldn’t find anything. Well, we have done what we could. Why wouldn’t we send him
to the child psychologist. And hurry to the next patient. This gives us a chance to finish
the ward round in time.
No! Think about it! Such stubbornness in a child must mean something. Assume
that he has a good reason not to go to school, he just cannot explain it. Let’s examine
him again. A little pale. Head, throat, lymph nodes under the jaw and on the neck:
nothing abnormal. Heart: palpation unremarkable. Let’s listen to it. The second heart
sound is very clearly split, as is usual in children, but—hey! Wait a second! This second
heart sound is broadly split when the boy is breathing out, it is the reverse of normal!
There has to be a delay in the contraction of the left ventricle, the boy must have a left
bundle branch block. It was not on his ECG recorded yesterday. Let’s record it again .
. . Yes, now there is a left bundle branch block. Everything is explained. The boy has
diphtheritic myocarditis.90
All great physicians whom I’ve had the privilege to know had the striking, never
failing ability of complete and undisturbed mental concentration on every patient they
saw. The worst medical mistakes occur when doctors, while seeing the patient, think
of something else. This pattern of mental dissociation is well known from daily life: we
think of something else while brushing our teeth, and even while performing complex
activities such as driving a car in the traffic. But with many kinds of serious work such
dissociation is inadmissible, and in medicine it is an unpardonable sin. There are no
excuses. The fact that the doctor is seeing his fifteenth or thirtieth patient of the day is
no excuse.
A man of 27 was admitted one night to the Sterling Teaching Hospital in Lodz,
complaining of pain in his right side, and breathlessness. The doctor on duty found the
breathing sound considerably weakened on the right side, as when there is fluid in the
pleural space, muffling the sounds of respiration. He diagnosed pleurisy. In the morning
I saw the patient, a young man in good general condition. From the patient’s first words
I had to doubt the diagnosis. He did not have the typical pleuritic pain that occurs with
every deep breath. He had had a single sharp sting, and fainted. Patients with pleuritis do
not faint! But patients with spontaneous pneumothorax, a sudden collapse of one lung,
sometimes do. There were no X-ray films available yet. On examination, the respiration
90
FENIGSEN, supra note 30, at 205.
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sound was not just weakened over the right lung: it was totally absent. I told the student
trainee who was with me: “Look, this is spontaneous pneumothorax. These things occur
in slender young men when a bleb bursts on the surface of the lung, allowing the air
to pass from the lung’s airways to the pleural cavity, and the lung collapses. Let’s take
him to X-ray. There is no need of suction drainage just now. The patient is no longer
breathless. If the hole is closed, there is a chance that the lung will gradually expand.”
The student, a very smart young fellow, grasped everything in a flash. The X-ray
revealed a pneumothorax. The right lung had collapsed to the size of a mandarin orange. I sent the patient with the trainee back to the ward and stayed for a while at the
X-ray department. Back in the ward, I was told that Dr. M, the associate professor, had
already been and seen the patient. “And what did he say?” “Dr. W who had admitted the
patient presented him as a case of pleuritis,” answered my trainee, “and the professor
examined the patient, and said, ‘give him the classical treatment.’” “For goodness sake,
why didn’t you tell him that the patient has pneumothorax?!” “Who, me? No, thanks!”
I looked at the trainee, and said: “Young man, you’ll go far in life.”
M was a well-trained and experienced internist, with some special expertise in
hematology; but he was busy promoting his career, attending important meetings,
gaining support of the faculty, and developed the terrible habit of being in a distracted
mood when seeing patients, always thinking about something else. He still had good
days, now and then; but one could never be sure.
On Concentration and Beyond. Not only concentration is required, but perseverance:
never stop thinking, never stop worrying. When you stop worrying, disaster looms.
A few years ago I was struck by the unexpected death of F, my friend and high-school
classmate, a barrister at the Appellate Court of Paris. All I knew about his death was
what his son and widow told me on the telephone; but it was enough to disturb my
peace of mind. After they came back from a trip to Australia, my friend was sleepless
and uneasy; he also lost his appetite. His granddaughter, a law school student, came
for their usual tutoring session, found his appearance changed, and urged him to take
his body temperature. It was 42° centigrade (that is 107.6° Fahrenheit)! A doctor, their
neighbor at the Parisian suburb, was called, could not find the cause of the fever, and
sent in a mobile X-ray unit. There was nothing unusual on the chest X-ray. The doctor
prescribed an oral antibiotic and promised to return. The next day was uneventful.
I don’t know what my friend’s body temperature was then because it was not taken.
Early that night the patient got up to go to the bathroom, fell on the floor, stood up,
fell again, and died.
For several days I could not stop thinking of his death. I recalled my friend’s wit,
erudition, incisive intelligence, eloquence in several languages, his perfect absorption
of the French culture. I thought of his heroism in the Nazi death camps. These were
stories he himself never told, I heard them from other people: how, putting on a show
to mislead the guard, he pulled two small nephews of his future wife from the crowd
selected for gassing, and chased them to the group destined for labor; how during the
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death march in the winter of 1945 he half-carried, and then actually carried his ailing
father. Life would never be the same without him.
I engaged in mental dialogue avec ce con de praticien, with this fool of a family
doctor. “Weren’t you frightened seeing a man of 74, heavily overweight, with such
a tremendous fever? Didn’t it occur to you that he might die? This must have been a
particularly virulent infection. Some of these infections are curable. A patient like this
should have been immediately hospitalized, and thoroughly and hastily examined!”
Taking Risks. While practicing medicine, at every turn we take risks hoping for
success. Thus, gambling is a quiet companion to medical practice. The doctor who is
not willing to take any risk at all is a mortal danger to his patients.
In Nakskov Hospital, on Denmark’s southernmost island, surgery was done only
when the anesthetist approved it. She did not approve any surgery if the risk of the
procedure, expressed as the operative mortality, exceeded a figure that she considered
acceptable. Therefore, in Nakskov, a 70 or 80 year old patient with an abdominal vascular catastrophe, such as a bursting aneurysm of the abdominal aorta, or an occlusion
of the mesenteric artery, would not be operated on, but instead, given morphine and
left to die. The high surgical risk—a mortality of, respectively, 50 and 85 percent—was
deemed unacceptable. A 100 percent mortality for patients not receiving surgery was
deemed acceptable.
In Lodz, I was called by Dr. T, a surgeon, to see a patient at this department. The
lady, 43, was acutely ill with an intestinal blockage, but surgery had been postponed
because the consulting internist found signs of an inferior-wall myocardial infarction
on the patient’s electrocardiogram. She had no history of chest pain or fainting, and it
was not clear when the infarction had occurred—perhaps it was recent?
I insisted on immediate surgery, and within a half an hour the abdomen was opened.
The lower portion of the small intestine was occluded by a huge gallstone in the shape
of a flattened pear, 2.5 by 1.5 by 0.5 inches in size. The gallbladder communicated with
the upper small intestine through a large perforation; this was the hole through which
the stone had escaped. The surgeon removed the stone, but necrosis of the intestine
and diffuse peritonitis were already present. Delaying surgery for two days proved fatal. I was amazed and terrified by this course of events, and tried to understand how it
happened. It was unlikely that a doctor, singlehandedly, would make such a macabre
blunder. Such a blunder required two doctors, neither of whom felt responsible for the
decision. The young internist was hypnotized by the electrocardiogram. The surgeon,
fixed on the internist’s objection, must have been struck by a kind of mental paralysis.
The patient died because the surgery, which was necessary to save her life, was too risky!
The personal risks doctors take involve their self-esteem, reputation, and career.
But it is the patient who takes the enormous risk: her life is at stake. Therefore, the
physician must be a cautious and discerning gambler.
There are exceptional situations in which a doctor’s actions may impress an observer as almost pure gambling. It’s the surgeons who probably most often experience
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this kind of situation, particularly while exploring organs within the abdominal cavity.
A close friend of mine, Dr. J, had had his gallbladder removed and then underwent
another surgery for a stone that had been missed in a bile duct. Months later he was still
not well, with fever, chills, tenderness at the right upper part of his abdomen, and an
elevated white blood cell count. There could be infection somewhere in the area, and Dr.
Kieturakis, a talented surgeon, was called to explore the abdomen. The year was 1965,
and CT scans, MRI imaging, and ultrasound were not yet available. Kieturakis opened
the abdomen and immediately found a large abscess manifest as a bulge on the surface
of the right lobe of the liver. He made an incision and emptied the abscess, and then
went on inspecting and palpating the whole accessible surface of the liver. He found
nothing definitely abnormal; and yet it seemed to him that a certain area of the right lobe
offered less resistance to hand pressure than the rest of the organ. Kieturakis hesitated
for a moment: the liver is a vital organ full of blood vessels apt to bleed profusely, and
cutting it without necessity is a grave error. But he did find an area that slightly differed
from the rest and to miss another liver abscess and leave it untreated would mean the
death of the patient. Kieturakis made an incision at the suspect spot, and deep inside
the liver there was a huge second abscess. It was emptied and the patient was cured.
From my own experience, I recall a case of almost pure gambling. One morning,
in Den Bosch, a family physician announced on the phone that Mr. B was on his way to
the hospital, a “young man of forty-two, complaining of some chest pain, which probably
has nothing to do with his heart, but to be on the safe side I’m sending him in,” said
the doctor. I ran to the emergency room and saw a pale man in acute distress, carried
in on a trolley. He tried to sit up, but fell back on the stretcher. I had to jostle away a
woman—apparently his wife, who tried to talk to me—and jumped to the patient. He
was unconscious and I could feel no pulse in his groin. The nurse pressed the electrodes
of the scope/defibrillator to the patient’s chest. The device is supposed to simplify our
task: the electrodes pick up the patient’s ECG, and if the tracing seen on the screen
shows the deadly ventricular fibrillation, we deliver the electric shock that restores a
normal heart rhythm through the same two electrodes. But for some reason—I never
discovered why—no ECG appeared on the screen! Meanwhile the patient had no pulse
and every second the danger of brain damage drew nearer. Maintaining the circulation
with hand massage until an ECG was obtained would be the usual course of action,
but would give the patient less chance of full recovery than an immediate defibrillation
would, if successful. A defibrillation is not an innocuous procedure—it’s hitting the
patient’s chest with up to 400 Wattseconds of power; it should only be done on good
grounds. But the patient had no pulse, and when the heart stops pumping blood in the
first hour of chest pain, ventricular fibrillation is the most probable cause. I shouted
“Klappen!” (which means “Hit!”, the Dutch hospital slang word for “defibrillate”). My
excellent male nurse, De Jong, gave me a frightened look: he knew I had no ECG and
no diagnosis. I repeated “Klappen! Klappen!” He pressed the buttons, the patient’s body
jumped, a pulse appeared on the femoral artery and the patient’s eyes opened. I made
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a bet and I won. Now, thirteen years after the event, Mr. B is alive and well. He gave up
his demanding job as managing director of a foundation governing one of the Dutch
universities, and enrolled as a student in the department of philosophy.
Chapter IX. On Therapy
Dr. Loeb’s Five Rules of Therapeutics. Dr. Robert F. Loeb was said to be “in semi-humorous vein” when he proposed his Rules:
1. The Golden Rule: Don’t do to the patient what you wouldn’t like to be done
to yourself.
2. If what you are doing is working effectively, keep it up.
3. If what you do is not working, stop it.
4. If you don’t know what you are doing, don’t do anything.
5. Keep the patient out of the surgeon’s hands.
“Semi-humorous” or not, the Rules 2, 3, and 4 are simply valid, and wise is the
doctor who follows them to the letter. There is also some truth at the core of the other
two rules.
Dr. Loeb’s First (Golden) Rule. My friend John M. Dolan, the philosopher, observed
quite rightly that unqualified application of the Golden Rule of ethics to the doctor-patient relationship would be inappropriate. Doctors may have personal weaknesses that
would prevent them from accepting a treatment they know would be most advantageous
to their health; or, being healthy, they may display a “cavalier attitude” toward their own
lives. Such failings of the doctor should not be visited upon his patient. The doctor’s
duty is to propose to the patient not what the doctor would choose for himself but what
he knows is the best course of action.
Yet there is some merit to applying a personal standard. Before I read Dr. Loeb’s
excellent set of maxims, for years I used to apply a “first rule” of my own. Whenever
in doubt I asked myself: “How would I treat my aunt, were she in the same condition
as this patient?”; and I used to ask the residents how they would treat their aunts. The
“aunt” word reminded the doctor that the patient was not only a problem to be solved
but a fellow member of the human family, in need of tender and cautious care. Ultimately,
strictly following the rules of the art should prevail because this is what gives the patient
the best chance; but applying Dr. Loeb’s Golden Rule, or, preferably, the “aunt test,” is
useful as a first approximation. It may prevent some annoying or dangerous mistakes.
A patient whom I knew very well fell and broke his hip when he was 99 years and
nine months old. The surgeon knew that immediate hip replacement was the patient’s
only chance to stay alive, but temporized, “waiting for the general condition to improve.”
Meanwhile the patient was kept in an intensive care unit. A bladder catheter was introduced and left in place, as was the department’s routine with all bedridden elderly.
It’s a pity the intensive care physician, Dr. H, did not apply the “uncle test.” Had she
done so, had she considered the pain and anxiety bound to occur with the catheter,
had she taken into account the transurethral resection of the prostrate the patient had
undergone 20 years earlier, and has had no trouble urinating ever since, she probably
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would have tried to maintain the patient without a catheter, risking - what? At worst,
wetted sheets. She might have waited for the “Texas catheters” which I was bringing,
condom-like devices that may not be as leak-proof as an indwelling catheter, but are
non-invasive and non-irritant. But no, catheter was introduced, causing the patient’s
constant anxiety and repeated attempts to pull the thing out. Morphine had to be given
to relieve this torment, and after the second injection the patient stopped breathing.
Dr. Loeb’s Fifth Rule: “Keep the patient out of the surgeon’s hands.” How could Dr.
Loeb give such advice?! More than any other branch of medical practice, surgery saves
lives. Just think of the abdominal catastrophes, the intestinal blockage, the perforated
ulcer! How about a gallstone blocking the common biliary duct, an operable cancer of
the colon, a kidney full of pus, a young female suffocating from tight mitral stenosis?
Of course, Dr. Loeb did not mean these obvious cases. But his Fifth Rule is a warning
against seeking “radical solutions” when the situation calls for patience and moderation.
One should not choose an invasive intervention if it may cause worse injury than the
patient’s complaint. When somebody hurts his knee and within minutes it swells to
twice the normal size, a panicky doctor would immediately think of bleeding which
might make the joint stiff forever. He would, therefore, grab the needle and puncture
the knee, intending to proceed, if necessary, to arthroscopy and surgery. Even the first
step, the puncture, carries a sizable risk of infection. And only patients with hemophilia
easily bleed into the joints; in all other people, a simple exudate is what one can expect
under the circumstances. Why not try a non-steroid anti-inflammatory drug? In nine
cases out of ten the traumatic swelling of a knee disappears within an hour after a single
100mg dose of diclophenac.
Another unreasonable course of action is to call the surgeon because the patient
is not getting better with conservative therapy. This does not yet prove that he would
get better with the surgery! Since there is no truly effective treatment of chronic bowel
inflammation called Crohn’s disease, in many cases surgical resection of the bowel was
undertaken in an attempt to cure these patients. Unfortunately, in the majority of cases
full-blown Crohn’s disease recurred after surgery.91 The patients sacrificed up to a yard
of the bowel, they have been exposed to the risks of surgery, and the painful recovery,
and gained only a short respite.
As a very young medical student I had a memorable conversation with my father.
He was a trial lawyer and used to tell us about his court cases, omitting the names. One
day he came home very satisfied with the verdict: the prosecutor demanded four years’
imprisonment for his client, but the court sentenced the man to only one year and a
half, and granted my father’s request to set the defendant free pending appeal. “How
can you be so happy about that,” I exclaimed, “you told me he was innocent! And
now you rejoice because he is sentenced to one year and a half in jail, and is, perhaps
temporarily, released?” “My dear.” my father answered “his innocence is a great thing.
91
R. Glickman, Inflammatory Bowel Disease, in HARRISON PRINCIPLES OF INTERNAL MEDICINE 1281 (J. D.
Wilson et al., eds. 1991).
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Let’s hope it will be recognized. Meanwhile, it is good to have him out of that filthy
jail, at home with his wife and children.”
Medicine, too, is the art of the possible. The error of the “radical therapists” is not
that they seek radical solutions, sometimes such solutions do exist, but that they reject
other ways to help their patients. Mr. A, of Brookline, Massachusetts, a man in his early
seventies known with adult-onset diabetes and narrowing and occlusions in the arteries
of the legs, suffered his first two attacks of chest pain, one after a meal and one while
lying in bed. His electrocardiogram remained normal and the heart enzymes were not
raised in his blood, which showed that Mr. A had not suffered a myocardial infarction.
A catheterization was immediately done: the catheter was introduced through an artery
in the groin to the aorta, iodine dye was injected into the coronary arteries and the left
ventricle of the heart, and films were made of these structures. This study showed
narrowing of two major coronary arteries. The important anterior descending artery
was not narrowed. According to the criteria based on large studies,92 and accepted on
both sides of the Atlantic, such patients should have coronary bypass surgery if attacks
of chest pain persist in spite of adequate treatment with medicines. In other words,
treatment with drugs (and diet etc., of course) should first be tried; and this was what
two experienced cardiologists advised in Mr. A’s case. The so-called beta-blockers are
the drugs of choice. They do not make the coronary arteries any wider, but they reduce
the work and the oxygen demand of the heart, allowing it to adapt to the diminished
blood flow and oxygen supply. In a significant percentage of cases this treatment prevents
chest pain, myocardial infarction, and death.93
But Mr. A’s attending physician disdained “half-measures” and had not started
any drug treatments. Within two weeks a new attack of chest pain occurred, and Mr.
A was directly sent to the operating room. The patient’s chest was opened, his heart
stopped, extracorporeal circulation installed, and two bypasses were made, pieces of
patient’s veins that led blood from the aorta to two coronary arteries beyond the narrowing. Mr. A’s recovery was uneventful. He continued his treatment for diabetes and
his cholesterol-lowering diet. No beta-blockers were given; the problem was radically
solved, wasn’t it?
Nine months after the surgery Mr. A’s attacks of chest pain recurred. A new catheterization showed that both bypasses were occluded by clots.
European Coronary Surgery Study Group, Long Term Results of Prospective Randomized Study of Coronary Artery Bypass Surgery in Stable Angina Pectoris, 1982 LANCET 1173; T. Killip et al. & CASS Principal
Investigators & Their Associates, Coronary Artery Surgery Study (CASS): A Randomized Trial of Coronary
Artery Bypass Surgery, Eight-Year Follow Up and Survival in Patients With Reduced Ejection Fraction, 72 CIRCULATION Supp. 102 (1985); CASS Principal Investigators & Their Associates, Coronary Artery Surgery
Study: A Randomized Trial of Coronary Artery Bypass Surgery, Survival Data, 68 CIRCULATION 839 (1983).
93
M. G. Myers, Changing Patterns in Drug Therapy for Ischemic Heart Disease, 312 CAN.MED.ASS’N J.
644 (1984); P. J. D. Snow, Effect of Propanolol in Myocardial Infarction, 1965 LANCET 735; R. Roberts et al.
& MILIS Study Group, Effect of Propoanolol on Myocardial Infarct Size in a Randomized, Blinded, Multicenter
Trial, 311 NEW ENG.J.MED. 218 (1984); Beta Blocker Heart Attack Study Group, The Beta Blocker Heart
Attack Trial, 246 JAMA 2073 (1981).
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Therapeutic Nihilism. In the not so distant past when 95 percent of drugs listed
in the pharmacopoeias produced no demonstrable effects, therapeutic nihilism was
the usual attitude of intelligent physicians. “Apply drugs when they are new and still
have the power to cure,” wrote Trousseau, the great French clinician of XIXth century.
When a colleague asked “after what” the patient improved, witty doctors used to answer:
“After the 16th of October,” or whatever the date might have been. As the Warsaw century-old medical legend had it, at the department of internal diseases led by professor
Jozef Pawinski, there were three mixtures in use, one of which was white, the other
green, and the third one brown. If the white did not work, Pawinski would try one of
the other colors. Only the hospital’s old pharmacist remembered what these mixtures
contained. In an American hospital, I was told a similar anecdote about aspirin being
available in three different colors.
The Cardinal Sin of Traditional Medicine. Nihilism notwithstanding, therapy, the
need – and the duty! – to treat, very much preoccupied the physicians. Even when
nothing sensible could be done, gestures were made, or medicines given, ut aliquid fieri
videatur, to let it be seen that something was being done. There used to be a compulsion to treat, very strong in Continental European medicine, and also present, though
somewhat better resisted, in English-speaking countries. Recalling that time, an American doctor wrote: “What we wanted was treatment, any treatment!” Treating patients,
making them better (or at least trying to), was what a doctor was supposed to do. It is
what made him a doctor. Treatment was an absolute necessity. The possible perils of
treatment were belittled.
At the age of ten, I became a victim of doctors’ therapeutic obsession. A week after
a minor bike accident, I fell sick with high fever, sore throat, and a widespread skin rash.
Two doctors were called, both of them Vienna-trained physicians and friends of our
family. They immediately agreed upon the diagnosis; it was scarlet fever. The rash could
best fit it, there was the typical “raspberry tongue,” and between my two red cheeks was
the typical butterfly-shaped pallor around the mouth and nose. Considering my high
body temperature, and the well-known dangers of scarlet fever, the urge to do something
was very strong. The year was 1935 and Domagk’s sulfa drugs were not yet available.
A potent treatment did exist: the anti-scarlet-fever serum. It was the blood serum of
horses immunized against the “A” hemolytic streptococci; it contained the anti-toxin.
But a week before that, when my wound from the bike accident was being dressed, I
had already received an injection of horse serum – the anti-tetanus shot. Knowing that,
and aware of the dangers of injecting foreign protein into a patient who had already
received it once, one of the doctors asked: “What about anaphylactic shock?” “Have
you ever seen shock?” retorted his colleague. The medic approached me with a huge
syringe to inject the serum intravenously, and this was the last thing I remembered. As
I was later told, I had an anaphylactic shock so severe that it resulted in cardiac arrest.
A third doctor who just arrived, the excellent surgeon Dr.Kleinberger, resuscitated me
with an injection of adrenaline into the heart.
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It is interesting to review the mistakes the two doctors made. First of all, they were
mistaken in their diagnosis. I had no scarlet fever. My rash, fever, and redness of the
tongue and throat did indeed mimic scarlet fever, but all that was my body’s reaction
to the anti-tetanus serum I had been given seven days earlier. The proof that this was
so was obtained the very next day when all these symptoms disappeared (the fever and
the rash of scarlet fever would persist for five days, and the scaling for several weeks).
Thus, what I had was acute serum sickness. At the height of my serum sickness, when
huge amounts of antibodies against horse serum protein must have been present in my
body, I was injected with a large dose of horse serum directly into my vein. The two
doctors were not ignorant of the danger, but their urge to treat was so strong that they
disregarded risk. Apparently neither of them had previously seen anaphylactic shock.
Well, they saw it that night. There was a period of cooling in my family’s friendly relations with the two men, but after some years the cordiality was restored.
From Obsession To Neglect. If obsessed by therapy, the physicians of 1930’s, 40’s,
and 50’s also considered therapy, in particular the working of drugs and their use, a
serious and interesting matter, and paid full attention to it. Many achieved true mastery
in the art of treating patients with drugs.
Shedding the “therapeutic obsession” was a necessity, but the pendulum swung
too far. Many doctors of the new generation have learned to depreciate pharmacotherapy, lost the vivid interest in the subject that we used to have, and lost the skill and the
fine touch. I remember the patient who with bang and clatter fell on the floor in the
corridor of Nakskov hospital. The day before that, his large-dose prednisone treatment
had been abruptly stopped because of some side-effects.
Our patients did not faint when taken off prednisone treatment. It used to take us
a month to gradually decrease the dosage. This gave the patient’s own adrenal cortex,
which had been suppressed by extraneous prednisone, ample time to recover.
To Die of a Misprint? In 1969, in Denmark, I saw for the first time doctors who
every time before prescribing a medicine looked it up in a book. The book contained
concise descriptions of all medicines available. I was very much surprised. We used
to prescribe only medicines we knew very well. We didn’t need to look them up in a
book before writing the prescription! The practice that amazed me so much in Denmark turned out to be generally accepted among doctors of the new generation. These
doctors prescribe medicines with which they are not really familiar.
The Lost Therapeutic Touch. Nowadays, patients given their first medicine to lower
the blood pressure, or a new one, are told to take one tablet twice daily and come back
in six weeks. Such a practice would work well with some drugs and some patients,
but not with all. A few will return the very next day on a stretcher because their blood
pressure fell to very low levels and they fainted while getting up. Most will keep their
appointments in six weeks’ time, and then it will turn out that four out of ten still have
a blood pressure of 200/110, if not 240/130: the arbitrarily chosen dose was for them
too low, “under the threshold,” and produced no effect at all.
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I must smile recalling the heroic 1950’s, the time when the first drug that effectively lowered the blood pressure was introduced. It was the ganglion-blocking agent,
hexamthonium; the effect of the injection was violent and short-lasting, making the
treatment much too brutal for most people with high blood pressure. But for patients
who were afflicted with the severe or the malignant form of high blood pressure it was,
for the first time, a chance to stay alive. We, the doctors who undertook this task, used
to spend hundreds of unpaid hours taking the patients’ blood pressure in various body
positions (it could be very low in a standing patient, but still high with the patient supine), adjusting the dosage, teaching the patients to keep up the bed-heads at night, to
sit down or lie down when they were dizzy, to take their own blood pressure and adjust
the dose themselves. We wrote for them detailed and individually tailored instructions
which provided for dose reductions in case of fever, diarrhea, or a heat wave, and for
dose increases when the patients went swimming or fly-fishing (body immersion in
water counteracted the blood-pressure lowering effect of hexamethonium).
The effects of present-day drugs are smoother and treatment of high blood pressure
no longer requires such painstaking control; but, for heaven’s sake!, when you start a
new drug, or change the dosage, please check the effect the same day or the next, and
then again!
Treating Hypothyroidism. While treating the insufficient function of the thyroid
gland in a patient known to have heart disease, I used to start with a quarter of the
smallest 1-thyroxin tablet, to be taken not every day, but once in two days, and saw the
patient twice a week, then once a week, increasing the thyroxin dosage ever so slightly
and only after I made sure that no chest pain or attack of palpitation had occurred in the
meantime. The usual plan in such cases was to reach the full dosage of thyroxin in half a
year. Moreover, I protected with a beta-blocker every cardiac patient receiving thyroxin,
and the protection with a beta-blocker is necessary because thyroxin, the hormone of
the thyroid, is a powerful stimulant of the heart, which increases the oxygen needs of
the heart muscle and makes it overly irritable. This may easily prove too much for a
heart damaged by coronary or valvular disease.
However, the doctors of the younger generation let themselves be guided by
simple logic (“the dose of the thyroid hormone must be high enough to substitute for
the normal function of the thyroid”), and do not sense the danger. The results of this
approach can prove deadly because the cardiac complications of thyroxin treatment
tend to be extremely severe. One day in Aalborg I deeply regretted having diagnosed
hypothyroidism in a patient with myocardial infarction. A cardiology resident called
an internist who prescribed a full dose of thyroxin, 200 micrograms a day. On the second evening, the patient erupted into a tremendous cascade of life-threatening cardiac
arrhythmia; I had never seen anything like this in my whole life. In Den Bosch, an
internist found hypothyroidism in my patient with coronary heart disease, and started
to treat the man with full dosage of thyroxin from the very first day. A huge myocar-
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dial infarction, complicated by cardiogenic shock, occurred on the seventh day of this
treatment. The patient barely survived.
At my retirement in 1990, I sent detailed letters to all my patients who had both
heart disease and hypothyroidism, explaining how I had treated them and why, and
warning against attempts to speed up the cure. The hospital’s cardiologists and internists received copies. I have not had the courage to inquire what happened to these
patients after I left.
Back to the 1940’s? When I look back at the beginnings of my hospital work,
more than half a century ago, I realize how helpless we were then. True, we had our
diagnostic skills and a number of treatments that worked. But we couldn’t do anything
for patients with the worst form of high blood pressure, malignant hypertension, and
they all died within months. There were no pacemakers for the people who fainted and
died of slow heart beat. Patients with Hodgkin disease, with various forms of cancer
that are now curable, and children with acute leukemia died because even if means of
treatment existed we did not know how to use them in a really effective way. We were
doing little to prevent bedridden patients from developing dangerous blood clots. Patients with inborn heart defects, or diseased heart valves, were not protected against
deadly bacterial infections. We were tragically helpless when young people suddenly
and unnecessarily died of penicillin allergy, or of the heart’s electrical disturbances in
the first hour of a heart attack, even when this happened in the hospital.
I also clearly see those shortcomings of that time’s medicine, which could be viewed
as both professional and ethical. We disregarded the dangers of some of the drugs we
were using. Many treatments we offered to patients were unverified, and quite a few
were subsequently shown to be worthless.
The reader of the present work will come across some nostalgic pages. Indeed, I
think that effort should be made to restore those intellectual achievements, skills, and
ethical blessings of traditional medicine that have been lost in the process of modernization. I certainly do not dream of a return to the therapeutics of 1940’s or 1950’s. It
is impossible and would be disastrous.
Chapter X. The Traditional Clinician
When I turn my mind to the environment in which I was educated as a physician,
to my teachers and my colleagues, a certain radiance surrounds this circle of people.
What kind of people were they? What kind of person did I try to become? The general attitude to which I refer is difficult to define. We did not analyze it, we lived it; I
only became fully aware of it when I was confronted with the very different conduct
of “modern” doctors.
Years ago I coined the (only slightly ironic) term “Grand Seigneur Attitude” to describe the cast of mind, the manners, and the rules of conduct that have distinguished
clinicians for a century and a half.
For many of us in Lodz, Poland, my teacher Dr. Jerzy Muszkatenblit Jakubowski (1887-1967) was the embodiment of a great physician. Born to a middle
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class Jewish family, in his youth he got involved in leftist politics, knew tsarist exile
to the far North, escaped, studied medicine in Paris, served as a military doctor with
the Russian Army in World War I, lived through the revolutionary years in Russia, and
returned to Poland to become one of Warsaw’s most successful practitioners and later
the popular and revered teacher of clinical medicine in Lodz. Trained in excellent hospitals, disciple of Huchard, Vaquez, and Widal, at home in three great cultures, having
a native’s command of the three languages, a friend of Polish, French, and Russian
writers, theatre people, painters, and poets, he had broad interests and saw medicine
in proper perspective. He realized how helpless we ultimately were, yet he knew, too,
what a difference we often were able to make; and he had the calm certainty that ours
was a unique art, one that made exceptionally high demands on a person’s learning,
diligence, judgment, emotional balance, and moral strength. All his diverse interests
notwithstanding, Jakubowski had the gift, and the firm habit, of focusing his attention
entirely on a patient. While he was listening to a patient’s history, examining the patient,
pondering a decision, he wouldn’t let an irrelevant thought enter his head.
Jakubowski’s diagnostic insights which impressed us so much were the workings
of his quickly associating mind that drew on a solid medical learning,vast knowledge
of life, and intuitive understanding of fellow human beings.
He knew very well that money did not matter, but good name and being faithful
to the rules of the art did; and he lived up to his convictions. He calmly dismissed
all authorities’ attempts to meddle with our work, was smilingly skeptical before high
dignitaries, and trustful and invariably attentive to all who depended on him, whether
patients, students, or subordinates. Many of us tried to be like him.
Jakubowski was a very special person, but he was a representative of the entire
class of traditionally educated clinicians. Many prominent doctors whom I had the
privilege to know were “Grands Seigneurs,” each of them in his own way.
The traditional medical education, both the medical school, and in particular, the
subsequent hospital training in one of the main specialties, instilled in the physicians
the belief in their high calling, a conviction that the work they were doing was important and unique. The physicians’ lofty status, the power they wielded, and the extreme
vulnerability of patients justified especially high ethical standards, set for doctors high
above those required from other members of the society.
There always has been a great diversity of individuals in the medical profession,
but we should not fail to acknowledge the existence of a typical personality representative of traditional clinicians, one that served as a model, was generally appreciated, and
facilitated promotion to the positions of senior consultants and teachers of medicine.
This model personality of a traditional clinician was particularly harmonious. With my
children and then grandchildren leaving home and entering the world, I often thought
of people who would lead them further and influence their destinies; and I always have
wished that those teachers, sport coaches, military commanders, civilian bosses might
deal with my youngsters the way a traditional clinician would.
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The Clinician and the Powers That Be. The attitude toward health care administration, hospital managers, and all kinds of regulations, and every officialdom, prevailing
among doctors in Eastern and Central Europe at the time when I worked there, and
to some extent in France, is worth mentioning. We had the unyielding certainty that
whatever an authority could conceive must belong to a much lower order of phenomena
than medicine. It goes without saying that each of us believed – and I must avow I still
believe – that our work made much more sense, was more noble and more important
than the activities of some prime minister of a country. While the view itself is debatable, we certainly were not isolated in our opinion. In Poland, every opinion poll in
the 1950’s, 60’s, and up to the 90’s placed the doctor, among all professions, highest in
public esteem.
In Moscow, in 1952, when everybody sagged under the oppression, I was delighted to see that doctors preserved a good deal of independence. I don’t mean the
ultimate situations in which a dissident’s life would be at stake, but those more frequent
circumstances under which a person may, or may not, show civil courage. Dr. Dmitriy
Pletniov, great Russian cardiologist of the 1920’s and 30’s, was convicted in 1938 on
fabricated charges and, as far as I know, was never released. The usual Soviet way was
to erase the unfortunate’s name from all publications and from memory. However, at
the Moscow hospital where I stayed for two months, the Medical Academy’s Institute
of Therapeutics, Pletniov was openly revered, quoting Pletniov’s diagnosis settled the
discussion of a case, and Pletniov’s textbook of heart disease stood on a place of honor
in the department’s library.
At the meeting of the Moscow Internists’ Society, with Dr. Lukomskiy presiding,
a man tried to introduce some ideological rubbish into the proceedings. “What is your
name and where do you work?” somebody asked harshly. The debater, a Dr. Ivanov, had
to disclose that he worked at “Special Hospital #3,” an institution run by the NKVD,94
whereupon the gathering resumed the discussion Ivanov had interrupted.
The Doctor’s Well-Deserved Fee. I was raised in the belief that we should be decently
paid for our work, but we were also willing, and had the obligation, to treat sick people
without pay. We accepted a fee not just as what was due, but as a token of acknowledgment. If the patient did not pay, I did not want his money. And we made it a point of
honor to treat a number of patients without pay. In Lodz my list of non-paying patients
was patterned after that of Dr. Jakubowski, and was, therefore quite ample: it included
doctors, veterinarians, university students, teachers, artists, actors, writers, journalists,
and the close families and parents of the above. The situation with poor people was
rather delicate: if a person of very modest means appeared as a patient at my private
office, my refusal to accept payment would offend him. I therefore accepted a small
fee. We jokingly called the non-paying patients “praxis aurea,” “the golden practice.”
The funny thing about it was that the larger it grew the better off we were. Apparently
the non-paying patients were sending in the paying ones.
94
Peoples Commissariat for Internal Affairs (the Soviet police, forerunner to KGB).
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Whatever money a doctor had was to be used for the good life, art, travel, and
education of the children. Investing money in commercial enterprise or the stock market
was unthinkable. But these injunctions have been forgotten. I remember the day in
the 1980’s when the Hong Kong stock exchange (or was it the commodities market?)
collapsed. With awe and pity I watched two of my colleagues in Den Bosch, good
people and good doctors, struck by the disaster, trying to guess it’s possible causes, and
devising means of damage control. A doctor should never allow this kind of garbage
to clutter his brains.
Dissolution of the Doctors’ Exclusive Club? From Den Bosch I once mailed a letter to
a gynecologist in another town, asking for information about a patient of mine, a lady
of 35 who had a skin blood vessels’ disorder of unknown origin. Two years before that
she had undergone gynecological surgery but did not know why or what had been done.
If there had been a malignancy and/or the ovaries had been removed, the knowledge
of these facts might contribute to the understanding of the patient’s present complaint.
The gynecologist sent me a stunning answer; it read: “What do you need this for?”
He didn’t simply assume that whatever I asked must have been for the sole purpose of
helping the patient. No, he thought, apparently judging me by himself, that I might
pursue some other goals. Gone was the traditional doctors’ conviction that we all were
pure and honest men acting solely for the patients’ good.
The traditional doctors’ esprit de corps often bordered on elitism. If you entered
at lunch time any European hospital’s cafeteria in the 1950’s or early 60’s, you could see
the doctors sitting at tables with other doctors. Now they preferably sit with nurses. It
is not that I don’t like the company of nurses whose work I greatly appreciate and many
of whom I like and admire, but we were irresistibly attracted by other doctors’ company, vividly interested in what other doctors had to say, how they saw things, how they
reacted. As my good acquaintance at Hopital Lariboisiere in Paris, Dr. Sikorav, crisply
put it: “Ce qui est interessant dans un hopital ce sont les autres medecins,” “other doctors,
that’s what is interesting in a hospital.” The shared experience of lifelong learning, the
participation in the same chain of intellectually challenging, highly emotional events
that is the daily practice of medicine, used to create a closeness, a spiritual bond that
we cherished so much.
The traditional doctors’ esprit de corps, like the Latin of late-medieval scholars,
caused national borders to lose importance. Ockham was welcome at Sorbonne, Copernicus in Bologna, and in my time a doctor from whatever country, especially a hospital
doctor of your own specialty, used to be welcomed as a brother. Not much was needed
to recognize somebody of your own crowd; sometimes a single word or gesture. In
Lodz, we immediately opened our hearts to doctors from Prague or from Kharkov when
we saw how they examined a patient. At Lariboisiere, I met Dr. Sikorav at the bedside
of a female patient who fired all sorts of atrial arrhythmias. Sikorav saw that with my
hand I was reaching out to the patient’s neck – and immediately understood I was his
brother: my first thought – and his – was to check whether she had a nodular goiter.
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I was at once accepted at Lariboisiere when together with Dr. Slama we saw a patient
who suddenly deteriorated on the third day of his myocardial infarction. We listened
to the patient’s heart: there was a loud blowing murmur. “Sa cloison!” I said; meaning
that the partition between the heart’s two ventricles ruptured. Slama thought the same.
Quick catheterization confirmed the diagnosis, and the patient had surgery to patch
the hole. In Rotterdam, Dr. Arntzenius took me to the intensive care at Dijkzigt Hospital to show me a special case. There was a huge elevation of the ST-segment on the
patient’s ECG, and I said “Oh, Prinzmetal” because such electrocardiogram is typical of
“variant angina,” chest pain due to a spasm of the coronary artery, as described by Dr.
Myron Prinzmetal. Arntzenius looked at me and invited me to work at his department
of cardiology at Leiden University.
There are signs indicating that the medical esprit de corps is still alive, but there
are also observations showing that this spirit becomes alien to a growing number of
doctors. The doctors’ confidence in each other is fading together with their self-image.
Their interest in each other also disappears, it seems, under the influence of the idea that
the new scientific medicine is a sum of established objective truths. If so, there cannot
be anything important or interesting to an individual doctor’s views.
Chapter XI. What is Happening to Physicians’ Manners and Morals?
A Gothic Tale From The X-Ray Conference Room. When I left Poland in 1968, I first
settled in Nakskov, on Denmark’s southernmost island. I was appointed deputy head
of Nakskov Hospital’s department of internal medicine. This was a large department of
more than seventy beds. The working day used to start at 8:30 with an X-ray conference at which the radiologist commented on our patients’ roentgenograms. Sometimes
the X-rays revealed a cancer – mostly of the stomach, or the lung, or the colon. Every
time this happened, which was once a week or once a fortnight, all the doctors present,
the head of internal medicine Dr. S, the four residents, and the radiologist burst into
Homeric laughter. My sitting there, stone-faced, never spoiled the general hilarity. If
the cancer had not been suspected by the internists, the uproar would not abate for a
whole minute, at least.
I felt I had to find answers to nagging questions. How could adult men, doctors,
behave in such a bizarre, obscene way? Who were these people? And who were we,
men and women of my own circle? What made us what we were? Thus began the quest
which I have pursued for more than thirty years.
What’s Happening To Doctors’ Manners And Morals? More strange observations followed. In 1971, a public debate was going on in Denmark whether to close or maintain
the “unplanned” kidney dialysis center at a hospital in the town of Fredericia, on the
country’s central island of Fyn. The “abolitionist” party was led by the chairman of the
Ministry of Health’s committee on kidney disease, Dr. T-H, professor of internal medicine at Copenhagen’s Rigshospitalet. Trying to discredit the leader of a Citizens’ Action
Group, this doctor called a press conference, announced that he was that man’s attending
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physician, and divulged information from the patient’s hospital file. The good doctor
also mailed excerpts from the medical file to the editors of major Danish newspapers.
In Nakskov, I once told Dr. S, the head of the department that I applied for a position at the department of cardiology in Aalborg, a larger city in the North, and would
go for an interview. This was unpleasant news to S, who was known as a difficult man
and wouldn’t easily find another deputy. On the day of my trip, S, quoting a formal,
but never followed, point in my contract, kept me in the hospital past the hour of my
train. I had to drive in heavy snowstorm, on slippery roads. I sighed, lamenting the
professional circle I had left in my native Poland, the proud men who would never
debase themselves by such petty bullying. I became uncomfortably aware that I had
now fallen into bad company.
In Holland I was struck dumb seeing for the first time in my life doctors who
intentionally caused deaths of their patients. Some of these acts involved low cheating.
I discuss the subject elsewhere in this work; but let’s turn again to lighter subjects.
In Den Bosch, a cardiologist, let’s call him Dr. X, was asked to give out a patient’s
coronary angiography film for a second opinion. He refused. His pronouncement that
the patient was inoperable was final, and as the owner of the angiography film Dr. X
decided not to give it out. But the patient, a Mr. T, a half-Javanese former regular in the
Dutch Army, was not a man who would easily give up. He called the press. An article
in the province’s major newspaper told the whole story and depicted Dr. X as a stupid
bully. Only then did he agree to release the film. A second opinion was obtained: Mr.
T’s coronary arteries were slender and, indeed, a bypass could not be done by just any
heart surgeon – but it could be done by one particularly skilled in operating on thin
vessels. Mr. T had his coronary bypass done with good results by Dr. Cooley at St.
Luke’s Hospital in Houston, Texas.
The group of five cardiologists, of which Dr. X was a member, was also involved in
another scandal. For reasons of economy, the Dutch Ministry of Health had authorized
for the city of Den Bosch only one laboratory of cardiac catheterization. It was located at
the Great Old Hospital where the five cardiologists worked. The cardiologists working
at the city’s two other hospitals were to use the same lab on designated days. After initial
stiff resistance, the Great Hospital’s five cardiologists finally agreed; but they demanded a
part of the other cardiologists’ fees. The lab and the equipment were hospital property,
the technicians were hospital employees, and one could see no grounds for the five associates’ claim. True, they could obstruct our work, for example, by crowding the lab
with false emergencies. During the negotiations some of them alluded to such ability
on their part, but if these doctors wanted to be paid for refraining from such acts, they
engaged in racket, in extortion! Only after a court ruling that dismissed their claim did
the Great Hospital cardiologists give up.
Haggling was also going on at the town’s third hospital, the St. Charles. The cardiologist there, Dr. T, invited a friend, Dr. Y, his former fellow resident from Amsterdam,
to come as his associate. As was then usual at Dutch hospitals, the newcomer bought
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his part of the practice. I very much disapproved of such deals, but this one turned
sour indeed. At the end of the year, when the first installment was due, Y declared that
he was contributing much more to the associates’ income than T because he performed
twice as many heart catheterizations. This almost certainly meant that Y catheterized
patients who did not need it (a heart catheterization is an invasive procedure carrying some risk). Anyway, Y, referring to T’s “insufficient contribution,” refused to pay
the purchase price for the practice. Quarreling poisoned the atmosphere for a whole
year. Then the association was dissolved and the two cardiologists went on working
“separately” at the same hospital. This was not the end of Y’s scheming: he pressed the
secretaries to direct new patients to him and not to Dr. T.
In Lodz, when I worked there, a doctor acting like Y would have been considered
a psychopath. In Den Bosch he had the reputation of a tough guy.
In medical schools, the teachers’ position has undergone a remarkable evolution.
My teacher, Jerzy Jakubowski, used to quote cases he had seen and explanations he had
heard while following the Paris ward rounds of Fernand Widal and Louis Vaquez. On
his own ward rounds in Lodz (he wouldn’t see more than two patients), we followed in
full mental concentration, every time expecting to be shown something interesting, to
be told something important. Similar mood prevailed at the ward rounds of Alexander
Miasnikov in Moscow, Yves Bouvrain in Paris, Jack Shillingford at Hammersmith, Sir
George Pickering in Oxford. I behaved in my usual self-effacing way at my ward rounds
at Helen Wolf and Madurowicz hospitals in Lodz, and the doctors who followed me
were fully attentive and made pertinent remarks.
To Alex Arntzenius’s round at Holland’s most venerable university hospital, I set
out in my “grand round state of mind,” collected and exhilarated. I did not realize we
had entered the Modern Age. During the entire ward round two senior doctors, B and
D, loudly talked on casual subjects, interfering with professor’s inquiries, thwarting his
auscultation, and completely distracting all doctors present. B and D didn’t just show
their contempt for the professor; they scorned the patients and their problems, and made
mockery of medicine itself. These were Modern Times, and the professor wouldn’t dare
to rebuke them, not to mention throwing them out.
At the same university department of cardiology, incessant plotting among the staff
finally resulted in the demotion of the only man who was not involved in any scheming:
the head of the department. Dr. Z, who was appointed as his replacement, began by
dismantling everything the previous leader had created. First of all, he closed his predecessor’s brainchild, the excellently functioning post-myocardial-infarction outpatient
clinic, scattering the frightened and confused patients, and suspending the doctor who
was involved in this work. The research projects connected with the institution had to
be discontinued. The new boss had spent all his professional life in the catheterization
lab, and his expertise in general cardiology was somewhat below average. Being aware
of that, Z tried to build up his authority by bullying and threatening the staff. He used
to interrupt every discussion with the words, “I’m afraid our collaboration will prove
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impossible.” I heard him threatening three doctors in this way on a single day. The plotters began to bitterly regret their own success in ousting the previous department head.
To everybody’s relief, Z’s appointment was ultimately not confirmed by the university.
The trains, planes, and cars that took me in 1968 to Denmark, and later to Holland,
were time-travel vehicles. I not so much changed countries as moved into a different era.
Fortunately, there still were in Holland (and surely in America) noble medical figures
of the traditional cast, and also younger men who have adopted the traditional ways
and values and knew how to square these with modern erudition and technical skills.
But the new style was expanding. Specialists, senior consultants, teachers of medicine
behaved like wrangling hucksters, petty bullies, fought over money and influence or
openly acted to the detriment of their patients’ interests. I wouldn’t say that in my time
in Lodz nobody transgressed the ethical rules; some did. The doctors whom I now
watched in dismay did not trample upon any rules: no special ethical rules of medical
conduct existed any more. These doctors felt absolutely righteous about their conduct.
They simply exercised their rights. The old high standards had crumbled, together with
the doctors’ belief in their high calling.
Chapter XII. The Lost Skills, The Bad Habits
The Remarkable Congressional Hearings. The hearings were held in January, 2000,
and Ms. D, the fastest woman on earth, the 100 meter-sprint Olympic golden medallist,
took the stand. She told a stunning story. “A string of doctors failed to diagnose her
disease, despite classic symptoms,” reported the press. “It all started in 1988, when she
left her first Olympics, too weak to even make the finals.” “I was told I was over-training
and must take time off. I’d take time off and come back even worse,” Ms. H told the
congressional committee. “Her heart sped up to a dangerous rate. Her eyes began to
bulge... A huge goiter grew on her neck. She dropped from 125 pounds to 87, and
then the doctors suspected eating disorders.”95
Of course, also in Poland or Rumania it can happen that a doctor, particularly one
of those who have entered the practice without solid hospital training, would miss the
diagnosis of severe hyperthyroidism (Graves’ disease) in a case like this one. It is very
unlikely that several doctors would fail to diagnose such a conspicuous condition for
several years. Medicine is still old-fashioned in Eastern Europe, as it is – to a degree – in
the Mediterranean, and in those countries doctors still look at their patients.
I cannot resign myself to the notion that doctors of the new generation, so much
more knowledgeable than we were, so much more skilled in various techniques, should
be unable to see what we can see.
The Art of Seeing. For a long time the ability to see at a glance what was wrong
with the patient was admired as a clinician’s true gift. It has never been considered a
universal diagnostic tool; yet in quite a few cases an attentive look cast at the patient
could directly lead to the diagnosis of a disease that otherwise would be missed.
95
L. Neergard, Olympic Champion Recounts Her Ordeal: Devers Enters Debate on Medical Mistakes, BOSJan. 27, 2000, at A3.
TON GLOBE,
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There is nothing unique or mysterious in the “gift” of seeing. This was simply
the way doctors used to be trained. Looking attentively at the patient, and allowing a
flow of thoughts and mental associations to start if we noticed something peculiar, was
a working habit which we as medical students used to acquire while learning clinical
medicine under the guidance of senior physicians.
An excellent book was published in the 1920’s by Dr. Ortner of Vienna, under the
title “Strassendiagnose.” It was a treatise on diagnosis which a clinician could faultlessly
make just crossing people in the street. Indeed, it takes only a glance to notice the
bluish-purple “butterfly” on the cheeks of a lady with mitral valve disease; the “haggard
look” and protruding eyeballs of a woman with hyperthyroidism; the drooping foot of
a patient with peroneal nerve palsy, the coarse facial features and heavy jaw of a man
with acromegaly, the brown skin of a person with Addison disease; or the incompletely
recovered stroke patient’s arm, bent and drawn to his chest, while his leg is making an
awkward half-circle at every step (the Wernicke-Mann posture and gait). Extensive
chapters on visual diagnosis can still be found in all good textbooks of medicine.
In Lodz, my good assistant Dr. W, an experienced internist, asked me to see one
of her patients. The 60 year old lady, whom I had known socially, for several weeks
had complained of a finger that badly hurt. “A finger is just a finger,” said Dr. W, “but
her complaint is so intense that I am worried about her.” I looked at the patient whom
I hadn’t seen for about a year. The change in her appearance struck me. She was
masculinized, had a thin mustache and the shade of a beard, almost a goatee. Even
the skin on her cheeks was thickened, grayish, with pores showing, as is only seen in
some males. With her shoulder-long hair the patient looked very much like the XVIIth
century’s portraits of the Polish king Jan Casimir.
By sheer happenstance – these cases are exceedingly rare – I had once in the past
seen a female patient looking precisely like this one. I said to Dr. W: “Admit her to the
hospital, and first of all take a chest X-ray. I’m afraid we’ll see many round shadows. The
patient apparently has a masculinizing tumor of the adrenal cortex, and these tumors
immediately metastasize to the lungs.”
Alas, I was right: the lungs were packed with round secondaries, and the primary
tumor was in the adrenal cortex. What was wrong with the patient’s finger we never
found.
Well, I just happened to have seen one such patient in the past. I also happened
to have known this lady before her illness, and was able to notice at once the change in
her appearance. Impressive as my diagnosis was, it did not allow much generalization.
Diagnosing thyroid disease is more instructive. In Denmark, while working at the
department of cardiology in Aalborg, I was surprised seeing how my colleagues were
using the thyroxin test (the more refined test for thyroid-stimulating hormone was
not yet in use at that time). Thyroxin is the hormone of the thyroid gland; low blood
levels of thyroxin indicate hypothyroidism, insufficient function of the thyroid, while
high levels are typical of hyperthyroidism. Well, the doctors at the department ordered
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thyroxin test when I wouldn’t; and they didn’t ask for thyroxin levels when I did. The
difference between us in using this test – that is, in considering the possibility of thyroid disease – was so striking that I thought it should be researched. There had never
been such a difference between my diagnostic queries and those of other members of
the team in Lodz!
I pulled from the lab register all 96 thyroxin tests ordered by our department in
1971. What I found was an even more pronounced difference than I had expected.
That year, I ordered four thyroxin tests. All four were abnormal: two showed hyperthyroidism (overactive thyroid gland, Graves’ disease), and the other two indicated
hypothyroidism. The department’s other five doctors ordered 92 thyroxin tests. All
these, with no exception, showed normal levels of the hormone. In other words, the
doctors ordered 92 thyroxin tests that weren’t really needed.
I then asked each of the five doctors separately what their reasons were for ordering a thyroxin test. Every one of them answered that he ordered the test because the
patients had heart problems, and hyperthyroidism (nobody mentioned hypothyroidism)
was one of the possible causes of cardiac complaints.
None of the doctors said that he ordered the test because the patient looked like
having thyroid disease. I, on the other hand, ordered the thyroxin test only when something I saw directed my attention to a disease of the thyroid. A goiter can be present
or absent, but bulging eyes, or the whites of the eyes showing above the irises and
giving a lady’s face a “frightened” look, the swift pulsation of the arteries, the smooth,
warm skin, the somewhat excessive movements of arms and of the whole body, the fine
tremor of hands point to an overactive thyroid. Sometimes, in an elderly gentleman,
just the somewhat shining eyes and, on auscultation, a too loud first heart sound draw
my attention.
I also ask for a thyroxin test when a patient’s “tired look,” swollen eyelids, dry
skin, rough and darkened at the knees and elbows, or a lady’s deep voice, alert me to
the possibility of hypothyroidism.
The results of the 96 thyroxin tests showed that this “Polish approach” was efficient
while that of my “modern” colleagues was a waste of time, money, and patients’ blood.
Even in Holland, where many doctors’ clinical training is still very good, errors
now occur due to the modern fashion of not looking at the patients. Leaving for a
vacation, my excellent young associate in Den Bosch asked me to see at least once
during her absence a patient she was worried about. The 50 year old lady was referred
to the cardiologist because the blood test showed an elevated creatine phosphokinase
(CPK). Inordinate amounts of this enzyme are released from the heart muscle in cases
of myocardial infarction. The patient’s CPK, however, was of a different kind, not the
MB fraction originating from the heart, but the MM from the body’s other muscles.
A very thorough examination failed to reveal the cause. There was a thick file full of
results of various tests.
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The patient complained of tiredness, and in the last two months, moderately
swollen legs. She was so tired that she had difficulty with climbing stairs. I looked at
her. She did not look ill, but was rather pale and had slightly swollen eyelids. This gave
the direction to my further questioning. Yes, she did sometimes perspire (this did not
support my hypothesis). Yes, she was sensitive to cold, “but it has been so all her life.”
Yes, she has gained weight. Her voice was a deep alto, but not the typical bass. Her
pulse rate was about 60, the skin was dry and rather rough and slightly darkened at the
elbows and knees. I sent the patient to the lab for a thyroxin test. It was very low. By
the way: this explained the high CPK levels in the patient’s blood: in hypothyroidism
the CPK MM fraction is raised due to the muscular waste.
While writing the letter to the internist I could not refrain from making a nasty
remark. “Dear Nico – I wrote – will you please take this patient over for treatment of
her hypothyroidism. I enclose the result of thyroxin test. I also enclose the results of
52 tests that Frieda had ordered.”
This was a case of hypothyroidism which manifested itself in a discreet way, but
another time I came across a patient with a most conspicuous myxedema (extremely
severe hypothyroidism) that a doctor, lost in details, and busy with treating each symptom separately, managed to miss. We admitted the lady to the coronary care unit in
Den Bosch with an acute myocardial infarction. She had it; but she also had another
serious problem. She had previously been sick for two years, and assiduously treated
by her doctor for several ailments. The family physician treated her with a diuretic for
her swollen legs, with iron pills for her anemia, with symvastatin for high cholesterol,
and with inhalation therapy for her hoarseness. The lady’s face and legs were swollen,
the skin dry, pale, grayish, and thickened, her pulse rate was 50 per minute, and her
voice was a hoarse basso profondo. It was the most obvious myxedema I have ever
seen. All those various “ailments” – the swelling, the anemia, the high cholesterol, and
the hoarseness – were manifestations of hypothyroidism.
Apparently, the habit and the skill of looking at the patients are not being developed
in young doctors trained in the “modern” and “scientific” way.
Several friends of mine, Polish doctors who have been confronted with the “modern” medicine in the west, made observations similar to mine. Dr. Jadwiga Brukner, a
wonderfully modest lady who after her emigration worked for many years in New York,
relates her experiences most succinctly. During her residency at the Bellevue Hospital,
whenever the senior physicians looked for a shortcut in an undiagnosed case somebody
would say: “Let’s ask Jadzia what she thinks.” Once a senior colleague asked her: “How
come you see what we don’t see?” and she answered: “At the school where I studied
they taught us to look at the patient before doing the tests.”
The “Modern” Doctors’ Inability to See is a Crippling Fault. The patients bear the consequences. Why and how does the “scientific” training of doctors prevent them from
seeing? Does it have to be so?
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I once made an observation that seemed to reduce the problem to its simple elements. Reviewing the chest X-rays together with two well-trained Dutch radiologists,
I found, to my surprise, that they did not recognize the characteristic heart silhouette,
typical of that most common valvular heart disease, the mitral stenosis. This pattern,
with the bulging arch of the left atrium, small left ventricle, and rounded shadow of
the right atrium, is so characteristic that everybody who saw it twice would recognize it
ever after. However, the Dutch, Dr. N and Dr. H, looked at such X-rays and did not see
anything abnormal. Since the cardio-thoracic ratio, the relation between the composite
transverse dimension of the heart and the breadth of the chest, did not exceed 0.5, they
would describe the X-rays as normal. They were keen on measurable facts, but were
not interested in shapes or patterns.
The story of the family physician who treated every symptom separately, but did
not see that the patient had severe hypothyroidism, also allows some insight. He seized
upon the hard facts: swollen legs, anemia, high cholesterol, hoarseness – all of them
concrete, perceptible, most of them measurable. He wouldn’t trust something as vague
as the patient’s looks. Ironically, this disregarded general impression, how the patient
looked, how she sounded, would have directed him to the only hard fact that mattered:
severe hypothyroidism.
The eagerness to know and use hard facts and measurable data is a natural consequence of a science-steered medical education. It is, by itself, a commendable development. Unfortunately, it has instilled, in most medical men so formed, a contempt
for facts that are difficult to measure: shape, configuration, relation between parts of a
complex whole, difference between what you see and the norm. Yet, that is how the
medical reality often manifests itself. The recognition of shapes may not be the only way
to know the reality, as the proponents of Gestalt psychology maintained, but it certainly
is an important one. By renouncing this ability, the “modern” doctor has given up an
important diagnostic avenue.
Such development has not been unavoidable. It can still be corrected. The fault
has been the teachers’ and they are now responsible for undertaking a remedial action.
The Ripe Pulsating Cherry. A “modern” doctor’s inability to see may amount to total
blindness: the most conspicuous abnormalities are missed, and as a result the patient
may lose his life.
The man was admitted to Nakskov Hospital on Lolland, Denmark’s southernmost
island, because of an unexplained fever. In the last two weeks he also had a nosebleed,
moderately profuse but incessant.
The patient presented a strange and disquieting sight. His cheeks and nose were
purplish-red due to hundreds of dilated blood vessels in the skin (the so-called telangiectasiae). A trickle of blood appeared from his left nostril. On his left ear lap there was
a ball-shaped hemangioma,96 the size of a ripe cherry, dark red, and visibly pulsating: it
expanded by about a tenth of an inch with the patient’s every pulse wave. Never before
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Hemangioma is a benign growth composed of blood vessels.
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had I seen anything like that. To complete the picture, the skin on patient’s upper chest
and above his collarbones showed dozens of spider nevi, the characteristic small blood
vessels’ dilations, each with a tiny elevated red central dot from which the blood vessels
radiated like spokes of a wheel.
We all gathered at the bedside of this patient: the head of the department Dr. S,
myself, and all the four residents. Dr. S had a penchant for performing – or ordering
– liver biopsies. Unexplained fever was one of the situations in which he tended to do
a liver biopsy as soon as possible. He did not say anything about what we saw, and
checked the items on his Liver Biopsy Protocol. The patient’s bleeding time, clotting
time, number of blood platelets and prothrombine time were normal.
Dr. S then turned to me and asked me to do a liver biopsy the very same day. “I
will not do a liver biopsy on this patient,” I said. S, clearly intent on avoiding argument,
immediately turned to one of the residents and said: “then G will do it.”
Neither was I eager to start a discussion. The patient had a flagrant widespread
abnormality of small blood vessels and already bled from a vessel in his nose. The liver
is an organ thickly packed with blood vessels of three kinds: the branches of the hepatic
artery, those of the portal vein, and the tributaries of the hepatic veins. To stick the very
thick biopsy needle into the liver of a patient with obviously defective blood vessels, and
harpoon a portion of the organ without direct visual control of the damage (and that’s
how a liver biopsy is done), would mean exposing the patient to an inordinate risk of
internal bleeding. If S – and, apparently, the other four doctors – did not see that, my
attempts to explain would be futile.
Half an hour after the biopsy an alarmed Dr. G came to me running. The patient’s
blood pressure fell from 120/80 to 90/70, and his pulse accelerated to 120 beats per
minute. We ran to the patient. He “felt weak,” was strikingly pale, his skin felt cold
on touch, and there were drops of sweat on his brow. “He is bleeding,” I said. At the
same time Dr. S, somewhat alarmed but resolved, entered the room. “No,” he said, “I
know the man, he is a neurotic.” I said, “Let’s sample his blood for hemoglobin, and
if it is significantly reduced, we’ll give him a transfusion and call the surgeon to open
the abdomen.” “It is unnecessary to take his blood now for hemoglobin. We shall do
it tomorrow,” said Dr. S, and left for a conference to be held in Nykobing Falster some
30 miles away.
As soon as the door closed behind Dr. S, I shouted to G: “sample the blood for
hemoglobin and start the transfusion, and I’ll call Wielandt” (the surgeon on duty).
“But the boss said...” “The boss saw the patient at 2 p.m. and the time is now 2:02 and
the situation, as it is now, requires surgery.” When Dr. Wielandt opened the abdomen,
and with a rake retractor drew the right costal arch aside, I saw a terrifying picture,
one that I hope never to see again. From a 2mm wide hole on the upper surface of the
right lobe of the liver gushed a forceful straight-lined jet of blood which hit the inside
of the costal arch some five inches away. In the abdomen there was a bucket of blood
in which the bowels floated.
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Quickly sewing-up the hole in the liver, and a massive transfusion of blood stopped
the disaster. Leaving the operating room I saw Dr. S telling the patient’s family that a
complication of a diagnostic test occurred, necessitating surgery. Somebody had reached
him at the conference and brought him back to the hospital. We never talked again with
S about this case. The patient had a malignancy (quite apart from his inborn defect of
the blood vessels), and the disastrous liver biopsy did contribute to a quick diagnosis.
Dr. G and his wife Merethe, a resident at radiology, met me at lunch and asked
rather anxiously, “Actually, on what grounds did you refuse to do the liver biopsy on
this particular patient? All the parameters required according to Liver Biopsy Protocol
were normal, weren’t they?” My answer was evasive. If they still did not know, what
sense did it make to attempt explanations? Dr. G was a very nice and particularly bright
young man whom I greatly liked. He was an avid reader of good books, and had an
exquisite taste in food, wine, and operatic music. I owed him an enchanting evening
of listening to records of Jussie Bjorling, the great and strangely moving Scandinavian
tenor. Dr. G just had the misfortune of having studied medicine at the wrong place at
the wrong time.
Laying Hands on the Patient and Allowing the Flow of Thoughts. A lean middle-aged
man came with his wife to my office in Lodz to thank me for my cure. “You put your
hand on my chest, and you said just one word: “Cedilanide” – and the next day I was
reborn!” (Cedilanide is a digitalis preparation related to digoxin).
What patients say about their doctors is not always true, but this story was right.
I had seen this man in a hospital where he remained some weeks after his myocardial
infarction, unable to walk, let alone climb the stairs. The doctors at that department
were baffled. “He is not in congestive heart failure – they said – there is no overfilling
of neck veins, no congestion of the lungs or the liver, no edema.”
Placing my hand on patient’s chest I felt a prolonged, heaving, “dome-shaped”
pulsation of grossly dilated left ventricle. The doctors at that hospital were right: this
wasn’t a congestive heart failure. It was, as my teacher Dr. Jakubowski used to say, “a
heart failure that begins and ends in the heart;” a failing heart which, however hasn’t led
to organs’ congestion. With that outstretched and flabby heart pump of his, the patient
was unable to do the slightest exercise. Luckily, Cedilanide did the trick.
Mr. K, 34, a cattle breeder by profession, came to my office in Den Bosch and said
that every time he had to chase a runaway cow he was getting quite exhausted and out
of breath having run some twenty yards and had to give up. This had been so for eight
years but was gradually getting worse. Respiratory function tests were done, the family
doctor, then an internist, and then doctors in a hospital treated him with medicines for
asthma but this didn’t help. Recently one of the doctors ordered an electrocardiogram,
it was “bad,” and the patient was referred to the cardiologist, that is, to me. Except for
varicose veins on the legs he had no other complaints, “has never been sick in his life.”
Yes, he had some “inflammations” of these veins, red spots, a bit painful, but every time
it was over in a few days. He had been “very fit, a real athlete” up to his late twenties.
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I examined the patient; he was in good shape, looking healthy, not breathless while
at rest. The neck veins were not distended. The lungs were normal on percussion and
auscultation. The apical impulse of the heart could not be felt below the left nipple,
which is normal in a well-built and well-fed adult. There were no palpable thrills in
the precordial area.
Then came the shock. When I placed my palm flat along the left edge of the patient’s
breastbone (as I always do), I felt my hand lifted almost half an inch at patient’s every
heart beat! Never before had I felt a right ventricular heave so powerful as this patient’s.
He had a tremendous hypertrophy of the heart’s right ventricle. I looked at that “bad”
electrocardiogram of his. It had been interpreted by an internist as “possible true posterior infarction,” but this was not so. The electrocardiogram was concordant with what
my hand felt. The right precordial leads, with very high R waves, delayed downward
turn, and deep negative T waves, indicated an extreme right ventricular hypertrophy.
But why did he have it? Congenital heart disease, chronic bronchitis and emphysema with obstructive lung disease, and South American parasitic Chagas’ disease could
be instantly excluded. The cause remained a mystery.
“Idiopathic” pulmonary hypertension, that is, a “spontaneous” thickening of the
walls of the small blood vessels in the lungs, obstructing the blood flow, and straining
the right ventricle, remained a possibility. But to assume that the disease is idiopathic,
that is, without a cause, must be the last resort. First, all efforts must be done to find
a possible cause.
There was nothing to get hold of, except for those varicose veins. All this time I
haven’t even considered any connection between Mr. K’s varicose veins and his breathlessness on chasing cows. Millions have varicose veins. And inflammations of superficial
veins, which may bother them but otherwise do little harm.
But how about his deep leg veins? When there are visible varicose veins, the deep
ones may also be dilated, with valves incompetent, which results in stagnation of blood,
and possibly clots?
I asked the patient a number of questions. He was not sure if he ever had a swollen
leg, or a painful calf. But he did admit that at least once, and perhaps twice, he coughed
up some bloody sputum. “It was so little he didn’t even tell the doctor.”
Now I knew. K had pulmonaryhypertension due to multiple pulmonary emboli.
Clots wandered from the veins in his legs to the lungs. A few caused local damage to
lung tissue resulting in bloody sputum. Other clots have obstructed so many branches
of the pulmonary artery that resistance to blood flow greatly increased, straining the
right ventricle of the heart.
I catheterized Mr. K. The blood pressure in his main pulmonary artery was
enormously raised, to 90mm of mercury (normally it is about 18mm, and should not
exceed 25). I injected the dye, and serial X-ray pictures were taken. In both lungs,
the branching of the pulmonary arterial “tree” was to a large extent amputated. The
majority of middle-sized arteries were filled with dye up to where their apparent diam-
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185
eter decreased to about 2mm, in some branches 3mm. Here the filling with contrast
abruptly stopped. The picture was typical of multiple arteries’ obstruction of emboli.
K was put on permanent anticoagulant treatment to prevent further embolization.
The damage already suffered could only be repaired by a double transplant of heart
and lungs, but since the patient had no symptoms at rest or with mild exercise, such a
heroic intervention wouldn’t be justified. He was advised to hire a farmhand and leave
to him the chasing of the cows.
For several years, four physicians groped in diagnostic darkness in this case. “Laying a hand on the patient” was not the only possible way to find out what was wrong
with Mr. K (A correct interpretation of the electrocardiogram would also lead to the
diagnosis). But it was the palpation of the chest that in fact provided the immediate clue.
Are there still doctors who palpate the chest? The British used to pay particular
attention to this method, and all of us who in the 1950s or 60s spent time at Hammersmith Hospital’s school of continued medical education, acquired and preserved the
skills. But how many of us are still professionally active? In North America, Sir William
Osler, and the clinicians of the next generation after him, notably Dr. William Dressler
of Brooklyn, New York (formerly of Vienna, Austria), and Dr. J. Willis Hurst of Atlanta,
Georgia, were masters in the art of palpation. They may have left disciples.
Understandably, palpation of the chest is not favored by “modern” doctors: it is
inexpensive, (seemingly) simple, and involves direct bodily contact with another person.
Perhaps they can be persuaded of its scientific merits: it utilizes two instruments of high
precision: the human hand and the human brain.
The Simple Task of Taking History.
Sir Maurice Cassidy, a true great physician and a great gentleman, taught me the value
of good history, and how to be exacting.97
Sir George White Pickering
The patient complains of pain or discomfort in the chest. He would be asked to
show where he felt it, and showing with a finger would be differently evaluated from a
flat palm or a fist. Questions would be asked: Is it painful? How long does such pain
last? A few seconds? A fraction of a second? A few minutes? Hours? Do you feel it
only in the chest? Where else? When did you get it for the first time? Where were you
then? At home? In the street? How often since? Does it hurt when you take a deep
breath? Does it hurt when you lift your left arm? When you turn while you are seated,
or when you bow? Or when you press your chest with your finger? Do you get this
pain while walking outside? Only then? Do you sometimes get it while at home? Do
you get it every time you walk outside, or not every time? Does cold weather or wind
make a difference? Does it make a difference whether you walk after a meal or before
eating? Do you get it only when you walk at a quick pace? Or only when running to
catch a bus or train? Or only while walking uphill? While climbing stairs? If not only
97
Sir George W. Pickering, Farewell address at his retirement as Regius Professor of Medicine, Oxford University. On file with the author and in the archives of Pembroke College and Radcliffe Infirmary,
Oxford.
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then, do you get it sooner under these circumstances? Can you avoid it by walking at a
slow pace? How far can you walk before you get it? When you get this discomfort, do
you stop in the street or keep walking? Do you have to stop? Does standing still bring
relief? How long does it take? What is “a short time” – ten minutes? Fifteen seconds?
One minute till it begins to ease down or till it entirely disappears? Do you have to stand
still on your way from home to the bus stop? Just once? (Questions like “do you get it
while shoveling snow from the driveway?” “while jogging?” “riding a bike?” “swimming?”
would be added, depending on time of the year and other circumstances). When you
were getting this discomfort while at home, at what time of the day was it? Was it after
a meal? How long did it last? Have you ever had it while in bed? Or immediately after
laying down? Did you have to sit up? Did this help? How soon? On how many pillows do you sleep? Since when on two? Have you ever tried nitroglycerin, the tablets
one takes under the tongue? Did you take them while at home or in the street? When
was it? How often? Did it help? How long did it take? What is “quickly”? Did the
pain subside before the tablet entirely melted? Why did you take nitroglycerin in the
street – did standing still bring no relief?
When we conclude from such interrogation that the patient’s symptoms are, or are
not, due to coronary heart disease, is this conclusion as reliable as one based on coronary
angiography plus thallium exercise test? Well, it’s comparable. Either approach allows a
conclusion which is highly probable if not infallible. The conclusion from history-taking
may be even less fallible than the other approach. After all, even if a narrowed coronary
artery is found at angiography, and the thallium exercise test reveals insufficient blood
supply to an area of heart muscle, the patient’s pain may still be due to something else,
e.g., inflammatory swelling of a rib at the bone-cartilage junction (Tietze’s syndrome).
Looking at a lady who complained of dizzy spells, and seeing that the pupil of
one eye was narrow and the other wide, which is a possible sign of neurosyphilis, I
would fall back upon the special method of inquiring about venereal disease. A central
or eastern European patient with a history of syphilis would never offer this information to just any doctor who happened to see her; and she would indignantly deny it
if abruptly asked. She would, in a guarded way but at least in part truthfully, answer
questions about various points that could be relevant to the subject: was she married,
did she have any children, how many, how old, and were they all alive and well, had
she had any stillborn ones, or born prematurely, and in which month of pregnancy, and
did some children die in infancy, and what was the cause; was her husband in good
health, and if not, what was wrong with him; had she ever had a rash on her skin, had
she ever had a cure of injections, when, how long did it take, was it penicillin; had she
ever had a blood test, what kind of blood test, and so on. While the doctor increasingly
demonstrated that he knew what questions to ask, a rapport was created, and finally
more direct questions could be asked.
Other People’s Lives: Reflections on Medicine, Ethics, and Euthanasia
187
The Bad Habits
The Questionnaires. Forty years ago I coined the phrase “organization is replacing
medicine”; the process has made much headway since then. Organization has even
encroached upon the most fruitful, the most refined, and, therefore, most vulnerable
work of medical art: the medical history taking.
Patients are handed printed questionnaires, the extent of which may vary from
specialist to specialist: some ask only about the patient’s allergies and present medication,
others purport to encompass the whole medical history. Questionnaires to be answered
by the patient are not the only way: more conscientious specialists (to be sure, rather
few of them) send a nurse or an intern to ask questions listed on a printed form, and
note the answers.
The procedure is not even remotely related to history-taking. The exacting, steered
questioning, the checking and re-checking, pursuing hypotheses, immediately abandoning them when disproved, overcoming the patient’s reluctance, unfocused attention,
tendency to sidetrack, “fighting that duel which we have to win in the interest of the
other part” – all this strenuous work is omitted. And the eyes of the intern who reads
the questions from a printed list, and writes down the answers, are fixed on the paper.
The patient’s facial expressions, his whole body language, his – sometimes all-telling
gestures which may directly lead to a diagnosis, all that is lost. The knowledge the
doctors miss will be compensated by more tests.
Practicing Medicine on the Phone. Can sensible medical advice be given over the
phone? Of course it can. In Den Bosch, while working within the system prevailing
in most Dutch hospitals (doctors on call, no doctor on duty in the hospital), almost
every night I gave phone orders to the coronary care nurses. These orders concerned
patients I knew well, usually one I had seen just one hour or two before that; and always
addressed a single problem: administering another dose of the painkiller, or injecting
the anti-arrhythmic drug lidocaine, or preparing the equipment for the insertion of a
pacemaker.
For such decisions to be permissible, there must be a doctor on the call who knows
the patient well; the problem must be narrowly defined; and there must be reasonable
certainty that the facts transmitted on the phone are correct.
Unfortunately, the present practice has rejected such restraints. The danger of
idiotic blunders looms over such proceedings. One morning in Nakskov, I was called
to see a patient with pulmonary edema (accumulation of fluid in the lungs due to acute
heart failure). Dr. G, the junior assistant physician, had seen him the preceding night
and described him as gasping for breath and coughing, with coarse crackles audible
over the chest. Dr. G had a phone consult with the head of internal medicine Dr. S,
whereby the diagnosis of pulmonary edema was established and appropriate treatment
was instituted: sitting posture, nasal oxygen, digoxin, and intravenous diuretic.
At patient’s bedside I thought at first that the nurse led me by mistake to the wrong
man. He ran a fever, and I saw on his chart that the preceding night he had made a
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temperature peak at 105.8°F. Yes, he shivered last night, and his teeth chattered. Then
he had an attack of cough, difficulty with breathing, and something gurgled in his chest.
Finally he coughed up a mouthful of thick yellow sputum; this brought relief.
On the right side of his chest there was a scar typical of rib resection, as is done
in cases of empyema (pus in the pleural cavity). Yes, eight years before that he had
pneumonia with such complications that a piece of his rib had to be excised. I looked
at the X-rays. In the lower lobe of the right lung, bordering on a grossly thickened
pleura, there was an oval shaped cavity with fluid.
I stopped the oxygen, the diuretic, and the digoxin, and ordered postural drainage:
keeping the patient lying on his left side, with hips elevated, to facilitate the flow of
pus. I also ordered bacteriological examination of the pus and referred the patient to the
thoracic surgeon. A few hours later Dr. S stopped me in the corridor: “You changed my
orders! You put the patient in bed, head down! Patients with pulmonary edema must
be kept seated!” “Absolutely,” I said, “But this man does not have pulmonary edema.
He’s got a lung abscess.” “I diagnosed acute pulmonary edema in this case,” said S. “You
diagnosed it on the phone,” I replied. “It’s all the same, on the phone or not,” said S.
“Oh no, it’s not the same,” was my reply.
Fluorescent Lights in the Examination Room. I don’t feel happy entering the “modern”
doctors’ offices or modern hospitals’ examination rooms. I even get quite angry with
the doctors who agree to work there. Often these offices don’t have windows at all; or
else any window that does exist is curtained with blinds, in a misguided attempt to
protect patients’ privacy (though only from a helicopter dangerously approaching the
building would anybody be able to peep into that room). The premises are lit with
fluorescent lights.
These doctors do not need daylight. Yet, pallor, cyanosis (blue coloration), the
brown skin of Addison disease (adrenal insufficiency), the tawny color of patients with
chronic uremia, the café-au-lait tinge of patients with subacute bacterial endocarditis,
the silvery skin glow of argyrosis (chronic silver poisoning), and, in general, the healthy
versus unhealthy looks cannot easily be discerned in artificial light, and jaundice is
altogether missed. With electric light, moderate jaundice does not show at all, and the
skin of a patient with severe jaundice appears swarthy, but not yellow.
Invariably I hear this answer: “You want to see jaundice but we would rather have
hard figures” (meaning, of course, the blood level of bilirubin; jaundice, the yellow
coloration of the skin and of the whites of the eyes, appears when there is an excess of
bilirubin, bile pigment, in the blood).
But will you have your hard figures? Do you always order a determination of bilirubin level in the blood? Would you ask for bilirubin level if the patient’s complaint
is breathlessness?98
No Need For The Doctor To Be There. Somebody said tartly: “In the past, a patient
could die with the devoted family doctor holding his hand; now he can be cured by
98
See the case of acute hemolytic anemia in Chapter VIII, “Medical Diagnosis is a Job Like Any Else.”
Other People’s Lives: Reflections on Medicine, Ethics, and Euthanasia
189
an expert residing hundreds of miles away.” True; but the quip does not tell the whole
story. There are times when the presence of physician can make all the difference.
The traditional physician was there when the patient was admitted to the hospital
and orders had to be given pertaining to the patient’s nursing, eating, drinking, I.V. line,
tests, medication, etc. Now the “modern” physician is nowhere in sight while the frightened, confused, and deadly tired patient is tossed about among eight or ten “members
of the team” who are supposed to know what to do with the patient but don’t, “haven’t
had any orders yet,” and anyway would be only interested in small points such as “what
d’you order for tomorrow’s lunch?” or “will you rent the TV?”
The traditional physician was there, in the hospital, and came at a run when the
patient needed urgent help. The traditional physician could be reached on the phone
whenever a patient was having some alarming symptoms at home, or needed a clarification, or just felt lost and helpless. These are still the ways of top Boston specialists
who keep up good clinical traditions. It is different with “modern” doctors. After hours
of fighting the secretaries, the answering services, the paging operators, and listening
to unwanted music you may obtain a promise that “the doctor will call you back.” By
the way, have you noticed that the secretaries of traditional clinicians make every effort
to get you in touch with your doctor while the secretary of a “modern” doctor is there
to prevent you from reaching him.
The Importance of Organization: The Proper Channels. One evening in 1993 I was at
one of Boston’s great hospitals at the bedside of a family member who was very sick with
cholangitis, a grave infection in the bile ducts. She had been admitted with a fever of
103°F., but under a tremendous array of intravenous antibacterial drugs, gentamycin plus
amoxcillin plus metronidazole, covering almost the whole spectrum of possible infectious
agents, the body temperature fell considerably, which indicated that the infection was
subsiding. That evening, however, after 72 hours’ treatment and with all the antibiotics still running in full dosage, the patient’s body temperature suddenly rose to almost
106°F. A new and extremely high peak of fever meant, under the circumstances, that an
infection had supervened caused by a microbe not covered by the hitherto administered
antibiotics. Such new severe infection occurring under a broad-spectrum antibiotic
treatment in a hospitalized patient who has an intravenous line, is most often due to a
bacterium called Pseudomonas aeruginosa. This is an emergency because Pseudomonas
in the bloodstream may be quite deadly. Blood culture must be done immediately, and
an antibiotic to which Pseudomonas is sensitive must be given. The time was 9 p.m.;
I called the resident on duty and told him clearly what was happening. The resident
admonished me; he sounded like a schoolmaster reaffirming his authority. “You may
tell the nurse,” he said, “and if she finds it necessary she will tell the intern.” By the
way, the nurse could not be directly reached: the bells were answered by personnel who
might (or might not) call a nurses aide. I called their boss, Dr. Friedman, and reached
him at his home. A blood sample was immediately collected and, without waiting for
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the culture’s findings, an intravenous antibiotic against Pseudomonas was started. The
next day the blood culture confirmed the diagnosis.
But that senior resident responsible for patient care! An alert man, he vigorously
reacted to the dangers, the improper sources of information, bypassing the channels,
breaking the chain of command! There was only one piece of news to which this doctor
did not react at all: the information that a patient suddenly got a fever peak to 106°F.
The Fear of Human Link. In Leiden, a young patient with valvular heart disease
was to be referred to a dental surgeon for the extraction of a few infected teeth. She
was a country girl frightened by the hospital, afraid of all examinations and procedures.
“Don’t be afraid,” said the young intern, “you’ll get a shot to make your jaw numb, and
it won’t hurt at all. And I’ll stay with you during the procedure.”
“No, you won’t,” said Dr. O, the resident, when we left the room. “This would
create the appearance of a personal, perhaps emotional involvement in the case, which
is unacceptable. It would make the patient emotionally dependent on you.”
“Go with her,” I said to the intern, “if you think she needs you.” All my life I used
to accompany my patients, whenever I could, to the examinations and procedures performed by other doctors. I wanted to watch the specialist at work and so improve my
own skills. I was curious to know the result of the examination, and I hoped to grasp
it better by attending the procedure. And I felt responsible for my patient’s well-being
and safety. Over the years, it occurred several times that I intervened, restraining a
perfectionist surgeon from doing too good of a job. At least once I regretted not having intervened. I perfectly understood the intern’s initiative. But these were not the
ways of Dr. O. Here was a terrified human being craving for our support, and instead
of lending a helping hand, Dr. O resorted to theories! He apparently had heard this
nonsense expounded ex cathedra.
If I must not become involved with my patients, suffering people who trust me and
need my help, what am I supposed to be involved with: sports or politics? I recalled
that stupefying laughter in the X-ray room whenever a cancer was revealed.99 It was an
obscene manifestation of the “noninvolvement” attitude.
The Prophecies. The mother of a nationally known statesman died in New York at
the age of 97. A resourceful lady, she had been, in the words of her son, “the practical
one in the family.”
Several years before her death, a fall in the kitchen left her unconscious. After some
time, the doctors wanted to remove her life-support. Her son wouldn’t let them do it.
“Even if she recovers somehow,” argued the doctors, “she would be unable to think or
speak.” The statesman replied: “You don’t know my mother.”
Days later, the patient awoke and asked her son: “What day is it?” When he told
her it was Tuesday, she said: “Cancel my 10 o’clock dentist appointment.”100 She still
had some good years left.
99
100
See Chapter XI.
Paula Kissinger, 97, BOSTON GLOBE, Nov. 17, 1998, at B11.
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The statesman proved, also on this occasion, a sensible and alert man. But what
do you think of those doctors?
They knew what would come, and they knew it in details and for sure. And they
were in a hurry to act accordingly, to hasten the old woman’s death.
Socrates was of the opinion that virtue and wisdom were the same thing. Evil, we
might add, is often inseparable from stupidity.
Shaking Off the Old Worries and Fears.
If you are not worrying, you loose your mental edge.
Steve Redgrave101
One of the differences between medicine as it was practiced forty years ago and
today is that in those times we used to worry much more than today’s doctors do.
In some “modern” Dutch hospitals, the new manners can be easily perceived:
doctors and nurses whistle in the wards. Whistling is heard while a doctor tries to listen
to a patient’s heart, it interferes with a nurse’s efforts to calculate the correct number of
drops of the I.V., it resounds over the heads of worried families and in the ears of the
dying. Doctors and nurses manifest their disengagement.
We did not whistle in the hospitals, it would have been unthinkable. Our mood
could be relaxed in the doctors’ room, but whenever we entered the ward, our attitude
was outwardly – and inwardly – one of serious concern.
Sometimes our timidity put the patients at a disadvantage. Patients were kept in
bed for at least a full week after almost any surgery, and often much longer. We were
afraid of letting the patients walk with unhealed surgical wounds. However, a long stay
in bed exposed them to the risk of muscle and bone wasting, difficulties with urinating
(and infections from bladder catheters); and, most importantly, the slowed blood circulation led to the formation of clots which could travel to the lungs with grave or even
deadly consequences. Today’s practice of getting these patients out of bed the very next
day after surgery may be quite painful for some but is, as a rule, safer.
We knew from microscopic studies that when a myocardial infarction occurred,
that is, a portion of the heart muscle was deprived of blood and died, the formation of
a scar, the hardening which reinforced the damaged heart wall, took from six to nine
weeks. Therefore, every patient with myocardial infarction was kept in bed for a full
six weeks, at absolute rest. We wouldn’t let them move, afraid that the weak spot might
burst or bulge. The patients had to suffer the repulsive and humiliating procedure of the
bedpan, and risked all the complications of prolonged stay in bed. Many developed a
painful and disabling condition, the stiff shoulder joint.
Two Bostonians, Dr. Samuel Levine and Dr. Bernard Lown, dared to try a different
approach. They showed that early mobilization, allowing the patients to be seated from
the second day and soon to walk, did not significantly increase the cardiac risks and
avoided the annoyances and dangers of prolonged bed rest. At first most doctors were
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Steve Redgrave, TIME MAG., May 20, 1996, at 22 (British Olympic gold medalist).
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reluctant to join the revolutionary movement, but ultimately hospitals all over the world
switched to the new method. It was an enormous relief for both patients and doctors.
This time, worrying less proved the better way.
Another manifestation of change was the introduction of an exercise test as a diagnostic tool in cardiology. The test is being done as follows: we let the patient exercise on
a standing bike or a treadmill, gradually increasing the difficulty. The patient is closely
watched, the blood pressure is checked at regular intervals, and the electrocardiogram
is continuously recorded. It can be combined with a thallium scan of the heart. Usually we stop when one of the “end points” is reached: total exhaustion of the subject,
typical chest pain of angina pectoris, or ECG changes showing insufficient blood supply
to the heart muscle.
To perform an exercise test was very much against the intuition of a traditional
doctor. It meant to knowingly provoke a painful and potentially harmful condition, to
elicit that cry of warning, the chest pain, and the ominous ECG changes. The whole
idea seemed contrary to our cardinal rule, primum non nocere, first of all, do no harm.
Indeed, I had to overcome some reluctance before I started doing exercise tests in 1969.
Some years later a friend, Dr. Marek Edelman, a talented doctor of the traditional cast,
was visibly and disapprovingly surprised when he saw that I was doing the exercise tests.
But the rule to do no harm is not absolute. We do some harm if we are convinced
that the gains for the patient clearly outweigh the harmful effect: we do cut open the
patient’s abdomen to remove an obstruction of the bowel. Exercise tests are used to the
patient’s advantage. While it is not the gold standard in the diagnosis of coronary heart
disease, it is a useful step. The test helps to decide whether to proceed to the invasive
study, or adopt a wait and see attitude. It also helps to decide whether a patient’s treatment should be continued, stopped, changed, or intensified. The traditional doctors
were disgusted with the idea of exercise tests because, in their considerations, they
stopped at the intentionally provoked harm. They were not yet familiar with the gains.
Clearly, we now dare more than forty years ago. But has the pendulum swung
too far? Indeed, some of the liberties now being taken with the patients are neither
reasonable nor safe.
Moving the patients early in the course of an acute illness or directly after surgery,
from hospital to home, from one hospital to another, from one country to another, and
not on a medical indication like moving someone to a specialized center, but for reasons
unrelated and sometimes trivial, is something that now occurs daily, and was not done
when medicine was practiced the traditional way.
A lady was admitted with acute chest pain to my coronary care unit in Den Bosch.
Having spent just twenty minutes with us, and told that she was having an acute myocardial infarction, she demanded immediate transfer to a hospital in Eindhoven where
it would be easier for her family to visit her. In Holland nowadays, a doctor’s warnings
carry little weight with many patients. The simple truth that patients come to the hospital to be under medical care, and only in second place to receive visits, cannot be told:
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it would be laughed at. Fortunately for the patient, her trip, made in the second hour
of acute myocardial infarction, at the height of the danger of ventricular fibrillation,
was uneventful. That something succeeds once, or five times, does not prove it would
succeed every time.
An American doctor of my acquaintance was admitted to a hospital in Maine with
a moderately severe stroke. The left side of his body was paralyzed. He was fully conscious, could speak and demanded to be transferred to “his own” hospital. There was
a reason to do that: the patient wanted to come under the care of a colleague who had
treated him previously and knew him well. Yet most traditional clinicians would refuse
to move this patient; I certainly would refuse to do that. We had the feeling that when
damage occurred to such vulnerable and immensely precious tissue as the brain, one
should not shake or stir the patient for some time. However, the doctor who admitted
the patient complied with his request, and up it went: from bed to stretcher, then in the
ambulance, with some bumps along the road, then stretcher again, and again to bed.
Soon the patient lost consciousness and some hours later he stopped breathing. I don’t
know whether all this shaking and stirring contributed to the extension of the patient’s
cerebral infarction and the death of this excellent man. Since I visited Dr. George White
Pickering’s lab at Radcliffe Infirmary, Oxford, I have known that our fears, and reluctance to move such patients, have been well founded. In live rabbit brain preparations
which Sir George’s assistant let me see under magnifying glass, I watched how within
seconds a white clot of platelets formed beyond the narrowing of a blood vessel; and I
saw how extremely fragile such a fresh clot was, spraying particles into the blood stream
almost all the time. When a larger part of the clot broke off, it was propelled by blood
stream to the vessel’s nearest bifurcation and occluded it, cutting off the blood supply
to a sizable portion of brain tissue. The danger of “shaking” such a fresh clot was pretty
obvious. Some movement in bed is unavoidable, but transporting the patient involves
much more commotion than that.
A 23 year old female student of Leiden University, a member of Holland’s national
rowing team, was admitted with severe myocarditis, an inflammation of the heart muscle
due to a viral infection. The patient produced a whole array of cardiac arrhythmias,
irregularities of the heart beat, and some of these were of life threatening variety. She
recovered, and was very much taken aback when I told her that she should very gradually expand her activities and that in the coming months we would repeatedly check
her condition and several times she would be asked to wear a portable device recording
her heart beat round the clock. The point is that recovery from myocarditis may be
incomplete; threatening arrhythmias may recur.
Then I had an argument with Dr. O, the head of intensive care, and himself a keen
athlete. “There is an international rowing competition seven weeks from now,” said he,
“and our patient must know whether she may resume her training and then make the
trip and take part in the contest. Let’s give her a maximum exercise test and see how she
would be doing.” Dr. O was not as much worried about the danger as I was. During
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the exercise test the patient’s electrocardiogram would be continuously monitored. If
the exercise elicits no arrhythmias, we would allow the girl to resume training and send
her to Montreal with our blessing. If serious arrhythmia was provoked, we would stop
the exercise and, if necessary, restore normal heart rhythm with intravenous drugs or
electric cardioversion. If it came to the worst, resuscitation was available.
I was less optimistic. First, the predictive value of the exercise test is limited.
The patient may pass the test and yet suddenly die while rowing. Besides, continuous
monitoring gives the patient optimal chance, but not a 100 per cent guarantee of safety.
There still was some risk of dying of an exercise-induced arrhythmia; this would be a
death of our doing. “Be reasonable,” I said, “people should not risk their lives for the
sake of an athletic event.”
“But don’t you realize,” replied Dr. O, “that you try to impose your own values
on another person? Competitive rowing, representing the country at an international
competition is her life. She does not mind taking a risk for that.”
“I don’t think I’m imposing anything on her. I’m protesting against our involvement.
I must remind you that after severe myocarditis any other patient, not an oarswoman of
the national team, would be closely followed for at least half a year, and advised to limit
her exercise, while we would repeatedly record her for 24 hours’ ECG. Why are you
willing to waive our rules for this patient? Does an Olympic oarswoman not deserve
the same care and protection as any other person?”
I won.
But I lost another case. The owner of the fanciest butcher’s shop in Den Bosch, a
bright, handsome man, full of energy, suffered a bad myocardial infarction after which
he was left with a heart twice the normal size. Putting the examining hand on this
patient’s chest one could feel the tremendous pulsation of the dilated left ventricle. On
auscultation there was a gallop sound of the ominous kind. Looking at this heart on
the catheterization film, and seeing how little blood the distended left ventricle expelled
with each beat, one felt the urge to place the patient on the list for heart transplantation.
He had no symptoms at rest or with very light exercise, thus, for the time being transplantation was not justified. I adopted, therefore, a wait and see attitude.
The patient, however, was not satisfied. He wanted to resume his favorite activities,
playing handball, volleyball, and running three miles. He was increasingly impatient
and argued that “according to medical science” physical exercise would do him a lot of
good. After three or four talks I had to tell him: “Look, I told you many times what I
think. With a heart like yours, you should be content with walking. Anything more
than that is not good for you and is dangerous. I cannot change my opinion, but you
can change your cardiologist. If you insist, I’ll refer you to another doctor.” He did insist.
In my letter of referral I provided all the findings and clearly stated my opinion. In the
other hospital the patient was included in a revalidation program, and exercised in the
gym with gradually increasing load, under close supervision and ECG-monitoring. He
died after three weeks. Of course he might have died anyway.
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Sometimes I wonder if those doctors who worry less, and dare more than we used
to, simply don’t care.
Chapter XIII. Farewell to Clinical Medicine?
My Left Kidney. I recently complained of pain in my left side; it appeared during a
urinary infection, and recurred four months later. I examined myself as well as I could,
and told my HMO internist that I had palpated the lower pole of my left kidney, that
it was tender, and that squeezing the organ reproduced my complaint. I was not really
worried, that is, didn’t think of a tumor; if the pain were due to a tumor, why should it
appear during a urinary infection, or disappear for several months? I rather thought of
a cyst, or an impairment of the outflow of urine with, as a result, hydronephrosis, that
is, overfilling of the kidney’s urine-collecting spaces, distending the organ. I asked the
doctor if he would consider examining the kidney with ultrasound. I told him that I duly
identified the kidney by its rounded, slightly flattened shape, resiliency, “ballottement”
between the two palpating hands, and typical mobility with respiration.
The doctor gave me a long look, as if I were telling him I was seeing ghosts. Then
he patiently explained to me that “palpation of kidneys was a method of low sensitivity”;
that what I had felt could have been the colon, or anything else; and that the kidney,
being situated outside the peritoneal cavity, could not move with respiration.
All these explanations were complete rubbish. When a positive finding is claimed,
the sensitivity of the method is not in question. Colon, being felt as an oblong soft wad
without palpable lower end, cannot be mistaken for a kidney. The site of organs within
or outside of the peritoneal cavity has nothing to do with their respiratory mobility.
Organs move with respiration if they are attached to the diaphragm, as is the liver, or
if they are loose in their bedding as are the spleen and kidneys, and the movement of
the diaphragm pushes them down when the subject is breathing in. It is respiratory
mobility that enables us to palpate the kidney.
Thus, each of us knew for sure that the other was talking nonsense. Having denied
the value of kidney palpation, the doctor nevertheless tried to do it. He told me not
to breathe deeply, and several times poked the left side of my belly with the tips of his
outstretched fingers. The maneuver could not serve any purpose, either in medical
examination or otherwise. It certainly could not be used to palpate a kidney. Finding
nothing, the doctor said: “No ultrasound is needed, but since you are a physician, and
ask for it, I’ll order it for you.” The ultrasound revealed a hydronephrosis.
The ineptitude of my HMO internist in his attempt to examine my kidney is, alas,
no exception; it is now the rule. It is the sad consequence of the fact that medical men
and women no longer learn the art of medicine from experienced physicians.102
A master would show them how to position the patient and how to teach the patient
diaphragmatic breathing; how to warm up the examining hand and place it flat on the
patient’s skin; how to exert delicate pressure, avoid eliciting muscular defense, run the
hand first cursorily around the abdomen, check the points that give clue to disease of
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See Ch. VII, The Medical Mind, subd. “Learning Medicine From a Master.”
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the appendix, of the gall bladder, of the colon; how to slip the hand off to check for
peritoneal irritation, and then set about examining each particular organ. He will explain
to the student what he feels under his fingers, will verify his findings, confirming that
this round shape, moving with respiration, is the distended gallbladder, and the soft
touch he’s felt, yes, is the spleen.
Nowadays, this kind of instruction is rarely given and even less frequently requested.
Since I moved to the United States I’ve had the opportunity to watch more than a dozen
American doctors trying to examine the abdomens of their patients. It was a sad picture
every time. They exerted rather brutal pressure with one or both hands, here and there,
without a slightest chance to identify any of the abdominal organs; determine their size,
shape, or tenderness; reproduce the patient’s complaint; or check the classical signs of
disease.
I would respect these colleagues more if they refused altogether to touch a patient’s
abdomen and relied exclusively on CT scan, etc. Such a decision can be criticized, but
it can also be defended. But no, they tried to do the examination of the abdomen, so,
they recognized its importance, yet had not the slightest idea how to do it.
There have been in mankind’s history arts and skills that fell into neglect and
oblivion, but clinical medicine has been the first one to be jeered at, scientifically refuted,
and buried with relief. Studies have been published showing that history taking did not
contribute to diagnosis and was a source of errors, and that palpation of the abdomen
was devoid of diagnostic value and misleading. These studies were initiated in the new
era, when clinical methods had already fallen into neglect. The subject of these studies
was history taking and palpation of the abdomen as performed by “modern” doctors
who had never learned how to do it. What they studied was their own ineptitude.
Which Test Shall We Order? Some years ago in Leiden, at Holland’s most venerable
university, at the weekly conference of the department of cardiology, one of the residents
presented a patient as a candidate for coronary angiography. The patient, a man of
35, “complained of chest pain,” said the resident. The routine electrocardiogram was
normal, the lab findings were unremarkable, and the exercise test gave ambiguous
results. Coronary angiography, introducing a catheter to the aorta and injecting dye to
the patient’s coronary arteries, was necessary to determine the cause of the pain.
“Wait a minute,” somebody said. “I talked to this patient, and his complaint is
not in the least suggestive of coronary heart disease. The man never felt any pain or
discomfort behind the breastbone, never had any symptoms while walking or riding
his bike, never had to stand still in the street. He complains of sharp ‘stings’ of a very
short duration, just one second or less, localized somewhere at the left side of his chest,
and occurring at rest, mostly when he is in bed. I would think of painful premature
ventricular contractions. There is no reason to do coronary angiography. Give him a
Holter” (a portable device for round-the-clock registration of heart rhythm).
That resident was simply a fool. Still, he had gone through medical studies,
successfully passed all exams, started a specialist training; and in all those years of
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intense, science-oriented schooling it was never impressed on him that one could talk
to the patient, ask him questions, and try to get the gist of the matter. Thus, he catches
– not even a complaint, but what he mistakes for the patient’s complaint – and rushes
to do invasive tests.
Who Has Read Your Ultrasound? A few years ago in Boston, someone in my family
noticed a growth in his mouth, on the upper jawbone, and consulted an ear-and-throat
specialist. The doctor ordered an ultrasound, and said that the tumor could be malignant,
and that the extent of surgery would depend on intra-operative pathology findings.
Perhaps the right halves of the jawbone and palate will have to be removed.
I looked into the patient’s mouth. There was a growth the size of a large plum. It
was as hard as a stone. My heart sank. Was this honest, hardworking man, in his early
forties, fresh in the new country where his child had just been born, going to have a
terribly mutilating surgery, with very uncertain result? The tragedy of it struck me.
The one good thing was that the gum’s and mouth’s mucosa was intact; this was a ray
of hope. I called a friend in Iowa City, Dr. Janusz Bardach, the excellent head-and-neck
surgeon whom I knew from Lodz, and asked him to recommend somebody in Boston.
“Go to Dr. Mackenzie at the Mass. Eye and Ear Hospital,” he said, “he is the best of
them all.”
When Dr. Mackenzie entered the room where we all gathered, he said to me: “I have
shown your son-in-law’s ultrasound to the radiologist; and not to just any radiologist
but to one that really sees what there is on an ultrasound” (Hurrah! I mentally shouted,
you are my kind of doctor!). “This is a cyst originating from an infected tooth. We shall
resect it. No danger.”
How Should the Aorta Look on Translumbar Aortography? Clear X-ray images of
abdominal aorta are obtained by puncturing this great vessel and filling it with dye. It
turns out that caution is called for – not only while puncturing the aorta but also when
interpreting the images. While in Den Bosch, I received a call from Paris, from my old
friend Joe F. He sounded worried and downcast. Our mutual friend and high school
classmate George K. was admitted to a hospital with a gangrenous toe. The toe was
amputated, then some nerves were cut (lumbar sympathectomy) in the hope this would
improve the blood flow to the foot; but now the vascular surgeon told the patient that
another surgery was necessary, a huge and risky intervention involving the body’s main
artery. George wanted a second opinion; could I quickly come?
Since his early youth George had insulin-dependent diabetes, and in the last decade
complications began to appear. He had previously lost another toe; he also underwent
several laser treatments for his eye ailment, the diabetic retinopathy. I found him in
one of these small private clinics Frenchmen until recently preferred for the homey
ambiance and the purported personal attention to every patient. Unfortunately, the
quality of care at these clinics not always equals that offered by the great Paris hospitals.
The vascular surgeon who attended to George seemed a distraught man. He could not
find the X-rays he wanted to show me, shouted at the clerk and threw his arms about.
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Finally the X-rays were found and the doctor explained to me what he proposed to do.
George’s translumbar aortography showed an abnormally thin abdominal aorta; instead
of 2cm, the width barely reached 1.5-1.6 cm. The aorta, filled with iodine dye, looked,
indeed, unusually slender. “It must be the plaques breaking off this almost-clogged aorta
that block the toes’ arteries. I am personally involved in this patient,” said the doctor, “I
know George socially and like him very much, and he’s a bridge partner of my father’s;
but I see no other solution than to replace the whole abdominal aorta including the
bifurcation.” The renal arteries would have to be replanted into the graft. This was an
enormous surgical enterprise and the risk was great that the patient wouldn’t survive it.
There were no solid grounds for such intervention. I tried to bring the man to
his senses without offending or overly irritating him. “Cher confrere,” I said, “your
idea is quite logical” – here I made a pause – “but with an aorta so heavily lined with
atherosclerotic plaques one would expect a murmur to be heard at the abdomen and the
femoral arteries, and perhaps a reduced pulsation of one femoral or both. There is no
murmur and the pulsation is good. Also – let’s look again at that aortography – there are
no bumps on the aorta’s contour, actually, the walls are nice and smooth. So, this aorta
is very narrow, but is it atherosclerotic? Can it just be an individual variant?” “Mm . .
. I cannot exclude that,” said the doctor. “And we must also admit,” I continued, “that
there are other possible explanations of George’s toe gangrene. Can he have the affliction
so common in diabetics, the narrowing of small arteries supplying blood to the toes?”
“This is a possibility,” agreed the doctor. We refrained from the great surgery. Instead,
the patient received a prescription for one tablet of aspirin to be taken every day.
The New Untouchables. I closely watched a gravely ill patient during her three
week stay in a large hospital in the Boston area. Four doctors attended to her: a
gastroenterologist specializing in liver disease, a urologist, and two residents. They used
to spend some time in the recess behind the nurses’ station, studying the charts and
the laboratory and ultrasound reports. Almost every day one of the doctors came to
the patient’s room for a short talk. In the three weeks of this patient’s grave illness, no
doctor ever touched her. She was treated with an array of antibiotics, and could become
allergic to one of these, but not once has anybody looked at her to see if she was having
a rash; not even the nurses did. Nobody looked into the patient’s mouth to make sure
she wasn’t developing the white patches of that common fungus, the Candida albicans.
Nobody ever checked if this almost completely bedridden person was developing
low-back edema, bedsores, or a heavy calf due to a clot in a leg vein.
Four doctors were involved in the case, but it took a family member to notice a
swelling at the patient’s legs. The edema necessitated an immediate modification of her
treatment, which was promptly done; but this important sign would have never been
discovered by the four medicos. They ran around pondering scientific problems, but
would not deign to touch a patient’s ankle. In the view of these doctors, touching a
patient’s body was unscientific, unhygienic, and unnecessary.
Is a “Physical” Once a Year Good Enough? Let me tell you the story of a young patient.
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He was a doctor himself, my classmate from the medical school, amiable, handsome,
slight, and almost girlish in appearance. He had just taken up his first job, at a psychiatric
hospital some fifty miles from the city, and used to come home to Lodz on weekends.
That Saturday he arrived carrying a large sack of apples. He climbed the four flights of
stairs, put the sack on the floor in the living room, sat down on a chair, and suffered a
stroke which deprived him of speech and paralyzed the right half of his body. He was
admitted to the department where I was a resident. The cause of a stroke in a young
man of 28 was a mystery. His blood pressure was normal. He had no valvular heart
disease nor a heart rhythm disturbance that might be a source of clots traveling to the
brain. There was a distinct possibility that he could have an aneurysm, a balloon shaped
dilatation of a brain artery which could have burst causing bleeding. A neurosurgical
exploration had to be considered.
But just then, on the fifth day, while examining the patient’s body as I did every
morning, I found a nodule, a small knob in his skin under the left shoulder-blade. It
was 1/5 inch in diameter, flat, grayish, rather hard, and accreted to the skin. One could
have dismissed it as a cosmetic fault without importance – except for the fact that it
hadn’t been there the preceding day!
I immediately did a biopsy and sent it to the lab. The nodule consisted of cancerous
cells. The consultation with the brain surgeon was called off. The patient died quietly
three weeks later. At the post-mortem there was a cancer of the liver with a large
metastasis to brain’s left hemisphere, and bleeding into that secondary tumor. The
daily physical examinations did not cure the patient, but spared him the burden of an
invasive investigation.
Ars medica tota in observatione, “the medical art, all of it, lies in observation.” The
course of treatment for a hospitalized patient should be carefully followed. Never be
satisfied with what you ordered, planned, and conceived. Check every day, and, if needed,
every hour, what is really happening. To achieve such control, tests may be necessary,
e.g., daily blood tests under chemotherapy, but questioning the patient, and the daily
examination of his body, are indispensable. When this work is neglected, downhill
course of the disease, complications, ineffectiveness of treatment, important side effects
and drug allergies are missed or recognized with harmful delay. No test discovers skin
rashes, swollen legs, or bedsores.
All my life I followed the clinical rule that a hospitalized patient must be completely
examined on every single day. “Modern” medicine has abandoned this superstition. Was
it cost-effective? I don’t know, and it did not matter. To be sure, the findings were often
worth our while. In a bedridden patient who ran no fever, crepitations at the base of one
lung warned us of a pneumonia. Pasty edema at the small of a patient’s back, able to be
indented with the examiner’s finger, revealed a beginning heart failure. On the next day
after the admission of a febrile patient, a sparse rash on his trunk and abdomen, and a
palpable soft spleen turned the diagnostic search in the right direction: toward typhoid.
In a child with rheumatic fever, a faint new heart murmur, which yesterday hadn’t
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been there, showed that a heart valve was affected. When patients were admitted to the
coronary care unit with chest pain, normal blood enzymes, and ECG abnormalities that
did not quite fit the “coronary” pattern, I would inquire whether the pain was aggravated
by breathing in, and listen to their hearts every few hours; at one of these examinations
I would hear that characteristic rustle, the pericardial friction rub. The patient had
pericarditis, could be moved from the coronoary care, and given aspirin for his pain.
People are stricken with alarming or truly life-threatening illnesses while in theaters,
on airplanes, boats, beaches, or on a photo-safari in Masai Mara. When the cry resounds
“Is there a doctor on this plane?”, it’s bad luck if a doctor is there but cannot help the
patient because he is unable to diagnose paroxysmal supraventricular tachycardia without
electrocardiogram or a collapsed lung without X-rays.
The only honest and effective way to make American health care more accessible
and less expensive is to increase the number, and enhance the role, of primary care
physicians. The diagnosis of most patient’s problems should not be deferred to the time
when they are seen at highly specialized departments. High quality care should begin at
the family physician’s office. The means at his direct disposal: history taking, physical
examination, and thinking, should be put to full use.
Unlike the “modern” doctors who seem to believe that their science is finite and
infallible, we viewed medicine as a never-ending quest, an imperfect knowledge full of
gaps. A life-long study, a continuous effort at self-improvement were the only way to
avoid too many errors. We never organized our time as efficiently as “modern” doctors
do. We never felt that any length of time spent at the bedside, on physical examination,
was a waste: it was learning, training in an important skill.
While we were at it, we noticed after some years, an unexpected bonus: patients
appreciated our attention, the unhurriedness, our readiness to touch them, our skill
and mental concentration while doing the physical. Confidence and close mutual bond
evolved.
Farewell to Clinical Medicine? There are two main reasons for which the “modern”
doctors tend to do only perfunctory questioning and physical, or skip the latter altogether,
and quickly proceed to do “the tests.”
One of these reasons is cowardice. Doctors are reluctant to undertake the tremendous
task of facing a sick person who may have a grave and difficult problem, and has a claim
upon doctor’s full attention and sincere effort. One must intensely try to establish the
facts, to understand and clarify, then find a solution, or at least propose a reasonable
next step, all the while keeping one’s composure. The encounter may leave the doctor
utterly exhausted. Almost every physician has experienced, once in a while, the feeling
that to see another patient would be beyond his endurance.
Well, doctors now have a way to evade the difficult confrontations. They stay clear
of the patient, or reduce the exposure to a minimum, and order the tests.
The other reason is the real progress in medical science. Many modern laboratory
and instrumental tests do offer direct and precise answers to diagnostic questions. The
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doctors choose what they think is the most purposeful approach. Why waste one’s time
questioning and examining the patient, and perhaps arrive at no conclusion, if a CT-scan
can immediately show what’s wrong.
However, theirs is not a reasonable course of action. First of all, it is good to have
an idea which tests to order. Moreover, incredible as it may seem to the “modern” student
of medicine, there are diseases that cannot be detected with any existing tests, but are
readily discovered on physical examination. No test presently in use detects a hernia
in the groin. And the results of various tests do not always provide straight answers to
our questions.
Clinical examination, that is, listening to what people say, asking questions, and
recording what we perceive with our senses, may lead us to the truth or into error. But in
evaluating the findings from these sources we rely on the bulk of knowledge our species
has accumulated, and on our life experience. Compared with this huge data bank, our
experience with, say, ultrasound of the jaw, or translumbar aortography, is modest. The
number of aortographies a vascular surgeon has seen, as well as the published series, add
up to several dozen, at most a few hundred images. Dimensions accepted as “normal”
on the grounds of such limited number of cases hardly cover the entire range of possible
individual variants. We are as yet not very skilled in discerning the relevant from the
incidental on these pictures, the “normal” from the “abnormal.”
There is a set of laboratory and instrumental tests that have been routinely performed
on millions of patients for one hundred twenty, one hundred, or eighty years, and
have proved their diagnostic value: basic blood and urine tests, chest X-rays, and the
electrocardiogram. These methods have indeed become “basic”: the clinician is using
them with the same ease and confidence as his own five senses. This is not true of some
of the other tests.
Lab tests may lead us directly to the truth and clinical examination may prove
misleading. Say, a girl in her teens complains of bad pain quite low in her right abdomen.
Yes, she confirms that her loins hurt, too, on the right side. Also, her answer to the
question, “Do you have frequent urge to urinate?” is in the positive. Yes, hand pressure
on the belly, “along the course of the right ureter,” reveals tenderness. Knocking at her
loins, on the right side, is painful. The clinician, a quite consummate one, concludes
that the girl probably has a urinary infection, a pyelitis. A well-grounded conclusion,
isn’t it? Then, the urine culture proves negative, and the ultrasound reveals the true
cause of the patient’s complaint: a burst cyst of the right ovary.
Some tests have tremendous diagnostic power in well-selected cases, or are simply
irreplaceable. From an MRI of the head, an expert can with near certainty distinguish a
stroke due to a bleeding, from one caused by a clot, which is crucial in deciding whether
to administer the clot-solving treatment.
Yet, when the entire impact of modern laboratory and instrumental methods is
estimated, it turns out, surprisingly, that they have not increased the doctors’ ability to
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diagnose diseases. The confrontations of doctors’ diagnoses with postmortems103 have
shown that at present, with many modern tests at the doctors’ disposal, the number of
faulty diagnoses remains 20 to 40 per cent, the same as half a century ago, when most
of these tests were not yet available. The gains from the lab and instrumental tests have
been outweighed by losses due to the neglect of history-taking, physical examination,
and further attentive observation of the patient.
Chapter XIV. Nurses Misled
The Nurses Take Over the Physical. You should not think that clinical medicine
has been totally abandoned. At the Boston area hospital where I spent a whole month
watching a single patient, almost every day a physical examination was performed –
by the nurses. I was interested in this new development, and approached it with open
mind. Nurses are as intelligent as the doctors and quite a few are much brighter. There
is no reason why they shouldn’t be able to learn the physical examination.
True, some limitations were predictable. The nurses’ ability to interpret the findings,
and choose the direction of further search, may not equal that of the doctors because the
nurses’ general medical knowledge is somewhat less broad and less detailed. Further, it
took almost 200 years of confronting the physical signs with the findings at postmortem
and surgery, and with the data obtained by instrumental methods, before the clinicians’
skills in physical examination achieved the peak of exactitude and sophistication. For a
century and a half, the training of young doctors in physical examination has been, as
a rule, entrusted to clinicians well versed and keenly interested in the subject. There is
no comparable tradition behind the nurses’ training in this particular field.
I watched six nurses doing the physical examination. They used to begin with
auscultation of the chest. This they did in a cursory way, placing their stethoscopes at
two or three, seldom four points (a routine auscultation of the lungs involves 10 to 12
points). Most nurses did not listen to the base of the lungs, where the wet crackles of
pulmonary congestion or bronchopneumonia are most likely to be heard. The patient
was not told to breathe deeply, through open mouth, or to cough. The nurses then
proceeded to cardiac auscultation which was limited to counting the heart rate. This
was followed by auscultation of the abdomen, rather superfluous in a patient who
passed normal stools and had no abdominal complaints. A number of vitally important
steps were omitted. The nurses did not look into the patient’s mouth or at her skin, did
not check the small of her back for edema nor the buttocks for bedsores, and did not
103
Editorial, The Problematic Death Certificate, 313 NEW ENG.J.MED. 1285 (1985); T. Kircher et al.,
The Autopsy as a Measure of the Accuracy of the Death Certificate, 313 NEW ENG. J. MED. 1263 (1985); R.
E. Anderson et al, The Sensitivity and Specificity of Clinical Diagnostics During Five Decades: Toward an Understanding of Necessary Fallibility, 261 JAMA 1610 (1989); L. Goldman et al., The Value of the Autopsy in
Three Medical Eras, 308 NEW ENG. J. MED. 1000 (1983); M. Boers, Obduceren is vooruitzien: De toekomst
van obductie [Performing Autopsies Means Looking Ahead: The Future of the Postmortem], 134 NED. TIJDSCHRIFT V. GENEESKUNDE 1346 (1990); E. Wubeke et al., Obducties in een verpleeghuis [Autopsies in a Nursing Home], 133 NED. TIJDSCHRIFT V. GENEESKUNDE 765 (1989); W. D. Rees et al., “Patients with Terminal
Cancer” Who Have Neither Terminal Illness Nor Cancer, 295 BRIT.MED. J. (Monthly Dutch Ed.) 488 (1987).
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inspect the legs. The patient whom I closely observed had a pronounced edema on the
legs, feet, and ankles, an important and ominous sign. None of the nurses noticed that.
I saw enough to draw my conclusions. What these nurses were doing was inaccurate
and sadly incomplete. Unfortunately, the nurses took the physical examination over
from the doctors at a time when the doctors themselves had already deeply neglected
this art. The nurses whose work I watched had never had the chance to properly learn
the physical examination, or to fully appreciate its importance.
Practicing Medicine. Can non-physicians practice medicine? It was tried in the past. I
remember the medics who practiced in Central and Eastern Europe in the 1930s and 40s.
The institution was inherited from pre-WWI German and Russian imperial armies. A few
civilian schools offered a two year curriculum modeled upon military medics’ training.
Around 1950, the institution of practicing medics was abolished in those European
countries where it still existed. It was assumed that diagnosing diseases and treating
sick people should not be entrusted to half-qualified practitioners.
Fifty years later I learned, much to my surprise, that medical practice of half-qualified
persons was being reintroduced in the United States. I recently watched a case of a
13-year old girl who suddenly fell ill, vomited several times (first food, and then some
water-like liquid), and complained of a bad pain in her belly. The mother called her
pediatric medical center. A nurse answered the phone, asked some questions, diagnosed
“abdominal virus,” and advised Tylenol. I marveled at this nurse’s self-assurance. The
girl’s symptoms could be due to various conditions, some of which would require
immediate intervention.
In June, 2003, in a Miami juvenile detention facility, Omar P., 17, “retched, wept,
and moaned from stomach pain,” and wrote a request to see a doctor. He was seen by a
nurse, Mrs. L, who diagnosed him with a stomach virus. Guards say they never saw her
touch his abdomen. “Suck it up, my boy, and walk around,” said the supervisor, who
relied on L’s diagnosis. After a few days of agony, Omar P. died of a burst appendix.104
In February, 2000, Mr. & Mrs. G reluctantly filed a Boston lawsuit against one of
the universities, and two doctors working at the students’ medical center. Said Mr. G:
“We are not the kind of persons who sue somebody; but we decided that we have to do
it because other people may be exposed to the same danger.” In the fall and winter of
1992/93 Mr. and Mrs. G’s 18-year-old daughter was seen several times at the university’s
medical center. “The last time,” reported the Boston Globe, “the nurse working that
Saturday concluded that [G] had a virus and sent her back to her dormitory. . . . Just
like her other visits, no blood test was ordered.”105 The patient was advised to take
more fluid and Tylenol. Fifteen days later G died of acute myelogenous leukemia. The
parents’ attorneys argued that were the disease diagnosed, aggressive treatment could
have prolonged the patient’s life by some years.
Records Say Dying Youth Was Ignored, BOSTON GLOBE, Feb. 28, 2004, at A6.
J. Ellement, Parents Sue Over Undiagnosed Leukemia Death, BOSTON GLOBE, Feb. 9, 2000, at B1; J.
Ellement, Pair Sues Two Doctors, Northeastern on Daughter’s Leukemia Death, BOSTON GLOBE, Feb. 12, 2000,
at B1.
104
105
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I am not an advocate of doctors’ monopoly in helping sick people. On the contrary, I
have done much to involve and train non-physicians in recognizing and solving medical
problems on the spot, and treating the emergencies. Since 1956, I taught patients with
severe form of high blood pressure, and their families, to take the blood pressure and
to adjust the dosage of potent pressure-lowering drugs. I taught diabetics and their
families to recognize and prevent hypoglycemia and acidosis. I have trained scores of
nurses and medics in cardiopulmonary resuscitation. In Den Bosch, I taught the intensive
coronary care nurses so much of electrocardiography that quite a few became experts
in diagnosing ECG abnormalities and cardiac arrhythmias.
In American health care, the practice of entrusting medical tasks to nonphysicians
has gone one crucial step too far. At present, in many medical centers in New England,
nurses see the patients or receive their telephone calls, take a short history, establish the
diagnosis, and give advice or dispense medicines.
In general, the public approves of the fact that nurses practice medicine. People
address nurses with confidence and appreciate their advice. Many prefer to be treated
by nurses who, unlike the doctors, can be reached, and listen to patients.
It is the doctors who are specifically trained to diagnose and treat diseases,
not the nurses. Why are doctors not available in such places as Boston or Concord,
Massachusetts, or New Haven, Connecticut, is something I do not understand.
The argument that the nurses’ work is supervised by doctors is an obnoxious
nonsense. The phone consultation is often omitted, and even when done, it is useless.
In their lawsuit against the university medical facility in Boston, the parents of the
deceased leukemia patient pointed out that one of the doctors had “checked” the nurse’s
actions (with a 3 days’ delay), and “approved” her decision to send the patient to her
dormitory with Tylenol.
A doctor in Cambridge, Massachusetts, said to me recently: “Out of ten patients,
seven can be very well treated by a nurse.” Yes, but which ones? Are nurses qualified
to pick these cases? An 18 year old student, Miss G, an undiagnosed leukemia patient,
was feeling sick for several months in a row, and six times sought help at the medical
center. Was it right that she was only seen by nurses?
I don’t say a mistake like that with Miss G could not have been made by a doctor.
It could, and on the doctor’s part it would be negligence, lack of mental concentration,
substandard care. On the part of the nurse, the decision to send the patient home with
Tylenol was not negligent or substandard care. It was on the level of standard care as
provided by a nurse.
As to the case of Omar P., it is clear from the press report that this patient presented
a dramatic, highly alarming picture. It is most unlikely that a doctor would act in this
case in such ignorant, thoughtless, reckless way as Ms. L.
Only a minority of patients are harmed, those “three out of ten”; let it even be one out
of ten: patients with problems that are life-threatening and out of the most common daily
routine. But this is an important minority. Helping them is what medicine is all about.
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Nurses trained in special fields, like anesthesia, coronary care and resuscitation,
surgery room assistance, are doing an excellent job, often better than a physician would.
What they should not undertake is seeing unselected patients and making the diagnoses.
This task is difficult (and sometimes too difficult) for a well-trained and experienced
physician. The nurses are not equipped even to try.
The prominent Polish-Jewish medical ethicist, Dr. Zygmunt Kramsztyk, wrote one
hundred years ago: “Medicine is like jewels: only the rich can afford it. Yet it should be
like water: accessible to all people, and of best quality for everybody.” It is sad to see
that the goal of best medical help for all people is being abandoned in the twenty-first
century, in the richest country of the world.
Who has been wronged? The patients, the American public, of course; but there
is still another group very much wronged by the developments: the nurses. Instead of
taking pride in their most humane, highly demanding, highly skilled profession, they
are now encouraged to direct their ambitions toward practicing medicine, to enter a
field in which they are, and will be, unqualified.
Replacing doctors with practicing nurses may seem an easy way to make American
medicine more accessible and less expensive. The right solution is more difficult.
Incentives should be created for doctors to choose careers in primary care. Effort must
be made to educate again doctors who, before ordering tests, will first use direct human
contact, talking, questioning, and looking at the patient, examining him or her, and
thinking.
Chapter XV. Is Medicine Still for the Patient?
The Patient Is Our Priority. In 1991, I said the following in answer to a question
from an interviewer: “In a hospital, the sick person may be taken aback when confronted
with all those machines and with an organization which seems so impersonal; but this
organization is conceived to serve the patient, functions for the patient, and is manned
by caring people.”106 I am not sure I would repeat this statement now, having watched
the developments in American health care and the daily workings of several hospitals.
I recently spent a month, every day including weekends, in a large hospital in the
Boston area, watching the proceedings. At some specialties’ outpatient clinics all patients
had to wait at least forty-five minutes, and often up to two hours past the scheduled
time of their appointment; and this was not an exception, due to some emergency, but
the rule. Lack of realistic planning? Certainly, but the underlying cause was a lack of
concern for the patients.
In the wards, the intercom operators immediately answered a patients’ bell, but
actually getting to see a nurse, or a nursing assistant, could take anywhere from twenty
minutes to twelve hours, especially if the patient was known for making frequent requests.
One night, an elderly patient with a grave ailment felt terribly sick, was afraid of
dying, and begged a nursing assistant to stay with her for a while. This was refused, and
the patient was given the usual lecture: “There are many patients on the floor, most of
106
J. Grimstad, Interview with Dutch Pro-Life Physician, 13 ALL ABOUT ISSUES 20-24 (1991).
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them sicker than you, and we have our priorities.” Whatever their priorities, which I
respect, there were behind the nurses’ station, at all times, several nurses and nursing
assistants engaged in lively conversation.
Procedures for which the patient must fast after midnight were scheduled for the
next day’s afternoon and then further delayed till late in the evening. The patient was
given no explanation, and was kept waiting, hungry, thirsty, and exasperated. In two
instances which I witnessed, even after the procedure the patient was denied food and
drink, because the order “nothing by mouth” had not been cancelled.
A procedure involving some risk of infection was supposed to be done “under the
cover of an oral antibiotic,” but “nothing by mouth” had also been ordered, thus, the
antibiotic was not given to the patient.
Another time, an antibiotic, augmentin, was ordered, and was to be given twice
daily by mouth. The nurse scheduled it for 8 a.m. and 8 p.m. It was already 9 a.m.,
therefore, the patient was left without the antibiotic for the whole day.
Facing omissions and mistakes, the frightened patient begins to distrust the staff,
the organization, and everything that is being done, and demands to see the attending
physician. Such requests are seldom granted.
Spending Money on Palaces, Not on Nurses. Fund-raising activities and the pressure
to cut costs have produced bizarre results. Wicked tongues say that brass plates with
sponsors’ names can only be put on buildings, not on nurses. Therefore, millions are
spent on new, huge, magnificent buildings in which people get lost and transporting a
patient to a lab becomes a long and difficult journey. Meanwhile, the nursing staff, found
to be too expensive, is reduced to a skeleton. Nurses are replaced by semi-qualified
and unqualified employees. The change is not only unsafe for the patients, it also is
terribly aggravating.
Nursing, a Job Just Like Any Other? Nursing is understaffed and many nurses are no
longer the conscientious, dedicated care-givers they used to be. But there are exceptions.
A distinct generational divide has appeared. There still are, in the large hospital which
I have closely watched, several nurses in Florence Nightingale’s tradition, scrupulous,
never tiring, unswervingly protective of the patients. They are now in supervising
positions. Even among the younger hospital nurses there are exceptions to the general
rule, for example, Miss Estelle d’Arcy, R.N. She is young, competent, dedicated, and
wonderfully soothing. But most nurses of the new generation have been educated in
a different way. They see nursing as a job just like any other. No special diligence or
dedication is needed. These “modern”nurses are self-protective, and neither kind nor
forbearing. They lecture the patients, argue with them, refuse to grant their requests,
and punish the troublesome ones by abandoning them for hours at a time.
The Organization. There is a way of “natural growth,” as when a group of people
start doing work and then make this or that organizational arrangement when they
feel it’s needed. The other way is the “a priori” approach. Before any work is started,
consulting firms make list of the tasks and then plan the organization, the division of
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labor, the hiring of various crews and the communication system. No grand project
like building a mile-long bridge, drilling a tunnel, etc., would be possible without such
planning. Applied to the workings of a hospital, as is now being done in the United
States, organization conceived “a priori,” operating in great numbers, inflexible, rigidly
sticking to the division of labor, produces bizarre effects and is clearly detrimental to
patient care.
Every move in the large institution I have watched depended on the various
detachments of the ancillary staff. Scheduled ultrasound tests had to be rescheduled
for another day when the “escorts” supposed to transport the patient failed to appear.
Nobody else would dare to push the patient’s bed along the corridor to the ultrasound
lab. Outpatients who came for a transfusion of blood had their blood promptly matched
with the donor’s, and thick I.V. needles inserted, but had to wait long hours for the
transfusion because only a “courier” was qualified to bring a pint of blood from the Blood
Bank located on the same floor, and no couriers happened to be available.
At 11 a.m., the floors in patients’ rooms were still littered with used facial tissues,
scraps of paper, etc., waiting for the cleaning crew to sweep it. In the corridors, huge,
open bundles of soiled linen created that untidy picture which so surprised me when I
first visited American hospitals in 1987. In Western European hospitals, which charge
three to four times less for a hospital day, every ward is kept shining clean by a single
worker responsible to the ward’s chief nurse.
Meanwhile, in a Smaller Boston Hospital, which I closely watched in 2003, in the
congestion of people and events in the ward’s narrow space, I could see that this
institution, with too few nurses, was in fact incongruously, ludicrously overstaffed. Waves
of various crews, the cleaning people, the restaurant room service, the electricians, the
floor-polisher with his noisy machine, the escorts from the X-ray department, invaded
the floor, with here and there a couple of plumbers, a security man, the newspaper
carrier, the librarian, and the medical gas technician. Patients under the care of various
specialists were kept in the same ward; as result, I watched seven doctors standing
around the nurses’ desk at the same time, gesticulating, loudly talking to the nurses or
on the phones, reading the charts and writing orders. There has recently been much
concern about hospital mistakes. Instead, I wonder how in that bedlam any orders are
correctly issued and understood.
The Hospital Mergers. A wave of hospital mergers flowed over New England in the
late 1990s. These deals, presented as the way to salvage financially shattered institutions,
were negotiated and carried out by hospital managers, business consultants, accountants,
and lawyers. I wonder if much thought was given to possible repercussions on patient
care. Yet a negative effect of some mergers could have been predicted, and did occur.
A good hospital is a place where state-of-the-art services are offered in several
medical specialties, and attention is paid to the safety, needs, comfort, and feelings of
every patient. Examples given by good doctors and nurses, a sensitive management,
the recruitment of good people, and attrition of those who would not adopt the spirit
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of the place, ultimately create an environment where dedication to serving the patient
becomes the prevailing attitude.
Institutions with these qualities do not suddenly appear from nowhere: they
gradually evolve over the years. It does not take long to damage and destroy them.
In 1998, a Boston hospital well known for several world famous departments and
an exemplary patient-friendly atmosphere merged with a larger teaching hospital,
academically excellent, but not particularly renowned for kindness to patients. As the
larger hospital’s bureaucracy invaded the smaller institution, imposing their own ways
and values, and the two crews intermingled, dealing with patients was quickly reduced
to the larger hospital’s soulless standards. Some patients were dismayed and left for other
institutions. An exodus of highly qualified workers followed. The team of anesthetists
left, and while temporary measures were taken to replace them, a series of errors of
anesthesia occurred. Then the excellent hepatobiliary surgical department and liver
transplant unit left for another hospital, taking with them the nurses, the secretaries,
and the patients. Incidentally, the hospital’s financial situation after the merger proved
worse than before.
Do Hospitals Still Exist for the Patient? One cannot but admire the tremendous
diagnostic and therapeutic powers of the great American hospitals. This is not only a
matter of equipment, but also of skills and organization. It is awesome how much the
doctors in these hospitals can do to help the sick and save lives.
Yet many patients feel abandoned, confused, even unsafe. They no longer have
the feeling that sick people used to have in the modest hospitals of fifty years ago: the
feeling of being in good hands.
The truly patient-centered hospitals have always been those shaped and led by
clinicians, that is, doctors whose intellectual interests, and life ambitions, were focused
on patient care.
A few clinicians are still present in the hospitals, but it is now the scientifically
educated modern doctors who dominate the scene. Of course they, too, are committed
to patient care. However, dealing directly with patients is not what these doctors do
well, or like to do. Staring at the computer screen, doing work in the lab, performing
high-tech procedures, organizing special projects, writing applications for grants, all
that and any other business take precedence before attending to the patients. As a result,
when the details of a patient’s nursing and treatment have to be settled, when orders
need clarification, when the patients hurt, or ask for explanations, or are frightened and
need reassurance, the doctors are not there.
Where are they? Let’s assume they are, all of them, busy with very important
projects, doing fruitful medical research – even though this is not always the case.
Now, I am an enthusiastic supporter of medical research; but I maintain that research
which may benefit thousands of future patients should be conducted without harming
or neglecting the present ones. That’s why “in every good hospital there should be a
place for clinical doctors, clinicians to the core. In their hands rest the well-being and
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209
the safety of the patients.” So said the 1958 prof. Ignacio Chavez, the president, at the
Third World Congress of Cardiology.
It is now even more difficult to fulfill Chavez’s postulate. It is also much more
urgent; it is simply the only way to redeem our hospitals. Clinicians must come to work
there, as the patients’ attending physicians, and not in some subordinate positions, but
in most prestigious ones; and not just one or two, but as many as are needed to assure
continuity of care.
Of course it is far-reaching reform. To carry it out, the prestige of clinical medicine
must be restored, and clinical careers must be made attractive to medical students and
residents. Hospitals, medical education, and every professional and academic medical
forum have to be involved. But it is feasible. If clinicians regain an important role,
there is a good chance that the right priorities in the functioning of hospitals will be
reinstated. The view would gradually prevail that financial efficiency, a laudable goal in
itself, should not be pursued at the expense of good patient care.
It is difficult to humanize huge institutions right away; but it can be done by
recreating the departments. The traditional departmental structure of the hospital
has been almost abandoned in the quest for efficiency. The territorial identity of the
departments has been abolished. In a Boston hospital, a cardiologist’s ward round which
I followed led us to patients scattered on three floors in two different buildings. Many
nurses are daily rotated from one ward to another. In the large hospital where I spent a
month, the patient whom I watched had twenty-one nurses in a single week.
Some concessions to efficiency may prove unavoidable, but considerable effort
should be done to restore the traditional department, and, most importantly, the
department’s team, which the leading clinician would be able to educate and inspire.
Chapter XVI. In Defense of Medicine
The Crisis. One of the principal causes of the current crisis in medicine is the
profession’s failure to control the invasion of basic sciences and technology, the inability
to subordinate their contribution to medicine’s human aims. Obviously, we shall never
renounce the enormous benefits which science and technology bring to diagnostics
and therapy. We must not allow science and technology to determine our goals or
impose on us their value system. Unfortunately, this is precisely what is happening
quite often today, the result of which is a medicine that is increasingly effective and less
and less appreciated by people, does not satisfy the doctors themselves, becomes too
expensive even for the richest nations, and is criticized from every quarter. For doctors,
basic sciences and technology are only means and must remain so; they must not be
used needlessly; the enormous contribution of the basic sciences must once again be
subordinated to the thinking human being, the physician, and directed toward human
goals. It is our task, and that of the next generation of physicians, to resolve the crisis
in medicine; a difficult end to achieve, but the only possible solution.
Facing this task the profession stands divided. In the previous chapters I have
already mentioned the increasing polarization into two types of physicians: the traditional
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clinicians and the “modern” doctors. They look almost indistinguishable and share most
characteristics yet their ways and even goals are not the same.
The clinician is a doctor who tries to absorb new scientific achievements and
master new technologies (life-long learning is the true tradition in medicine), but has
never renounced the skills, the experience, and the spirit of clinical medicine. He knows
how to reconcile a naturalist’s objectivity with sincere involvement in his patients and
emotional involvement in his own art. The medicine he practices is of a personal kind,
his own contribution dominates the whole course of events. The diagnosis, discovering
what’s wrong with the patient, is for him a personal victory and a source of pride. The
therapy which he adjusts to every individual patient, displaying resolve when needed
and restraint when necessary, personally following the effects from one hour to the next,
is for the clinician an opportunity to show what is best in his mind and character. As
Marguerite Yourcenar so aptly noted,107 for a clinician, a patient whom he has cured of
a serious illness is l’oeuvre de sa vie, his masterpiece.
The “modern” physician lives in a very different professional climate, where the
doctor’s personal role is being belittled (and is, in fact, reduced), where diagnosis (or
its fragments) arrive on scraps of paper from the laboratory, and the doctor will not
even say “Madam, you’ve got this or that,” but “the blood test has shown…,” where
treatment is no longer the work of a doctor but of “a team” (that is, of no one); where
further observation of the patient is left entirely to the nurses; where it is not thought
that a doctor must devote the maximum of time, attention and effort to his patient, but
only as much as is “reasonably” due; where lack of emotional involvement is praised as
a virtue; where ultimately the doctor’s dissatisfaction with his own role leads him to the
melancholy view that all medical endeavors are meaningless. Not trained to rely on his
own understanding, not accustomed to trust his own human reactions, a doctor who
has received this sort of ill-balanced, inharmonious, “modern” education is inclined to
extreme and unbalanced views. He is entirely serious in his belief that medicine is a
science (whereas for the traditional doctor science was a tool of medicine). He tends
to view the truth of medicine and his own diagnoses as scientific certainties, and may
even believe in prognoses. Having taken on the value system of the “exact” sciences, he
sees no proof that one should be kind or caring, or that human life has infinite value:
these are, after all, nonscientific postulates.
In making a defense of medicine I do not mean the “modern” misconception, but
Hippocratic medicine, humble and skeptical, a skilled craft scientifically verified as
far as possible, equipped with technical means as much as needed, but always in awe
before the miracle of life.
Medicine as an Anachronism. The traditional medical profession is singularly maladjusted to the 20th/21st century. It claims esoteric knowledge in this age of universally
accessible information, invokes motivations and a code of ethics different from the
107
M.YOURCENAR, L’OEUVRE AU NOIR 266 (Gallimard, Paris 1980).
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211
generally accepted ones, tries to impose decisions on autonomous rational individuals,
and refuses to fully submit to the laws of the market.
Powerful societal and economic forces converge to change medicine and adapt it
to the present time. If this transformation fully succeeds, it will be the end not only
of “medicine as we know it,” but of medicine as such. Professions, as bodies claiming
special skills, setting their own standards, committed to serve the individual and the
society, are historical phenomena. They arise and flourish in ceratin epochs and may
dissolve in a different era. The physician as a professional with a broad vision, and a
moral agent committed to the good of the patient, may disappear. He will be replaced by
technicians who, to the extent found profitable by commercial health care enterprises,
will fulfill consumers’ orders. We must not let this happen.
Medicine as an Integral Part of Civilization. In the course of its 2500 year known
history, medicine has created important intellectual and ethical values. Strongly motivated
medical researchers have often been in advance of other branches of natural sciences.
Enormous work has been invested in learning the structure and functions of human
body and the changes it undergoes in disease, and perhaps even greater effort has been
expended to free science from magical thinking, fantasy, and mistaken a priori judgments,
and to adopt sober observation of facts as the governing rule. Vesalius’s anatomy, Miguel
Serveto’s discovery of pulmonary blood flow and William Harvey’s discovery of general
blood circulation, Malpighi’s microscopical studies, Heberden’s description of coronary
disease and Bouillaud’s description of rheumatic heart disease, Bright’s description of
hypertensive kidney disease, Hope’s description of the mechanism of pulmonary edema,
the discovery of causative agents of tuberculosis and cholera by Koch and his “postulates”
stating how to establish the causes of all infectious diseases, the discovery of dietary
causes of beriberi by Jacob Bontius, Ross’ discovery of the plasmodium of malaria and the
mosquito’s role of transmitting it to man, the sixty-year search for the cause of diabetes
which led from Mehring’s and Minkowski’s discovery of the role of the pancreas to the
isolation of insulin by Banting and Best, and, ultimately, to today’s production of genuine
human insulin by manipulating the metabolism of bacteria, Landsteiner’s discovery of
blood types, which made blood transfusions possible, Whipple and Minot’s discovery of
the mechanism of pernicious anemia, later crowned with the isolation of vitamin B 12
– these triumphs of keen observation, courage, persistence, and creative thinking have
placed medicine on a level with physics, chemistry, geology, and astronomy, as one of
mankind’s important avenues of knowledge. This progress in research was paralleled by
practicing physicians, from Hippocrates, Galen, Linacre, Paré, Sydenham, and Boerhave
to Traube, Stokes, Potain, Billroth, Mikulicz, Babinski, Charcot, Widal, Vaquez, Osler,
Obraztsov, Herrick, Wenckebach, Abbott, Cournand, White, Lown, and thousands of
others who created the theory and practice of clinical medicine, the school of accurate
observation, rigorous thinking, and purposeful and humane action.
Medicine’s contribution to ethics is at least as important as its share in mankind’s
intellectual advancement. I completely disagree with the current opinion that medicine
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creates no values or ethical standards, but assumes and should assume the values and
standards prevailing in the society. That is not true. Medical ethics was formed independently, five hundred years before Christianity and 2300 years before Kant, with some
influence of ancient Greece’s ethics of agape, but primarily dictated by the internal logic
of medical calling and medical practice.
The strength and significance of medical ethics lies in the fact that it always set its
norms above those of the society, and did not let itself be drawn into the various kinds
of madness to which society is subject. We know what happens when doctors abandon
their own ethics and adopt the ethical norms momentarily prevailing in the society:
this is what the doctors in Nazi Germany did who exterminated people with mental
and physical disabilities, as well as those with mental illness, and some committed
atrocities in the concentration camps; this was what Soviet psychiatrists were doing in
hospitals run by the KGB, and in the West the doctors who see their profession mainly
as a means to make money, and social-Darwinist doctors who attempt to cleanse society
of its weaker members.
Medical ethics, as it was formed at the time of Hippocrates, and subsequently
developed in Hippocratic spirit, teaches that for the doctor only a human being exists,
and that it cannot be of significance to us whether that human be poor or rich, wise or
foolish, powerful or downtrodden, a respected member of the community or a vagabond,
thief or prostitute, or what religion she professes, or what is the color of his skin. All that
can exist for us is a human being and his suffering, and we cannot set any other good,
that of other people, the state, society, or the doctor himself over that of the patient:
Salus aegroti suprema lex, the good of the patient is the supreme law. The ironic smiles of
medicine’s critics are out of place. Innumerable doctors have died of infectious diseases
that they contracted while practicing their profession, people who stayed at their post,
aware of the dangers they were exposed to; among them my friend, Dr. Jakub Taubenfeld, treated patients in a typhus ward until he contracted typhus himself and died. In
the Warsaw ghetto, Dr. Janusz Korczak, the pediatrician, renounced the opportunity
to escape in order to remain with his orphans until the end and went to be gassed with
them in Treblinka. Doctors in South America who rendered assistance to wounded
guerillas, did so at the risk of their own freedom and life. Hundreds of American and
European doctors take unpaid leave and travel to areas of war and disaster to aid the
suffering. Throughout our lives, all of us, general practitioners and hospital doctors, give
up a significant portion of our night’s rest, free time and family life in order to help the
sick, not because we are better than other people, but because we cannot do otherwise.
We may not distinguish among our patients on the basis of their social standing.
“I hope that you will treat me not quite the same way as all those beggars of yours,” said
the King of France to Ambroise Paré. “Sire, I treat my beggars as if they were kings,”
was the surgeon’s reply.
Other People’s Lives: Reflections on Medicine, Ethics, and Euthanasia
213
When criminals convicted of murder fall ill, we may not treat them differently
from our other patients (and we wouldn’t know how to do so), nor in wartime can we
treat wounded enemy soldiers other than our own countrymen.
In its very one-sidedness, its absolute subordination of all interests and values to a
single one, the good of the patient, the Hippocratic code of conduct has come closer to
the ideal of an absolute ethics than any other non-revealed ethical system. It proclaimed
the equality of all people centuries before the French and American revolutions, and
infinite value of each human life long before Christianity, and longer still before Kant.
This ethics is not so much the heir and disciple of the great general ethical systems, as
their precursor and, often, their teacher.
Owing to both its ethical values and to its intellectual contribution, medicine has
become an integral part of our civilization. It must be defended in the interest of us all.
Those who today attack medicine from without and from within, and attempt to destroy
it, do not realize that they are working for a world even more inhuman than today’s, a
world where one more oasis of wisdom and humanity would be buried under the sands
of stupidity, cruelty, and indifference.
Part Two: Medicine Versus Euthanasia
Sympathetic readers of this book’s manuscript advised me to rewrite this part in an
attempt to achieve a more unified result. I have earnestly considered their advice; yet I
ultimately decided to leave the manuscript as it was. The whole has been written in the
same spirit and with the same purpose; to affirm the art of medicine and the high calling
of physicians. If the focus is changing in Part Two, this reflects the change which during
my lifetime occurred in the mood and the preoccupations of the medical profession.
The movement in favor of euthanasia or physician-assisted suicide is primarily
interpreted as a vote for individual autonomy and freedom of choice. But this is hardly
a full explanation. The growing societal acceptance of voluntary euthanasia can only be
truly understood if placed side by side with other manifestations of changed attitude
towards human life, crypthanasia, and the new biological cleansing.
Crypthanasia is the covert medical killing of people who are infirm and of advanced
age, sometimes with diminished mental capacity, without their consent or knowledge,
and often without the knowledge of their families. Biological cleansing is an ancient
way of purifying the tribe. Today, the practice of letting children with disabilities die has
been resumed. Some babies’ deaths are actively hastened. We shall see, in the following
chapter, that certain groups within the adult population may also be targeted.
Chapter XVII. Do We Treat All Patients, or May We Refuse to Help Some of
Them?
Mount Taigetos. In Sparta all newborn children had to be presented to the Ephors
of State, who selected the ones they considered robust and healthy. All other children
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were left on the slopes of Mount Taigetos as prey for wild dogs and predatory birds.
The mothers were not allowed to display grief.108
The Physician on the Rocks of Taigetos. I use the term “Taigetian mentality” to denote
the philosophy of life claiming that society should free itself of its weak and “useless”
members. This philosophy is often called “social Darwinism,” which, however, misrepresents the views of Darwin and the genuine social Darwinists. Darwin described natural
selection and the “survival of the fittest” as the way blind nature operates; he never
proposed that society consciously regulate human affairs in that manner. The original
social Darwinists, William G. Sumner, Herbert Spencer, and Walter Bagehot, did indeed
postulate survival of the best adapted as a principle of social organization, but exclusively
on the socio-economic level. The proposition to exterminate the biologically weak, and
to entrust doctors with the task, has its source in later writers, especially Ernst Haeckel,
Karl Binding, and Alfred Hoche.109 With these reservations, I will be using the terms
“social Darwinism,” “Taigetian mentality,” and “biological cleansing” interchangeably.
Dr. Isaac van der Sluis traced the history of biological social Darwinism in his
excellent book.110 I will limit myself to manifestations of this mentality with which I
was confronted in the last twenty years of my medical practice.
UÊ A young woman doctor opposes the implantation of a pacemaker in a 75 year old
patient suffering from heart block, and states that, as a matter of principle, she is
against the implantation of pacemakers in people over 75 and that society should
not be burdened with keeping the elderly alive.
UÊ A team of anesthesiologists at a university hospital decide to refuse to provide
anesthesia and thereby to prevent surgery for congenital heart disease in children
with Down syndrome.
UÊ In Rotterdam, a cook in a hospital kitchen is suffering from progressive kidney failure.
An internist at that same hospital refuses to make use of renal dialysis and allows
the patient to die because the patient is a bachelor and has no immediate family.
UÊ A family physician sends our hospital in Den Bosch two women patients, both
suffering from pulmonary edema (a buildup of fluid in the lungs due to heart failure:
this is a sudden and life-threatening condition, but one which usually can be quickly
relieved), and, in both cases, stipulates by phone that these women were “too old”
and should be refused treatment. In the second of these two cases, the doctor even
demanded that the woman be refused admission to the hospital.
A.R.BURN,THE PELLICAN HISTORY OF GREECE 115 (1981).
Karl Binding & Alfed Hoche, Permitting the Destruction of Unworthy Life, 8 ISSUES IN LAW & MED.
231 (Walter E. Wright, trans., Patrick G. Derr, ed., 1992) (Translated and published in full with permission from Felix Meiner, Leipzig, Germany, first published 1920).
110
I. VAN DER SLUIS,HER RECHT OM GROOTMOEDER TE DODEN [The Right to Kill Grandma], (Editions Saint
Jacques, Amsterdam, 1979).
108
109
Other People’s Lives: Reflections on Medicine, Ethics, and Euthanasia
215
UÊ When transferring a patient with acute myocardial infarction and pulmonary edema
to me, an internist colleague warns me “not to make overly vigorous attempts to
save this man since he is a widower and without family.”
UÊ Another doctor tells me that “as a family physician” he opposes the implantation of
a pacemaker to his patient since she is 86 years old. The woman had fainted due
to a heart block, striking her head on the kitchen stove as she fell, and was found
on the floor in a puddle of blood.
To form an idea of how widespread this attitude is, and how many sick people are
refused treatment, one has to multiply these observations made by a single specialist
by several thousand.
Holland is not the only country infected with Taigetian attitudes; the specter seems
to loom over the part of the world around the North Sea. In the early seventies, I heard
the opinion that pacemakers should be denied to older people, expressed by a doctor
in Aalborg, Denmark (the view was found inadmissible by the head of cardiology). In
Copenhagen, doctors at the only hospital doing the coronary bypass surgery at that
time refused to do it in patients over 60, not because of less favorable results expected
in them, but on principle, as a self-conceived rationing. An American poet living in
Copenhagen, Mr. Robert H., 64, had severe coronary disease, but was refused surgery
because of his age and soon died of a heart attack.
Thus, there are doctors who think they have the right to deny life-saving treatment
to adult, competent patients asking for help. This is such a striking phenomenon and
I was so much shocked when I was confronted with such attitudes and practices that I
decided to analyze them in every detail and from all sides.
Before we pass judgement on such conduct, it would be useful to answer the
question of whether such actions are indeed medical, that is, one of the doctor’s tasks.
They are not, according to the accepted definition of “medicine,” which is “the
learned calling concerned with treatment and prevention of disease.”111 Such actions have
also been explicitly placed outside the bounds of medical practice in the International
Code of Medical Ethics,112 in the Declaration of Tokyo adopted by the World Medical Association,113 and in the 1984 U.S. Public Law 98-475.
The Taigetian Philosophy. The system of concepts and arguments used by Taigetian
physicians to justify their actions is largely inauthentic in nature since it almost never
mentions its essential social-Darwinist motivation. Nevertheless, those arguments will
be examined here.
Medicine, VI NEW ENCYCLOPEDIA BRITANNICA 740 (15th ed. 1976).
World Medical Association 1949/1968/1983, International Code of Medical Ethics, in GEDRAGSREGELS
VOOR ARTSEN [Rules of Physicians’ Conduct] 64 (K.N.M.G., Utrecht 1984).
113
World Medical Association, Declaration of Tokyo, in GEDRAGSREGELS VOOR ARTSEN [Rules of Physicians’ Conduct] 69 (K.N.M.G., Utrecht 1984).
111
112
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First of all, let us examine an argument frequently (though not always) used by
Taigetian physicians: that when they deliberately allow certain people to die, they are
doing this for the person’s own good, in his own best interest.
Even before it is examined in detail, this argument arouses mistrust because the
same assertion was made by the ideologues of genocide (it will be better for the Untermenschen themselves if they die114) and by their precursors (“the kindest thing one can
do for a native is to let him die”115).
Are the Taigetian doctors speaking the truth when they assert that they are acting
for the patient’s own good? And were it true, would this argument be valid?
It does not follow from any of the cases cited that the doctor was acting in the
patient’s best interest. Any doubts on the question cease to exist when one considers
the way those people had to die.
UÊ If a person afflicted with acute pulmonary edema is not immediately treated, several
hours or sometimes a few days of torture ensue; the patient, in mortal fear, his throat
rattling, desperately gasps for breath, coughing up bloody foam.
UÊ If a person in severe kidney failure is not put on dialysis, the poisoning by the waste
products of his own body will gradually increase and the patient, bleeding from
his nose and covered with bloody spots on his skin, will vomit hundreds of times;
so-called Kussmaul’s respiration, a strained gasping for breath due to excess of acids
in the blood, will utterly exhaust the remainder of his strength; dying takes months.
UÊ If a person suffering from heart block or other form of very slow heart beat is not
provided with a pacemaker, the patient will suddenly lose consciousness, but
never dies during the first attack; no, he will faint dozens of times, falling on the
floor, injuring his head, breaking an arm or a leg; finally he will die in one of these
fainting attacks.
Indeed, considering the way all these people had to die we can clearly see that
the doctors were not acting in the patient’s best interest, nor did they even consider the
patient’s good or personal interest.
We must further examine whether the argument of “acting for the patient’s good”
is in principle valid; whether one person (the doctor) has the right and the ability to
judge on behalf of another person that it is in the person’s interest to end his life.
To sustain the assertion of “acting for the patient’s good” the Taigetian doctor must
know better than the patient himself what the patient’s good is. The entire line of reasoning is patent nonsense. What a person feels, desires, and values are by definition that
person’s subjective attitudes, and no one can know better about them than he. Secondly,
one cannot claim to be acting in the interest and for the good of another person if to
so act means destroying all that person’s interests once and for all. The right to decide
114
115
R. J. LIFTON, THE KILLING AND THE PSYCHOLOGY OF GENOCIDE, 196, 208, 310, 453 (1986).
E.M.FORSTER, A PASSAGE TO INDIA 28 (1967) (quoting Mrs. Callendar).
Other People’s Lives: Reflections on Medicine, Ethics, and Euthanasia
217
on behalf of another person “in his own interest” that he must die cannot exist either
morally or logically.
In none of the cases described here did the Taigetian doctor ask the patient if he
or she wanted to live. And yet he was aware that most older persons want to live “as
long as possible,” that people with mental disabilities do not commit suicide; that the
majority of people who are alone in the world have adapted to that way of life and chose
it themselves.116 When making their decisions, the Taigetian doctors are acting against
those people’s will and in opposition to their interests.
The Taigetian philosophy further proceeds from the assumption that medical
assistance is different from other forms of assistance to people in danger: therefore, medical
assistance can be refused while the other forms of help (at present) cannot be. In its
particulars, medical assistance is indeed different than, for example, rescuing people
from a fire; but in substance it is no different at all. A person trapped in a burning automobile or drowning ought to be pulled from the car or from the water as quickly as
possible. Similarly a person who has a sudden buildup of fluid in is lungs (pulmonary
edema) ought to be as quickly as possible injected with a diuretic.
In the philosophy of the Taigetian doctors we also find the commonplace idea
that sooner or later we all have to die: this person, too, has to die at some point and, that
being so, it can just as well be now. Obviously, it is true that we all must die. However,
in medicine, as in all human activity on this planet, what matters is not what ultimately
must happen, but what can be done in the meantime. Were we to be consistent in conclusions to be drawn from our inevitable death, we would not work for our daily bread
or build houses; it would suffice to sit and wait for all of us to die. Yet we act otherwise,
even though we realize that everything we do can only bear temporary results.
In the Taigetian philosophy we also encounter the idea derived from the works of
Ivan Illich (see Chapter III) that anyway, medical treatment has never helped anyone. This
view is at odds with reality.
The Taigetian theorists also assert that medical treatment is of itself neither good nor
bad, and is not inherently moral. This contention is used to justify the refusal of medical
assistance: to refuse a person something that is neither good nor evil in itself, is not an
evil act. But it can just as well be asserted that everything we do, think or feel is “in itself”
neither good nor evil. “Good” and “evil” are value judgments that cannot in principle
be objectively discussed; they can be discussed, however, if we agree in advance to a
(subjective) criterion, for example, “that which is favorable to man is good.” Shoes themselves are neither good nor evil; but they are good (from the wearer’s point of view) if
they protect someone’s feet against sharp stones and in winter from ice. Stomach surgery
is of itself neither good nor evil, it is indeed good (from the patient’s point of view) if
For many years we could see on the television that John Paul II was a man conspicuous for his
vitality and greatly enjoying his life and mission. Indeed, as victim of an assassination attempt he had the
good fortune of finding himself in the hands of “ordinary” physicians. “Taigetian” doctors, consistent in
their beliefs, would have quickly allowed him to die: after all, he was a single person without immediate
family.
116
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it saves the life of someone suffering from perforated ulcer. The statement that medical
treatment is of itself neither good nor evil is a “truth” without content or meaning.
“Extraordinary” or “heroic methods of treatment” is a frequently used concept in
Taigetian philosophy. Allegedly, it is only such methods that are refused to certain
categories of patients while “ordinary treatments” are not refused them. Is this a true
statement? Let us examine the cases earlier cited from this point of view. The means
and methods of assistance refused those patients are not only those to which access is
limited and which are allocated in turn to people on waiting lists, like renal dialysis and
kidney transplantation, and not only those which are complicated and expensive like
heart surgery, but also those that are simple, easy and cheap like the routine treatment
for pulmonary edema: with the patient in sitting position, oxygen is given through a
nasal catheter, and a diuretic and morphine are injected; sometimes bloodletting is done.
Are these “extraordinary” or “heroic” measures? And yet they were refused. How then
should one define which means of assistance are “extraordinary” or “heroic”? Clearly,
there are two possible definitions (and they both are cogent): (1) the means that in a
given situation are essential to saving a person’s life are defined as “extraordinary”; and
(2) “extraordinary means” are those which we wish to refuse to a person in danger.
A further argument, one that is not in fact used by doctors, but represents the
same mentality on the part of family members, proclaims that a person’s life should not
be prolonged by artificial means. A 78 year old lady had a pacemaker implanted because
as a result of a heart block she several times fell unconscious in the street and in convulsions pounded her head on the pavement. After a few weeks she received from her
older brother a letter that read: “I have heard about the medical intervention you’ve
had. Please have that contraption immediately removed from your body. A human
being cannot and should not live by means of artificial devices.” I used to know very
well the letter’s author. A prominent lawyer, a polyglot fluent in several languages, an
accomplished violinist with a deep understanding of music, and a writer of interesting
short poems, he was known for his meticulous handling of money matters. His sister
was a well-to-do childless widow and the children of the letter’s author were supposed
to inherit her estate. The awareness of this fact – I would not say inclined him, oh, no, it
certainly was dictated by a deep conviction – did not deter him from writing that letter.
I once informed the family of a patient with myocardial infarction that a perforation
of the interventricular septum has occurred and that it was necessary to introduce a
so-called balloon pump onto the aorta in order to support blood circulation until the time
of surgery. The patient’s son was opposed to the use of this “artificial means.” His opinion,
like any objection made by the competent patient’s family, had no legal significance or
any influence on my actions, but that is not point here. To oppose “the artificial” (done
by man) to “the natural” is a relative thing; man sees himself in opposition to nature,
but he is also a part of it; everything we make, including the balloon pump, we make
from elements of nature. But, first and foremost, “if it come from nature, is it also good?”
Other People’s Lives: Reflections on Medicine, Ethics, and Euthanasia
219
This excellent question, pithily formulated by Helen B. Hiscoe,117 implies the other one:
if something is artificial, must it be bad? An earthquake is natural, but it is not good for
the people living in the affected area. To die from a perforated appendix is part of the
natural course of events; surgery that prevents such death is unnatural. Eyeglasses are
artificial, but good if they allow me to read. If a person who rejects “artificial” means
has forgotten these simple truths, it means his position has not been well considered. If,
however, the argument of “artificial means” is put forward by someone who is well aware
of all this, then that argument is itself artificial, that it, used to conceal his true motives.
The term “quality of life” also figures in the Taigetian philosophical vocabulary.
Thinking people, people of conscience, from the very beginning objected to this term.
“The quality of life, a deplorable phrase,” wrote the Nobel laureate Saul Bellow.118 “I
had hoped that six thousand miles from home I would hear no more about the quality
of life.”119 The concept is false in more ways than one. It implies an objective, impartial
assessment, but its very point of departure is biased: the user of this concept assumes in
advance that life as such, life independent of its “quality,” has no intrinsic value. Next,
the concept of quality of life is in turn used to justify the assertion that staying alive is
not worth some people’s while. Thus, one concludes what was initially assumed, which
is an error of logic (circulus vitiosus).
And there is another reason for which the concept “quality of life” is both logically
flawed and morally vicious. The users of this concept do not view “quality of life” as
the way the individual in question experiences and enjoys his life, but as an objective
measurable feature, cognizable for everybody. This means that one person would have
the right and the ability to determine the quality of life of another person, and therefore,
the right and the ability to determine that quality of life as insufficient, and ultimately, the right, and probably also the duty, to put an end to such a life. Never mind the
fact that people who are blind, deaf and mute, or have missing limbs, work, achieve,
and are happy fathers and mothers; that boys and girls with Down syndrome are so
friendly and cheerful, that Stephen Hawking, totally paralyzed, has become one of the
most prominent theoretical physicists in the world – in view of the severe disabilities
of these people, the quality of their lives will be considered very low, and, at present,
this is a life–threatening verdict. The concept of “quality of life” is neither scientific nor
objective. It is a tool of extermination.
The Taigetian philosophy also makes use of an argument which appeals to the world
solidarity among people: “for what it costs to surgically correct a congenital heart defect
in a child with Down syndrome, a hundred starving Third World children can be kept
alive for several months.” What is wrong with this argument? The fact that it is never
used in support of aid to our brethren overseas, but always and exclusively to justify
refusing medical aid to people who are in danger of death here, at home.
H. B. Hiscoe, Als het uit de natuur komt, is het dan ook good? [It Does Come From Nature, But is it
also Good?], 127 NED.TIJDSCHRIFT V.GENEESKUNDE 2423 (1983).
118
S.BELLOW,TO JERUSALEM AND BACK 19 (1977).
119
Id.
117
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There remains nothing more to say on the subject of Taigetian philosophy. Its
assertions, concepts and arguments do not hold. This philosophy must be rejected in
its entirety.
May We Refuse Help to a Person in Danger? Is rendering aid to each and every person in danger a universal legal duty which we all bear, or can such aid be considered a
favor which we can choose to bestow on some people and refuse to others? And do the
general principles obliging us to render aid also hold in regard to medical assistance?
Thus: Is refusing life-saving help legally permissible? Is it ethically permissible?
Is it compatible with an honest and professional practice of medicine? Is it consistent
with the spirit of our civilization? Is it what “We the People” want?
The answer to the first question is not difficult because of the unequivocal formulation of the law. From the standpoint of civil law, the doctor seeing a patient enters into
a contract according to which he is obliged to provide the sick person with assistance.
If such assistance is not rendered, then the contract has not been kept.120 For the sake
of clarity, let us note that civil law does not distinguish between older persons, single
persons, or any others. In the eye of the law (Art. 255 and 450 of the Dutch Penal Code),
the doctor refusing someone the help which is due also commits a criminal offense. These
articles make no exception for people of advanced age, people with mental disabilities, or those without close family. The European Convention on Human Rights and
the Basic Freedoms (1950), to which Holland is a signatory, guarantees every person’s
right to life and to medical assistance.121 The Convention does not deny these rights to
older persons, people with mental disabilities, or persons without family. Thus, denial
of medical assistance to some persons is simply illegal in Holland. When acting in violation of the law, the social Darwinist doctor is also violating the oath which he swore
when obtaining his license (“I swear that I will practice medicine . . . in keeping with
the pertinent provisions of the law”122).
Here we also enter the domain of professional medical ethics. I will limit myself to the
rules of professional ethics which have been unequivocally formulated, and accepted by
national and international medical associations. Of the Rules of Conduct passed by the
Royal Dutch Society of Medicine (K.N.M.G) three apply here. Rule 1 states: “A physician
should provide every patient with most suitable assistance in keeping with the accepted
professional standards.”123 Thus, a doctor who refuses to render adequate care to older
persons, people with mental disabilities, or persons without close family, violates the
first ethical rule of the K.N.M.G. Rules 6 states: “A doctor should treat . . . his patient
to the best of his ability . . . making no distinctions as to the person of the patient.”124 A
“Taigetian” doctor affords such treatment to some persons, but refuses it to others, thus
H. J. J. LEENEN, GEZONDHEIDSRECHT [Health Care Law] 115 (Samson Publishers, Brusells, 1981).
Id. at 23.
122
Ede of Belofte bij het artsexamen [Oath or Solemn Pledge at the Receiving of the Diploma of Physician], in GEDRAGSREGELS VOOR ARTSEN [Rules of Physicians’ Conduct] 69 (K.N.M.G., Utrecht 1984).
123
Id.
124
Id. (emphasis added).
120
121
Other People’s Lives: Reflections on Medicine, Ethics, and Euthanasia
221
violating this rule as well. Rule 7 states: “A doctor is free to express his own philosophical
convictions . . . but only in a manner so as not to offend his patients and on condition
that this does not restrain him from providing each patient with such care as is best for that
person and to which that person has a right.”125 I contend that a premature, unnecessary,
and usually horrible death is not the best thing for a person, even if he is old, mentally
disabled or single; these people, like everyone else, have the right to genuine medical
assistance. When a doctor decides not to provide them assistance and to let them die,
the doctor is acting on his own social-Darwinist philosophical convictions. Thus, all
K.N.M.G. rules applicable in this instance are violated by doctors, most of whom are
members of the K.N.M.G. and have accepted its ethical code.
The International Code of Medical Ethics passed by the World Medical Association in
1949 and amended in 1968 and 1983 states: “A physician shall owe his patient complete
loyalty and all resources of his science.”126 The conduct of a social Darwinist doctor
runs counter to that rule: he does not allow certain groups of patients to benefit from
the resources of his science, and it would be putting it mildly to say that his attitude in
regard to these patients is not marked by the required loyalty. The Declaration of Tokyo
passed by the World Medical Association in 1975 states: “It is the privilege of the medical doctor to practice medicine in the service of humanity, to preserve and restore . . .
health without distinction as to persons” and also contains an explicit ban on “Taigetian”
practices: “The doctor’s fundamental role is to alleviate the distress of his or her fellow
men, and no motive whether personal, collective or political shall prevail against this higher
purpose.”127 So much for the professional ethics of physicians.
What rules of general, normative ethics are we to apply when examining the problem
of refusing help to people in danger? The existence of absolute ethical rules is debatable:
for religious persons, rules that are part of revelation are absolute in nature, but society
is formed both of believers and non-believers. Those who have attempted to formulate
normative ethics independent of revelation (e.g., Kant), think that they have succeeded;
others have their doubts.128
Let’s limit ourselves to the following criterion: anyone who commits acts that
go against a rule he himself accepts, is acting improperly. I shall, therefore, put the
social-Darwinist practices to trial applying the norms arising from the Judeo-Christian
tradition in which, one way or the other, most of us were raised; Kant’s ethical norms
because his two great laws have proven to be those which most people accept as just
when they reflect on their own life experience and the actions of their fellow men; and,
finally, the everyday rules of good conduct accepted at present by the majority of people
in our part of the world.
Id. (emphasis added).
World Medical Association 1949/1968/1983,International Code of Medical Ethics, in GEDRAGSREGELS
VOOR ARTSEN [Rules of Physicians’ Conduct] 64 (K.N.M.G., Utrecht 1984).
127
Declaration of Tokyo, supra note 113 (emphasis added).
128
L. Kolakowski, Mala etyka [Concise Ethics], in CZY DIABEL MOŻE BYĆ ZBAWIONY [Can the Devil Be
Redeemed?] 83-120 (Aneks Publishers, London 1982).
125
126
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Until recently it seemed obvious that to refuse help to a person in danger was
contrary to the spirit of Judeo-Christian morality, but this has apparently ceased to be
self-evident, if one is to believe certain theologians.129 We must, therefore, limit ourselves to the letter of Scriptures. In Leviticus 19:32 we find a prohibition of doing harm
to people who are disabled: “Thou shall not curse the deaf, nor put a stumbling block
before the blind.”130 There is an injunction to respect older persons: “Thou shall rise up
before the hoary head, and honor the face of the old man” (Leviticus 19:32), which is
difficult to reconcile with the refusal to help them when they fall sick. In Proverbs 31:8,
we read: “Open thy mouth for the dumb,” and in Isaiah 57:15, “I dwell in the high and
holy place, with him also that is of a contrite and humble spirit, to revive the spirit of
the humble, and to revive the heart of the contrite ones.” Christ respects the mentally
challenged: “Blessed are the poor in spirit” (Matthew 5:13) and condemns those who
consider their fellow men fools: “whosoever shall say to his brother . . . Thou fool, shall
be in danger of hell fire” (Matthew 5:22). He defends people with disabilities: “And his
disciples asked him, saying, Master, who did sin, this man, or his parents, that he was
born blind?” “Neither hath this man sinned, nor his parents; but that the works of God
should be made manifest in him” (John 9:2, 3). He enjoins charity for them: “But when
thou makest a feast, call the poor, the maimed, the lame, the blind: And thou shalt be
blessed; for they cannot recompense thee” (Luke 14:13, 14). He explicitly condemns
those who refuse to help people who are sick and especially those considered the “least”
among the people: “I was . . . sick . . . and ye visited me not . . . inasmuch as ye did it
not to one of the least of them, ye did it not to me” (Matthew 25:43-46).
The first of Kant’s rules states: “Man should always be the end, never the means.”
That rule is consistent with Christian morality which ascribes inestimable worth to
every individual, with the basic principle of medical ethics, i.e., “Salus aegroti suprema
lex,” which means “The patient’s good is the highest law,” and with the life experience
of every person.131
Those who evaluate human beings as either “useful” or “a burden” to society, and
on that basis decide whether or not to save a life, are treating a person not as an end in
himself, but as a means that society uses to achieve its goals. Those who are prepared
to save a person for the sake of his family, but not for his own sake, are treating that
person as a means of satisfying his family’s material and emotional needs, and not as
an end in himself.
129
GENERALE SYNODE DER NEDERLANDSE HERVORMDE KERK [General Synod of the Dutch Reformed
Church], EUTHANASIE, ZIN EN BEGRENZING VAN HET MEDISCH HANDELEN.PASTORALE HANDREIKING [Euthanasia: The Meaning and the Limits of Medical Actions, A Manual for Ministers] (The Hague 1972); and
WERKGROEP EUTHANASIE VAN HET KATHOLIEK STUDIECENTRUM [Catholic Studies Center, Working Group on
Euthanasia], VRAGEN OM DE DOOD:BESCHOUWINGEN OVER EUTHANASIE [Requesting Death: Reflections on
Euthanasia] (G. Dierick, ed., Amboboekin, Baarn 1983).
130
All biblical quotations are from the King James Version (1611).
131
We will suffer defeat in raising our children and in our love relationships if we treat the child or our
partner as a means of satisfying our own emotional needs, but we will be successful if we treat our child or
partner as an end in himself or herself. This ultimately also proves true in our relations with other people.
Other People’s Lives: Reflections on Medicine, Ethics, and Euthanasia
223
Kant’s second law, the categorical imperative, states: “Always act as if you wished
the principle of your action to become an universally binding law.”132 The principle of
universalization which Kant counsels here is not only an intellectual operation facilitating the moral evaluation of conduct; it reveals to us the broader, practical, social
consequences of our actions.
Such universalization is what will occur in reality. The Taigetians I know have
refused life-saving aid to older persons, people with mental disabilities, and single
persons without close family; other Taigetian doctors might refuse medical assistance
to still other categories of patients. If rendering aid to every person in danger of death
is no longer considered an absolute duty, and a doctor can choose to refuse help to one
group of patients or another, then it is perfectly possible that in certain situations the
fact that a patient is blind, or unemployed, or homosexual (or heterosexual), or has
black skin, or lives in a mobile home, will be sufficient reason to let him die. Moreover,
it is unthinkable that a principle accepted in one domain of social life, and applicable
to others, will remain confined to that one domain. People are able to draw logical conclusions and will do so. The mailman will decide not to deliver mail (or social security
checks) to old people. If hoodlums are beating a “retard” in the street, the policeman
will refrain from intervening. A fire chief will refuse the highest priority to the fire in a
nursing home; of course, other nearby buildings could also burn in the process.
Finally, it is fair to test the practices of medical social-Darwinists against the common norms of good conduct, accepted by the majority of people in our time and in the
developed world. To apply these norms is justified if the reader accepts them and all
the more so if the Taigetian doctor himself professes to accept them.
One of those rules is the principle of equality, the right to be treated like everyone
else. We require that everyone who buys goods in a store, boards a train or brings a
case to court, receives that same quantity of goods as everyone else, can travel where his
ticket allows, and that his case will be examined in court like anyone else’s. Whether the
person in question is young or old, strong and healthy or disabled, can have no bearing;
these individual qualities should not even be noticed. Similarly, anyone who is choking
of pulmonary edema, or falls in seizures because of heart block, has the same right as
every other person suffering from the same ailment to adequate (and indeed available)
medical assistance – regardless of whether he is 40 or 80, bright or feebleminded, a
family man or alone in the world. The Taigetian doctor deprives some of his patients
of their right to equal treatment.
We recognize that any person who finds himself in trouble has the right to defense,
the right to counsel who will represent his interest, not those of society or of third parties.
That principle was also binding in medicine as long as the doctor acted exclusively in
the patient’s interest, for his good and his life, brushing aside all other interests, third
parties’, society’s, and his own, in keeping with the old clinical maxim “Salus aegroti
suprema lex,” i.e., “The good of the sick one is the highest law.”
132
I. KANT, FOUNDATIONS OF THE METAPHYSICS OF MORALS 38 (L. W. Beck, trans., 2nd ed., 1990).
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The social-Darwinist doctor no longer wishes to defend his patient’s interest to the
exclusion of all others; he also defends the interest of third parties, those of the patient’s
family and of the society, and not only does he take them into account but holds them
higher than the good of his patient. This doctor does not act as the defender of the
person whose life is threatened, but rather as a sentencing judge. In the most difficult
trial of someone’s life, a trial to which he is brought by nature itself, by illness,133 he is
left without a defender. The sick person is deprived of the right which we acknowledge
without hesitation to people accused of crimes.
In accordance with the standards of our common ethics, we expect everyone to act
honestly. Do the Taigetian doctor’s actions fulfill that requirement? As we have seen, such
doctors sometimes reveal their true motivation to their colleagues (they are unable to
imagine that other doctors might not share their way of thinking). However, the doctor
never dares do so with his patient. Either he does not acknowledge that he is depriving
the patient of assistance, or gives him non-existent or pseudo medical reasons for refusing assistance. At times, a doctor of this kind will try to hide behind others, like the
above-mentioned family physician who sent patients to the hospital to make it appear
that he was doing everything to help them, while at the same time trying to persuade
the cardiologist on duty not to treat these patients or even admit them to the hospital.
Indeed, the Taigetian doctor cannot tell his patient the truth. We are not in Auschwitz. It would be unthinkable to say to a patient: “You won’t get an injection to make
your breathing easier because you’re too old and should die,” or “Die, why should I treat
you since you’re not married.” A doctor would not dare speak that way to a patient. He
has made a decision that must be kept secret from the person involved. He must say
one thing while secretly doing the opposite. The necessity of dishonest action is built
into Taigetian medicine.
According to the standards of our everyday ethics, only an authorized person has the
right to act on behalf of a group or all of society. No one has granted the doctors the right
to exterminate the weak. They act arbitrarily, and make unlawful use of their position.
We further require everyone to act in a trustworthy manner. An evaluation of the
Taigetian doctor based on the criterion will prove negative. A person, any person, be
he old, without family, or mentally disabled – aren’t they all human? – a person whose
life is in danger turns with his pain, fear, and hope to someone whose calling is to help
the sick; he goes to a doctor with complete trust, certain that the doctor will do for him
everything he can. His trust and hope will be betrayed.
Thus, all the norms of everyday ethics are violated by the social-Darwinist doctors.
Those are norms which the doctors themselves fully accept; if asked, they would confirm
this without hesitation. They just have to suspend the rules when they fulfill a duty of
higher order: exterminating the weak for the good of society.
133
Kafka’s “Trial” may be interpreted in various ways; however, one may assume that Kafka, among
other things, if not primarily, was thinking of this ultimate “trial,” in which illness is the prosecutor.
Other People’s Lives: Reflections on Medicine, Ethics, and Euthanasia
225
From a Purely Professional Point of View. How is one to judge a doctor who refuses
life-saving aid to certain groups of patients? His position is untenable from this standpoint as well. Every human activity must fail if it is subjected to alien and irrelevant
criteria and rules of conduct. The racist criterion of truth introduced by the Nazis, e.g.,
“Jewish physics is false, Aryan physics is true,” brought about the decline of German
science that lasted a quarter of a century. The political criterion of truth – Lysenko’s
progressive genetics is correct because it has been approved by the Party – bankrupted
Russian biology and contributed to the failure of farming. A policeman or a car mechanic
who would apply political criteria to their work – not to intervene when a member of
the opposing political party is mugged and assaulted, not to tighten the oil pan on an
immigrant customer’s car – are not only acting wrongly but also unprofessionally: the
former as a policeman whose task is to uphold law and order, the latter as a mechanic.
A doctor who does not judge the cases on their merits, but applies his own non-medical, political, social-Darwinist criteria, and makes decisions on that basis, is not only
morally wrong, but also violating the rules of medical art.
Allowing the Weaklings to Die Out: Is This the Mainstream of Our Civilization? The
Spirit of Our Society? Is This What Dutch People Want? Indeed, some facts would seem to
indicate that this is the case. A number of doctors leave weaker and “useless” individuals
without assistance so that they may die; and those doctors are aided by some nurses,
employees of old age homes, etc. The parents of disabled children and the relatives of
older sick persons often display sympathy to a Taigetian doctor’s decisions or take the
initiative themselves. Time and again articles and letters to the editor express support
for social-Darwinist decisions. The long history behind Taigetian way of thinking and
acting demonstrates that this is not an ephemeral phenomenon; its recurrence over
the centuries and its current recidivism justify our asking whether this might be the
mainstream of our civilization that it would be rash to resist.
Yet that is not true, as we are all well aware. Today’s society is not built on the
Spartan tradition, the killing of older citizens on some Greek islands, or on the old
German law which did not punish the euthanasia of children with disabilities, on the
theories of Ernst Haeckel or on the ideology of the Nazis who first killed children with
disabilities, patients with mental disabilities, and then several million people “unworthy
of life.” That such currents exist in society is undeniable, but it is an underground river
that does not dare come to the surface precisely because it would be in striking opposition to the mainstream of our civilization. We locate the sources of our civilization, the
roots of our society in our instinctive defense of others of our species, a trait we share
with our fellow mammals; in the ancient Greek ethic of agape and the Hippocratic code,
the writings of the Essenes, and the Judeo-Christian heritage. Today’s Dutch society has
succeeded in protecting the poor against hunger and privation. This is a society that
was nearly unanimous in condemning the Nazis crimes. A society which devotes great
effort and a significant portion of its wealth caring for the old, the sick and the disabled;
and no matter that we sometimes tire of that effort and try to limit the expenditures;
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we will never renounce the principle itself because that is what the nation wants. And
this is not a doctrinal policy isolated from the will of the people, but a deep universal
desire, as is witnessed to by the great sums that citizens voluntarily donate for the fight
against cancer, to aid people with disabilities, and to help the Third World; as is also
witnessed to by those thousands of wonderful young people who consciously chose a
walk of life in which they can care for older people, the sick, and the disabled; and I
never tire watching how they perform that difficult work with enthusiasm, patience,
and sensitivity to suffering. It is not the social Darwinists but people of good will who
are in the mainstream of our civilization.
What Goes on in the Mind of a Social-Darwinist Doctor? Finally, one may indeed ask
why the Taigetian doctor goes to such extremes, with no regard for anything; why does
he act against the law, ethics, his own oath, and the rules of his profession, and does so
for no personal gain! Whence does he derive his strength of conviction, his self-confidence, the unshakable sense of self-righteousness? What motivates him? Sadism134 and
the intoxication of power may play a role, but that does not fully explain the challenge
he hurls to society and its rules.
The Taigetian doctor does not consider these rules to be binding. Neither is he
bound by what he signed and swore. In his mind exist two parallel human communities:
the official and the real one. Standards and rules are the standards and rules of the official,
unreal state, the state of democracy, law and order, equal treatment for all people, care
for the poor and the weak. He secretly swore allegiance to another human community,
the true, the real Holland,135 the ancient tribe which kills its crippled children, throws
the mentally ill into the Rhine, strangles the old and infirm, and thus maintains its
strength, purity, and readiness for battle. That true Holland exists but cannot yet reveal
itself, still cannot unmask the fictional, official state. The faith in a true Holland was
inculcated in the Taigetian doctor during his study years, and grows stronger whenever
he sees a colleague acting in that same spirit; whenever the family of a disabled child or
the relatives of a grandma ask that he refrain from treating them; whenever he reads an
article by a moralist, philosopher, or theologian about the manifold social forces that
cut lives short, about the relative value of human life, about the “meaning and limits”
of medical actions, about the charitable deeds of those who allow others to die. He
realizes that only he can do the work that needs to be done. After all, other forms of
extermination, apart from medical ones, are not yet possible. So, he performs his task,
does not expect payment, and finds satisfaction in the fulfillment of a sacred duty. The
Taigetian doctor is a genuine idealist.
But he need not be a person of exceptional courage. The laws of official, fictional
Holland are lenient and are not enforced. Besides, he is not killing his patients, he allows their illness to kill them. The distinction between what is part of a doctor’s task
Jongkees, supra note 69.
The idea of two nations, the “official” and the “real” is taken from Sartre who, in his analysis of
antisemitic mentality, discovered the concepts of “France réelle” and “France abstraite, oficielle, enjuivée.”
J. P. SARTRE, RÉFLEXIONS SUR LA QUESTION JUIVE 36-37 (Gallimard, Paris 1954).
134
135
Other People’s Lives: Reflections on Medicine, Ethics, and Euthanasia
227
and what he is forbidden to do is not clear in the public mind, nor is it clear in his own
foggy mind. He speaks of his actions and motivations only to those who profess the
same views; people outside that circle never gain an insight into his actions nor do they
try to. No Taigetian doctor has yet been the cause of a scandal and none, of course, has
been reprimanded or punished.
In Defense of People Who Are Sick or Disabled. It could be thought that the duty to
care for the weaker members of society is obvious and to speak out in their defense is
thus unnecessary; but it is by no means unnecessary since there is a group of doctors
who consider those people useless and a burden to society, and are resolved to let them
die as quickly as possible. Are “the maimed, the lame, the blind” (Luke 14:13) and the
“poor in spirit” (Matt. 5:3) truly a useless burden to society? They are human beings so
their lives have the same infinite value as the lives of all others. But do their lives also
have a specific meaning for us all? I am convinced that they do. Their existence enriches
our vision of the world and humanity, indicating that there are various ways of being
human. Their will to live, their patient acceptance of their disabilities and their heroic
surmounting of them are examples to us all and lend us courage, sometimes for all the
world to see, as was the case with Antoine de St. Exupery and Franklin D. Roosevelt.
But, most importantly, people with disabilities have yet another role in the human
community: they bring out the best in us. This is a service they render to us all; this is
their great and irreplaceable role in building a humane society.
The Taigetian Mentality: A Recapitulation. I use the term “Taigetian mentality” to define the world view that society should be rid of weak and “useless” members. To achieve
this goal, “Taigetian,” social-Darwinist doctors refuse life-saving medical help to people
belonging to the targeted groups. Holland is perhaps not the only country where such
policy is tolerated. The Taigetian practices violate the law, professional medical ethics,
all general ethical rules, and the commonly held rules of good conduct. These practices
also run counter to entire system of values which Dutch society publicly accepts. The
public’s ignorance, and the vagueness and lack of disclosure that surround Taigetian
practices create an atmosphere conducive to the spread of the phenomenon. To avert
this danger Taigetian practices must be brought out of the dark and into the light.
Chapter XVIII. Biological Cleansing at the Beginning of Life
In 1988, a baby born with Down syndrome vomited all nourishment and was
admitted to one of Holland’s leading centers for pediatric surgery, the Sophia Hospital
in Rotterdam. It was found that the child had an inborn defect of the digestive tract,
duodenal atresia, which made it impossible for food to pass from the stomach to the
intestines. In these cases, surgery to remove the obstruction is feasible and life-saving.
But the parents and the pediatric surgeon, professor Molenaar, decided to refrain from
surgery and let the child die. The family physician, who could not reconcile himself with
putting the child to death, called the district attorney. The latter warned the Council
for Children’s Protection, but this body decided not to intervene. No surgery was done
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and the child died.136 A court, and then the Supreme Court, exonerated the surgeon.137
The family physician was harshly criticized because his call to the D.A. broke his oath
of confidentiality.138
The case provoked a broad discussion, which took an unexpected turn: most
debaters criticized professor Molenaar’s course of action,139 and the Minister of Health,
Welfare and Culture declared that medical treatment should never be refused on grounds
of mental disability.140 There was no doubt that the case was just one example of a more
widespread practice. Indeed, a team of anesthetists at a teaching hospital decided never
to provide anesthesia for cardiac surgery in children with Down syndrome, and from
other centers there were reports of three children with this syndrome who were denied
vitally important surgery for their inborn cardiac defects.141 The parents persevered and
finally found hospitals that agreed to do the surgery.
The circumstances of euthanasia of other newborns and children are illustrated
by three published case histories: First, a girl born prematurely, in the thirty-second
week, recovered from an infection, but there was suspicion of an excess of intracranial
fluid. The parents refused to allow the insertion of a drainage tube. On the thirtieth day
after birth the girl was killed by a pediatrician with injections of morphine-like drug
and potassium chloride.142
Second, after consulting several specialists and getting the approval of the parents,
Dr. H.P., an obstetrician, killed a girl born with cleft spine and hydrocephalus. The
136
J. C. Molenaar, K. Gill & H. M. Dupruis, Geneeskunde, dienares van barmhartigheid [Medicine, Servant of Mercy], 132 NED.TIJDSCHRIFT V.GENEESKUNDE 1913 (1988).
137
H. J. J. Leenen, Niet-behandelen van een pasgeborene voor de Hoge Raad [Nontreatment of a Newborn
Tried at the Supreme Court], 133 NED. TIJDSCRIFFT V. GENEESKUNDE 1281 (1989).
138
J. M. Baks, Mongolen niet uitsluiten voor operaties [Mongoloid Children Should Not Be Barred from
Surgery], NIEUWSBLAD GEZONDHEIDSZORG, Apr. 18, 1989, at 9.
139
F. A. E. Nabben et al., A. T. Grootenhuis et al., J. M. Butting et al., Letters to the Editor, 133 NED.
TIJDSCHRIFT V.GENEESKUNDE 86-91, 573 (1989); J. C. Molenaar, Het nalaten van medisch handelen [Refraining from Medical Interventions], 132 NED. TIJDSCHRIFT V. GENEESKUNDE 1925 (1988); Balk-Smit Duyzenkunst, Geneeskunde en taal: Bijwerking of bedoeling? [Medicine and Language: Side Effect or Intention?] 133
NED. TIJDSCHRIFT V. GENEESKUNDE 2272 (1989).
140
Zwakzinnigen wel opereren [Surgical Operations Should Be Performed on the Menatally Handicapped], Brinkman: Geestelijke handicap geen reden behandeling na te laten [(Secretary of Health) Brinkman:
Mental Handicap is No Reason to Refrain from Treatment], BRABANTS DAGBLAD, July 15, 1989.
141
R. FENIGSEN, EUTHANASIE, EEN WELDAAD? [Charitable Euthanasia?] 12 (Van Loghum Slaterus, Deventer 1987); J. Janssen & M. Janssen-Emmens, Wij maken geen verschillen, wij opereren alle kinderen [We
Do Not Discriminate, We Operate on All Children], in GEBROKEN WERELD [The Broken World] 44-45 (J.
Stolk, ed., Kok Publishers, Kampen, 1988); R. W. M. Croughs, Euthanasie, een vergelijking van huidige
discussie in Nederland met de discussie in Duitsland voor 1933 [Euthanasia: The Present Discussion in
the Netherlands Compared with German Debate Before 1933], in GEBROKEN WERELD 104, 121.
142
R. de Leeuw & P. E. Treffers, Een zachte dood voor pasgeborenen [A Mild Death for Newborn Babies],
128 NED. TIJDSCHRIFT V.GENEESKUNDE 841 (1984).
Other People’s Lives: Reflections on Medicine, Ethics, and Euthanasia
229
Minister of Justice decided to put Dr. P. on trial, expecting a verdict that would establish
a legal precedent.143
Third, Danny had cleft spine and hydrocephalus but was in fair general condition.
No drainage tube to relieve the hydrocephalus was inserted. Once Danny seemed to
have some abdominal pain, and another time he apparently felt not quite well for two
consecutive days. This prompted the parents to ask for euthanasia. With this purpose
the child was admitted to Rainier de Graff Hospital in Delft. One of the nurses opposed
the decision, and on the next day she and her husband offered to adopt the child. The
offer was rejected. On August 19, 1990, Danny, then aged three and one-half months,
was killed with drugs administered by intravenous drip. The nurse was reprimanded
because by involving her husband in the adoption offer she violated professional confidentiality.144
These case histories should seem familiar to the American reader. The first child
had Down syndrome and an inborn obstruction of the digestive tract, as had the unhappy Baby Doe from Bloomington, Indiana.145 Two other babies had cleft spine, the
same defect as the babies that in 1983 were starved and neglected to death in Children’s
Hospital in Oklahoma City.146 But some peculiar features can be seen. One of these is
the doctors’ readiness to administer lethal injections, and their openness about such
actions. Another peculiarity are the punishments meted out to persons who opposed
the termination of children’s lives.
The Extent of the Practice. Euthanasia of newborns and children became known
due to the nationwide survey ordered by the Dutch government in 1995. In that year
190,000 babies were born in the Netherlands. One thousand forty-one children died
before the age of one year, which means that the country’s infant mortality is the lowest
in the world.147
The Netherlands: The Baby “Maartje” Case, IAETF UPDATE 8, 10 (1994); Dutch Use Courts to Formalize Infant Euthanasia, IAETF UPDATE 9, 9 (1995).
144
B. Versteeg, De wens van de ouders en het recht op het leven van een kind [The Wish of the Parents and
the Child’s Right to Life], 4 IN PERSPECTIEF 12-13 (1991).
145
C. E. KOOP, THE MEMOIRS OF AMERICA’S FAMILY DOCTOR 240-61 (1991). See also, Victor G. Rosenblum & Edward R. Grant, The Legal Response to Babies Doe: An Analytical Prognosis, 1 ISSUES IN LAW & MED.
391 (1986); Thomas E. Elkins & Doug Brown, An Approach to Down Syndrome in Light of Infant Doe, 1
ISSUES IN LAW & MED. 419 (1986); Declaratory Judgment in the Infant Doe Case, 2 ISSUES IN LAW & MED. 77
(1986); and Martin H. Gerry & Mary Nimz, The Federal Role in Protecting Babies Doe, 2 ISSUES IN LAW &
MED. 339 (1987).
146
Id. at 251-52; Gross et al., Early Management and Decision Making for the Treatment of Meningomyelocele, 72 PEDIATRICS 450-58 (1983). See also, Martin H. Gerry, The Civil Rights of Handicapped Infants: An
Oklahoma “Experiment,” 1 ISSUES IN LAW & MED. 15 (1985); and Sharon M. Paulus, Suit Filed in Oklahoma
Alleging Twenty-four Infants Died After Being Denied Beneficial Medical Treatment, 1 ISSUES IN LAW & MED.
321 (1986).
147
G. VAN DER WAL & P. J. VAN DER MAAS, EUTHANASIE EN ANDERE MEDISCHE BESLISSINGEN ROND HET
LEVENS EINDE [Euthanasia and Other Medical Decisions Concerning the End of Life] 181 (Sdu Publishing
House, The Hague 1996).
143
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Forty-five percent of neonatologists and 31% of general pediatricians stated that
at some time in their careers they have actively terminated a newborn’s life.148 In 1995,
the lives of fifteen newborns were actively terminated with lethal injections.149 In almost
600 cases, life-prolonging support was withdrawn or withheld, and in more than 400
of these cases this was done with the explicitly stated intention to cause death.150 If the
children did not die after withdrawing or withholding life support, in more than eighty
cases drugs were administered with intention to hasten death.151
Pediatricians who withdrew medically non-futile life-prolonging treatment in
twenty-three percent of the cases did so without consulting the parents.152
The Justification of Euthanasia of Newborns. The most extensively discussed subject
has been euthanasia for very premature babies, those with brain damage due to birth
trauma, cases of complicated spina bifida with a chance to develop hydrocephalus when
the opening is closed, and children with Down syndrome, with or without coexisting
cardiac or gastrointestinal malformations.
The argument used to justify terminating the lives of newborns with disabilities
has developed along several lines. One of these is the negative evaluation of medical
treatment in general; this argumentation is used to justify the denial of medical treatment
to babies with disabilities who need medical intervention in order to survive. Medical
treatment is represented as an insolent display of medical power,153 as an always questionable and often meaningless action, an inexcusable violation of the patient’s privacy
and bodily integrity, and as a premeditated severe bodily injury punishable under
criminal law.154 This assault on medicine led by doctors who disavow everything they
do is as surprising as it is inconsistent: doctors who deny life-sustaining treatment to
babies with disabilities grant the same treatment (incubators, oxygen tents, duodenal
surgery) to non-disabled children, which shows that the reasons to deny it lay not in
the treatments’ criminal or morally reprehensible nature, but elsewhere.
Some euphemisms used are misleading, as when the denial of surgery to a baby
with duodenal obstruction is presented as “conservative treatment,”155 while no treatment is given and there is no question of conserving anything since the patient will die.
The other and more important line of reasoning portrays euthanasia of severely disabled children as an act of compassion that is done in the child’s best interest.
Statements deviating from this humane creed have been very infrequent. Defending
the denial of lifesaving help to a child with Down syndrome, J.C. Molenaar, K. Gill,
and H.M. Dupuis declared that the value of human life depends on how valuable this life is
Id. at 187, Table 17.1.
Id. at 189.
150
Id. at 188, 224.
151
Id. at 188, Table 17.2, and 224.
152
Id. at 194, Table 17.5.
153
J. H. VAN DEN BERG, MEDISCHE MACHT EN MEDISCHE ETHIEK [Medical Power and Medical Ethics]
27-30 (G.V. Callenbach, Nijkerk 1969).
154
Molenaar et al., supra note 136, at 1913; Molenaar, supra note 139, at 1925-26.
155
Molenaar et al., supra note 136, at 1914.
148
149
Other People’s Lives: Reflections on Medicine, Ethics, and Euthanasia
231
for other people.156 Apparently they did not realize that they were reinstating a maxim
very close to principle that the director of German public health Dr. Arthur Gütt and
the founder of German racial hygiene Dr. Ottmar Verschuer had proclaimed in 1934
and 1935.157 The importance of the statement lies in the fact that it was the common
declaration made by a leading pediatric surgeon (Molenaar), a prominent professor of
family medicine (Gill), and the country’s most cited medical ethicist (Helen Dupuis).
Another statement, more drastic, but of much less authority, was that by a Mr. Klaij,
who exhorted his readers to exterminate all handicapped newborns in order to breed
a strong human race.158 His outburst was not entirely devoid of significance, since it
was published without editorial comment and provoked no protests, which amounted
to some tacit support.
As a rule, however, the Dutch argumentation in favor of euthanasia of newborns,
in contrast to important currents of British, German, and American thought, does not
refer to eugenics. Euthanasia is needed not in order to strengthen or purify the nation,
but for the good of the child involved, who should be spared an imperfect life, sufferings, and dependence. True, the interests of the parents and of the community are often
mentioned, but not as the only or prevailing reasons for euthanasia: the best interest
of the child is decisive.
The logic of killing someone in that person’s best interest is questionable, since death
annihilates all interests of a person once and for all. It would seem that the absurdity of
saving people by destroying them has been sufficiently exposed and even ridiculed: “We
had to destroy the village to save it from the Reds” is a well-known example. However,
reasoning of this kind is still considered valid medical ethics. One would also think that
the person best qualified, actually the only one who is qualified to judge whether it is
worth his while to stay alive, is the disabled person himself. Why not wait and let him
choose? After all, the proponents of euthanasia for disabled newborns have proved wrong
in the past. The victims of Thalidomide, whom Van den Berg wanted to exterminate,159
study, work, join the Dysmelia Association160 or the German Behindertenbewedung,161 and
assert that they have the same right to live as everyone else. People severely disabled by
cerebral palsy win literary awards,162 and some young people with Down syndrome turn
J. C. Molenaar et al., Answer to Critics, 133 NED. TIJDSCHRIFT V. GENEESKUNDE 91 (1989).
Gütt and Verschuer, quoted in R. PROCTOR, RACIAL HYGIENE: MEDICINE UNDER THE NAZIS 105 (1988);
R. J. LIFTON,THE NAZI DOCTORS 39 (1989); and M. Dietz, Which Will It Be? CENTER FOR THE RIGHTS OF THE
TERMINALLY ILL REP., Oct./Nov./Dec. 1989, at 1.
158
J. Klaij, Letter to the Editor, 2 KWARTAALBLAD V.D.NEDERLANDSE VERENIGING VOOR VRIJWILLIGE EUTHANASIE 4 (1976).
159
VAN DEN BERG, supra note 153, at 27-30.
160
Softenon-slachtoffer Mark Verwaert overwon al zijn handicaps: Een leven zonder ledematen [Thalidomide Victim Mark Verwaert Has Overcome All His Handicaps: A Life Without Limbs], BRABANTS DAGBLAD,
Oct. 27, 1987.
161
O. TOLMEIN, GESCHÄTZTES LEBEN:DIE NEUE “EUTHANASIE” DEBATTE [Quality of Life: The New “Euthanasia” Dabate] 119-74, 231 (Konkret Lit. Verlag, Hamburg 1990).
162
Handicapped Author Wins £ 20,000 Award, INT’L HERALD TRIB., Jan. 21, 1988.
156
157
232
Issues in Law & Medicine, Volume 28, Number 2, 2012
out to be talented actors, as is well known to everybody who watched the TV series featuring a youth with Down syndrome, and the excellent French movie in which a young
man with Down syndrome played a main role. The advocates of euthanasia, however,
believe that such lives must not be allowed to speak for themselves: such lives must
be prevented. The decision should be taken soon after birth, no waiting is needed; the
parents together with the doctors have the right to decide: they embody the newborn’s
purported desire to die. With this I do not agree. A child born alive, with or without
disability, breathes, sucks the breasts or bottle, thus within it’s means manifests its will
to live. The only thing the advocates of euthanasia can prove beyond any doubt is that
they are stronger than the disabled newborn.
A scrutiny of the language of the argumentation, of its implied meaning, of the
attitudes it betrays, and of the emotions to which it appeals is quite revealing. I analyzed
three such texts.163 Newborns with disabilities are described as “severely misshapen,”
“incomplete,” “unfit,” “heavily disfigured”; if kept alive, they are bound to lead “a particularly primitive life,” or “a life that in the eyes of many is quite meaningless.” Those
babies are not viewed as people with disability or disease: it is their whole being that is
devalued, their humanity represented as incomplete and questioned. They aren’t even
patients, the doctor has obligations only to the parents, but none to the sick newborn.
The lives of these babies are so devalued as to make euthanasia imperative: such lives
“may be taken immediately after birth.” “Who could allow such a child to stay alive?”
What the language of the argumentation reveals is not compassion but repugnance, not
concern for the newborn’s best interest but reluctance to admit the “defective” child into
the community of the living.
Chapter XIX. Crypthanasia
I use the term crypthanasia (from Greek kryptos, secret, hidden, and Thanatos, The
Death) to denote covert medical killings of unsuspecting patients.164
Excerpts From Dutch Publications on Crypthanasia. The reality of crypthanasia is
illustrated by the following.
UÊ “‘Mother is bedridden, has to be helped with everything, she is unclean, does
not recognize people any more.’ . . . The small group enters the patient’s room.
The physician administers the lethal injection.” Jan Hendrik van den Berg,
Medical Power and Medical Ethics, 1969.165
UÊ “I think that when a human being . . . gets into such condition that he no more
can live in real social communication with others, (his) remaining life . . . can
no more claim a right to be protected . . . In this respect there is no reason
to make a distinction between the demented elderly, . . . the victims of road
VAN DEN BERG, supra note 153, at 27-28; Molenaar et al., supra note 136; and GENERALE SYNODE,
supra note 129.
164
FENIGSEN, supra note 141, at 36-40.
165
VAN DEN BERG, supra note 153, at 50.
163
Other People’s Lives: Reflections on Medicine, Ethics, and Euthanasia
233
accidents, . . . and children with Thalidomide-induced limb malformations.”
J. Ekelmans, The Mature Mortal, 1971.166
UÊ “Involuntary active euthanasia . . . . It is a public secret that this form of euthanasia does occur . . . . [W]e should summon up enough courage to look
closely at (it), and try to show understanding.” Sometimes Death Comes Too
Late: A Pamphlet of the Foundation for Voluntary Euthanasia, 1975.167
UÊ “[In] those smarting cases in which one can suppose that were the patient
able to express his will he would choose euthanasia, . . . rights of decisions
must be adjudged to other persons.” The Board of the Royal Dutch Society of
Medicine, Answer to the Questions of the State Committee on Euthanasia, 1984.168
UÊ “This patient . . . never said ‘put an end to it,’ only ‘relieve my pain.’ . . . We
tried everything . . . . And he simply did not die, whatever we did. Finally a
huge dose of potassium was injected, he lapsed into a cardiac arrest and that
was the end of him.” Internist interviewed by Henri W. H. Hilhorst, Euthanasia
in the Hospital, 1983.169
UÊ “I had a young patient who terribly clung to life . . . . He didn’t even want to
discuss his own bad situation. He had the kind of lung cancer that is inoperable,
when it is diagnosed it already had spread. Chemotherapy gives fair results,
so it also was with this patient. . . . And then suddenly I said: now it becomes
too crazy, I cannot go on like that . . . . Now give me active euthanasia! I gave
him an I.V. with such drugs that he died.” Chest physician interviewed by
Hilhorst, 1983.170
UÊ “How euthanasia used to be carried out? Stealthily, in deep secret, but always
out of love to mankind.” Physician interviewed by Hilhorst, 1983.171
UÊ “I do recognize the difference between termination of life upon request and
without request of the patient. But from the point of view of a doctor, from
moral point of view, these are two actions of almost the same kind.” Dutch
Secretary of Health, Mr. H. J. Simons, 1993.172
J. Ekelmans, De mondige sterveling [The Mature Mortal], 1971 MEDISCH CONTACT 791.
DE DOOD KOMT SOMS TE LAAT, EEN BROCHURE V.D.STICHTING VRIJWILLIGE EUTHANASIE [Sometimes
Death Comes Too Late: A Pamphlet of the Foundation for Voluntary Euthanasia] 20 (De Tijdstroom,
Lochem 1975).
168
Hoofdbestuur KNMG, Reactie op vragen Staatscommissie Euthanasie [The Board of the Royal Dutch
Society of Medicine, Answer to the Questions Asked by the State Committee on Euthanasia], 1984 MEDISCH CONTACT 1002.
169
H. W. H. HILHORST, EUTHANASIE IN HET ZIEKENHUIS: ZACHTE DOOD VOOR ZIEKENHUISPATIENTEN [Euthanasia in the Hospital: Mild Death for Hospital Patients] 108 (De Tijdstroom, Lochem-Poperinge 1983).
170
Id. at 175.
171
Id. at 99.
172
Euthanasie volgens minister vaker door arts gemeld [According to the Minister, Euthanasia is [now]
More Often Reported by Physicians], DE VOLKSKRANT, Feb. 3, 1993.
166
167
234
Issues in Law & Medicine, Volume 28, Number 2, 2012
The Public Awareness of Crypthanasia. For years crypthanasia remained a public
secret, just as the pamphlet Euthanasia asserted. Almost everybody knew this was happening, but there was no proof, no established facts, very little in writing.
In 1972, Holland’s largest illustrated weekly published the statement of Dr. Karel F.
Gunning who had returned from North Africa and was indignant about practices he had
encountered in some Dutch hospitals: when the general practitioners phoned specialists
in the evening, asking them to admit seriously ill older patients, sometimes they were
advised not to send the patients in, but to kill them with an intravenous injection.173
Then in 1983, the sociologist Henri W. H. Hilhorst published the book Euthanasia in the Hospital,174 based on his study, sponsored by the Royal Dutch Academy of
Science and the University of Utrecht, and conducted in eight hospitals. He found not
only voluntary euthanasia, but also secret involuntary euthanasia of children and adults
practiced in these situations.175 The book contained interviews with doctors who had
performed active euthanasia without the patients’ request, consent, or knowledge.
Alarmed by Hilhorst’s findings, the Dutch Patients’ Association (N.P.V.), warned
patients and their families that “in many hospitals” people were put to death against
their will, without their knowledge, and without the knowledge of their families.176 The
N.P.V. advised patients and their families to monitor the doctor’s actions as closely as
possible. Unfortunately, the real possibilities of doing so are negligible.
To protect patients from involuntary euthanasia in case of admission to hospital,
the N.V.P., together with the Sanctuary Foundation (Stichting Schuilplaats), printed a
Declaration of the Will to Live. “This card, which anyone can carry on his person, states
that the signer does not wish euthanasia performed on him.”177
In the spring of 1985 it came to people’s attention that in the De Terp nursing
home in The Hague twenty residents had died entirely unexpectedly in a short period
of time.178 An inquiry was launched, and doctor B. who worked at De Terp was apprehended. He admitted having put an end to the lives of five people without their consent
or knowledge.179
Interview with Dr. Karel F. Gunning, PANORAMA (Haarlem), No. 41, 1972, at 37.
HILHORST, supra note 169.
175
Id. at 99, 108, 136-37, 174-75, & 179.
176
NIEUWSBULLETIN NEDERLANDSCHE PATIENTENVERENIGING [News Bulletin of the Dutch Patients’ Association], Vol. 3, No. 1, 1985, at 8.
177
Codicil tegen euthanasie [Codicil Against Euthanasia], BRABANTS DAGBLAD, June 19, 1985; NPV/
STICHTING SCHUILPLAATS, LEVENSWENSVERKLARING [Dutch Patients’ Association & Sanctuary Foundation,
Declaration of the Will to Live].
178
Verzorgingshuizen in opspraak: Het onnodig sterven [Nursing Homes Become the Talk of the Town:
The Unnecessary Deaths], ELSEVIERS MAG., Apr. 20, 1985; Arts bekent vijfmaal euthanasie [Physician Admits
Having Carried Out Euthanasia of Five Persons], BRABANTS DAGBLAD, Apr. 17, 1985.
179
Arts bekent vijfmaal euthanasie, supra note 178.
173
174
Other People’s Lives: Reflections on Medicine, Ethics, and Euthanasia
235
In 1987 it was discovered that three nurses working at the intensive car unit of the
Free University Hospital in Amsterdam secretly killed several unconscious patients.180
They said they could no longer endure the sight of those unfortunate human beings.
These reports were followed by the estimates of Dessaur,181 Gunning,182 Dessaur
and Rutenfrans,183 and Van der Sluis184 that more people in the Netherlands were dying by involuntary than by voluntary euthanasia. There was also a series of six cases
reported by Innemee185 and my report186 on involuntary active euthanasia in one of the
hospitals in Rotterdam.
The VARA/Interview study published in 1990 revealed that – according to patients’ families – the decisions to terminate patients’ lives were often taken without their
consent or knowledge.187 The Royal Dutch Society of Medicine expressed concern in
connection with these findings but the Dutch Society for Voluntary Euthanasia dismissed
the problem by declaring that euthanasia was by definition voluntary. Whatever was
done without the patients’ request could not be euthanasia; such acts were, therefore,
beyond the scope of debate.188
It would be an easy way to make the world a better place if all evil could be eliminated by adopting definitions. The real question is whether patients are killed without
their request. They are. In a study done by the Medico-Legal Group of the Limburg
University in Maastricht, the questionnaire circulated among 299 doctors contained,
among others, the question whether they had performed euthanasia without the patient’s
180
Euthanasie op drie ongeneeslijk zieke patieten in Amsterdams ziekenhuis: Verplegers verdacht van moord
[Euthanasia of Three Incurable Patients at a Hospital in Amsterdam: Nurses Suspected of Murder], BRABANTS DAGBLAD, Jan. 16, 1987.
181
C. I. Dessaur, Euthanasie: de zelfmoord op zieken en bejaarden [Euthanasia: Suicide Committed on
the Sick and Elderly], 1985 DELIKT & DELINKWENT (Leiden) 913.
182
K. F. Gunning, Euthanasia in the Netherlands, NEWS EXCHANGE OF THE WORLD FED. OF DOCTORS WHO
RESPECT HUMAN LIFE, No. 96, 1987, at 8.
183
DESSAUR & RUTENFRANS, MAG DE DOKTER DODEN?: ARGUMENTEN EN DOKUMENTEN TEGEN HET EUTHANASIASME [May the Doctor Kill? Arguments and Documents Against Euthanasiasm] 38 (Querido, Amsterdam 1986). See also, C. I. Dessaur & C. J. C. Rutenfrans, The Present Day Practice of Euthanasia, 3 ISSUES IN
LAW & MED. 399 (1988).
184
DESSAUR & RUTENFRANS, supra note 183, at 44 (quoting I. van der Sluis, 127 NEDERLANDSE TIJDSCHRIFT V.GENEESKUNDE 472 (1983). See also, I. van der Sluis, The Practice of Euthanasia in the Netherlands,
4 ISSUES IN LAW &MED. 455 (1989).
185
C. Innemee, Commissie Remmelink krijgt zes gevallen voorgelegd: NPV geeft voorbeelden van ongevraagde levensbeeingdiging [Six Cases Presented to the Remmelink Committee: Dutch Patients’ Association
Presents Examples of Termination of Life Without Request], ZORG (Veenendaal), Vol. 8, No. 4, 1990, at
4-6.
186
FENIGSEN, supra note 141, at 37-39.
187
VARA-Onderzoek: Euthanasie komt veel vaker voor [The Study (by the TV network) VARA: Euthanasia Occurs Much More Often], BRABANTS DAGBLAD, Feb. 22, 1990.
188
Id.
236
Issues in Law & Medicine, Volume 28, Number 2, 2012
request. One hundred twenty-three doctors answered this question in the affirmative;
seven doctors performed involuntary euthanasia on more than fifteen patients each.189
Public Opinion on Crypthanasia. Whenever cases of crypthanasia were revealed,
attempts were made to dismiss them as “abuses” that had nothing in common with the
regular practice of voluntary euthanasia – as exceptional, sporadic, and criminal acts.190
However, the problem could not be discarded in this way. Neither could it be claimed
that the covert medical killings were perpetrated by some outcasts whose actions were
contrary to the public mood. The reverse was true. Two consecutive polls conducted by
NIPO Institute showed that while 76 percent of the Dutch public approved voluntary
euthanasia, 77 percent supported active involuntary euthanasia: 33 percent of the respondents showed “considerable sympathy” and another 44 percent “some sympathy”
for those who out of mercy kill their own father or mother without his or her consent.
Forty-three percent approved of involuntary active euthanasia for unconscious persons
“with little chance of recovery,” while 27 percent were certain or thought that they
probably would request involuntary active euthanasia for a demented relative.191 Ninety percent of the polled undergraduate students of economics supported compulsory
euthanasia of unspecified groups of people to streamline the economy.192
The perpetrators of covert medical killings enjoyed broad public and institutional
support, and total judicial leniency. The doctor who admitted having killed a number
of inhabitants of the De Terp nursing home in The Hague, and was convicted of several
murders, received public declarations of support from, among others, the president
of the Dutch Society for Voluntary Euthanasia, the vice-president of the Royal Dutch
Society of Medicine, and from a former attorney general at the Supreme Court.193 A
Citizens’ Committee of Support for the De Terp doctor was founded in Amsterdam.194
In an official statement, the Board of Royal Society of Medicine declared itself alarmed,
however, not by the killings, but by the conviction of the doctor, which could cause
F. C. B. VAN WIJMEN, ARTSEN EN ZELFGEKOZEN LEVENSEINDE: VERSLAG VAN EEN ONDERZOEK NAAR OPVAT[Physicians and
Voluntary End of Life: Report on a Study of Opinions and Conduct of Physicians Concerning Euthanasia
and Assisted Suicide] 24 & Table 18, and 31 (Vaakgroep Gezondheidsrecht Rijksuniversiteit Limburg
[Medico-Legal Group of the Limburg University], Maastricht 1989).
190
C. J. van den Berge (Dutch Society of Health Law), J. G. M. Aartsen et al. (26 signatories), Van
der Kloot Meijburg (Dutch National Hospital Council and the Board of the Dutch Society for Voluntary
Euthanasia), & A. van der Spek, Letters to the Editor, HASTINGS CENTER REP., Nov./Dec., 1989, at 47-50.
191
Meer Nederlanders voor actieve euthanasie [More Dutchmen Favor Active Euthanasia], NRC HANDELSBLAD, Jan. 13, 1986; Ruim driekwart Nederlanders voor euthanasie [More Than Three Quarters of All
Dutchmen Favor Active Euthanasia], BRABANTS DAGBLAD, Apr. 21, 1986.
192
Interview with Dr. Gunning, supra note 173.
193
Artsen bezorgd na vonnis De Terp: Euthanasie in kwaad licht [Doctors Express Concern Because of De
Terp Verdict: Euthanasia Put in an Unfavorable Light], BRABANTS DAGBLAD, Aug. 7, 1985; Jurist kraakt proces tegen arts De Terp [Lawyer Attacks Trial of De Terp Doctor], BRABANTS DAGBLAD, Aug. 17, 1985.
194
Euthanasie-dokter! Comité steun huisarts D. W. Bakker [Euthanasia Doctor! Committee for Support of
Family Doctor D. W. Bakker], AMSTERDAM STADSBLAD ZUID, Aug. 14, 1985.
189
TINGEN EN GEDRAGINGEN VAN ARTSEN TEN AANZIEN VAN EUTHANASIE EN HULP BIJ ZELFDODING
Other People’s Lives: Reflections on Medicine, Ethics, and Euthanasia
237
feelings of insecurity among physicians who helped their patients to die.195 Finally, a
court of appeals dismissed the accused doctor’s guilty plea and declared him “not guilty”
on a technicality,196 while a civil court awarded him 300,000 guilders ($150,000 U.S.)
in damages.197
The four nurses at the neurosurgical intensive care unit of the Free University
Hospital in Amsterdam, who admitted having secretly killed several unconscious patients, received support from the hospital’s Employees’ Council which demanded their
immediate release and reinstatement.198 While releasing the nurses from custody, the
Amsterdam court held that their actions had been prompted by humane considerations.
The victims’ parents who only after the arrests of the nurses learned how their sons and
daughters had died, thanked the nurses at an emotionally charged, televised ceremony.
Thus, crypthanasia is not an “abuse” of the practice of the voluntary euthanasia; it is
widely accepted, openly supported, and praised as a charitable deed.
Among repeated warnings by critics of euthanasia, and loud denials from the
pro-euthanasia establishment, the country and the international community waited for
a definitive statement.
Chapter XX. Dutch Government-Ordered Surveys of Euthanasia
In 1990, the government-appointed committee on euthanasia, chaired by professor
J. Remmelink, commissioned the Institute for Social Health Care of the Erasmus University in Rotterdam to conduct a nationwide survey. While the project was discussed
in the parliament, a Liberal representative, Mr. Jacob Kohnstamm, introduced a motion
that would restrict the investigation to euthanasia on the patient’s explicit request. On
June 14, 1990, the Second Chamber of the Parliament rejected this motion, and approved the committee’s plan, strongly supported by the Minister of Justice, professor
Ernst Hirsch-Ballin, to investigate both euthanasia upon patient’s request and the various
forms of termination of life without the patient’s request. Immunity from prosecution
and total anonymity were granted to all doctors participating in the study.
Three studies were conducted. In the retrospective study, more than four hundred
physicians were interviewed about their opinions on, and their practice of euthanasia.
Then, during a six month period, the same physicians were asked to record and report
their actions in cases with a fatal outcome (the prospective study). In the third part of
the survey, a representative sample of death certificates was taken from the register at
the Central Statistical Office, and the physicians who had been involved in the care of
Artsen bezorgd na vonnis De Terp, supra note 193.
Huisartsvrijgesproken van moord [Family Physician Aquitted of Murder],BRABANTS DAGBLAD, Nov.
13, 1986.
197
Terp-arts krijgt schadevergoeding [Physician of De Terp Nursing Home Awarded Damages], BRABANTS DAGBLAD, June 6, 1987.
198
Opnieuw steun VU-verpleegkundigen: Ondernemingsraad ziekenhuis wil drietal direct op vrije voeten
[More Support for Free University Nurses: Employees’ Council of the Hospital Demands Immediate Release of the Three From Custody], BRABANTS DAGBLAD, Jan. 23, 1987; VU-verplegers vrijgelaten [Free University Nurses Released From Custody], BRAGANTS DAGBLAD, Jan. 30, 1987.
195
196
238
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the deceased were asked to provide information. National estimates were obtained by
weighed extrapolation of the findings.
When the committee released their report,199 it immediately became clear that it
contained the most valuable, extensive, and reliable information on euthanasia in the
Netherlands to date. The data on active euthanasia are shown in Table 1.
The total of 11,800 persons who died of active euthanasia in 1990 is nine percent
of all deaths in the country. As estimated by attending physicians, most patients who
underwent active euthanasia would soon die anyway; however, in about one-third of
the cases euthanasia shortened the patients’ lives by one to six months, or even by more
than six months.200
The great majority (80%) of patients who underwent active euthanasia upon their
request suffered from various forms of cancer. In cases of involuntary euthanasia the
percentage of cancer patients was lower. Most of the remaining patients suffered from
heart or lung disease or a disease of the nervous system.
In the year 1990, physicians rejected 6,700 requests for euthanasia. In the Committee’s opinion, this indicated that such requests were seriously considered and not too
easily granted.201 This conclusion is open to doubt. A later government-ordered study
found that if requests for euthanasia were not granted, in half the cases this was simply
due to the fact the patients died before euthanasia could be carried out.202 Another study
showed that when the requests for euthanasia were granted, euthanasia was carried out
on the day of request in 59 percent of cases, and within one hour after the request in
11% of cases,203 which suggests rather hasty decision making.
MEDISCHE BESLISSINGEN ROND HET LEVENSEINDE. I. RAPPORT VAN DE COMMISSIE ONDERZOEK MEDISCHE
II. HET ONDERZOEK VOOR DE COMMISSIE MEDISCHE PRAKTIJK INZAKE EUTHANASIE
[Medical Decisions About the End of Life. I. Report of the Committee to Study the Medical practice
Concernign Euthanasia. II. The Study for the Committee on Medical Practice Concerning Euthanasia]
(State Publishing House SDU, The Hague 1991) [hereinafter “REPORT I” and “REPORT II,” respectively].
Volume I has not been translated. Volume II appeared in English translation in P. J. VAN DER MAAS, J. J. M.
VAN DELDEN,&L.PIJNENBORG,EUTHANASIA AND OTHER MEDICAL DECISIONS CONCERNING THE END OF LIFE: AN
INVESTIGATION PERFORMED UPON THE REQUEST OF THE COMMISSION OF INQUIRY INTO THE MEDICAL PRACTICE
CONCERNING EUTHANASIA (Elsevier, Amsterdam-London-New YorkTokyo 1992). [The page numbers quoted in the present chapter refer to the Dutch original.]
200
REPORT II, supra note 199, at 37 (Table 5.13).
201
REPORT I, supra note 199, at 31-32.
202
G. VAN DER WAL ET AL.,MEDISCHE BESLUITVORMING AAN HET EINDE VAN HET LEVEN:DE PRAKTIJK EN DE
TOETSING PROCEDURE [Medical Decisionmaking at the End of Life: ThePractice and the Checking and
Verifying Procedure] 52-53 (De Tijdstroom, Utrecht 2003). The finding tends to support the opinion of
critics who argue that euthanasia, however we judge it from the moral point of view, is simply superfluous.
203
G. van der Wal et al., Euthanasie en hulp bij zelfdoding door artsen in de thuissituatie [Euthanasia
and Physician-assisted Suicide at the (Patient’s) Home], 135 NED. TIJDSCHRIFT V.GENEESKUNDE 1593-1603
(1991).
199
PRAKTIJK INZAKE EUTHANASIE.
Other People’s Lives: Reflections on Medicine, Ethics, and Euthanasia
239
Table 1.
Active Euthanasia in the Netherlands in 1990204
Voluntary euthanasia:
Lethal injections administered upon
patients’ explicit request
Physician-assisted suicides
Lethal overdoses of painkillers administered
with patients’ consent with intention to cause death
Total, voluntary euthanasia
Estimated number of cases
2,300i
400ii
3,159iii
5,859
Active involuntary euthanasia:
Lethal injections administered without
patients’ explicit request
1,000iv
Lethal overdoses of painkillers administered
with intention to cause death, without
patients’ consent or knowledge
4,941v
Total, active involuntary euthanasia
5,941
Grand total of deaths actively caused by physicians
_______________
11,800
REPORT I, supra note 199, at 13.
Id.
iii
Report II, supra note 199, at 58 (Table 7.2), 61 (Table 7.7), and 145.
iv
Report I, at 15; Report II, at 145.
v
Report II, at 58 (Table 7.2), 61 (Table 7.7), and 145.
i
ii
The figures in Table I, with the exception of the lethal overdoses of painkillers, are those explicitly
stated in the report. The numbers of cases of lethal overdose of painkillers have been computed from the
report’s total (22,500 cases), the percentage of deaths caused intentionally, and the percentage of overdoses
administered without the patient’s request. REPORT I, supra note 199, at 13, 15-16; REPORT II, supra note
199, at 58 (Table 7.2), 61 (Table 7.7), and 145.
204
240
Issues in Law & Medicine, Volume 28, Number 2, 2012
“Passive Euthanasia.” Life-prolonging treatment was withdrawn or withheld with
consent of the patients in 5,800 cases,205 and without patients’ consent or knowledge
in 25,000 cases.206 Ninety-eight percent of physicians working in nursing homes have
withheld or withdrawn lifeprolonging treatment without patients’ consent.207
More Information on Active Involuntary Euthanasia. Fifty-nine percent of physicians
viewed active euthanasia without the patient’s request as “conceivable,”208 and 27%
have actually performed such acts.209 The latter figure was lower than 41% found in
1989 study.210 Among the 1,000 patients whose lives were actively terminated without
their request there were 140 conscious, fully competent persons.211 Some physicians
proceeded to active involuntary euthanasia even though they believed that other courses
of action were still possible.212 “Low quality of life,” “no prospect of improvement,” and
“the family could not take it any more” were among the most frequent cited reasons to
terminate the patients’ lives without their request.213 In 45% of cases in which the lives
of hospital patients were actively terminated without their consent, it was done without
the knowledge of their families.214
Administering lethal doses of painkillers without patients’ consent or knowledge,
and with intention to cause death, is, of course, a form of involuntary active euthanasia, but in the report these cases are listed in the chapter on “Pain Relief.” Among the
patients whose lives were terminated in this way, more than 1300 were conscious and
fully competent.215
Compliance with “Rules of Careful Conduct.” These guidelines, worked out in the
1980s by the courts and the Royal Dutch Society of Medicine, and approved by the
Parliament, state that the doctor who reports a case of euthanasia should plead that he
acted out of higher necessity. The “rules” require a free, explicit, emphatic, and repeated
request for euthanasia and an adequate explanation by the doctor of the medical alternatives for alleviating the patient’s sufferings. Another physician and the next of kin (unless
the patient objects) should be consulted, written records of the proceedings should be
kept by the doctor, and the case should be reported to the authorities.
The study shows that the rules were often disregarded. The practice of active involuntary euthanasia, which in 1990 involved 5,900 cases, violated the most important
rule. In cases of voluntary euthanasia, many general practitioners disregarded the rules
205
206
207
208
209
210
211
212
213
214
215
REPORT I, supra note 199, at 15.
REPORT II, supra note 199, at 69, 72 (Table 8.15).
Id. at 69 (Table 8.8).
Id. at 46-47 (Table 6.1).
Id.
VAN WIJMEN, supra note 189.
REPORT II, supra note 199, at 49 (Table 6.4)
Id. at 50 (Table 6.5).
Id. at 51 (Table 6.7).
Id. at 52 (Table 6.8).
Id. at 61 (Table 7.7).
Other People’s Lives: Reflections on Medicine, Ethics, and Euthanasia
241
to consult another physician and to record the proceedings in writing.216 Sixty percent
of the general practitioners did not consult another physician before carrying out involuntary active euthanasia.217 In the death certificate, 72% of the doctors concealed
the fact that the patient died by euthanasia.218 In cases of active involuntary euthanasia,
the doctors, with a single exception, never stated the truth in the death certificate.219 In
cases labeled in the report as lethal overdoses of painkillers administered with intent to
cause death, none of the rules was ever followed by the doctors.
According to Dr. Herbert Cohen, a prominent Dutch advocate and practitioner
of euthanasia, “the concept of patients needing protection from doctors would be incomprehensibly foreign to [the] Dutch.”220 Indeed, the “rules of careful conduct” are
not safeguards to protect the patients; they are just instructions to doctors on how to
avoid inquiries. Yet the study showed that doctors often did not bother to follow even
these most forbearing rules.
It is noteworthy that doctors who practice euthanasia are fully entrusted with
controlling themselves. It is the doctor who makes the diagnosis, informs the patient,
suggests the decision, chooses his own consultant, decides to follow or disregard the
rules, carries out euthanasia, keeps the records, and composes the report or decides
not to report the case.
The first report of the Governmental Committee of Euthanasia must be seen as
an extremely valuable source of information on euthanasia in the Netherlands and a
most important document.221 It was the first official admission that active involuntary
euthanasia was regularly practiced in the country, not as sporadic and punishable acts
committed by some outcasts, but as part of common medical practice. The reports also
showed that the authorities’ attempt to control, or at least to keep track of the practice
of euthanasia, were largely ineffective.
The research team of the Institute for Social Health Care, working for the Committee, made every effort to obtain truthful and reliable information. This team, and
the Committee, showed honesty and courage by publishing all obtained data, however
distressing they turned out to be.
To us who for years kept warning that euthanasia, in spite of humane assumptions, proved a disorderly, uncontrollable practice, and that grisly violations of human
rights occurred, the report of the Governmental Committee brought full confirmation
of our pessimistic views. Actually, the report revealed an even worse picture than we
had suspected.
Id. at 39 (Table 5.15).
Id. at 52 (Table 6.8).
218
Id. at 38 (Table 5.14).
219
Id. at 53.
220
Interview with Dr. Herbert Cohen, in H. HENDIN, SEDUCED BY DEATH: DOCTORS, PATIENTS, AND THE
DUTCH CURE 91 (1997). See also, H. Hendin, Seduced by Death: Doctors, Patients, and the Dutch Cure, 10
ISSUES IN LAW &MED. 123 (1994).
221
R. Fenigsen, The Report of the Dutch Governmental Committee on Euthanasia, 7 ISSUES IN LAW &MED.
339 (1991).
216
217
242
Issues in Law & Medicine, Volume 28, Number 2, 2012
No direct legalization of euthanasia was possible after the report’s finding that a large
part of the practice was involuntary. It was felt, however, that, without a legal sanction,
the country needed some parliamentary acknowledgment of the existing widespread
practice. The regulations passed by the Parliament in 1993-1994 confirmed the “rules
of careful conduct” that had lingered in parliamentary documents for four years.222 The
regulations require the doctors to report both voluntary euthanasia and “termination of
life without explicit request of the patient.”223 In the years that followed, the compliance
with the rule to report voluntary euthanasia has remained sketchy, and the rule to report
involuntary euthanasia has never been followed.
The Government-Ordered Surveys of Euthanasia, 1995-1996224 and 2001-2002.225 The
general conclusion that could be drawn from the two follow-up studies was that the
practice of euthanasia has more or less stabilized. The number of cases of voluntary
euthanasia gradually increased.
The categories of patients eligible for euthanasia also gradually expanded. First,
euthanasia of newborn babies and infants was accepted. This was the most important
issue included in the 1995 report. An account of the findings was given in Chapter
XVIII. Second, euthanasia of psychiatric patients was accepted. Psychiatrists receive from
their patients about 300 requests for euthanasia a year, but only a few such requests
are granted.226 Third, physician-assisted suicide for healthy persons “tired of life” was
accepted.227 According to the report of the 2001 study, 45 percent of Holland’s population believe that old people who wish to end their lives should have access to the
means; 29% of physicians share this opinion.228 Fourth, physician-assisted suicide for
people with incurable diseases or conditions was accepted. American publications often
refer to “Dutch assisted suicide,” but this is a misunderstanding. In the Netherlands,
the way to terminate a sick person’s life has been and remains a lethal intravenous injection administered by a physician. Physician-assisted suicide has been an infrequent
and marginal phenomenon.229 People shun assisted suicide because the method, oral
ingestion of lethal drugs, is thought to be unreliable. In a number of cases, an attempt
REGELEN MET BETREKKING TOT DE HULPVERLENING DOOR EEN GENESKUNDE DIE ZICH BEROEPTOP OVER[Rules Concerning
Assistance Rendered by a Physician Who Pleads Higher Necessity When Terminating Life of a Patient
Upon His Explicit and Serious Request], Tweede KAMER DER STATEN-GENERAAL,VERGADERJAAR 1987-1988,
Nos. 1-2, 20, 383.
223
R. Fenigsen, The Netherlands: New Regulations Concerning Euthanasia, 9 ISSUES IN LAW & MED. 167
(1993).
224
VAN DER WALL & VAN DER MAAS, supra note 147.
225
VAN DER WALL et al., supra note 202.
226
VAN DER WALL & VAN DER MAAS, supra note 147, at 204-05.
227
Th. Boer, De pil van Drior: Voorbij de betovering [Drion’s Pill: Beyond the Fascination], 9 PRO VITA
HUMANA 141 (2002); Hoge Raad der Nederlanden, ‘s-Gravenhage [The Supreme Court, The Hague], rolnr. 00797/02; Hoge Raad: Levensmoeheid geen grond voor euthanasie [The Supreme Court: Tiredness of Life
Does Not Justify Euthanasia], 10 PRO VITA HUMANA 44 (2003).
228
VAN DER WALL et al., supra note 202, at 108 (Table 10.6).
229
Id. at 67 (Table 7.1).
222
MACHT BIJ LEVENSBEEINDIGING OP UITDRUKKELIJK EN ERNSTIG VERLANGEN VAN EEN PATIENT
Other People’s Lives: Reflections on Medicine, Ethics, and Euthanasia
243
at assisted suicide had to be finished with a lethal injection by a doctor.230 As a Dutch
family physician put it, “if the drink doesn’t work, there is always a syringe at hand.”231
And the authors of the 2001 report comment that “the argument that assisted suicide is
[an act] more respectful of patient’s autonomy often weighs less than the better control
achieved when the doctor injects a lethal drug.”232
Active Involuntary Euthanasia in 1995-1996 and 2001-2002. In all three government-commissioned surveys, in 1990-1991, 1995-1996, and 2001-2002, the number
of cases declared as active termination of life without patient’s request remained stable,
around 1000 per year. “Apparently it is difficult to avoid this kind of action,” commented
the authors of 2001 study.233 In the 1995-1996 report the authors expressed the opinion that avoiding involuntary termination of life was the responsibility of the patient
himself,234 a remarkable view by any standard. The patient should clearly state, verbally
and in writing, and well beforehand, that he does not wish to undergo euthanasia.235 In
the 2001-2002 report the same bizarre assertion was repeated.236
Thus, the reports’ authors see involuntary euthanasia not as a human activity that
can, and should, be prohibited, but as inexorable drive, like a force of nature that cannot
be curbed by man. It is the endangered individuals’ responsibility to use precaution
and so avoid a lethal outcome.
The Dutch Reports: Increasingly Defensive and Less Informative. Every five years since
1990, nationwide surveys of euthanasia were conducted by orders of the Dutch government. There is no doubt that these studies have provided the most valuable information
on the subject. Every reader of the first report (1991) stood in awe before the extent
and quality of the research, and the honesty and courage of the authors who did not
hesitate to publish very alarming findings.
That first nationwide euthanasia survey revealed that in 1990 an estimated 8,100
persons died due to overdose of painkillers administered with the intention to cause
death,237 and in 4,941 of these cases this was done without the patients’ request or
knowledge238 (see Table 1 in this chapter). This brought the total annual number of
cases of involuntary active euthanasia to 5,941239 which exceeded the number of cases
of voluntary euthanasia (5,459).240 The findings shocked the international community
REPORT II, supra note 199, at 142.
“Als het drankje niet wekt, dan ligt de spuit al klaar” [“If the Drink Doesn’t Work, the Syringe is Ready
at Hand”], NEDERLANDS DAGBLAD, July 6, 1994.
232
VAN DER WALL et al., supra note 202, at 195.
233
Id. at 201.
234
VAN DER WALL & VAN DER MAAS, supra note 147, at 237.
235
Id.
236
VAN DER WALL et al., supra note 202, at 201.
237
REPORT I, supra note 199, at 16; REPORT II, supra note 199, at 58 (Tables 7.1 and 7.2), and 145.
238
Report II, supra note 199, at 61 (Table 7.7).
239
Id., REPORT I, supra note 199, at 15-16; REPORT II, supra note 199, at 58 (Tables 7.1 and 7.2), and
145.
240
See Ch. XX, Table 1, supra.
230
231
244
Issues in Law & Medicine, Volume 28, Number 2, 2012
and led many to the conclusion that Dutch euthanasia was a social experiment that
went terribly wrong.
In the reports of the next two studies (1995-1996, 2001-2002), there appeared
visible efforts to limit the damage. In the 1995-1996 study, the number of intentional
lethal doses of painkillers was dramatically reduced,241 not because of a change in the
practice itself, but due to a change in the method of interrogation: doctors’ statements
of intention to cause death were not as readily accepted as in 1990, and other possible
motives were suggested with some insistence.242 As a result, fewer cases were labeled
as intentional.243
A further step to eliminate the findings that proved so alarming in the 1990 report
was taken in the 2001-2002 study: in cases of intentional lethal overdose of painkillers,
the attending physicians were simply not asked whether they did it with patient consent
or without patient’s knowledge. As a result, the total number of people who died by
this form of involuntary active euthanasia cannot be found in or computed from the
2001-2002 report.244
Chapter XXI. The Philosophy of Euthanasia
Use logic to overcome the scruple.245
Francois Mauriac
The advocates of physician-assisted suicide, or voluntary euthanasia, present the
following argument:
UÊ Hopelessly ill people who in the end will have to die in unbearable pain, wish to be
freed from a life that has become a burden to them. They should not be compelled
against their will to endure their meaningless suffering. Medical progress can now
extend the lives of the gravely ill; in doing so, the doctors are guided by technical
considerations, without regard for the human aspect of such interventions. As a
result, people are condemned to an unbearable life and to a death unworthy of
human beings.
UÊ Another important factor is the aging of the population, the prevalence of disabling
infirmities inherent in old age, and the proliferation of nursing homes and institutions
for chronically ill residents, who are cut off from their families, isolated from the
rest of society, and who have lost faith in the meaning of their lives.
UÊ And let’s not forget the terrible scourge of Alzheimer’s disease. “Do any of us want
to end our lives with the paralyzing fear and anxiety and the complete loss of one’s
241
VAN DER WALL & VAN DER MAAS, supra note 147, at 77 (Table 7.2), 80 (Table 7.4), 90 (Table 9.1),
91-92.
Id. at 41-42, 92; and P. J. van der Maas et al., Euthanasia, Physician-assisted Suicide, and Other Practices Involving the End of Life in the Netherlands, 335 NEW ENG.J. MED. 1700 (1996).
243
R. Fenigsen, Dutch Euthanasia Revisited, 13 ISSUES IN LAW & MED. 301, 303-04 (1997).
244
VAN DER WALL et al., supra note 202, at 195-96.
245
FRANCOIS MAURIAC, LA PHARISIENNE 112 (Grasset, Paris 1972).
242
Other People’s Lives: Reflections on Medicine, Ethics, and Euthanasia
245
mental faculties? Do any of us want our spouse to spend ten long, lonely years after
losing all real contact with a lifetime partner?” asks a proponent of death by own
choice.246
UÊ Like every important social problem, this one can and should be solved by society. We
have achieved freedom of belief and expression. All problems can now be discussed,
all taboos can be shaken and outdated dogmas doubted. The old taboo on killing
is at odds with compassion and a truly humane attitude. Suffering people desire to
put an end to their lives. The rational autonomous beings’ right to make such a
decision should be recognized as a fundamental human right.
UÊ However, the extremely painful problem of unnecessary human suffering cannot
always be solved by the victims’ conscious and voluntary decision. By rigidly
adhering to the voluntary principle we deprive infants who are severely disabled and
people who are demented or comatose of the chance for a painless death.247 A
number of comatose persons are being kept alive by artificial means, at great effort
and expense, and to the despair of their families. Caregivers do not dare to make
a decision and cut short these lives. But to keep a comatose person alive is also a
decision and the one who makes such decision should be obliged to justify it.248
UÊ Steps should be taken to avoid errors and abuses. The patient’s families should
be involved in the decision. The carrying out of euthanasia and assisting patients
in suicides must be entrusted to doctors. The conclusion that the patient’s
condition is hopeless should be confirmed by a committee or at least another doctor.
Physicians who carry out euthanasia or assist their patients in committing suicide
should proceed with due care.
While appealing to noble emotions, the argument of the proponents of euthanasia
also makes a logical, cogent impression. But assertions that entail irreversible
consequences for human life must be supported by irrefutable proof. Thus, all elements
in the narrative and all assumptions in the reasoning of the advocates of euthanasia,
or assisted suicide, ought to be meticulously examined.
The Abolition of All Taboos. The overthrowing of taboos occurs selectively. Perhaps
it is worth reflecting on the fact that society offered little resistance in defending the
inviolability of human life while still defending with great force the taboo on private
property. Not only have we maintained certain old taboos, but we also have created
G. Bachrach, Death with Dignity, BOSTON GLOBE, June 14, 2004.
J. Fletcher, Ethics and Euthanasia, in TO LIVE AND TO DIE: WHEN, WHY, AND HOW 113-22, and in
particular 118 (R.H. Williams, ed., Springer Verlag, New York, Heidelberg, & Berlin 1973); The “Right” to
Live and the “Right” to Die, in BENEFICENT EUTHANASIA 44-53 (M. Kohl, ed., 1975); G. Tindall, It’s My Life
and I’ll Die If I Want To, THE INDEPENDENT (London), Sept. 18, 1987; and Hoofdbestuur KNMG, Reactie
op vragen van de Staatscommissie Euthanasie [The Board of the Royal Dutch Society of Medicine, Answers
to the Questions Asked by the State Committee on Euthanasia], MEDISCH CONTACT (Official Sec.), Aug. 3,
1984, at 1002.
248
A. van den Akker, Hoe lang moet sterven duren [How Long Must It Take to Die?], BRABANTS DAGBLAD,
Feb. 25, 1985 (Interview of Gerard Stinissen, the husband of a comatose woman).
246
247
246
Issues in Law & Medicine, Volume 28, Number 2, 2012
new ones, like the inviolate right of growing and grown children to live their own lives
without the restraining intervention of parents and without concern for them. When
Dr. P killed her mother at her request in a home for the chronically ill (the Leeuwaarden
trial, 1973), she was reproached in a letter to the editor of Time Magazine: “probably
taking the mother home would have solved the problem, but this did not occur to Mrs.
P.” Indeed it did not. Killing her mother was an acceptable solution, but disturbing her
own well-ordered life was not. In Dr. P’s eyes, the taboo on killing had already been
abolished, but the taboo on privacy was binding. The issue of abolition of taboos would
not seem to require further commentary.
All Problems Are Solvable and Every Important Problem Should Be Solved by Society.
This is the basic idea and point of departure for the pro-euthanasia movement. It is an
expression of the triumphant self-confidence of Western industrialized society which
has succeeded in solving so many problems. We produce great wealth, we have created a
government of law and order and a pluralistic, tolerant community; we are approaching
the ideal of peaceful and free life for all citizens. If there are problems, they can always
be solved providing there is a genuine will to solve them. If some minority is being
discriminated against, we will enforce the appropriate laws and launch an educational
campaign. We will set up special classes for children having difficulties with learning.
When ice damages the highways, we will repair them. There are no unsolvable problems,
only problems awaiting a solution, for example, that people must suffer and then die.
The time has come to solve this problem, and it can be done.
But it cannot be done. The notion that all problems are solvable is quite obviously
at variance with the truth. It denies the sad reality and man’s inevitable tragedy. It is
man’s fate on this earth to be born, to strive, to struggle, to hope, and in the end, to be
disappointed in all he sought, to suffer defeat in every battle, to lose those he loved, to
be conscious of the inevitability of death, to suffer and to die; this is a tragic fate and
one without a solution. We can solve many problems, but not the ultimate ones.
The “solution” proposed by the pro-euthanasia movement is obviously a sham. We
can blow up a ship that is taking on water, but we cannot assert that thereby we have
solved the problem of leakage. No problem is solved by destroying the thing involved.
Institutions for the Elderly and the Chronically Ill. These institutions have been created
due to a great demand, are maintained at high financial cost, and perform a very useful
function. On the other hand, the negative aspects of these institutions are also evident.
Some people, isolated in an institution, lapse into depression and may even think of
hastening their own death. But to use this argument to justify euthanasia is logically (not
to mention morally) inadmissable. Institutions for the ill and aged are not natural disasters
to which, with all their consequences, we must resign ourselves. These institutions are
the result of our own deliberate actions. They were created as places where the elderly
can live. Had our efforts produced only the opposite result, leading to people asking
for death, then the logical conclusion would have been to close the institutions, not to
kill the residents.
Other People’s Lives: Reflections on Medicine, Ethics, and Euthanasia
247
But, of course, in reality this is not necessary. Married couples manage well in
institutions and many single persons adapt quite reasonably. And we should encourage
other solutions for those who fare poorly: first of all, quality care for the elderly who
stay with their families or alone in their own apartments. It is less expensive than
maintaining the institutions.
The assertion that “we have done so much to improve the lives of the elderly
that now we must kill them” is obviously absurd.
Keeping the Sick Artificially Alive with Modern Technology. The allegation that it is
modern technology that produces the demand for voluntary euthanasia can hardly be
substantiated. In Holland, in the majority of cases, euthanasia is performed by family
physicians, at patients’ homes, on patients treated without any special techniques.
Hospital patients who are conscious and tired of treatment and all the machines, have
the right to refuse treatment, and have always had this right and exerted it. If the patient
is unconscious there in no question of “voluntary” euthanasia.
The theorists of euthanasia do not take into account that the hated “modern
technology” can actually encourage patients’ will to live. Patients in respiratory failure,
admitted to intensive respiratory care units, after a few days of assisted ventilation,
clearing the airways, antibiotics, and steroids, leave the hospital in improved condition
and an optimistic frame of mind.
And let’s note that the allegations of senseless prolonging life through use of modern
technology were already made in 19th century: In 1875, Ernst Haeckel wrote about
“improved modern medicine” which supposedly was not permitting “those unworthy
of life” to die,249 and in 1899, Baldwin accused “subcutaneous injections, transfusions
and intravenous infusions” of allowing medicine “to keep us from the grave in a state
of constant struggle for life.”250 And yet at that time the ability of medicine to prolong
human life was almost nil. Thus, to use the “modern technology” argument it is not
necessary for somebody’s life to be prolonged, or even for any such technology to exist.
Death Unworthy of a Human Being. The fate of people who die after longsuffering is
decried as “unworthy of a human being.” A value judgment, of course, but one worth
reflecting on. Death, after a short, long, or very protracted illness and suffering, is not
an invention of modern medicine, it was always the sad fate of many people. Victims of
plague pneumonia died in few days, but patients in congestive heart failure dragged on
for a couple of years, breathless and on swollen legs, and soldiers with abdominal
wounds sometimes took months to die. To believe the advocates of euthanasia, the
majority of our predecessors on this planet, hundreds of millions of human beings,
Mozart, Goethe, and Einstein, my grandfather and your grandmother, all died a death
unworthy of a human being. It was not their privilege to die in a way worthy of a human
being, that is our discovery alone: to be put to death by a professional. The use of the
249
ERNST HAECKEL,NATÜRLICHE SCHÖPFUNGSGESCHICHTE 154 [The Natural History of Creation] (6th
ed., Georg Reimer Verlag, Berlin 1875).
250
E. Baldwin, The Natural Right to a Natural Death, 1 ST.PAUL MED. J. 877 (1899).
248
Issues in Law & Medicine, Volume 28, Number 2, 2012
“death unworthy of a human being” argument is a display of considerable arrogance,
and an insult to our ancestors, and to mankind’s entire past.
Meaningless Suffering. Does suffering have meaning? Various answers can be given
that question depending on the way the issue is formulated. To wit, it may be formulated from the point of view of religion, biology, or from an anthropocentric standpoint.
Dualistic religions consider evil (and human suffering) to be on an equal footing with
the good in the universe, whereas monotheistic religions assume that evil and suffering
have a meaning which cannot be understood by man, but is clear to God. The latter
construct is necessary to reconcile the existence of evil and suffering with a beneficent
and omnipotent God, and thus is useful to those who have the good fortune to believe in
such God. The theorists of euthanasia leave both of these religious concepts of suffering
out of consideration, for which the present author will not reproach them.
From the biological standpoint, the suffering and the pain are meaningful in so
far as they elicit reactions that tend to reduce the injury, i.e., favoring a broken limb,
the reflex to raise from supine posture when there is congestion of the lungs, etc.
These reactions are expressions of adaptation to the external world, an adaptation of a
high degree, formed during the evolution of the species. The biological role of pain is
demonstrated by pathological conditions that deprive the patient of pain sensation, as
for example, syringomyelia or leprous neuropathy: unprotected by the ability to feel
pain, these patients are prone to severe injuries and burns. From the biological point of
view, suffering and, in particular, pain, become “meaningless” (cease to be of use to the
organism) when they overstep their functions of warning, correcting, and reducing injury.
The idea of “meaningless suffering” as used by advocates of euthanasia cannot
be reduced to the biological concept because it leads to consequences farther reaching
than a biological reaction to suffering. The biological reaction to suffering contains
no impulse to self-destruction.251
From the anthropocentric point of view (which I share with the proponents of
euthanasia, though not their conclusions) suffering that exceeds its biological function
has no greater “meaning” than an earthquake or other natural phenomena. The “meaning” of such suffering depends on how we deal with it. Some people find their suffering
a stimulus to creativity; thus Dostoyevsky exploited his epilepsy, Pascal his headaches,
and Van Gogh his mental illness. Others have been spiritually enriched by suffering.
The following truth applies to everyone: when it is no longer possible to live without
suffering, one will suffer in order to live. And that is the “meaning” of suffering: the price
we pay for preserving the higher, singular,and unique value: our lives.
To be sure, the adherents of euthanasia consider the value of human life to be
relative, a value that can be quantitatively estimated and weighed against other values
like relief from pain, unburdening of family or even society; having weighed these
values one can make a choice. But this is not a true choice. The values compared are
incomparable. Suffering is only one of the elements in the life of a suffering person, the
251
The suicide of a scorpion when surrounded by flames is a myth.
Other People’s Lives: Reflections on Medicine, Ethics, and Euthanasia
249
burden on his relatives is only one of many things in their lives, not to mention society’s;
but for the person making the “choice,” his life is everything, and the only one he has.
This is also not a true choice because if the person chooses death, and dies, the values
he had chosen cease to exist. There is no more suffering, nor is there liberation: only
a person can be liberated, but the person no longer exists. A dead man has no family
and is not a member of society. To opt in favor of one’s own death is a desperate step
and must be seen as such; someone who attempts to justify that “choice” logically is
deceiving himself, or others.
But let us return to the concept of “meaningless suffering.” This is a value judgment derived from the principle of utilitarianism (“man desires as much happiness and
as little suffering as possible, and nothing else is worth desiring”). I shall discuss this
principle in the next chapter. Let us bypass that and examine the role of the concept
of “meaningless suffering” in the argument in favor of euthanasia. Let us compare the
standpoint of an old fashioned person O who has never heard of euthanasia, with that
of the “modern” individual M, who considers euthanasia a possible solution. O says, “I
hope that my suffering will pass and I’ll live a while yet.” M replies, “But your suffering
may not abate, what then?” O says, “That would be very bad, but what can I do–I’ll
have to go on suffering.” M replies, “That’s not true, your suffering is meaningless, I
mean unnecessary, so there is no need for you to go on suffering at all; you can accept
euthanasia and be immediately freed of suffering.” Thus, the concept of “meaningless
suffering” finds application only when an end can be put to suffering, and to life, through
euthanasia. The entire line of reasoning proves to be a vicious circle. The possibility of
euthanasia makes the suffering meaningless; in turn, we use the concept of “meaningless
suffering” to justify euthanasia. This is the well known logical fallacy called circulus in
probando. One may use the concept of “meaningless suffering” to express one’s personal
feelings, but not to prove anything.
Unbearable Suffering. Before taking a position on how to act in the event of unbearable suffering, it makes sense to consider how not to let it happen. Our present
ability to alleviate pain is very great, and in extreme cases, one can resort to blocking or
surgically destroying the nerve pathways carrying the pain stimuli or the cells receiving
them. Patients suffering from trigeminal neuralgia, who in the past sometimes committed
suicide out of fear of a new attack, never do so now thanks to effective medical treatment.
I will go as far to say that there is currently no reason for pain, in and of itself, to bring
a sick person to despair. Severe disfigurements of the face, with the exception of those
caused by malignancy, can to a large extent be corrected by plastic surgery; isolation
hospitals for the “gueules cassées,” which were created after the First World War, are
no longer needed. The situation of people irreparably paralyzed, who require help of
others in their daily functioning, cannot unfortunately be changed, but a great deal is
being done to ensure them good care and, most importantly, the majority of those who
care for such patients do so willingly, with patience, and humanely; it is thanks to them
that the affected persons are able to bear their fate.
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But progress in these good works in recent decades has been accompanied by
changes in the way sick people are dealt with, changes that have exerted a perverse influence and have caused sick people to feel that their sufferings are unbearable. I have
in mind, first of all, the new way of informing the patients. This is the result of a
new role that the public has imposed on doctors and that some doctors have imposed
on themselves: the doctor is no longer a person who brings people help and solace, but
is now an “impartial expert.” This is an unfortunate change because no one really wants
or needs to be brought before an impartial medical judge, nor is a doctor really able to
perform that new function. Luckily, the majority of physicians have kept some common
sense and empathy with the patient; the majority still remember what medicine is about.
Without these qualities, the “impartial expert” becomes a true sower of misery. With a
morose expression, he informs the patient of his gloomy suspicions.252 When a patient
asked me, “Doctor, how long can I live with this?” I answered, “How can I know? I don’t
even know what will happen to me this evening. Let’s all try to live as long as we can.”
And this is more or less the answer given by my colleagues, the “traditionally” educated
doctors. And in answering this way we are faithful to the truth because the fate of each
of us is uncertain, and I really don’t know who will die first, my patient, a sick person,
or I, though I seem healthy. And in answering this way we make the patient feel that
he shares the common human fate with all of us, the common hope, and the common
uncertainty. We do not exclude him from the human community. But in recent years I
have seen patients who have been given a death sentence, they have “another two
months” or “another two weeks” to live. A prediction of this kind can never be true,253
it can only come about through pure chance; but how is a person supposed to live
while awaiting a fixed date for execution? Fortunately, the patient usually maintains a
bit of healthy skepticism, but the more he believes in the doctor’s expertise, the more
unbearable his life and, of course, every symptom becomes to him.
There are a few simple and sensible rules that a good doctor follows when speaking
to a patient:
UÊ
Don’t tell him anything you yourself don’t know;
UÊ
It is not your task to make this world crueler than it is; and
UÊ
Don’t let yourself think you know the future; many patients with a bad prognosis
have lived to attend his or her doctor’s funeral.
But today these rules no longer seem to be followed. We are greatly contributing
to making suffering–and life–unbearable for the sick.
Before one begins to legally kill patients “upon their own request,” it would make
sense first to put a stop to doctors’ actions which drive patients to consider suicide.
To present a gravely ill person with the prospect of an “easy death” is an act which
directly intends that the patient begin to view his suffering as unbearable. People have
252
253
See subsec. entitled The Lethal Avalanche.
See subsec. entitled The Oregon Law, in Ch. XXVIII.
Other People’s Lives: Reflections on Medicine, Ethics, and Euthanasia
251
an admirable ability to reconcile themselves to protracted suffering. Stroke victims,
dependent for years on help from others, are able to enjoy all the little pleasures of daily
life, and beam with happiness when visited by a grandchild. Patients who twenty years
before had part of their intestine removed because of cancer, and have an artificial anus
created on their abdomen, bravely empty the plastic bag containing their own excrement
a few times a day, and work, attend concerts, and are happy in their marriages. There are
patients who have had their larynx removed, but who work in their garden and take an
interest in everything that is happening in the world; to be able to speak, they adroitly
put a finger on the tracheostomy opening on their throat. What will-power and
endurance these people must have, and renew it each morning! I have for them the
greatest admiration and respect. Who would dare to shake their willpower, sow doubt in
their mind, force them to wonder if all that effort was worth it, and tempt them to give
up? And yet that is precisely what we are doing today, showing these people euthanasia
as a possibility, as a desirable solution, and a brave, wise decision. We justify the
need for euthanasia referring to unbearable human suffering, while at the same time the
prospect of euthanasia causes people to view their suffering as unbearable and instills in
them the desire to be freed of it by death. We are in a vicious circle once again.
Doctors and all people of good will should seek to relieve suffering, not exterminate
the sufferers.
The Decision to Leave a Person Alive. The case of Mr. and Mrs. S became well known
in Holland because of press reports and TV broadcasts.254 As a result of an error in
anesthesia, Mrs. S had been in a coma for years. Her husband did not abandon her, visited
her every three months, and had been very involved on her behalf. He had devoted all
those years to intense reflection, and many times had requested the doctors to put an
end to her life. “No one wanted to make this kind of decision.” But—so reasoned Mr.
S—to keep a comatose patient alive is also a decision, and one that needs to be justified.
Is it really a decision? We get up every morning and don’t commit suicide; is that
a decision? We don’t set our houses on fire; is that a decision too? A mother feeds her
child several times a day; is she making a decision in doing this? Only if we assume
that she could have acted otherwise; but a mother cannot act otherwise. We only make
decisions when we have a choice. But a mother has no choice. She feeds her child
and does not consider allowing him to die of hunger or thirst. She makes no decision,
and does not need to. People who nursed and fed Mrs. S were still not aware that one
could put a person to death (though Mr. S knew that already). They had no choice and
did not have to make a decision.
A Higher Necessity: Euthanasia an as Act Performed Under Constraint. The theorists
of euthanasia maintain that under certain circumstances a doctor may decide to kill a
person. The Dutch Supreme Court went farther: the high-ranking justices have acknowledged that under certain circumstances a doctor must kill his patient.255 This is when a
Van den Akker, supra note 248.
H.J.J. Leenen, Euthanasie voor de Hoge Raad [Euthanasia (heard) at the Supreme Court], 129 NED.
TIJDSCHRIFT V.GENEESKUNDE 414, 414-17 (1985).
254
255
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conflict of duties occurs: on one hand, there is the doctor’s duty always to preserve life,
and the law (art. 293 of Dutch Penal Code), which prohibits euthanasia; but, on the
other hand, there is doctor’s duty toward his desperate patient who begs to be delivered
of his misery. It is in such situation of higher necessity that doctors decide to carry out
euthanasia. After several such rulings by the Supreme Court, a provision providing for
“acting out of higher necessity” has been included in the official guidelines instructing
doctors how to avoid prosecution (i.e., the “rules of careful conduct”).256
Higher necessity is not an independent and separate concept, but depends on
the actions that are considered admissible in a certain situation; actually it is an offshoot
of these actions. Someone who has robbed a bank will find it fruitless to plead that he
acted out of higher necessity (his family’s poverty, impending bankruptcy), fruitless
because his act—theft, bank robbery—is considered absolutely inadmissable under
any circumstances whatsoever. A doctor who kills a patient can only appeal to higher
necessity if his action is a priori considered as possibly permissible. It is only the a priori
acceptance of euthanasia which creates the “higher necessity” stipulated by the Supreme
Court. Once again we find the vicious circle. “Higher necessity” is an argument based
on a logical fallacy, circulus in probando, and cannot be used to prove anything.
Furthermore, whatever state of necessity, “higher” or otherwise, the doctor is
in, he has brought himself (and his patient) to that state. The “ordinary” doctor, who
treated and guided his patient the traditional way, was never asked by a patient to put
an end to his life.
And if a patient driven to despair requests to be killed, is the doctor then compelled
to kill him? Shouldn’t he rather do his best to alleviate the patient’s suffering, and explain
that killing is a savage, unthinkable, and entirely unnecessary act?
The Right to Self-Determination. The demand to recognize a person’s right to decide
about his own life and death reflects the change in the value system accepted by society.
Traditional society considered human life the value worthy of highest protection and
the life of every individual a value in which all other people had a share. The death
of each person was a loss to all people; when any individual’s life was in danger, the
intervention of all people was required; all other values, including freedom, must be
subordinate to the defense of a person’s life (at least in peacetime). Thus, not only could
no one take the life of another, but there also must be a limit on the freedom of anyone
who would put an end to his own life: forcible hospitalization was justified in cases of
mental illness that posed a danger of suicide. That social attitude and practice has not
only been codified in law but is consistent with the deep belief we all share and which is
a natural reaction: everybody rushes to help at the sight of a clothed person preparing to
jump from a bridge into a river. “No man is an Iland, intire of itselfe,” wrote John Donne
Regelen met betrekking tot de hulpverlening door een geneskunde die zich beroept op overmacht bij levensbeeindiging op uitdrukkelijk en ernstig verlangen van een patient [Rules Concerning Assistance Rendered
by a Physician Who Pleads Higher Necessity When Terminating the Life of a Patient Upon His Explicit
and Serious Request], in Tweede KAMER DER STATEN-GENERAAL,VERGADERJAAR 1987-1988, at 383 (Nos. 1-2,
20).
256
Other People’s Lives: Reflections on Medicine, Ethics, and Euthanasia
253
four hundred years ago, “every man is a peece of a Continent, a part of the maine; if a
Clod be washed away by the Sea, Europe is the lesse … any man’s death diminishes me,
because I am involved in Mankinde.” There is no argument to justify this stance, and
no need for one; whoever believes it is true can appeal to “the evidence of his heart.”257
Thus, the traditional view of the value of human life cannot be logically proven true.
One can, however, apply logical analysis to point out fallacies in the opposite position.
The “permissive” society makes of freedom an absolute value, placing it higher than
human life: everyone should be free to commit suicide and no one should interfere; a
person should also be free to aid others in committing suicide, or to kill them at their
own request.
These postulates are questionable. Freedom is certainly a high value, but in a society
a person never has absolute freedom, his freedom is always limited. We are not free to
steal, rape, or commit arson. We are not even free to spend our earnings without limit:
we have to pay taxes. Since, one way or another, limits must exist on freedom, those
limitations that defend human life are particularly justified. A person’s life is unique,
irreplaceable, and clearly a higher value than private property or social security.
Moreover, in making freedom an absolute value and placing it above life, still
another and basic error in thinking is committed. Suicide and voluntary euthanasia
are not the realization, but the destruction, of a person’s freedom. Only the living have
freedoms. A corpse is utterly and forever devoid of all freedom.
Thus, the absolute right to self-determination is a controversial concept, to put it
mildly. Yet it is the basis and the justification of voluntary euthanasia. In recognizing
the individual’s right to self-determination, we supposedly recognize eo ipso the right
to voluntary euthanasia.
The latter assertion is, however, untrue. Those who recognize the right to self-determination recognize the right of each individual to decide what will happen to his own
body, his own life. But assisted suicide or voluntary euthanasia includes more than that.
Other people take part in carrying out these acts: a doctor, often a nurse, and sometimes
others. The right to assisted suicide or voluntary euthanasia (were we to recognize such
right) would thus include not only the right to exert control over one’s own person, but
over other persons as well, their acts and their conscience. The person deciding on his
own death would also have the right to make killers of the doctor and the nurse, and
to make others accomplices to the killing. He would have the right to compel society
to renounce the principle of inviolability of human life, to destroy the barrier protecting
the life of each person. The right to assisted suicide or voluntary euthanasia is thus not
identical with the right to self-determination, but is broader in content. It is not true
that anyone who accepts a person’s right to self-determination eo ipso accepts the right to
voluntary euthanasia. This is the first reason why the pro-euthanasia movement cannot
invoke the right to self-determination as an argument.
257
“Evidence of one’s heart” is the phrase used by Polish philosopher Tadeusz Kotarbiñski to denote
moral intuition.
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But in addition, the movement in favor of euthanasia cannot invoke the right to
self-determination because this movement itself does not accept such right, either on
principle or in fact. It is the basic tenet of pro-euthanasia argument that rational autonomous human beings who are hopelessly ill should have the right to decide when and
how they will die. But why only the suffering and the hopelessly ill? Healthy people
also are rational, autonomous human beings. Why don’t euthanasia advocates recognize
their right to assisted suicide? The movement that denies the right of self-determination
to some (actually, the majority of) human beings does not recognize this right at all. It
cannot invoke the right to self-determination in its arguments.
On the other hand, no mention is made of targeted individuals’ right to self-determination when American and British proponents of mercy killing call for compulsory
non-voluntary “euthanasia” of people with dementia,258 children who are gravely ill,259
people who are mentally retarded,260 disabled newborns,261 people who are comatose,262
or when Dutch patients who never asked for death are given lethal injections.263
The Patient’s Own Request. From the point of view of pure logic, a request to die is
not valid because the person making it cannot fully know the meaning of that request,
since “no one can imagine his own total absence, without that being a contradiction in
terms.”264 But also other questions must be asked: Does such request always signify a
death wish? And, to what degree is that request the patient’s own?
It is common knowledge that, in reality, a request to die very often signifies
something else: it can be a cry for help, for understanding, or an attempt to dramatize
the situation.265 Even when someone requests death repeatedly and emphatically, in
writing or in the presence of witnesses, this does not preclude the possibility that he
is actually asking for help and attention. Many such cries for self-destruction have
traits of hysterical behavior, typically marked by theatricality and hyperbole. Such an
hysterical cry for help may, indeed, prove effective if it is addressed to good and wise
Tindall, supra note 247.
D.C. MAGUIRE, DEATH BY CHOICE 173-79 (1977); G. Williams, Euthanasia and the Physician, in
BENEFICENT EUTHANASIA 154-57 (M. Kohl, ed. 1975); and H.T. Engelhardt, Jr., Ethical Issues in Aiding the
Death of Young Children, in BENEFICENT EUTHANASIA 180-82.
260
E.W. Lusthaus, Involuntary Euthanasia and Current Attempts to Define Persons with Mental Retardation
as Less Than Human, 23 MENTAL RETARDATION 148 (1985).
261
J. Lachs, On Humane Treatment and the Treatment of Humans, 294 NEW ENG. J. MED. 838 (1976); J.
Fletcher, Ethics and Euthanasia, in TO LIVE AND TO DIE: WHEN, WHY, AND HOW 113-22 (H. Williams, ed.,
Springer Verlag, New York-Heidelberg-Berlin 1973).
262
S. M. Wolf, Nancy Beth Cruzan: In No Voice At All, HASTINGS CENTER REP., Jan./Feb.,1990,
at 38; W.H. Colby, Missouri Stands Alone, HASTINGS CENTER REP., Jan./Feb., 1990, at 5; P. Busalacchi, How
Can They? HASTINGS CENTER REP., Jan./Feb., 1990, at 6; R.E. Cranford, A Hostage to Technology, HASTINGS
CENTER REP., Jan./Feb., 1990, at 9.
263
See Chs. XIX and XX.
264
L. Kolakowski, Fabula mundi and Cleopatra’s nose, in: CZY DIABEL MOŻE BYĆ ZBAWIONY? [Can the
Devil be Redeemed?] 71 (Aneks Pub., London 1982).
265
This is also the case in many attempted suicides. An attempt to kill oneself is by no means always a
step taken out of despair and hopelessness; more often it is dictated by hope that this will come as a shock
to other people, attract their attention,and change their attitude by arousing a feeling of guilt.
258
259
Other People’s Lives: Reflections on Medicine, Ethics, and Euthanasia
255
people who would understand its true significance and show the despairing person
that he is important to them, that they are staying at his side. However, the danger is
now great that such a request will be taken literally, will be seized upon, and the person
crying for help will be killed! Hysterical persons most often survive suicide attempts;
euthanasia does not give them that chance.
The other important question is, to what degree a request for death is a genuine
request of the person involved? In a widely publicized Dutch case, a retired professor
of geology coerced his healthy 72-year-old wife into submitting to euthanasia, promising to take recourse to it himself in three days, but instead he went off to Austria
where he married another lady.266 We will never know whether this was all planned as
a cold-blooded murder in advance, or whether he changed his mind only after his wife’s
death. If that was so, I would not condemn him for shrinking from his own “euthanasia”; it’s good that at least somebody survived this heinous affair (the only pity is that
he escaped punishment). What good would it have done if he had also bid life farewell
three days after his wife had been killed by a doctor? Would it have annulled his wife’s
death, her desperate struggle for life, her futile entreaties for a postponement, one more
weekend with friends? We saw all that on the TV, the proceedings had been filmed on
husband’s request! And who was the culprit here? Was it only this old man or was society
which had created the atmosphere favorable to “euthanasia,” which treated that man’s
murderous plans as a respectable, trend-setting idea, which prompted a doctor to be a
killer, and which so bewildered a TV journalist that he wanted to turn this sordid affair
into a morality play about the leading figures of our time?
That woman did not want to die, but was in fact killed at her own request. The
dominating husband coerced her into asking for death. Sometimes it is not the husband but a wife who dominates in a marriage. A wife who no longer wished to care for
her sick husband offered him a choice between euthanasia and admission to a nursing home.267 The man, afraid of being in unfamiliar surroundings and in the care of
strangers, chose death. The family physician, though aware of the coercion, performed
the euthanasia. The patient’s daughter, a nurse by profession who took part in carrying
out the euthanasia, developed a severe depression and for a long time remained under
psychiatric treatment.
One might object that these two cases belong to the registers of crime rather than
the chronicle of euthanasia; he would be mistaken. Indeed, both these persons were
killed by doctors, and though both cases were published, and widely publicized, no
judicial inquiries were launched.
W. VAN DEN LINDEN,ZIJ MOEST EERST ...HET DOSSIER VAN BOMMELEN:EEN GEVAL VAN EUTHANASIE? [She
Had to go First . . . The Van Bommelen File: A Case of Euthanasia?] (Strengholt Pub. Naarden 1984);
Waarom heeft Wibo niet ingegrepen? [Why (the TV journalist) Wibo (van den Linden) Did Not Intervene? ZONDAG (Beusichem), Jan. 22, 1984; G.A. Lindeboom, Een z.g. euthanasie-drama [The Drama of the
So-Called Euthanasia], 11 VITA HUMANA 100 (1984).
267
H. TEN HAVE & G. KIMSMA, GENEESKUNDE TUSSEN DRROM EN DRAMA [Medicine Between Dream and
Drama] 83-87 (Kik-Agora Pub., Kampen 1987); G. F. Koerselman, Hoe mondig zijn moderne patienten?
[How Mature are Modern Patients?], 130 NED. TIJDSCHRIFT V.GENEESKUNDE 2017 (1986).
266
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But it is not these flagrant cases that matter here, it is all the others. For thirty-five
years many countries, including the U.S., and in particular Holland, have been subjected to all-intrusive propaganda in favor of euthanasia and physician-assisted suicide.
Large-scale brainwashing is taking place; all efforts are made to convince people that
this is what they ought to desire, and what is best for themselves and their families.
Anyone who doubts that such a fatal step can be taken under the influence of fashion
and the pressure of public opinion, should remember that less than a century ago in
several European countries serious people, fathers of families, allowed themselves to
be shot in duels only because this was what public opinion expected of them in certain
circumstances.
Apart from fashion, there is almost always another important factor operative in the
request for death: the doctor. It is striking that some doctors publish articles in which
they boast of having already dispatched many people to the next world “at their own
request” (Dr. K gave a figure of seventeen268), while traditional physicians have never
heard any such request from their patients. Evidently we, the traditional doctors, are not
suited for euthanasia; all we know is to treat sick people, bring them relief, encourage
them, support their hope and will to live. But the euthanasia doctor knows what to do
to fulfill his calling. He begins by acquainting the patient with the situation, sparing him
no description of the horrible complications which have already ensued or “may ensue”
in the future. He terms the patient’s condition hopeless (without mentioning that sooner
or later a hopeless fate awaits us all). He speaks with the full power of infallible science
(and omits saying how many errors science has made). He predicts precisely how long
the patient has to live (predictions which never come true), and excommunicates the
patient from the community of the living while he is still alive. Such a harangue (and
not the illness itself) plunges the patient into depression, and, sometimes into reactive
psychosis. And when the patient driven to despair requests death, that request will not
be treated as a call for help, or a complaint which escaped the patient’s lips at a moment
of mental breakdown, no, that request will be seized upon, treated as a possible solution,
discussed in all seriousness, often in the presence of family members or other persons,
so that the sense of shame will prevent the patient from retracting “his own decision.”
The Patient’s Own Request—A Case Report. As already mentioned above, the patients
of traditional doctors do not request to be put to death. Yet it did happen to me once.
The patient was swollen all over and suffering from such shortness of breath that he
had not slept for three weeks and had spent all those nights sitting in a chair, breathing
heavily. Two hours after his transfer to my department he said to me: “Doctor, I cannot
take it anymore, please give me that injection, you know what I mean.” Obviously he
had a fatal injection in mind. Had he chanced on a euthanasia-doctor, probably this
request would have been granted. He was suffering horribly. His condition seemed to be
an irreversible congestive heart failure with no prospect of improvement, and it could
268
E.G.H. Kenter, Euthanasie in de huisartspraktijk [Euthanasia in Family Physician’s Practice], 38 ME(1983).
DISCH CONTACT 1179
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even be assumed that “the dying process had already begun.”269 And the patient himself
demanded that he be put to death, didn’t he?
But he had addressed the request to the wrong person. I’m only an old fashioned
doctor, I often doubt my diagnoses and never trust my prognoses. It never entered my
mind to turn the words the patient spoke in a moment of despair against him. It also
never entered my mind that I might kill anyone and I don’t even know how it is done.
Along with a curt letter, I had sent back the Handbook of Responsible Euthanasia which,
like all doctors in Holland, I had once received from a society involved in such matters.
So, I must admit that I did not pay due attention to the patient’s request. My reply was:
“Please don’t bother me with this kind of talk, you see I’m very busy trying to give you
some relief.” This patient survived his request for many years. His heart failure was
linked to inordinately quick heart rate,and it occurred to me that this atrial flutter could
have been caused by multiple pulmonary emboli; a diagnosis which I subsequently
confirmed by pulmonary artery angiography. Step by step, I succeeded in expelling
excessive fluid from his body, restoring normal heart rhythm, and preventing further
embolization by anticoagulant treatment. The patient was followed at the out-patient
clinic for six years; he never again mentioned the request he had made in a moment of
despair, nor did I.
The Patient’s Family Should Take Part in Making the Decision. A person may appoint
his relative or somebody else as his proxy in medical decisions in case he himself is incapacitated. However, as long as an adult patient is competent, in all countries I know,
the law does not allow his family to decide the treatment. This is not an error or a gap in
the law, but a correct position taken by lawmakers. It is the rights of the patient himself
that are assured in the first place: only he can decide whether to submit to a therapy
or surgery proposed by his doctor. He also retains full freedom as to whether or not to
consult with his family. The relatives are spared the need to make a decision that they
are, anyway, not particularly qualified to make, and a responsibility which they are in
no position to bear. Also, in this way the law precludes decisions that would be to the
detriment of the patient and those dictated by questionable motives. However, in recent
decades this wise legal principle has often been disregarded in practice; especially in
cases of grave illness, when doctors seek permission for treatment from a competent
patient’s family. No one has ever provided justification for these practices and no such
justification exists; the consequences are detrimental. An unbearable burden of decision
is thrust onto unwilling family members. Relatives indifferent or hostile to the patient are
granted rights not vested in them, including the veto-right. This course of action hampers the doctor in his professional duties and inadmissibly relieves him of his personal
responsibility. Decisions of vital importance to the patient are made behind his back.
It is now demanded that the patient’s family take part in the decision on euthanasia.
This is indeed a logical demand in the eyes of those who hold it permissible to put a
269
This term is particularly “elastic,” and anyone may stretch it according to his own opinion. It may
also be asserted on good grounds that every human being’s dying process begins at birth.
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person to death in the interest of other people, especially in the interest of his family.270
I will not discuss this “moral principle” or the actions resulting from it. Let’s confine
ourselves to those situations in which a patient’s life is to be cut short “for his own good.”
In the great majority of cases we still see normal human reactions of family members: fear for the life of the seriously ill person, hope, even against all odds, desire that
he recover and remain alive as long as possible. But we do sometimes encounter families
who ask doctors to cut a patient’s life short.
It is tacitly assumed that the motives of the relatives who ask that a patient’s death
be hastened cannot be other than pure and disinterested compassion, a desire to free
the patient from his suffering. But can that be assumed uncritically?
In reality, families’ less-than-noble motives are sometimes quite obvious. The
wife of an unconscious patient under my care said: “I see him only as a corpse” which
clearly suggested a feeling of indifference to the patient. Ten days later he was discharged
from the hospital in fair condition, fully recovered from his subarachnoidal bleeding.
The son of another patient, an elderly man who was slowly recovering from congestive
heart failure, told me: “My father has lived his life, and actually has lived too long,”
and gave me a “choice”: either euthanasia or admission to an institution. Caring for the
father at home had become too burdensome for the son.
These are, of course, quite exceptional cases; as a rule, the situation is otherwise.
Family members request euthanasia “because the father cannot take it any longer” and
they sincerely believe that this is what moves them to ask for euthanasia.271 They do
not realize that it is themselves who can no longer bear this extremely trying situation,
the enormous psychological burden, the sheer physical torment, the hours, days and
nights spent in the hospital, nearly sleepless, unwashed, without clean clothes or regular meals; every few hours they hear that the patient’s condition has not improved. We
should see and understand the relatives’ ordeal, support them in every way, but not kill
the patient for their sake!
Genuine empathy with another person, especially with a suffering family member,
is possible, but this is an infrequent occurrence and one that borders on mystical experience. As a rule, people capable of such empathy do not ask for euthanasia.
Granting a patient’s family the right to take part in the decision on euthanasia has
still another important aspect, to wit, the influence such right must have on the institution of the family. There are already reports of older people overcome by fear of
270
The husband of a woman in coma requested her doctors to put his wife to death, arguing that he
wished to marry another woman but as a Catholic could not divorce his wife. WERKGROEP EUTHANASIE
VAN HET KATHOLIEK STUDIECENTRUM [Catholic Studies Center, Working Group on Euthanasia], VRAGEN
OM DE DOOD: BESCHOUWINGEN OVER EUTHANASIE [Requesting Death: Reflections on Euthanasia] 172-73 (G.
Dierick, ed., Amboboeken, Baarn 1983).
271
Tolstoy noted this form of self-deception a hundred and twenty years ago: “[Nekhludov]
recalled how toward the end of [his mother’s] illness he frankly desired her death. He tried to tell himself
that he wished her deliverance from suffering; actually he wished himself to be delivered from the sight
of her suffering.” L.N. Tolstoy, Voskreseniye [Resurrection], in 11 SOBR.KHUD.PROIZVED. 88 (Pravda Pub.,
Moscow 1948).
Other People’s Lives: Reflections on Medicine, Ethics, and Euthanasia
259
their own families in connection with the possibility of euthanasia.272 And indeed, in
a society that permits euthanasia, a person, even one young and healthy, will look with
different eyes on his own family; they will no longer be the persons who enrich lives, lend
them scope, purpose, and meaning, but those who, at the decisive moment, will decide
whether or not to put an end to our lives. A person will always be aware of this, even
when concluding marriage, if not before. Just as a world harboring stockpiles of nuclear
weapons is no longer the world it once was, so in an age of euthanasia a family will no
longer be what it once was—nor will society be what we had hitherto known it to be.
Consultations, Coordination and Agreements. “I am appalled” said the president of
the British Association of General Practitioners when he learned the sentence received
by the doctor defendant in the Leeuwaarden trial (a week in prison, suspended for a
year, for killing her mother). But a different reaction was expressed by a young woman,
Dr. D, with whom I discussed that case at the time: “Dr. P did indeed act improperly,
she should have first consulted with another physician.” Thus, it’s O.K. to kill one’s
mother, but remember to talk first to a colleague. The majority of the theorists of
euthanasia recommend, or require, that there be some form of consultation or that
decision be made by a committee.
The value of consultation with another physician picked by the euthanasia doctor
(if such a consultation occurs at all), can be learned from the report of the 2001 government-ordered Dutch study: even before the consultation, the attending physician
already had promised the patients to carry out euthanasia, and in some cases, even set
the date.273
The idea that the decision on euthanasia should be taken by a committee belongs
to “the founding father” of Dutch euthanasia, professor Jan Hendrik van den Berg.274 Is
it true that errors may be avoided in this way? I doubt it. The outcome of deliberations
will always be influenced by the composition of such bodies: the committee will only
include people who accept euthanasia in principle; understandably, a person who entirely rejects euthanasia cannot be a member. What role is such a committee supposed
to fulfill? The doctor submitting a case will not want to act alone, but have a group of
people assume legal and moral responsibility for putting a patient to death. Everyone
makes the decision and everyone shares the responsibility, meaning no one does. And
this is what the euthanasia committee’s role will in reality be: to dissolve, dilute, and
destroy personal responsibility. This is not an especially praiseworthy role. And from
the linguistic point of view, “committee meeting” is not the most accurate term for an
agreement among several people to act against the law and, in particular, to deprive
M. Wagner, Stervenshulp: Wensen van patienten [Assisted Death: The Wishes of Patients], 49 ME(1984).
273
G. VAN DER WAL ET AL.,MEDISCHE BESLUITVORMING AAN HET EINDE VAN HET LEVEN:DE PRAKTIJKENDETOETSINGPROCEDURE [Medical Decisionmaking at the End of Life: The Practice and the Verification Procedure] 149, 188 (De Tijdstroom, Utrecht 2003).
274
J.H. VAN DEN BERG, MEDISCHE MACHT EN MEDISCHE ETHIEK [Medical Power and Medical Ethics] 41,
50 (G.V. Callenbach, Nijkerk 1969).
272
DISCH CONTACT 1569
260
Issues in Law & Medicine, Volume 28, Number 2, 2012
someone of his life. Language has more accurate terms to describe such behavior, such
as “conspiracy” or “collusion.”
Moreover, can one on principle accept committee determination of whether or not
a person is to be put to death? Meetings, debates, and voting are indeed the right path
to take when various important human affairs are to be resolved, like the expenditure
of money, sharing burdens among the members, and so on. But no group or meeting
has the right to decide whether a person lives or dies—not by voting, and not by
unanimous decision. Speaking one’s mind about somebody’s life or death is a matter of
conscience. But there is no collective conscience, only the individual has conscience.
It is a meaningless act to assemble several people to decide a question of conscience.
Agreements Not to Resuscitate. When too broadly and indiscriminately applied, and
in particular, when issued without the patient’s consent or knowledge (as is often the
case275), Do Not Resuscitate (“DNR”) orders create the danger of untimely and unnecessary deaths. The following situation is typical: a patient with hemiparesis due to an
old clot in a brain artery is admitted to the hospital with a myocardial infarction and
an euthanasia-minded doctor orders “do not resuscitate.” A few hours later the CCU
nurses allow the patient to die of a trivial ventricular fibrillation. What is the cause
of that person’s death? Not the myocardial infarction and its complications because
that ventricular fibrillation could be stopped with a single discharge of the electrical
defibrillator. Neither is it the old partial paralysis with which that person had lived for
years and could continue to. This person died by agreement. Another feature of these
agreements is that they are made in advance, in the false belief that those making them
have knowledge of future events. We know how deceptive such predictions are, e.g., a
patient with severe emphysema can give the impression of having died—he lies there,
dark blue-grayish, not reacting, not breathing—but a few minutes later he sits up and
lights a cigarette “because that helps him clear his airways.” An agreement entered in
advance also means that no one is responsible any more, responsibility dissolves and
vanishes. The “agreement” is made but nothing immediately happens, it will only
happen later; one person issued the order, but does not directly cause the patient’s
death, others just carry out the doctor’s order, that is, do nothing at a critical moment.
. . . Of course, as in any field of human endeavor, mistakes can happen in connection
with such agreements; but these are macabre mistakes. In a university hospital, I was
witness to a conversation between Dr. G, who had just finished duty, and his colleague,
Dr. M. Dr. G said that he had been summoned to Dr. M’s patient who had suffered a
respiratory arrest, but he had done nothing because the nurse had informed him that
MEDISCHE BESLISSINGEN ROND HET LEVENSEINDE. II. HET ONDERZOEK VOOR DE COMMISSIEMEDISCHEPRAKDecisions About the End of Life. II. The Study for the Committee on Medical Practice Concerning Euthanasia] 75 (State Publishing House SDU, The Hague 1991). Volume II appeared in English translation in P.J. VAN DER MAAS, J. J. M. VAN DELDEN, & L. PIJNENBORG, EUTHANASIA AND
OTHER MEDICAL DECISIONS CONCERNING THE END OF LIFE: AN INVESTIGATION PERFORMED UPON THE REQUEST
OF THE COMMISSION OF INQUIRY INTO THE MEDICAL PRACTICE CONCERNING EUTHANASIA (Elsevier, Amsterdam-London-New York-Tokyo 1992). [The page number cited here refers to the Dutch original.]
275
TIJKINZAKEEUTHANASIE [Medical
Other People’s Lives: Reflections on Medicine, Ethics, and Euthanasia
261
it had been agreed not to resuscitate the patient. “What do you mean?” cried Dr. M in
genuine despair, “and she died? That can’t be! There never was any such agreement! I
mean there was one, but it was for another patient!” I tried to explain to him that the
point here was not the mistake, mistakes do happen, the point was that such agreements
are dangerous. He did not understand.
Of course, we cease treatment if there truly is nothing more to be done. We also
cease attempts at resuscitation when after an hour and half’s battle no pulse can be
detected. But that has to be your personal decision, made after losing the battle, hic et
nunc, in a situation you have seen with your own eyes. It should not be a decision made
in advance, based on a prediction of a future that is unforeseeable, and never a decision
imposed on others. It can only be a concession of our defeat, never a conspiracy.
The question arises how in a country where the “Protestant spirit” is so deeply
rooted that people reject all intermediary between their own conscience and the One
they consider the judge of their deeds, how nurses and doctors accept orders allowing
another person to take charge of their own conscience. The answer is simple—and
frightening. The decision of whether someone else is to live or die is no longer considered a matter of conscience. It has become an administrative matter to be handled
through the channels.
Agreements Not to Resuscitate II. When one speaks of the dangers entailed in modern
science, one usually has in mind nuclear fission or genetic manipulation. But there is
still another danger: the wreckage suffered by weaker minds when they come in contact with Science. Years ago, when I was working in one of the Scandinavian countries,
I observed a sad example of this in the person of Dr. S, head of a hospital department
of internal medicine. A patient at the department had fallen into severe hypoglycemic
coma (loss of consciousness caused by low blood sugar), which reached the point of
cardiac arrest; it became necessary to apply external heart massage and a ventilator.
However, after intravenous injection of glucose the heart resumed beating normally,
and the patient regained consciousness.276 Dr. S protested against such medical action.”
The guess diagnosis that it was hypoglycemia was brilliant,” he said, “but you had no
right to inject glucose until the lab report on blood glucose was known! I forbid such
unscientific277 proceedings in my department!” The lab report came half an hour later
and could not have been obtained earlier. It was impossible for a patient in such a deep
coma that it had caused cardiac arrest to survive that long without intravenous glucose,
as was entirely obvious to Dr. S as well. But this doctor was not concerned with whether
someone lived or died; his concern was Science. To die in accordance with the rules of
Science was just how it should be. To survive against the laws of Science was forbidden.
Well, this eminent scientist also issued orders “not to resuscitate” and “not to treat”
and also in doing so he was guided by strictly scientific criteria. A 55 year old woman
had surgery for a brain tumor (non-malignant at microscopy), but the growth could
See case described in subsec. entitled Sudden Insights, in Ch. VII.
In the opinion of Dr. S and those of like-mind, that which we see with our own eyes cannot be
science. Scientific information comes written on forms from the laboratory signed by a technician.
276
277
262
Issues in Law & Medicine, Volume 28, Number 2, 2012
not be totally removed. After the operation the patient was in fair condition except for
a moderate weakness of one arm and one leg. She was entirely independent, walked
a great deal, and devoted her time to reading and going to the movies and theatrical
performances. When she was admitted to the hospital with a severe pneumonia, Dr. S
“forbade” that she be treated! There are, however, other doctors who do not take such
prohibitions to heart, the patient was given penicillin, and quickly recovered.
On another occasion, ambulance attendants brought to the hospital the body of
a 16 year old boy who had suddenly lost consciousness and had no pulse or breath.
The paramedics had applied neither heart massage nor ventilation because the boy’s
(well-trained) parents showed them a note from Dr. S written two years before, containing the words “do not resuscitate.” The patient had a congenital heart defect, a so-called
transposition of the great vessels, and the university hospital decided that surgery was
not possible (it is possible now). The boy was the best student in his class and intended
to study law. Due to Dr. S’s note, the disturbance in heart rhythm, which could have
been corrected had life-saving action commenced at once, put an end to the boy’s life.
By now we have gained sufficient insight into the mentality and value system of
Dr. S. He is a true servant of Science. For him Science is neither a means nor even an
end, it is the Supreme Judge, empowered to pass death sentences. There are people
whose health Science was ready to improve—but look what happened! They proved
unfit! They were disqualified by Science! And, in their foolishness, these people feel
well, run around, study at school, date girls, attend the theater, while according to the
rules of Science, they are unfit for life! These rebels against Science do not have the
right to live. But the necessary steps have already been taken, orders issued, and, sooner
or later, one of those rebels will get pneumonia, another a ventricular fibrillation, and
we have already seen to it that when such occasions present themselves these people
disappear from the face of the earth.
It is a good rule which requires that our arrangements be “fool proof,” safe even
in hands of a stupid person. Alas, agreements “not to resuscitate” or “not to treat” do
not meet this requirement.
Prevention of Alzheimer’s Disease? All of us want to avoid this personal disaster and
spare our families the sorrow and the torment. The proponents of death by one’s own
choice point out that assisted suicide, or otherwise caused death of the person involved,
would prevent the misfortunes of Alzheimer’s disease.278
But the concept of preemptive death as a way to escape Alzheimer’s disease, logical
as it may seem when considered in the abstract, makes us shudder when imagined as
a reality. Moreover, in every case of suspected or presumably diagnosed Alzheimer’s
disease, and in any society abiding by law and fairness, an attempt to put this idea into
effect would present insurmountable difficulties.
278
2004.
Bachrach, supra note 246; A. Dorfman, Alzheimer’s and a Caring Society, BOSTON GLOBE, June 17,
Other People’s Lives: Reflections on Medicine, Ethics, and Euthanasia
263
Several questions must be asked: Who is the person we want to save by destroying? How and when is he supposed to state his will to die? By whom and how is this
will to be executed?
The Person. Please don’t let yourself be convinced by sophistries, assertions
that “the person is gone,” that “what’s left is an empty shell.” You know very well this
is your mother, your husband, the same person you’ve always loved, only afflicted by
terrible disease.
Making the Decision. To avoid Alzheimer’s disease, says a proponent of death by
one’s own choice, “we must place securely in our own hands how we end our life.”279
This seems to suggest that the patient himself should decide; thus, the issue is placed
in the familiar context of autonomy and freedom of choice.
But a patient with Alzheimer’s dementia, durable memory loss and deep cognitive
disturbance, unable to fulfill simple functions, obviously cannot make the decision to
end his life; nor do these patients even utter such wishes. A resolve to end such a life
can only be other people’s decision, not the patient’s.
How about earlier stages, when periods of confusion alternate with relatively lucid
intervals? A death wish uttered by a patient in this stage must raise terrible doubts. It
takes considerable pro-euthanasia bias to view it as a duly weighed decision.
Apparently, we are relegated to “living wills” or other directives issued in advance
by still sane, fully competent persons. But a substantial study showed that—in spite
of all encouragement and tremendous pressure—most Americans avoid signing living
wills;280 and rightly so. They are guided by caution, wisdom, and moral objections.
Cautious people are reluctant to issue clear instructions about what to do in the
future, in always complex, often difficult to grasp, and never entirely predictable situations. The textbooks list, besides Alzheimer’s, sixty other possible causes of dementia, of
which thirty are curable or otherwise reversible.281 In principle, all persons tentatively
diagnosed with Alzheimer’s disease should first be tested for all thirty curable causes of
dementia, but in practice this is not always done. What if the patient were killed while
her confusion could have been cured with a shot of vitamin B12 or B6?
Bachrach, supra note 246.
A. Fagerlin & C.E. Schnedier, Enough: The Failure of the Living Will, HASTINGS CENTER REP., Mar./
Apr., 2004, at 30.
281
M.M. Brown & V.C. Hachinski, Acute Confusional States, Amnesia, and Dementia, in HARRISON’S
PRINCIPLES OF INTERNAL MEDICINE 183, 190 (12th ed., J.D. Wilson et al. eds. 1991).
279
280
264
Issues in Law & Medicine, Volume 28, Number 2, 2012
Wise people understand that what they feel and desire while healthy and unwilling
to accept any limitations, is not the same as what they may desire when gravely ill.282
Morally sensitive people question whether their present selves have the right to bind
their future, changed selves, in the ways contemplated in living wills.283
Putting the Decision to Die into Effect. Let’s suppose there is a “living will” stipulating
to end the patient’s life when she no longer recognizes her daughter; the fatal moment
arrives; and we decide to break the law, overcome our instinctive repugnance, and grant
the request the patient had expressed years ago.
Shall we inform the mother what we are doing? The patient at that stage of cognitive
disability will not understand. If she does, she will probably shriek and defend herself.
Shall we cheat the unsuspecting patient, approach her with the milkshake into
which nine grams of barbiturate had been mixed, and say “Mum, I brought you a drink”?
Is this our idea of “patient taking firmly in her own hands how she ends her life”? What
advocates of “prevention of Alzheimer’s disease” propose would in reality boil down
to is lethal injections administered to patients without their knowledge. That’s how the
“compassionate society”284 will prevent the tragedy of Alzheimer’s.
Chapter XXII. Utilitarianism of Bentham-Mill-Singer and the Philosophy of
Euthanasia285
Jeremy Bentham was born in 1748 and died 84 years later, but it was said that
nothing ever happened to him; that he never experienced any human misfortunes or
elations; that he was arid, devoid of imagination; that instead of living people he saw
schematic diagrams; that being busy with reforming the prisons and the penal system,
he by mistake applied the same considerations to the field of ethics and social reform.
This description of Bentham’s personality has not originated with his critics, it was
penned by his true follower, John Stuart Mill.286
But Bentham had at least one very human trait: he was particularly sensitive
to suffering both in people and in animals. That’s why he readily adopted Helvetius’
opinion287 that living beings are governed by the search for pleasure and the desire to
People’s intuitive understanding that the wishes of the gravely ill are different from those of healthy
persons has been confirmed by substantive studies. Cf., M.L. Slevin, Attitudes to Chemotherapy: Comparing Views of Patients with Cancer with Those of Doctors, Nurses, and General Public, 300 BRIT. MED. J. 1458
(1990); D.E. Patterson, When Life Support is Questioned Early in the Care of Patients with Cervical-Level Quadriplegia, 328 NEW ENG. J. MED. 506 (1993); J.H. Hess, Looking for Traction on the Slippery Slope: A Discussion
of the Michael Martin Case, 11 ISSUES IN LAW & MED. 105 (1995). See also R. Fenigsen, Euthanasia and
Moral Reflection, in THE DIGNITY OF THE DYING PERSON: PROCEEDINGS OF THE FIFTH ASSEMBLY OF THE PONTIFICAL ACADEMY FOR LIFE 212-18 (J. de D.V. Correa & E. Sgreccia, eds., Vatican City 2000).
283
Fagerlin & Schnedier, supra note 280, at 30.
284
Dorfman, supra note 278.
285
Lecture delivered in 1996 at the Catholic University of Lublin, Poland.
286
John Stuart Mill, Bentham, in JOHN STUART MILL AND JEREMY BENTHAM 148-55 (A. Ryan, ed. 1987)
(hereinafter MILL & BENTHAM).
287
CHARLES TAYLOR, SOURCES OF THE SELF: THE MAKING OF THE MODERN IDENTITY 328 (1989) (quoting
HELVETIUS, DE L’HOMME).
282
Other People’s Lives: Reflections on Medicine, Ethics, and Euthanasia
265
avoid pain. Bentham elevated this hypothesis to the position of natural law.288 He also
assumed, on less certain grounds, that these are the only motives of animal and human
behavior. He therefore proclaimed the principle of utility as the only criterion of moral
evaluation: good deeds are those that increase the sum of happiness, the acts that increase the sum of sufferings are morally bad. All other criteria Bentham not only rejected,
but sharply condemned.289 Having grounded the whole of ethics on a single principle,
allowing only one criterion of evaluation, Bentham was able to build an exceptionally
consistent system. Moreover, in the true spirit of the Enlightenment, Bentham tended
to see ethics as a science, a branch of natural sciences; he demanded rigorous reasoning
and did not take anything for granted. He was not willing to admit that murder, robbery, or arson were bad acts, until convincing proof was presented.290 Premises had to
be verifiable; appealing to privileged information, such as intuition, or revelation, was
prohibited. It is owing to these scientific qualities that Bentham’s ethical system —
utilitarianism—became so popular among the philosophers of our time. Utilitarianism
is still sharply criticized, for instance by Bernard Williams291 and John Rawls,292 but in
the English speaking countries it is generally regarded as the most serious attempt to
create a reasoned system of ethics.
John Stuart Mill, raised since his childhood in an atmosphere of adoration of Bentham, as a young man suffered a nervous breakdown and rebelled against the Master’s
stiff doctrine, but later did a great deal to make it more humane.293 Mill’s original contribution (in many ways linked to the subject of our interest, euthanasia), is his excellent treatise On Liberty.294 In this book Mill asserted that neither the state, society, nor
neighbors should interfere with what an individual is doing as long as his actions are
not injurious to anybody but himself. The modern intellectual current directed against
paternalism in social relations and in medicine traces its origin back to that treatise On
Liberty first published by Mill in 1859.
Several variants of utilitarianism have been developed, which show that their
originators have been aware of certain faults in Bentham’s classic doctrine; but it also
means that these authors wished to maintain the utilitarian tradition. “Preferential”
utilitarianism295 recommends making people happy not after some universal pattern,
but in accordance to each individual’s preferences. The utilitarianism of rules postulates
that not so much our acts but rather the rules we follow should aim at increasing the
288
Jeremy Bentham, An Introduction to the Principles of Morals and Legislation, in MILL & BENTHAM, supra
note 286, at 65.
289
Id. at 70-83.
290
Mill, supra note 286, at 139.
291
Bernard Williams, A Critique of Utilitarianism, in J.J.C. SMART & B. WILLIAMS, UTILITARIANISM, FOR
AND AGAINST 77 (1993).
292
JOHN RAWLS, A THEORY OF JUSTICE 167-75, 183-92 (1972).
293
John Stuart Mill, Utilitarianism, in MILL & BENTHAM, supra note 286, at 272-338; John Stuart Mill,
A System of Logic, in MILL & BENTHAM, at 113-31; John Stuart Mill, Colereidge, in MILL & BENTHAM, at
177-227; and John Stuart Mill, Whewell on Moral Philosophy, in MILL & BENTHAM, at 228-71.
294
JOHN STUART MILL, ON LIBERTY (Penguin Books, London, 1988).
295
PETER SINGER, PRACTICAL ETHICS 94-96, 99-100, 110, 126-29, 153, 194-95 (2nd ed. 1993).
266
Issues in Law & Medicine, Volume 28, Number 2, 2012
general happiness.296 Further, the “non-hedonistic”297 and the so-called “negative utilitarianism”298 are worth mentioning, but we now turn to a more detailed discussion of
the views of professor Singer.
Peter Singer, formerly a lecturer at Monash University in Melbourne, at present Ira
W. DeCamp professor of bioethics at Princeton, is a brilliant and undoubtedly the most
influential utilitarian philosopher living. Among Singer’s publications, his monograph
with co-author Helga Kuhse, Should the Baby Live? (1985),”299 Rethinking Life and Death:
The Collapse of Our Traditional Ethics (1995),300 and Animal Liberation (1975)301 are pertinent to the issues here, but I’ll focus on Singer’s Practical Ethics,302 which contains a
full exposition of his views.
Always quite readable and usually sharply reasoned, this book first appeared in
1979 and has since been widely acclaimed as the conceptual framework of the New
Morality. The second edition (1993) was expanded and revised, but the core of the
doctrine was preserved in its pure form:
UÊ Ethics begins when we exceed the self-centered attitude and start to think
and act in consideration of others. Everybody’s interests must be equally
considered. The moral order is concerned with sentient beings, that is, beings capable of experiencing pleasure and pain, because only such beings
have any interests. In fact, seeking pleasure and happiness and avoiding
pain are the only interests they have. Actions, says Singer, should be
judged according to their consequences. They are morally right when they
increase happiness (or reduce suffering) for the greatest possible number
of beings. Actions which result in less happiness and/or more suffering
are morally wrong.
UÊ Murder is usually wrong because the pleasure of the killer is outweighed
by the suffering of the victim, the loss of his future pleasures, the grief of
his family, and the anxiety caused to others who knew him. However, if
somebody who could expect only further suffering is killed instantly in his
sleep, in complete secrecy, the classical utilitarian would find no reasons
to condemn the act. Mistaken as they may be, some persons wish to stay
alive even when they cannot expect anything pleasant in the future, and
J.J.C. Smart, An Outline of a System of Utilitarian Ethics, in SMART & WILLIAMS, supra note 291, at
296
9-12.
297
298
299
Id. at 12-27.
R.N. Smart, Negative Utilitarianism, 67 MIND 542 (1958).
HELGA KUHSE & PETER SINGER, SHOULD THE BABY LIVE? THE PROBLEM
OF
HANDICAPPED INFANTS
(1985).
PETER SINGER, RETHINKING LIFE AND DEATH: THE COLLAPSE OF OUR TRADITIONAL ETHICS (1995).
PETER SINGER, ANIMAL LIBERATION (2nd ed. 1990).
302
PETER SINGER, PRACTICAL ETHICS (1st ed. 1979; 2nd ed. 1993) (Unless otherwise indicated, the page
numbers cited are those of the second edition).
300
301
Other People’s Lives: Reflections on Medicine, Ethics, and Euthanasia
a “preference utilitarian” (but not the classical utilitarian) would respect
their preferences.
UÊ Animals, in particular those with a nervous system similar to ours, are
capable of suffering and feeling pleasure. Therefore, their interests must be
considered in the same way as our own. Partiality to the interests of those
of one’s own species (speciesism) is as unfounded and morally untenable
as tribalism, racism or sexism. Killing animals in order to use their bodies
as food is morally wrong because important interests of those killed (all
pleasures of their continued existence) are sacrificed for the negligible and
unnecessary pleasure of human consumers.
UÊ The intensity of a wrong doing depends on the degree of consciousness of
beings that are killed. It may be particularly wrong to kill a person that is
a rational self-conscious being able to remember himself in the past and
conceive of his own future. At least some animals are persons. Chimpanzees
and gorillas taught a sign language recall facts from the past, are aware of
their own identity, and inquire about future events. On the other hand,
large groups belonging to our own species, Homo sapiens, are non-persons:
fetuses, newborn babies, infants, the severely brain-damaged or mentally
retarded, and the permanently comatose. Non-persons may be killed if
the net result of the act is an increase of general happiness. Fetuses may
be killed if they carry a defect or if the mother does not want the child.
Obviously, the event of birth does not bring about any morally relevant
change. Therefore, infanticide is as admissible as abortion, and should be
left to the parents’ decision.
UÊ Morally praiseworthy results can be achieved not only by increasing the
happiness, or diminishing the suffering, of already existing beings, but
also by increasing the number of happy beings, or reducing the number
of unhappy ones. This means that some beings, in particular fetuses and
infants, are replaceable. If a couple intends to have two children, and one
of these turns out to be a hemophiliac, it is right to kill this baby as it will
enable the mother to conceive again, and, it is to be hoped, give birth to a
healthy child who will have a longer and happier life than the one killed
would have had.
UÊ Persons should be killed if they express the wish to die, and also when
they are unable to do so, but, if they were, would consent to euthanasia.
UÊ Causing death by omission is discussed in connection with euthanasia
and also a broader context. We are guilty of murder if we fail to donate a
sufficient part of our income to aid the Third World where millions die
prematurely.
267
268
Issues in Law & Medicine, Volume 28, Number 2, 2012
A surprisingly large part of Practical Ethics is concerned with killing. One only
refrains from killing if the prospective victim truly desires to continue living, and is able
to express such wish.303 A peculiar image of the world ensues. Killing seems to become
not a transgression but the regular course of action. Living beings seem to be constantly
preoccupied with decisions whether to put an end to their lives or to go on living.
Practical Ethics makes intellectually stimulating reading right to the very last chapter. In the appendix to the second edition, the author, whose grandparents perished
in the Holocaust, tells the story of his troubled visit to Germany: the association of
people with disabilities accused him of reviving the Nazi program of extermination
and barred him from lecturing.
Singer is a philosopher who, with some unavoidable exceptions, practices what
he preaches: he is a vegetarian, does not wear leather shoes, and shares his income with
the needy in the Third World.
The strength of Singer’s convictions, and the impressive logic of his writings keep
his readers under the spell. All the more is it important to verify what he writes.
The Facts. In the New York Review of Books, H.L.A. Hart praised Practical Ethics as
a book “packed with admirably marshaled and detailed information, social, medical,
and economic.” I do not share this favorable opinion. In reality, Singer’s command of
the biological, medical, and historical information he quotes is rather sketchy. When
writing the first edition, Singer believed that no animals had a cerebral cortex!304 In the
second edition this blunder had been only partially corrected.305
The author condemns using animals for food,306 and can well hold his ground as
long as his arguments are moral. But he also contends that eating meat is an entirely
unnecessary luxury.307 However, the meat of animals, birds, or fish, is the fullest and
easiest accessible source of the nine “essential” amino acids which we need to build
our bodies’ proteins. Thus, consumption of meat does serve a biological purpose.
The fact that it can be replaced by (duly supplemented) vegetarian diet does not make
it a thoughtless fancy.
Singer presents as conclusive the few experiments with teaching sign language to
apes.308 The interpretation and reproducibility of these studies are still quite uncertain.
On these shaky grounds Singer projects human mental states onto animals, anthropomorphizing them in the best pre-behaviorist, pre-Pavlovian, and even pre-Cartesian
tradition.
SINGER, supra note 302, at 171; SINGER, supra note 300, at 219.
SINGER, supra note 302, at 60 (1st ed.).
305
Id. at 70 (2nd ed.).
306
Id. at 62-72.
307
Id. at 62.
308
Id. at 111-17.
303
304
Other People’s Lives: Reflections on Medicine, Ethics, and Euthanasia
269
Singer incorrectly makes Christianity solely responsible for proclaiming the sanctity
of human life.309 In fact, the foundations of this doctrine had been already laid in the
Old Testament,310 and the Hippocratic ethics.
Singer uncritically accepts the Nazi’s claim that their euthanasia program was
aimed at the “elimination of useless eaters.”311 All evidence indicates that the supposed
“savings” were no more than rationalizations of what was on its face a hate crime, just
as the mountains of eyeglasses, children’s shoes, and human hair amassed in the death
camps were macabre rationalizations, and not the aim, of the genocide.
“Perhaps one day,” writes Singer, “it will be possible to treat all terminally ill and
incurable patients in such a way that no one requests euthanasia…, but this is now just
a utopian ideal.”312 The statement is a curious distortion of truth. For hundreds of years,
and until the present pro-euthanasia campaign, sick and dying people rarely requested
euthanasia, and in most countries of the world, still never do.
Singer derides the idea that euthanasia could ever be performed without a competent patient’s consent, and denies that such practice exists in the Netherlands.313 But
the official report of the Dutch government’s Committee on Euthanasia, available to
Singer in English translation since 1992,314 states that in 1990 the lives of 1,000 patients
who did not request or consent to euthanasia were “actively terminated” by doctors,
and that 140 of these patients were fully competent.315 Moreover, doctors intentionally
caused the deaths of patients without their request, consent, or knowledge, by giving
them lethal overdoses of morphine; among 4,941 patients who underwent this form
of involuntary active euthanasia, 27 percent (1,334 persons) were fully competent.316
The Corrections. Statements which irritated the readers of the first edition of Practical
Ethics: demeaning people with Down syndrome,317 calling retarded people “vegeta-
Id. at 88, 173.
Gen. 4: 10-13; Ex. 20:13; and Lev. 20:1-6.
311
SINGER, supra note 302, at 215.
312
Id. at 199.
313
Id. at 179, 196-97.
314
P.J. VAN DER MAAS, J.J.M. VAN DELDEN, & L. PIJNENBORG, EUTHANASIA AND OTHER MEDICAL DECISIONS
CONCERNING THE END OF LIFE: AN INVESTIGATION PERFORMED UPON THE REQUEST OF THE COMMISSION OF
INQUIRY INTO THE MEDICAL PRACTICE CONCERNING EUTHANASIA (Elsevier, Amsterdam-London-New York-Tokyo 1992).
315
Id. at 194 (“life is terminated without explicit request of the patient . . . in somewhat more than
one thousand cases annually”). Fourteen percent of these patients (140 persons) were “able to assess the
situation and [m]ake a decision adequately.” Id. at 61 (Tbl. 6.4).
316
Id. In 1990, 22,500 patients died of an overdose of painkillers. Id. at 183. In 36 percent of these
cases (8,100 persons) causing the patient’s death was one of the purposes or the only purpose of doctors
who administered excessive doses of painkillers. Id. at 73 (Tbl. 7.2). In 61 percent of these 8,100 cases
(4,941 persons), the decision was not discussed with the patient. Id. at 75 (Tbl. 7.7). Twenty-seven percent
of patients who died of an overdose of painkillers administered without their consent (1,334 persons)
were “totally able to [m]ake a decision.” Id.
317
Id. at 73 (1st ed.).
309
310
270
Issues in Law & Medicine, Volume 28, Number 2, 2012
bles,”318 and assessing the mind of a one-year old child as below that of many animals319
were excised in 1993, and do not appear in the second edition.
Ironically, these corrections have also drawn attention to Singer’s original, apparently more genuine views. Among statements that were expurgated from the second
edition of Singer’s Practical Ethics were his remarks on Nazi euthanasia. In the first edition
of Practical Ethics, Singer wrote that “[t]he Nazis committed horrendous crimes, but
this does not mean that everything the Nazis did was horrendous. We cannot condemn
euthanasia just because the Nazis did it, anymore than we can condemn the building
of new roads for this reason.”320
Thus, in 1979, Singer did not see anything horrendous in the Nazi euthanasia
program. Yet Nazi euthanasia (“Aktion T4”) was horrendous. Psychiatric patients who
guessed or, due to indiscretions of the personnel, knew what awaited them, loudly protested, begged not to go, tried to defend themselves, fled and hid themselves, screamed
at transport personnel “our blood cries out for revenge,” clung to their hospital beds
and had to be dragged from the building.321 In Absberg, a hundred “feebleminded”
persons resisted and had to be loaded with physical force into busses which transported them to the euthanasia center.322 At these centers (Grafeneck, Brandenburg on
the Havel, Hartheim, Sonnenstein, Bernburg, and Hadamar) the patients were gassed
with carbon monoxide. It took about an hour to cause death in this way; the victims,
crowded into closed chambers, experienced extreme terror and visibly suffered before
dying.323 Doctors and other attendants liked to watch the scene through a reinforced
glass aperture.324 The atrocities provoked a widespread indignation in Germany, and not
only among the families of the victims and the general public, but in the Wehrmacht
and in the Nazi party; on August 28, 1941, Hitler had to order a halt on “Aktion
T4.” A number of doctors, nurses and other personnel who gained experience in the
Nazi euthanasia program were later transferred to death camps and were also involved
in gassing the Jews.325 I’m not suggesting that Singer was cynical when he exonerated
the Nazi euthanasia in 1979. I think he was biased due to his general preference for
euthanasia and ignored the true facts.
Singer’s Reasoning is superb most of the time but not all the time. Contrary to his
assertion,326 the presence of a disability only allows one to conclude that a person’s life
is more difficult, not that it is less worth living. The latter is a value judgment reflecting
the author’s bias against people with disabilities.
Id. at 75 (1st ed.).
Id. at 122 (1st ed.).
320
Id. at 124 (1st ed.).
321
M. BURLEIGH, DEATH AND DELIVERANCE: “EUTHANASIA” IN GERMANY 1900-1945 140, 142 (1994).
322
Id. at 163.
323
Id. at 149; H. FRIEDLANDER, THE ORIGINS OF NAZI GENOCIDE: FROM EUTHANASIA TO THE FINAL SOLUTION 97 (1995).
324
BURLEIGH, supra note 321, at 147; FRIEDLANDER, supra note 323, at 97.
325
BURLEIGH, supra note 321, at 150; FRIEDLANDER, supra note 323, at 295-302.
326
SINGER, supra note 302, at 188.
318
319
Other People’s Lives: Reflections on Medicine, Ethics, and Euthanasia
271
Singer explains why, on paternalistic grounds, we may prohibit the use of heroin
but not voluntary euthanasia: the choice for euthanasia should not be prohibited because it is a rational choice.327 Value judgment again, this time on what is rational. Yet
it can be argued, and on firmer grounds, that the choice to use heroin is less irrational
than the decision to have oneself killed. An addict is very much a living person with
many choices open to him, including the choice to undergo detoxicating treatment; a
dead man has no choices.
Singer’s argument in favor of voluntary euthanasia for the incurably ill and suffering
persons328 is inconsistent. If respect for a person’s autonomy is the reason to kill him upon
his request,329 why must this person be incurable, suffering, or even sick? Aren’t healthy
people autonomous persons? Since Singer does not recognize the autonomy of healthy
individuals, he does not recognize the autonomy of human beings in general. He has,
therefore, no right to put forward personal autonomy as an argument for euthanasia.
Drawing hard conclusions from soft premises is Singer’s frequent error. If we aid
the Third World by donating ten percent of our income, arbitrarily proposed by Singer,330 we are righteous men, but if we give less, we are murderers.331 Singer approves
of killing “someone who has not consented to being killed, but if asked would have
consented.”332 What someone would have said “if asked” is an uncertain premise, but if
we kill him based on that uncertain premise, the resulting death is certain.
Singer argues that one may waive the right to life because “it is an essential feature
of a right that one can waive [it].” The utilitarian tradition, which Singer here abandons,
used to offer a sounder logic. “Over himself, over his body and mind, the individual is
sovereign,” wrote John Stuart Mill, but “an engagement by which a person should sell
himself … as a slave would be null and void…. The reason for not interfering … with
a person’s voluntary acts is consideration for his liberty …. But by selling himself for
a slave, he abdicated his liberty … He therefore defeats … the very purpose which is
justification of allowing him to dispose of himself.”333 Mill’s objection is a fortiori valid
against the freedom to have oneself killed, as this would abolish the person’s freedom
once and for all.
All Criticism On Principle, to which utilitarianism has been subjected for almost two
centuries, and which utilitarians never were able to refute, applies to Singer’s philosophy. Is it true that “Nature has placed mankind under the governance of two sovereign
masters, pain and pleasure”?334 No, it is not true, and even the very dichotomy of pain
versus pleasure is false. Everything that is important in a human being’s life, growing
up, learning, love, marriage, giving birth, parenthood, work and creativity, ambition
327
328
329
330
331
332
333
334
Id. at 199-200.
Id. at 193-200.
Id. at 194-95.
Id. at 246.
Id. at 222-24.
Id. at 179.
MILL, supra note 294, at 173.
Bentham, supra note 288,at 65.
272
Issues in Law & Medicine, Volume 28, Number 2, 2012
and struggle—all this brings about happiness and sorrow, pain and pleasure inseparably
tied together, and people by no means shun these happenings and strivings, they seek
them passionately.
People act out of a sense of duty, stand up against injustice, risk their own lives
for the sake of others, toil and mortify themselves in search of perfection, and none of
these endeavors fits the utilitarian description of man’s aim.
The utilitarian doctrine completely disregards the real contents of a person’s life.
Gradation of values, the source of all diversity and richness in our lives, does not exist for
a utilitarian: eating a freshly baked roll and making a scientific discovery are converted
to a common currency and added up.
The utilitarian seeks the balance of general happiness by adding up all people’s
pleasures and subtracting all pains. The fallacy of this moral arithmetic is evident.
Mankind only exists as individual human beings. Only individuals suffer or are happy.
There is no intermediate moral substance between individuals, no common pool of
happiness. The pleasures or sufferings of an individual cannot be added to or subtracted
from those of other people’s. Wrongs done to a human being cannot be compensated,
outweighed, or justified by increased happiness of other persons: they remain wrongs.
John Rawls correctly pointed out that in pursuit of greater happiness of the greatest
numbers utilitarianism justifies the sacrifice of innocent persons for the general welfare.
Let’s note that this principle can even justify acts of extreme violence if perpetrated
by large crowds to their full satisfaction, at the expense of a few victims, for example,
pogroms, lynching, or cannibalism, which allows all the villagers to enjoy the nutritive
and magic properties of the organs of the one person sacrificed. Not so, reassure us John
S. Mill and Peter Singer: justice takes precedence. Not that justice derives from any source
other than utility: it provides the sense of security people so much need. However, if
justice is not an independent moral principle, but one founded on utility, the protection
it lends in unreliable. Other utilitarian considerations may prevail. Exterminating a hated
minority may bring the populace a stronger feeling of security than justice ever would.
It is his defense of animals that has originally helped Singer to win so many
followers; but he is not a reliable defender of our biological brethren. In fact, some of
Singer’s views can be used to justify the extermination of whole animal species. Singer’s
doctrine that the wrongfulness of killing depends on the degree of consciousness of the
prospective victim is particularly dangerous in this respect. At present, some frogs are
threatened with extinction, but why should we protect them since their level of
consciousness is rather low? And why shouldn’t we exterminate some fish, or burrowing
rodents, which have hardly a memory of their past, no awareness of their own identity,
no conceivable will to continue their existence, and distinct plans for the future? We
are free to do that, even more so if the removal of that species will create more space
for another one, blessed with a higher degree of consciousness.
It has often been argued that utilitarianism is a “parasitic” philosophy because it
subsists on criticism of other systems. Singer excels in pointing out the inconsistencies
Other People’s Lives: Reflections on Medicine, Ethics, and Euthanasia
273
of intuitive and deontological ethics. We proclaim the sanctity of all life but do not
hesitate to pull up a cabbage. And would we attempt indefinitely to keep alive a child
born without brains and missing most of his skull? But Singer’s claim to victory is
mistaken. Intuitive and duty-based ethical systems can live with some inconsistencies.
These ethical systems have never claimed full consistency, perhaps because it was felt
that man, life, and the universe did not seem to exist or operate in a fully consistent
way. It is the reasoned utilitarian ethics that stands or falls with its consistency. It falls.
Why is “happiness of the greatest number” the standard? Reason can also justify opposite
aims, for example, “happiness for myself and misery for everybody else.” The choice
of the “happiness for the greatest number” was Bentham’s moral intuition. It turns out
the utilitarian ethics flow from a source utilitarianism has forsworn and condemned.
But it is not only this original sin of inconsistency, there is more. The reader of
Practical Ethics has accompanied Dr. Singer on the vertiginous adventure of that book,
construing with him consequentialist ethics free of moral intuitions, only to be told
that “[i]n real life … it is simply not practical to try to calculate the consequences … of
every choice we make …. It would be better if, for our everyday ethical life, we adopt
… soundly chosen intuitive moral principles.”335 The view is Richard M. Hare’s, but
Singer concurs. This is not just a pragmatic concession, this is a capitulation on principle. Singer has himself admitted that “an ethical judgment that is no good in practice
must suffer from a theoretical defect as well, for the whole point of ethical judgment is
to guide practice.”336
I wholeheartedly respond to Singer’s appeal never to torment animals, and, if
possible, to avoid killing them. But we don’t owe it to them, we owe it to ourselves.
Animals are objects of our moral order; a moral order they haven’t created and cannot
obey. Only Man has attempted that. Abandoning the human point of view and adopting
that of the universe, Singer tries to create a scientific system of ethics that is not partial
to Man. We are thrown into a nightmarish moral moonscape where the strong and the
“normal” stay alive, but the weak and “different” are killed, where murdering children is
no crime, and the pleasures of a sadistic killer are a positive moral value to be weighed
in the balance of general happiness. We are told this is the New Morality, but in fact it
is quite ancient. I am sure it prevailed in the Neanderthal.
Chapter XXIII. Doctors Who Practice Euthanasia
Even in the early days some observers warned that euthanasia was not just another
procedure added to the medical practice but would change the physician’s whole attitude
and also their professional performance. The predictions proved right.
Handling the Facts of the Case. Dutch doctors are excellently trained professionals
and many of them are strikingly talented individuals. Family physicians impress the
specialists by their ability to report from memory every patient’s medical history in
every detail. And yet two series of cases have been published, one by Innemee from
335
336
SINGER, supra note 302, at 92-93.
Id. at 2.
274
Issues in Law & Medicine, Volume 28, Number 2, 2012
the Dutch Patients’ Association,337 and the other by myself,338 showing factual errors,
misrepresentation of the facts, and negligence on the part of doctors in their attempts
to justify euthanasia.
A family physician phoned me three times to request that I allow his patient to
die. The man had suffered cardiac arrest in the street, and had been resuscitated by
passers by and transported to my intensive care unit. The family physician argued that
the patient also had lung cancer and that the family wanted euthanasia. Both statements
proved false. Six months before, the family physician had indeed suspected this patient
of lung cancer and had referred him to a chest specialist; the specialist ruled out cancer.
The patient’s two daughters (he had no other family) categorically denied that they had
requested euthanasia; they stated that they had not spoken about their father to the
family physician or any other doctor.
When transferring to me an acutely ill patient with myocardial infarction and
pulmonary edema, an internist colleague of mine tried to persuade me to let the patient
die “because he was a widower without family, entirely alone in the world.” Of course,
that argument had no influence on my actions and also proved untrue. This patient, Mr.
T, was under my care for the next eight years and always came to the outpatient clinic
accompanied by his loving sons, daughters, and in-laws.
After examining a woman patient of mine, the consulting neurologist wrote in his
opinion: “this elderly man is deeply comatose and, in my view, should not be resuscitated
again.” Having examined the patient, this doctor still did not know whether the patient
was a man or woman, but he did know that this person’s life should not be prolonged.
To be sure, the patient’s sex had no bearing on the conclusion; but the incident showed
that decisions about life and death could be made in a distracted state of mind.
The actions of Dr. W339 were not marked by scrupulousness, to put it mildly. This
doctor, who routinely put patients to death without their consent or knowledge, considered it unnecessary personally to examine the patient before making such a decision.
If, when making his (quick) ward rounds, he had the impression that a patient was in
critical condition, he would ask the nurse: “Ishij euthanasieachtig?” [“Is he suitable for
euthanasia?”] The nurse’s answer would decide the patients fate. In the case cited in
Chapter XXIV, Dr. W ordered that the patient be given a lethal injection though nobody
knew what was wrong with the patient (if anything). The patient was in a dimmed state
during the ward round because he had been stupefied by valium (diazepam), which
that same Dr. W had prescribed a few days before. Dr. W had forgotten that he had
prescribed valium and it did not occur to him that this might have been the cause of the
337
C. Innemee, Commissie Remmelink krijgt zes gevallen voorgelegd: NPV geeft voorbeelden van ongevraagde levensbeeingdiging [Six Cases Presented to the Remmelink Committee: Dutch Patients’ Association Presents Examples of Termination of Life Without Request], in ZORG (Veenendaal), Vol. 8, No. 4, 1990, at 4-5.
338
R. FENIGSEN, EUTHANASIE, EEN WELDAAD? [Charitable Euthanasia?] 69-72, 83-84 (Van Loghum
Slaterus, Deventer 1987).
339
See subsec. entitled Healer of Mankind’s Afflictions, in Ch. XXIV.
Other People’s Lives: Reflections on Medicine, Ethics, and Euthanasia
275
patient’s stupefaction. He did not even glance at the patient’s chart which would show
that the patient was receiving the drug.
That’s how scrupulously the doctors proceeded who attempted to subject patients to
euthanasia. In my entire medical career I have never encountered such a series of crude
errors and transgressions as those committed by doctors in their rush to euthanasia: lies,
distortion of fact, impaired powers of observation and concentration (to mistake a woman
for a man!), and, finally, complete negligence and carelessness as displayed by Dr. W.
Such wholesale departure from the rules of professional conduct cannot be accidental, it must have definite causes. In part, this has a simple explanation. In fact, it is
not surprising that the “euthanasia doctors” overlook, distort, or disregard facts; rather it
is surprising that “ordinary” doctors are able to master and remember such an immense
number of facts concerning their patients. There are dozens of patients from 10, 20,
or even 40 years back whom I and my colleagues still recall with all the details of the
course their illness ran. Practicing doctors keep in their memory innumerable points
of information concerning all their hospital patients and outpatients. I set myself the
task of analyzing the case history of one gravely ill elderly man; he was in congestive
heart failure due to aortic and mitral valvular heart disease. Six thousand two hundred
pieces of information were gathered on him in four years of outpatient treatment and
during his three stays in the hospital. In my daily work during this patient’s third
hospitalization I used the data arranged in more than 130 complex information sets
such as “the kidney function gets but moderately impaired under diuretic treatment,”
“pleural effusion recurs with three days after each tapping,” “the relative tricuspid incompetence had disappeared,” etc. To retain this amount of complex data and use it all
effectively requires a considerable mental effort which is only possible when the doctor
is constantly, strongly, and unambiguously motivated. Why should a doctor make such
extraordinary effort if he has already written off the patient?
But that only explains the carelessness of “euthanasia doctors” in part. To put
someone to death with impunity, with a clear conscience, in the belief that one is doing the right thing, excites certain people. This could be seen in the days of the death
penalty in England: before each execution excited crowds would gather at the prison
gate. The instances cited in this chapter show that some of the doctors who practice
euthanasia are no strangers to this kind of excitement. They make their great decision,
are powerfully driven to put it into effect, and will not allow any minor, inconvenient
facts to stand in their way.
Doing Less Than We Can, and Not Doing What Should Be Done. Called in Den Bosch
by two internist colleagues to a freshly admitted patient with uremia (kidney failure),
I found that he had pericarditis, an inflammation of the membranous sac around the
heart. This is a common complication of advanced uremia.
“Oh, that’s good,” said the doctors, “uremic patients who develop pericarditis soon
die of hyperkalemia (excess of potassium in blood), and that’s an easy death.
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Issues in Law & Medicine, Volume 28, Number 2, 2012
They still did not know what the cause of patient’s kidney failure was, whether his
condition could be improved or outright cured, but that did not interest them. Why do
all that painstaking work to see if there was urinary infection curable with antibiotics, or
an obstruction to urine flow, removable by surgery; to see if the patient was dehydrated,
and, if so, supplement fluid; why prescribe diet, correct the secondary disturbances in
bone metabolism, consider kidney biopsy, renal dialysis, or kidney transplant? Why do
all that when the doctor’s mind had already been set on euthanasia? Uremic pericarditis
indicates severe kidney failure—well, fine! We’ll just wait for an easy death.
On his first day at work in Nakskov Hospital’s coronary care unit, a young doctor
told me that his primary interest was “scientifically based contraindications to resuscitation, a precise definition of cases in which one should not reanimate.” He had come
to work in a unit that had been created to resuscitate people, to reactivate “hearts that
are too good to die.” He had not yet taken part in any resuscitation, still did not know
the practical side of the procedure, the difficulties entailed, and how to avoid these;
but that did not interest him. What interested him was the “scientific basis” for doing
nothing and waiting for patients to die. In the mind of this young man euthanasia was
replacing medicine!
I vividly recall a 14 year old girl who two years before the event here described
had been examined for fainting spells. At that time the pediatrician found nothing and
declared her in good health. Now she fell unconscious on the school’s sports field. Those
on the scene began heart massage and mouth-to-mouth ventilation. When the ambulance arrived, it turned out that the girl had ventricular fibrillation (a fatal disturbance
in the heart’s electrical activity, which can, however, be reversed by a shock from an
electric defibrillator). The attendants defibrillated the girl and she was brought to our
emergency room, breathing and with a normally beating heart, but still unconscious. I
found a young pediatrician with her and asked him why he was not moving the patient
to the intensive care unit which offered optimal facilities for resuscitation; after all, she
might relapse in ventricular fibrillation! “Oh, in that case I wouldn’t do anything further,”
said the pediatrician—that is, he would allow the girl to die.
This doctor did not want to give Life a chance, instead, he wanted to give Death a
chance. He knew everything about euthanasia, but did not want to know anything about
medicine. He did not know, or did not want to know, that ventricular fibrillation is the
form of cardiac arrest with a good chance of full recovery; that a patient’s unconsciousness
fifteen minutes after cardiac resuscitation did not mean anything, people may regain
consciousness after hours or days; that adolescents have a particularly good chance to
recover from a cardiac arrest without brain damage. He was enchanted by the concept
of euthanasia and did not want to consider anything else. Euthanasia had dislodged
medicine, reason, and compassion from this doctor’s mind. In his ideal, healthy, society,
there was no place for girls whose hearts suddenly stop beating on a sports field.
My voice hasn’t been the only one to warn that euthanasia, or even its mental
acceptance by doctors, leads to abandonment of viable treatment options. Similar obser-
Other People’s Lives: Reflections on Medicine, Ethics, and Euthanasia
277
vations had been reported early on by other Dutch and American authors.340 Then, the
nationwide surveys, ordered by the Dutch government in 1990 and 1995,341 indicated
that the trend was significantly narrowing the range of therapeutic interventions. It
showed that in many cases doctors proceeded to active euthanasia and disregarded the
existing treatment options.342 When “passive euthanasia” was intended (25,000 cases
in 1990), doctors arbitrarily withheld or withdrew potentially effective treatments.343
How Do We Treat a Cardiac Emergency. The following example344 will illustrate how
the acceptance of euthanasia is influencing the performance of highly skilled nurses at
an intensive care unit.
This fifty-two year old lady (Figs. 2 and 3) was admitted to the intensive care
unit because of breast cancer spreading through her lung to the pericardium, with
some accumulation of fluid around the heart. This was improving quite satisfactorily
on chemotherapy, and three weeks later the patient was discharged in fair condition.
During her stay in intensive care, her heart rate slowed down in an alarming way (Fig.
2). The intensive care nurses knew very well what to do in this situation: quickly check
the patient’s clinical condition, call the doctor on duty, get the equipment ready for the
eventual insertion of a pacemaker, and in the meantime make sure that the patient is
not given any medicines that cause slow heart beat.
The internist, however, had ordered “NR” (not to resuscitate) this patient (Fig
3). Therefore, the nurses had not reacted in any way to the emergency seen on the
monitor ECG. Moreover, the medicines which worsen (and probably had caused)
the patient’s slow heart rhythm, the beta-blocker sotacor and the digoxin, were not
stopped! (Fig.3). Medicine’s basic rule—“Whether or not you can help, first of all, do
no harm!”—was no longer valid.
340
I. van der Sluis, Mal-informed non-consent en andere medische gevaren van euthanasie [Mal-informed
Non-consent and Other Dangers of Euthanasia], 128 NED. TIJDSCHRIFTV.GENEESKUNDE1247 (1984); D.L.
Jackson & S. Younger, Patient Autonomy and “Death With Dignity”: Some Clinical Caveats, 301 NEW ENG.J.
MED. 404 (1979).
341
MEDISCHE BESLISSINGEN ROND HET LEVENSEINDE. I. RAPPORT VAN DE COMMISSIE ONDERZOEK MEDISCHE
PRAKTIJK INZAKE EUTHANASIE. II. HET ONDERZOEK VOOR DE COMMISSIE MEDISCHEPRAKTIJK INZAKE EUTHANASIE
[Medical Decisions About the End of Life. I. Report of the Committee to Study the Medical practice
Concernign Euthanasia. II. The Study for the Committee on Medical Practice Concerning Euthanasia]
(State Publishing House SDU, The Hague 1991) [hereinafter “REPORT I” and “REPORT II,” respectively].
Volume I has not been translated. Volume II appeared in English translation in P. J. VAN DER MAAS, J. J. M.
VAN DELDEN, & L. PIJNENBORG, EUTHANASIA AND OTHER MEDICAL DECISIONS CONCERNING THE END OF LIFE:
AN INVESTIGATION PERFORMED UPON THE REQUEST OF THE COMMISSION OF INQUIRY INTO THE MEDICAL PRACTICE CONCERNING EUTHANASIA (Elsevier, Amsterdam-London-New York-Tokyo 1992). [The page numbers
quoted in the present chapter refer to the Dutch original.]
342
REPORT II, supra note 341, at 45 (Table 5.7), & 62 (Table 6.5); G. VAN DER WAL & P. VAN DER MAAS,
EUTHANASIE EN ANDERE MEDISCHE BESLISSINGEN ROND HET LEVENS EINDE [Euthanasia and Other Medical Decisions Concerning the End of Life] 56 (Table 5.5) (Sdu Publishing House, The Hague 1996).
343
REPORT II, supra note 341, at 85-86, & 86 (Table 8.8).
344
This case was previously reported in Richard Fenigsen, Physician-Assisted Death in the Netherlands:
Impact on Long-Term Care, 11 ISSUES IN LAW & MED. 283, 296-97 (1995).
278
Issues in Law & Medicine, Volume 28, Number 2, 2012
This was precisely what the traditional clinician had foreseen and feared: the attitude of easily accepting, even inviting the death of gravely ill but treatable patients; the
suppression of traditional medical thinking, of medical working habits, of the medical
way of reacting to events. Euthanasia was not just changing medicine, it was replacing
medicine.
A substantial study showed that “Do Not Resuscitate” (DNR) orders inhibit doctors’
readiness to administer other treatments, those unrelated to resuscitation. If the patient
had a DNR order, the doctors were significantly less willing to order blood cultures,
place a central line, or give blood transfusions.345
Figure 2
345
M.C. Beach & R.S. Morrison, The Effect of Do-Not-Resuscitate Orders on Physician Decision-Making,
50 J. AM. GERIATRIC SOC. 2057 (2002).
Other People’s Lives: Reflections on Medicine, Ethics, and Euthanasia
279
Figure 3
Carefulness and Professional Integrity. It has been repeatedly stated in the Dutch
euthanasia debate that doctors should act with due care. This is, indeed, a legitimate
demand to make of any person and any action and especially of a doctor. But need a
doctor who decides to terminate a person’s life also act with such scrupulousness? A
number of reports from Holland indicate that he need not. Published cases and studies
revealed grave errors346 and criminal negligence347 on the part of doctors carrying out
euthanasia, lethal injections administered to get rid of troublesome patients,348 or to
free a needed hospital bed,349 decisions taken and euthanasia carried out in unseemly
haste,350 lethal injections given to patients who had clearly stated they did not want eu-
Innemmee, supra note 337.
Bedoelingen arts waren good: Voorwaardelijke celstraf voor “slordige” euthanasie [The Doctor Had Good
Intentions: Probation for “Sloppy” Euthanasia], BRABANTS DAGBLAD, Oct. 22, 1995; F. Abrahams, De huisarts die het niet zo nauw nam[The Family Physician Who Did Not Take It Too Scrupulously], NRC HANDELSBLAD, May 23, 1995.
348
Verzorgingshuizen in opspraak: Het onnodig sterven [Rumors About Nursing Homes: The Unnecessary
Deaths], ELZEVIERS MAG., Apr. 20, 1995; “Euthanasie” vertaald in viervoudig moord [“Euthanasia” Turns Out
to be Murder of Four People], BRABANTS DAGBLAD, July 24, 1985; Arts bekent vijfmaal euthanasie [Physician Admits Having Performed Euthanasia on Five Persons], BRABANTS DAGBLAD, Apr. 17, 1985.
349
REPORT II, supra note 341, at 64 (Table 6.7).
350
F.T. Diemen-Lindeboom, in DE DOOD, UITKOMST VOOR HET LEVEN? [Death as Deliverance From Life?]
109-110 (Bueten & Schipperheyn, Amsterdam 1987); G. VANDERWAL ET AL.,MEDISCHE BESLUITVORMING
AAN HET EINDE VAN HET LEVEN: DE PRAKTIJK EN DE TOETSING PROCEDURE [Medical Decisionmaking at the End
of Life: The Practice and the Verification Procedure] 52-53 (De Tijdstroom, Utrecht 2003).
346
347
280
Issues in Law & Medicine, Volume 28, Number 2, 2012
thanasia,351 euthanasia carried out by doctors aware that the patients had been coerced
to ask for death.352
Are these exceptional deviations from an otherwise orderly and conscientious practice? Alas, this is not so. The nationwide surveys of the practice of euthanasia ordered by
the Dutch government in 1990 and again in 1995 revealed that the doctors practicing
euthanasia, that is, the majority of the Dutch medical profession, in an exceedingly
high percentage of cases transgressed the “rules of careful conduct” established by the
authorities.353
Should Doctors Promote Death? The New Role of the Physician. Facing a patient with
a chronic and incapacitating illness the “traditional” doctor tried to improve her condition, relieve her symptoms, avoid side effects, and give her some encouragement. But
now we are witnessing a complete reversal of the aims of medicine. The following case
history,354 perhaps the saddest in my experience, illustrates the physician’s “new role.”
Mrs. P was a seventy-two year old widow who after a bad myocardial infarction
was left with a grossly dilated heart and congestive heart failure. She was treated with
digoxin, an aldosterone antagonist, a diuretic, and an anticoagulant, and for a whole
year had almost no symptoms at rest. True, she needed help with cleaning her house,
and her only exercise was walking a few blocks. One night her breathlessness recurred;
this required adding a third pillow and an increased dosage of the diuretic. Another
time she complained of dizziness, which turned out to be due to a fall in blood pressure
in upright posture; she was taught the necessary precautions. Mrs. P was an extremely
nice, mild-tempered lady who never showed any impatience and complied with
the doctor’s every order and advice. Barring some clot or a sudden disturbance in heart
rhythm (both of which could of course occur), she might have survived for years in that
condition. When she failed to appear at the outpatient clinic, I was very much worried.
Responding to my inquiry, her family physician, Dr. K, paid me a visit. He had had a
Geen straf arts voor euthanasie: van Ooijen wel schuldig van moord [No Punishment for the Doctor
Who Performed Euthanasia: But the Court Did Find (Dr.) Van Ooijen Guilty of Murder], BRABANTS DAGBLAD, Feb. 22, 2001. The seemingly paradoxical ruling (doctor guilty of murder, no punishment) is typical
of the Dutch legal situation. See also the case of the “young patient who clung to life” and was, nevertheless, killed by the chest physician. See subsec. entitled Impatient Chest Physician, in Ch. XXIV.
352
W. VAN DEN LINDEN, ZIJ MOEST EERST ...HET DOSSIER VAN BOMMELEN:EEN GEVAL VAN EUTHANASIE? [She
Had to go First… The Van Bommelen File: A Case of Euthanasia?] (Strengholt Pub. Naarden 1984);
Waarom heeft Wibo niet ingegrepen? [Why (the TV journalist) Wibo (van den Linden) Did Not Intervene? ZONDAG (Beusichem), Jan. 22, 1984; G.A. Lindeboom, Een z.g. euthanasie-drama [The Drama of
the So-Called Euthanasia], 11 VITA HUMANA 100 (1984); H.TEN HAVE & G.KIMSMA,GENEESKUNDE TUSSEN
DRROM EN DRAMA [Medicine Between Dream and Drama] 83-87 (Kik-Agora Pub., Kampen 1987); G.F.
Koerselman, Hoe mondig zijn moderne patienten? [How Mature are the Modern Patients?], 130 NED. TIJDSCHRIFT V. GENEESKUNDE 2017 (1986).
353
See supra Ch. XX.
354
Fenigsen, supra note 344, at 294-95. The case of Mrs. P was cited at the U.S. Congressional hearings on “physician-assisted suicide and euthanasia in the Netherlands” in Sept., 1996. Report of Chairman
Charles T. Canady to the Subcommittee on the Constitution of the Committee on the Judiciary, House of
Representatives, 104th Cong., 2 Sess., U.S. Government Printing Office, Washington, D.C., 1996.
351
Other People’s Lives: Reflections on Medicine, Ethics, and Euthanasia
281
talk with Mrs. P, he said, and explained the situation to her: This wasn’t going to get
any better, and living such a limited life, with all those pills, made no sense at all. Mrs.
P accepted everything he said. He stopped her pills, and three days later she died. My
only answer was to nod. I couldn’t emit a sound. I was overcome by deep sorrow. It
returns every time I think of Mrs. P.
Chapter XXIV. At the Bottom
The Reticent Family Physician. The story of a six year old boy, his parents, and their
family physician has been published in a leading Dutch medical journal.355 The boy
had some behavioral problems, and his intelligence seemed below average. He lived
with his parents and attended a school for children requiring special care. Then juvenile
diabetes was discovered. Patients with this type of diabetes must receive injections of
insulin, otherwise they develop severe disturbances in metabolism (ketoacidosis), fall
into a coma, and die. The family physician who diagnosed the diabetes did not inform
the parents that the child must be treated with insulin. Instead, he asked whether their
son should be treated. The parents, aware that non-treatment was tantamount to death,
chose not to treat the child. The boy was not given insulin, and died.
The Trickster.356 Dr. E, family physician at a town near Den Bosch, within a fortnight sent to our hospital two female patients, both acutely ill with pulmonary edema
(an accumulation of fluid in the lungs due to heart failure, a condition which is directly
life-threatening but most often responds to treatment), and both times phoned the
cardiologist on duty asking her to not treat these ladies who, in his opinion, were “too
old” (one was 76 and the other 72). In one of these cases he even suggested refusal of
admission to the hospital. This patient overheard fragments of this conversation on
the ambulance’s radio, and arrived to the hospital not only suffocating from pulmonary
edema, but also mortally frightened that she would be denied help.
Dr. E pretended to do everything he could to help: he called the ambulances and
referred the patients to the hospital, didn’t he? At the same time, behind the patients’
backs, he conspired to deny them assistance and let them die.
The Healer of Mankind’s Afflictions.357 In 1973, while making his rounds at a hospital
in Rotterdam, Dr. W, an internist, noticed that one of the patients was in a dimmed
mental state. He then asked the nurse if the patient was suitable for euthanasia which
after some hesitation, she confirmed. Dr. W then ordered that the patient’s life be terminated with an appropriate intravenous injection. However, one of the doctors present
protested, and euthanasia was not carried out. This woman doctor then asked what
actually was wrong with the patient. Dr. W did not know the diagnosis. It turned out
that there was no diagnosis: the patient had been admitted because of low-back pain,
but the reason for the complaint had not yet been determined. The findings so far did
J.M. Buiting, Letter to the Editor, 133 NEDERLANDS TIJDSCHRIFTV.GENEESKUNDE 90 (1989).
RICHARD FENIGSEN, EUTHANASIE, EEN WELDAAD? [Charitable Euthanasia?] 12 (Van Loghum Slaterus,
Deventer 1987).
357
Id. at 37-40.
355
356
282
Issues in Law & Medicine, Volume 28, Number 2, 2012
not indicate any grave illness. The doctor who had protested against euthanasia checked
the temperature chart for medications that could caused that patient’s semi-conscious
state. Indeed, it proved that he had been given rather large doses of valium (diazepam).
Dr. W had forgotten that he himself (unnecessarily, for that matter) had prescribed the
drug. It did not occur to him that this might have been the cause of the patient’s stupefaction. The valium was stopped and the next day the patient, who had come a hair’s
breadth from death, could again speak and stroll the corridor.
The incident was then discussed at a staff meeting attended by the director of the
hospital, Dr. S. Dr. W expressed surprise that one of the doctors considered all euthanasia inadmissible, and not for religious reasons, which Dr. W automatically accepted,
but for some other reasons which he could not understand. As for the way he acted on
his round, Dr. W had nothing for which to reproach himself. Admittedly, he had not
known the diagnosis when he decided on euthanasia, but, after all, you can’t know every
patient in detail. Indeed, he had overlooked that valium was the cause of the patient’s
stupefaction, but to err is human and we all make mistakes. True, the patient perhaps
wasn’t suffering from any serious illness, but that is no obstacle to euthanasia. Minor
errors, lack of diagnosis, or the fact that there’s nothing seriously wrong with the patient
should not deter a doctor from doing his duty which is to help his fellowmen die an
easy death. It does not matter that a person could live another twenty or thirty years.
Who knows what grave illnesses, how much distress and sorrow that individual would
have to endure were he alive! A doctor is a person in particularly privileged position
because he has the opportunity and the means to free his fellow human beings from
future suffering.
The Impatient Chest Physician. Can a doctor kill a sick person out of impatience,
in a fit of anger? It seems improbable; and yet it has happened. The chest physician
told the interviewer: “At the hospital where I previously worked, I had a patient, a very
young man, who clung to life. He did not even want to talk about his bad situation….
This patient had a kind of lung cancer that carries a very bad prognosis. No surgery is
being done in these cases because when the cancer is diagnosed it had already spread.
The treatment is chemotherapy and radiation, and can be quite successful; and this
patient did reasonably well. And then,” the chest physician continued, “I suddenly said
to myself: ‘now it becomes too crazy, I cannot go on with that, now [I must do] active
euthanasia!’ I gave him an I.V. drip with such drugs that he died.”358
Euthanasia at a Nursing Home. Dancing with Mister D.,359 the book written by Dr. Bert
Kiezer, physician at a nursing home in Amsterdam, had become a bestseller in Holland
and was most enthusiastically greeted by reviewers when published in Great Britain
and the U.S.: “Moving and profound”; “the most remarkable feature of this book is
the moral integrity of the writer”; “A delicate, moving and strangely enjoyable book.”
H.W.H. HILHORST, EUTHANASIE IN HET ZIEKENHUIS: ZACHTE DOOD VOOR ZIEKENHUISPATIENTEN[Euthanasia in the Hospital: Mild Death for Hospital Patients] 175 (De Tijdstroom, Lochem-Poperinge 1983).
359
BERT KEIZER, DANCING WITH MISTER D.: NOTES ON LIFE AND DEATH (NewYork-London-TorontoSydney-Auckland 1997).
358
Other People’s Lives: Reflections on Medicine, Ethics, and Euthanasia
283
A number of the nursing home’s residents asked Dr. Keizer to put an end to their
lives, and he obliged. He administered lethal drinks to Mr. B, an AIDs patient;360 to Mrs.
P who had lung cancer, but still was in rather good shape;361 and to Miss Van D who
had multiple sclerosis.362 He administered lethal injections to Mr. B whose lung cancer
was suspected from the X-rays, but not quite confirmed;363 to Mr. van den B who was
moderately disabled due to Parkinson disease;364 and to Mr. U, a stroke patient who did
not actually ask for death but had once, when he still was healthy, signed a euthanasia
declaration.365 Also, when Mrs. M almost choked on her own vomit, Dr. Keizer did not
try to free her airways but finished her with an injection of morphine.366
There also was Mrs. M with a brain tumor. She never asked for euthanasia and did
not know what was being done to her. She received from Dr. Keizer a lethal injection
because her husband insisted on it.367 The names in the book were changed, but I am
sure the facts have been truthfully rendered.
Dr. Keizer is not quite your typical physician. He hated studying medicine368
and now hates his work: “lately… I start my days with more revulsion than usual,” he
writes.369 It is the patients, their sores, their looks, their utterances, and most of all, their
physiological functions that cause his deep disgust.370 Unlike genuine physicians who
don’t notice the unappetizing side of their work and focus on quite different aspects of
the matter, Dr. Keizer remains fixed on the offensive sights, sounds, and smells.
He is also totally devoid of manual dexterity which is the distinguishing feature of
a physician. His hands are “riddled with cuts and wounds” which expose him to terrible
infections.371 Every medical procedure he performs goes wrong, with most unpleasant
effects for himself.372 He doubts whether he is a doctor at all.373 Quite obviously, Dr.
Keizer is one of these sad cases, an individual who practices medicine, but should never
have entered the profession.
Not that it matters: for this doctor rejects medicine. He unreservedly accepts all
devastating accusations with which the Dutch media have showered medicine in the
last thirty years, and adds some of his own. Medicine is a nonsensical and cruel hoax.374
360
361
362
363
364
365
366
367
368
369
370
371
372
373
374
Id. at 115.
Id. at 192-94.
Id. at. 276
Id. at 41.
Id. at 99.
Id. at 306-07.
Id. at 17.
Id. at 77-79.
Id. at 88-89.
Id. at 124.
Id. at 109, 114, 131-32, 156, 177-78, 198, 278.
Id. at 114.
Id. at 197, 206-09, 214, 278.
Id. at 135.
Id. at 5, 42, 68-70, 139, 261, 271, 312, 317.
284
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It cannot do anything for people, least of all save anybody’s life.375 Diagnosing diseases
is useless: “as if it matters whether your strangler is called Joe or Alexander.”376 Medical
interventions are scientifically groundless.377 “The medical repertoire is… full of crap.”378
Medical treatment is humbug.379 All medicines are “useless shit.”380 Three surgical operations are mentioned in the book: one did not remove the tumor and left the patient to
slowly die,381 the other blinded the patient,382 while in the third, the surgeon “finished
the patient off in twenty minutes”;383 the latter outcome provoked Dr. Keizer’s hearty
laugh. All attempts to treat a sick person are transgressions of patient’s privacy, bouts of
medical violence,384 or idiotic farces.385
We begin to understand now why Dr. Keizer performed euthanasia on Mr. B, even
though the diagnosis of lung cancer was still in doubt.386 What did it matter? Diagnosing
diseases makes no sense anyway.387
But Dr. Keizer disavows greater things than medicine. He disavows Life. Life is
not worth the trouble.388 Worse still, it is a situation in which we are trapped, a train on
which we keep riding only because we are too cowardly to jump off.389 What a relief to
hear that you’ve got a deadly disease!390
If Life itself is rejected, what are Dr. Keizer’s values? Telling the Truth. More precisely, the doctor’s duty (and privilege) to tell his patients that they are going to die.391
And Dr. Kiezer is convinced that patients, whether they want it or not, have a duty to
receive this information.
He also likes to tell his patients little jokes on the subject of their deaths,392 or to
express mock concern: “In a month or so, we’ll be stuck here with a hundred thirty
pounds of your sad remains, and I don’t even know where to put it.”393
A few more traits (indeed, provided in the text) are needed to sketch Dr. Keizer’s personality. He obsessively assaults God, religion, and the believer’s morality and
375
376
377
378
379
380
381
382
383
384
385
386
387
388
389
390
391
392
393
Id. at 139, 271.
Id. at 317.
Id. at 239.
Id. at 69.
Id. at 119, 312.
Id. at 70.
Id. at 210.
Id. at 282-83.
Id. at 283.
Id. at 286.
Id. at 243.
Id. at 37-38, 41.
Id. at 312.
Id. at 237.
Id. at 238.
Id. at 34, 177.
Id. at 237.
Id. at 129.
Id. at 204.
Other People’s Lives: Reflections on Medicine, Ethics, and Euthanasia
285
sanity.394 No smiling agnostic he, no liberal atheist respecting other people’s right to
believe; no, he is vehement, insulting, and derisive. “Christian assholes” is one of his
milder expressions.395 To render God harmless, Keizer invents for Him new names, for
example, Donald Duck.396
Keizer is quite versed in liturgy, he apparently had been an altar boy,397 rebelled,
and shouts out invectives. He never liberated himself completely.
Another Keizer obsession makes the reading of his book a particularly unpleasant experience: it is obscenity, and not so much the four-letter words pertaining to sex
(these are there, too), but defecation, excrement, and passing of intestinal gasses. The
foul language and imaging make “Dancing with Mister D” an extremely filthy book.398
Finally, we learn that “people seem such turds.”399
With his altar boy’s blasphemies, his naughty schoolboy’s foul language and obscene
imagination, his teenager’s cynicism, his adolescent fear of death,400 Dr. Keizer comes
across as an individual who has never grown up.
But this misfit, this complete professional failure, is “practicing medicine”; this
immature person assumes responsibility for the lives and deaths of people.
When we hear of orderly, restrained and compassionate euthanasia, and of the
good and wise Dutch doctors who grant their patients easy deaths, let us remember that
Dr. Keizer and others like him are among those who practice euthanasia.
Chapter XXV. The Hippocratic Physician and the Changing World
The date was January 8, 1997, I was on the witness stand at the Palm Beach
Court,401 and Judge Joseph Davis asked me: “Doctor, can you imagine some special
circumstances in which you would help a patient to end his life?” “No, Your Honor.”
“How so? Never?” asked the judge, and his incredulous surprise reminded me how
much the world has changed.
But has it? Our hopes and fears, and the necessity to face our destiny have not
changed, nor has, I deeply believe, the calling of physicians.
In this chapter I shall try to explain why the traditional clinician rejects euthanasia
and physician-assisted suicide:
UÊ
His attitude had been primarily shaped by his upbringing and traditions but
had been ultimately determined by medical considerations.
Id. at 147, 149, 180, 199, 216, 285, 298.
Id. at 147.
396
Id. at 299.
397
Id. at 198, 211-14.
398
Id. at 18, 32, 56, 69-70, 85, 128, 131-32, 192, 296, etc.
399
Id. at 288.
400
Id. at 53.
401
McIver v. Krischer, cause no. CL-96-1504-AF, Palm Beach Circuit Court. The plaintiffs were seeking to establish a right to assisted suicide, which Judge Davis granted, limiting the decision to this particular case. Florida Supreme Court reversed his ruling and upheld the state’s ban on assisted suicide.
394
395
286
Issues in Law & Medicine, Volume 28, Number 2, 2012
UÊ
As a young doctor, he had accepted the Hippocratic ethics on faith, but his life’s
experience, and the centuries long experience of his profession, have confirmed
the soundness of this ethical code.
UÊ
Knowing how dependent and vulnerable the patients are, the traditional clinician
is skeptical about the voluntariness of euthanasia.
UÊ
He would never draw fatal and irreversible conclusions from his diagnoses and
prognoses because diagnoses are fallible and prognoses notoriously unreliable.
UÊ
He is worried about the future of the medical profession, and foresees the
paralyzing effect of euthanasia on the professional performance of doctors and
nurses.402
UÊ
And he is convinced that confusing the role of a healer with that of a killer
must lead to disaster.
The Physician, the Patient, and “Voluntary” Euthanasia. At the time when so often
the courts intervene in medical practices, it will be useful to realize how different are
the images of a sick person as seen by Medicine and by the Law.
The Law sees the patient as he should be, as he has the right to be: an autonomous
being, able to make independent, rational, and sovereign decisions.
The Physician sees a very different person: weakened by the disease, dimmed by
the sedatives and painkillers, euphoric after some reassurance, but depressed when the
news is not so good, fully dependent on the information given by the doctor, easily
influenced not only by the content, but also by the way the information is presented.
In the view of the traditional clinician, if a patient is asking for death, probably
the doctor induced him to make such request.
Euthanasia, Assisted Suicide, and the Uncertainties of Medicine. A high degree of
certainty, or rather, a complete certainty should be required when an irreparable step is
considered, and human life is at stake.
Yet the present tendency to regard medical diagnoses as certainties, and medicine
as exact science, is obviously mistaken. On the contrary, the traditional clinician’s view
of medicine as the art of dealing with uncertainties has been right in the past and remains
valid at present.
Now as in the past, 20 to 40 percent of clinical diagnoses prove wrong in confrontation with the ultimate diagnostic standard, the post-mortem findings. In spite of
all precision tools which have been introduced, the accuracy of medical diagnoses has
not improved in the last fifty years, which has led to the notion of necessary fallibility
of medical diagnoses.403
An erroneous diagnosis of fatal disease remains a real possibility. In their efforts to
improve a patient’s condition or save his life, doctors have to rely on diagnoses that are
See supra Chapter XXIII.
For a detailed discussion and review of literature on confrontations of clinical diagnoses with the
post-mortems, see subsec. entitled The Oregon Law, Ch. XXVIII, infra.
402
403
Other People’s Lives: Reflections on Medicine, Ethics, and Euthanasia
287
only probable. To cause a patient’s death on the grounds of a diagnosis that may prove
faulty is as evil as it is mindless.
How Well Can Doctors Predict the Future? Doctors’ predictions that the patients will
die within so many weeks or months thrust some sick persons into such a psychologically intolerable situation that suicide or euthanasia may be seen as a way out. Death is
then sought, and perhaps granted, on the grounds of a false certainty.404
Doctors who predict when a patient will die engage in unprofessional and imprudent conduct resulting in spectacular blunders. Ms. Lisa W., “diagnosed with ovarian
cancer at the age of 31, knew the odds were against surviving for five years. It’s now
twelve years after her diagnosis, and W is doing well and working.”405 Mr. L, the man
who had initiated the New York City Marathon, was diagnosed with brain and thyroid
cancer and told that he had six months to live; two years later, on Nov. 1, 1992, he ran
the Marathon again.406 Mrs. Marilyn M was told she has at most two years to live with
her Lou Gehrig disease. She survived for eight years.407 In 1971, Mrs. Beatrice F. was
diagnosed with non-Hodgkin lymphoma and her doctor promised her that “he would
provide her with a gentle death.” She was cured, and 23 years later was still doing very
well.408 In 1984, Mr. Reynolds P. was found to have spinal cancer. A doctor told the family
that Reynolds “had six months to paraplegia, six months to quadriplegia, six months
to death.” In the ten years that followed, Reynolds, a writer by profession, published
thirteen books.409 A well-known politician was diagnosed with a brain tumor and told
it would probably kill him in three to six weeks. Two years later he was conducting
important Senate hearings, and ten years after that diagnosis and prediction, he was
chairing a committee and doing well.410 The doctors who in 1963 diagnosed Mr. Stephen
Hawking’s amyotrophic lateral sclerosis gave him two years to live. After this prediction
Mr. Hawking completed his Ph.D., was appointed to the prestigious Isaac Newton chair
of physics at Cambridge University, married, fathered three children, became the most
prominent theoretical physicist in the world, and authored the best-selling book A Brief
History of Time. Now, more than forty years since “the verdict” was pronounced, he is still
active in spite of his very severe disability.411 Mrs. Nancy H. “was diagnosed with breast
cancer in 1996, told to get her affairs in order, and given 24 months to live. Nine years
later, Mrs. H had traveled to Tunisia, Italy, France, Egypt, Spain, England, and enjoyed
the birth of two grandchildren.”412
404
In the subsec. entitled The Oregon Law, Ch. XXVIII, I discuss in detail the scientific unsoundness of
predicting how long a person will live.
405
B.A. Lehman, A Number that Often Means Little, BOSTON GLOBE, June 29, 1992.
406
Big Winner, BOSTON GLOBE, Nov. 2, 1993.
407
NATIONAL RIGHT TO LIFE NEWS, June 4, 1993.
408
R.A. Knox, Some Beat the Odds, But Lymphoma Resists Cure, BOSTON GLOBE, Jan. 24, 1994.
409
W.A. Henry, The Mind Roams Free, TIME MAG., May 23, 1994.
410
J.F. Dickerson, A Man of Choice; Arlen Specter, TIME MAG., Mar. 13, 1995.
411
M. WHITE & J. GRIBBIN, STEPHEN HAWKING: A LIFE IN SCIENCE 61 (1992).
412
N.V. Howard, Nancy Harrington, BOSTON GLOBE, July 19, 2004.
288
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Few products of human thought have been so thoroughly discredited as medical
predictions of patients’ time of death. It is not only evil but also a stupid act to hasten
a person’s death on the ground of such guesswork.
The Lives of the Comatose. We used to acknowledge that, with few exceptions, we
did not know which unconscious patients might eventually recover. At present, verdicts
of “irreversible coma” are pronounced with a certainty that admits no doubts. Hippocratic medicine’s truthful, modest attitude had become obsolete. Instead, a new ethic is
proclaimed, that of self-assured expediency.
We also used to admit that we were helpless at the bedside of a protractedly unconscious patient, that we had no solution; and there was none. The truth is that we
cannot do anything, we can only wait. And we used to wait, and shield the patient,
trying to hope. Now it is claimed that there is a solution: when we destroy the patient,
the problem is resolved.413 When Mrs. Jacqueline C., 44, of Baltimore, Maryland, suffered a cerebral hemorrhage and fell into a coma, her husband waited for 41 days and
then fulfilling the wish Jacqueline had expressed in the past, asked a judge to order the
doctors to let her die. Judge John C. Byrnes refused. Six days later Jacqueline awoke; she
soon was able to walk with a stick. In the Time magazine photograph she was smiling
and nestling close to her husband.414 In Holland, a fifteen year old from De Heurne, in a
coma after a head trauma, awoke after four weeks.415 Mr. Conley H., 26, of High Point,
North Carolina, who had been beaten with a log, awoke after a coma of eight years and
named his attackers.416 Patients in Vermont,417 Massachusetts,418 New Jersey,419 North
Carolina,420 Tennessee,421 and California422 awoke and recovered after weeks, months,
and up to eight years in coma.
Doctor’s pessimistic predictions proved false in many cases. John M., 21, in
Greenbrae, California, fell into a coma for two weeks after he was struck by a car; after
performing brain surgery twice, doctors removed him from life support and told the
patient’s mother her son would soon die. Instead, he came out of his coma within hours,
413
H.M. Dupuis, Patienten in coma, een oplosbaar probleem [Patients in Coma: A Solvable Problem],
132 NEDERLANDS TIJDSCHRIFT V.GENEESKUNDE 1926-28 (1988).
414
TIME MAGAZINE, Oct. 6, 1986.
415
Mishandeld meisje Dinxperlo uit coma [In Dinxperlo, A Severely Beaten Girl Comes Out of Coma],
BRABANTS DAGBLAD, Aug. 21, 1990.
416
Coma Recovery, USA TODAY, Mar. 6, 1991, at 5A; Second Man Regains Consciousness After 8 Years,
IAETF UPDATE, Apr. 1991, at 3.
417
T. Grant, Coma Over, Kin Are Now Life-Support, BOSTON GLOBE, Jan. 13, 1994.
418
G. Negri, Turning Limits Into Horizons: Rehabilitation Program Helps to Retrain Head-Injured Patients,
BOSTON GLOBE, Aug. 14, 1993.
419
L. Townsend, Woman Denied Food Awakes From Coma, NAT’L RIGHT TO LIFE NEWS, Jan. 8, 1991.
420
L. Townsend, North Carolina Man Wakes After Eight Years Unconscious, NAT’L RIGHT TO LIFE NEWS,
Apr. 9, 2001; R. McKay, Family is Rejoicing Over 9-Year Old’s Recovery from Coma, NAT’L RIGHT TO LIFE NEWS,
Apr. 28, 1992.
421
M. Williams, Man Awakes From Coma to Face Perilous Choice, BOSTON GLOBE, Feb. 15, 1996.
422
W. J. Smith, Eating His Words, NAT’L REV., Dec. 11, 1995.
Other People’s Lives: Reflections on Medicine, Ethics, and Euthanasia
289
squeezed mother’s hand and said “I love you.”423 John H. fell into coma following neck
surgery. Based on EEGs, brain scans, and his non-response to deep pain, all attending
specialists pronounced him brain dead. His wife, a R.N., insisted on tube-feeding in
spite of the prognosis that he would die within days, and advice to allow him to do so.
With continuous stimulation and tender care John started to communicate, and after
four months, when brought home, he regained full consciousness.424 In Los Angeles,
Maria Llydia H.L., pregnant with twins, suffered a brain hemorrhage and fell into coma.
Doctors performed the embolization of her arteriovenous anomaly in the brain, but
held little hope that she and her babies would survive. The family was about to remove
life support; however, after six weeks in coma, Maria Lydia awoke, and six days later
delivered healthy twins.425
An accident left a 42 year old British businesswoman in what was diagnosed as a
coma; in fact, she was completely paralyzed, but conscious, and could hear all that was
going on around her (the “locked-in” syndrome). Her biggest shock came when she
heard her husband telling the doctors that the respirator should be turned off because
his wife would not want to live under these circumstances. “My husband was issuing
my death sentence! I wanted to scream, but couldn’t,” she recalled. It was only due to
her daughter’s persistence that the treatment continued, allowing her to fully recover.426
In Wakefield, England, Mr. Jon B. was in a coma after a car crash, and the doctors
repeatedly tried to obtain his mother’s consent to switch off the life support. The mother,
a nurse by profession, did not agree. “What if it was your son?” she asked the doctors.
After twelve months in coma Jon started to wake up. At present, he still has memory
gaps, but can walk, has taken up swimming, and had completed a computer course.427
In Scotland, Dr. Fiona S., 46, a general practitioner, sued a Dundee hospital for
100,000 pounds for wrongly diagnosing her as being in a persistent vegetative state and
advising her family to withdraw her food and liquids. After a car crash in France she had
remained in coma. Local brain specialists told the family that she would probably regain
consciousness in three to four months. However, when she returned to Scotland, experts
at Dundee hospital diagnosed her as in a PVS with little or no chance of recovery, and
suggested discontinuation of feeding and fluids and letting her die. The family moved
her to another hospital where she was given more stimulation, physiotherapy, and was
dressed daily and transported to the TV lounge with other patients.Three weeks later she
regained consciousness.428 In New York, the mother of a well-known statesman died at
the age of 97. Several years before her death a fall in the kitchen left her unconscious.
After some time the doctors wanted to remove her life support, but the son would not
Death Denied, NAT’L REV., Feb. 17, 1995.
Charles Hutcherson, Life After Coma: John’s Story, LIVING WORLD, Spr. 1995, at 1617.
425
M. Fordahl, In California, A Miracle of 3 Lives Spared, BOSTON GLOBE, July 8, 1999.
426
THE SUNDAY TIMES (London), Dec. 13, 1998.
427
C. Brooke, Doctors Wanted to Let This Coma Victim Die: His Mother Refused, Now Look at Him, DAILY
MAIL (London), Oct. 6, 1998.
428
M. Whittaker, Back From the Brink of Death, TIMES EDUCATIONAL SUPPLEMENT (London), Jan. 9,
1998.
423
424
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Issues in Law & Medicine, Volume 28, Number 2, 2012
let them do it. “Even if she recovers somehow,” argued the doctors, “she would be unable
to think or speak.” The son replied: “You don’t know my mother.” She recovered and
had some good years left before her death.429
The “persistent vegetative state” is certainly not vegetative, and not always persistent. A number of “PVS” patients have recovered to full consciousness.430
The treatment of protractedly unconscious persons must be guided by the respect
for their humanity and the knowledge that some of them may recover. They must not
be denied the chance.
“Healers Should Not Be Killers.” The justness of this often repeated statement seems
obvious; yet it may be worth our while to ask for an explanation.
The first and simple practical consideration is that doctors who have embraced
euthanasia are not reliable as healers. They are too ambiguous in their motivation; they
don’t do everything they can to save a patient.431 And there are still other, farther reaching
objections.
The Covenant. The eminent logician John M. Dolan rightly stated that for a physician the duty to preserve life is not a rule of conduct but a constitutive rule, that is, the
rule that makes him a physician.432
For centuries, the gravely ill turned to doctors for help because of the certitude
that the physician was the defender of sick person’s life, that he would do everything
to protect it, that he would never consciously do anything injurious. Because of this
certitude the public trusted and appreciated the medical profession – and forgave us
our failures.
This covenant cannot be expanded to include aid in dying. The covenant would be
broken, the huge capital of trust irretrievably lost, the essence of medicine and Western
civilization forever changed.
Changed for better? There are thinkers willing to risk that change. The clinicians
are not of their number.
Too Many Opportunities to Kill. Practicing medicine so often means treading a narrow
path between patient’s life and death; and doctors doing this unique work are just plain
people. They may be irritable, exhausted after sleepless nights, frustrated by the failure
of their efforts, or troubled due to difficulties at home. They may be, and some of them
definitely are, emotionally unstable persons. Their actions, or, for that matter, the rate at
which a potassium drip is administered, are difficult to check or trace. And yet patients
used to be safe in our hands, certainly safe from any intentionally inflicted harm. This
derived from the particular, one-sided education and shaping of physicians. It has been
Paula Kissinger, 97, BOSTON GLOBE, Nov. 17, 1998, at B-11.
Comatose Woman Regains Consciousness, CAMDEN COURIER-POST, Dec. 27, 1991; Fairfax Teen Goes
Home in “Remarkable” Recovery, WASH. POST, Dec. 26, 1991; He Never Gave Up – And She Came Back, KANSAS CITY STAR, Dec. 20, 1991; Levin et al., Vegetative State After Closed-Head Injury: A Traumatic Coma Data
Bank Report, 48 ARCH.NEUROLOGY 580 (1991).
431
See Chapter XXIII, supra.
432
John M. Dolan, Is Physician-Assisted Suicide Possible? 35 DUQUESNE L. REV. 355 (1996).
429
430
Other People’s Lives: Reflections on Medicine, Ethics, and Euthanasia
291
imbued in us to identify ourselves, our ambitions, with the success of treatment, with
improvement of the patient’s health, with keeping him alive. For us, the clinical adage
primum non nocere preserved its literal and absolute meaning. Human life was sacred
and inviolable under any circumstances.
At present, however, a generation of doctors is being raised who learn that a physician may treat a patient or sometimes deliberately cause his death. The thought of
what’s happening to the most humane profession is terrifying. In Holland, the acceptance
of euthanasia by the public and the doctors has been followed by reports indicating
that doctors, indeed, were getting confused in their double role as healers and killers.
Pediatricians, called as healers to the cradle of disabled newborns, administered lethal
injections to their little patients.433 Obstetricians went beyond the scope of their specialty to kill a child with spina bifida.434 A mere pretext, crying, or a bellyache, was good
enough to justify euthanasia of a disabled child.435 Trusting, unsuspecting elderly were
stealthily dispatched by the physician who was paid for keeping them in good health.436
Doctors killed hundreds of gravely ill persons who had never asked for euthanasia.437
Some of these patients were demented but this did not protect their lives.438 Many were
fully conscious and reasonable, and yet they were not asked whether they wished to
live.439 A number of doctors who terminated sick people’s lives without their consent,
did so not because of the patient’s suffering but to relieve the patient’s families.440 A few
doctors even admitted that they killed the patients because they needed their beds.441
Doctors asked to relieve pain took this opportunity to administer lethal injections.442
Some doctors have assumed the role of executioners, killing people who were not sick
G. VAN DER WAL & P.J. VAN DER MAAS, EUTHANASIE IN ANDERE MEDISCHE BESLISSINGEN ROND HET LEVENS
and Other Medical Decisions Concerning the End of Life] 181-201 (Sdu Pub. House,
The Hague, 1996).
434
The Baby “Maartje” Case, 8(5) IAETF UPDATE 10 (1994); Dutch Use Courts to Formalize Infant Euthanasia, 9 IAETF UPDATE 9 (1995).
435
B. Versteeg, De wens van de ouders en het recht op het leven van een kind[The Wish of the Parents and
the Child’s Right to Life], 4 IN PERSPECTIEF 12-13 (1991).
436
“Euthanasie” vertaald in viervoudig moord [“Euthanasia” Turns Out to be Murder of Four People],
BRABANTS DAGBLAD, July 24, 1985; Arts bekent vijfmaal euthanasie [Physician Admits Having Performed
Euthanasia on Five Persons], BRABANTS DAGBLAD, Apr. 17, 1985.
437
REPORT I, supra note 199, at 15; VAN DER WAL & VAN DER MAAS, supra note 433, at 64-74.
438
REPORT II, supra note 199, at 61, Tbl. 6.4.
439
Id.; VAN DER WAL & VAN DER MAAS, supra note 433, at 70, Tbl. 6.5.
440
REPORT II, supra note 199, at 64, Tbl. 6.7.
441
Id.
442
Id. at 71, Tbl. 7.2 & 75, Tbl. 7.7; VAN DER WAL & VAN DER MAAS, supra note 433, at 77, Tbl. 7.2
& 80, Tbl. 7.4.
433
EINDE [Euthanasia
292
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but grieving,443 or “tired of life.”444 In a much publicized (and unpunished) act, a family
physician killed a healthy 73 year old woman on whose head “a contract” had been
made by her husband.445
We witness the fulfillment of Dr. Christoph Wilhelm Hufeland’s predictions of two
hundred years ago. Here is what Dr. Hufeland wrote:
When a patient is tormented by incurable disease, when he desires his own death
… how easily the thought can arise even in the soul of the best of men: should it not
be allowed, even a duty, to release that sufferer a little earlier from his burden…? As
plausible as such reasoning is, as much as it may be supported by the voice of the
heart, yet it is false…. It utterly annuls the nature of the doctor. He should and may
do nothing but preserve life – whether it is fortunate of unfortunate, whether it has
value or not, that is none of his business. And if he presumes to take this consideration into his practice, the consequences will be immeasurable and the doctor will
become the most dangerous man in the State.446
In my forty years of hospital work I attended thousands of patients and, much
to my regret, hundreds of them died. They needed moral support, relief from pain,
breathlessness, or nausea. Until their last conscious moments they needed to belong,
to share with all of us our common destiny, fears, uncertainties, and hopes. None of
them needed euthanasia or assistance in suicide, and, with a single exception in forty
years, none asked for it. It is, and has always been, the opinion of traditionally educated
clinicians that euthanasia is a wild, unworthy, and totally unnecessary act.
The world may be changing, but now, as in the past, young doctors embark on
their journey with a few ethical aphorisms, usually conveyed to them by a master. It is
up to them to understand that these maxims represent the shared experience and the
wisdom of the profession. The utilitarian ethics, subordinating the welfare of the individual patient to the greater good of large numbers, had been conceived by outsiders.
Baanbrekend arrest Hoge Raad: Euthanasie mag ook bij psychisch lijden [Eposh-Making Ruling of the
Supreme Court: Euthanasia Is Also Permitted in Case of Psychological Suffering], BRABANTS DAGBLAD, June
22, 1996; W. Houtman, Steun euthanasie door zaak Chabot kleiner [Decrease in Public Support for Euthanasia Due to the Case of Dr. Chabot], NEDERLANDS DAGBLAD, Mar. 3, 1995.
444
M.A.J.M. Buijsen, De zaak Brongersma [TheBrongersma Case], 8 PRO VITA HUMANA 165 (2001); Arrest van het Gerechtshof te Amsterdam onder parketnummer 15-035127-99 [The Ruling of the Circuit Court
in Amsterdam No. 15-035127-99].
445
W. VAN DEN LINDEN, ZIJ MOEST EERST ...HET DOSSIER VAN BOMMELEN:EEN GEVAL VAN EUTHANASIE? [She
Had to go First … The Van Bommelen File: A Case of Euthanasia?] (Strengholt Pub. Naarden 1984);
Waarom heeft Wibo niet ingegrepen? [Why (the TV journalist) Wibo (van den Linden) Did Not Intervene? ZONDAG (Beusichem), Jan. 22, 1984; G.A. Lindeboom, Een z.g. euthanasie-drama [The Drama of the
So-Called Euthanasia], 11 VITA HUMANA 100 (1984).
446
The article by Dr. Christoph Wilhelm Hufeland (1762-1836), professor of pathology at the University of Berlin, was written in 1804; the English translation appeared in The Journal of Practical Medicine
and Surgery in 1806.
443
Other People’s Lives: Reflections on Medicine, Ethics, and Euthanasia
293
Chapter XXVI. Staying to the Very End at the Patient’s Side
Letting Die. Obviously, this concept spans a wide range of decisions. Many such
decisions are medically and morally sound. At the other end of the spectrum are criminal
decisions such as deliberately causing death of a diabetic child by denying him insulin
treatment.447 The moral arguments tend to focus on that crucial moment in the course
of an illness when the patient’s death becomes imminent and unavoidable. Quite rightly
it is stated that since then all therapy becomes futile, all burdensome interventions
must stop, and the doctor’s duty is to stay at the patient’s side, to care, and bring relief.
However, such a distinct turning point occurs only in some cases, more often in
patients dying of cancer than in other persons. The death of every living being is unavoidable, but death at a particular time is often due to a coincidence of avoidable causes.
It would be a most unfortunate result of the moral debate if it were to discourage
all doctors who fight for their patients’ lives to the very end. Therapeutic obstinacy when
the patient is clearly dying is a failure of professional skills and of common sense. The
opposite error, allowing the death of patients who could stay alive, is a moral failure,
often due to ideological indoctrination.
Refraining from Treatment. Such decisions should not be taken arbitrarily by physicians or hospital officials against the wishes of the patient and the family. It is a good and
wise rule that the usefulness or futility of a treatment can only be determined together
by the physician and the patient: the doctor is best equipped to determine effectiveness,
the patient is the authority on benefits, and the two share the assessment of burdens.448
Respect for autonomy must be balanced with beneficence, otherwise it may lead to
unnecessary and untimely deaths. A competent person’s refusal of treatment must be
respected even when the proposed therapy would probably be beneficial; but the doctor
should try to persuade. Doctors who refrain from such attempt fail in their duty.
There are very few, quite exceptional situations when the treatment is life-saving,
the patient’s refusal ill-informed, and there is no way of explaining this to him. The two
examples I know from personal experience are: a patient who lost consciousness due
to massive bleeding from duodenal ulcer, having first refused to be operated on; and
a relapse of ventricular fibrillation in a still conscious patient449 who had already been
defibrillated once and refuses to undergo the electric shock again. In such situations
most doctors act against the will of the patient and assume the responsibility. We would
rather be sued by a living person than take the patient at his word and allow his totally
unnecessary death.
Buiting, supra note 355, and accompanying text.
E. Pellegrino, Decisions at the End of Life: The Use and Abuse of the Concept of Futility, in THE DIGNITY
OF THE DYING PERSON: PROCEEDINGS OF THE FIFTH ASSEMBLY OF PONTIFICAL ACADEMY FOR LIFE 219-41 (E.
Sgreccia & Vial Correa J.D.D.eds., Libreria Editrice Vaticana, Citta del Vaticano 2000).
449
During ventricular fibrillation the heart does not pump blood, and as a rule patients lose consciousness within seconds.Quite exceptionally, this patient, Mr. W, during his last two bouts of ventricular
fibrillation, remained conscious long enough to be aware of the first electric shock and to protest against
the second one.
447
448
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A conflict between the patient’s stated wish and the doctor’s duty may arise in
connection with an advance directive or “living will.”450 It is often questionable whether
the patient’s clinical situation is indeed what the patient had foreseen in the advance
directive. Moreover, for treatment-refusing provisos of advance directives to be valid,
we have to assume that the now incompetent, gravely ill person would stand by the
decision he made when he still was in good health. This is doubtful. Well-documented
studies have shown that the opinions of healthy people on life, death, and medical treatments differ from the views of gravely ill patients. The healthy persons tend to display
a “cavalier attitude” toward their own lives while the majority of seriously ill patients
choose life-prolonging treatments.451
A case reported by Dr. A. Dees from Ikazia Hospital in Rotterdam illustrates how
a previously stated patient’s wish may lead to tragic misinterpretation:
Mrs. S., 78, was admitted on Friday evening…. In the last few years she had been
several times hospitalized because of breathlessness…. She was also diabetic and injected herself insulin twice a day…. Some time before the admission she had said to
me: “Doctor, when it gets bad, don’t let me suffer longer than necessary.” The husband
remonstrated that such promise was not needed, “They take good care of you, don’t
they?” The children were in a somber mood, [thought that] the mother was nearing
the end. The morning after the admission there was a change in the condition of
Mrs. S., she hardly reacted when addressed. The children called the nurse. When the
resident arrived, that patient was comatose. The resident quickly found the cause: it
was hypoglycemia, very low blood sugar. He filled the syringe with glucose but the
angry children would not let him inject: “What for? This is a nice death, isn’t it?” The
patient’s husband did not want to let her go but did not speak up. Followed a heated
discussion at the bedside. The glucose injection was delayed but finally given. Mrs.
S. opened her eyes and asked “What happened?”452
The concept of proportionate treatment is in agreement with traditional clinician’s
view as long as it means that the burden and pain of a treatment should not exceed
the positive effect. But there is also an unacceptable interpretation of proportionality,453
R. Fenigsen, Post˛epy I porażki ruchu na rzecz eutanazji w Stanach Zjednoczonych [The Pro-Euthanasia
Movement in the United States: Its Advances and Setbacks], 9(1-2) ETHOS:THE QUARTERLY OF THE JOHN
PAUL II INSTITUTE AT THE CATHOLIC UNIVERSITY OF LUBLIN 247-59 (1996); R. Fenigsen, Euthanasia and Moral
Reflection, in THE DIGNITY OF THE DYING PERSON: PROCEEDINGS OF THE FIFTH ASSEMBLY OF PONTIFICAL ACADEMY FOR LIFE 212-18 (E. Sgreccia & Vial Correa J.D.D. eds., Libreria Editrice Vaticana, Citta del Vaticano
2000).
451
M.L. Slevin, Attitudes to Chemotherapy: Comparing Views of Patients with Cancer with Those of Doctors,
Nurses, and General Public, 300 BRIT. MED. J. 1458 (1990); D.E. Patterson, When Life Support is Questioned
Early in the Care of Patients with Cervical-Level Quadriplegia, 328 NEW ENG. J. MED. 506 (1993); J.H. Hess,
Looking for Traction on the Slippery Slope: A Discussion of the Michael Martin Case, 11 ISSUES IN LAW & MED.
105 (1995).
452
A. Dees, Euthanasiedebat anders dan praktijk [The Euthanasia Debate Is One Thing But the Practice
Is Something Else], NEDERLANDS DAGBLAD, Jan. 21, 2001.
453
Fenigsen, supra note 450, R 215.
450
Other People’s Lives: Reflections on Medicine, Ethics, and Euthanasia
295
which demands that no vigorous treatment be given to a patient in an incurable and
deplorable condition; in other words, that treatment should be proportionate to the
patient’s quality of life. Doctors who follow this rule refrain, for example, from treating
urinary infection in a comatose patient.
Reviewing the approach of Hippocratic physicians, and my own, I found that we
have always applied the principle of equal treatment.454 This is the only approach which
entirely excludes quality-of-life judgments. We treat pneumonia in a comatose patient
the same way as in any other person, and were his life threatened due to a heart block,
he would receive a pacemaker. The only exceptions are made on purely medical grounds:
therapies requiring the patient’s cooperation are not feasible in unconscious patients,
and some other treatments, like total hip replacement, or surgery for aortic stenosis, are
superfluous as long as the patient is unconscious and, therefore, bedridden. Otherwise,
the comatose patient is entitled to the same medical help as all other persons.
Palliative Care had traditionally been the commitment of several religious orders.
It is the historical contribution of Dame Cicely Saunders to have reintroduced the palliative care to the modern care of the sick.
Gravely ill patients near the end of their lives need an optimal relief from their
symptoms, a skillful and meticulous nursing, and a humanly warm, morally supportive
environment. This goal may be achieved in a hospice, or, preferably, by a palliative-care
team working at a general ward, nursing home, or at patient’s own home.455 The good
work of the nurses and auxiliary personnel, the loving presence of family, and, often, a
spiritual assistance are essential. However, the role of the physician is important, and
not only because of the symptom relief he can provide. To a degree, the conduct of all
other caregivers depends on his attitude.
The physician would be well-advised to avoid categorical pronouncements. Our
judgments are fallible and predictions notoriously unreliable, and persons who are (or
are considered to be) dying, are, by definition, living. They must not be excluded from
the community of the living.
Considering the fallibility of medical predictions, it is not surprising that a number
of patients referred for “terminal care” survive longer than expected, or plainly survive,
no term stated. When this happens we should rejoice, not punish doctors and hospices
as Medicare reportedly tries to do.456
All too readily the labels “hospice care” or “DNR” (Do Not Resuscitate) are considered warrants to invite a person’s death at every opportunity. People who signed a
DNR declaration have the right to revoke it at any time.
Id.
E. J. Latimer, When a Patient is Dying: The Physician’s Responsibilities and Rewards, ONTARIO MED.
REV., Feb. 1989, at 27.
456
D. Walsh & S. Gordon, The Terminally Ill: Dying for Palliative Medicine? 18 J. HOSPICE & PALLIATIVE
CARE 203 (2001).
454
455
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People may be diagnosed with a “terminal disease” (whatever that is), but must not
be allowed to choke on a piece of beef, to be electrocuted in the bathtub, or to succumb
to a perfectly treatable infection.
Pain Management is essential, first and foremost, in the care of cancer patients.
Rather that dwell on the technical side on which a large literature now exists, I shall discuss the reasons why the pain of gravely ill cancer patients has often been undertreated.
Doctors’ fear of causing drug addiction has been cited, but I doubt if any doctor
worth his name is afraid of that. If unexpectedly, an incurable, gravely ill patient gets
addicted to opioids, this would be an acceptable side-effect of a necessary therapy.
Besides, it has long been the clinical experience, later confirmed by well-documented
studies, that the gravely ill (or, for that matter, patients with congestive heart failure)
do not get addicted to narcotics. They enjoy the positive effect and stop the drug when
it is not needed.
The fear that the supervising authorities may suspect the doctor in terminal care
of prescribing too many addictive drugs is not justified under existing legislation and
would be further alleviated by the Pain Relief Promotion Act passed by the House of
Representatives in 1999. It is most inopportune that this Act was not also passed by
the Senate.
It has been stated that some doctors, not experiencing that pain themselves, are
not much concerned with a patient’s pain, and that some even are of opinion that “one
should be a man” and suffer. This must never be the attitude of a medical doctor.
“Leaving the pain untreated not to obscure the diagnostic picture” is a guideline
applicable to one clinical situation only: the acute abdomen, prior to the decision on
surgery. Applying this guideline to a suffering cancer patient near the end of his life is
a tragic mistake.
Failure to achieve full pain control may be due to the neglect of patient’s anxiety
and/or depression. Provoked by the awareness of bad prognosis, and aggravated by
protracted pain, these psychological conditions in turn influence the patient’s pain
perception. Tranquilizers, anxiolytics, or antidepressants should then be administered
along with the analgesics.
Fear of fatally suppressing respiration is real, but it should not paralyze the effort to
control pain. True, deaths from respiratory arrest, in particular of patients with valvular
heart disease, have sometimes occurred after a single therapeutic dose of morphine sulfate. On the other hand, effective oral doses of opioids given every few hours (without
waiting for the pain to begin), and small doses of morphine repeatedly self-injected by
the patients to the I.V. drip “as needed” are, as rule, well tolerated without respiratory
suppression. Adequate pain control tends to prolong life rather than shorten it.
No medical treatment is without risks, and effective pain control is no exception.
Shortening the patient’s life is a risk we take; it never should be our intention.
Invasive pain-relieving procedures by anesthetists and neurosurgeons are infrequently needed but should be not delayed when necessary. We have at present ample
Other People’s Lives: Reflections on Medicine, Ethics, and Euthanasia
297
means to control pain. If a gravely ill patient continues to utter this complaint, probably
not everything has been done to relieve him.
Breathlessness can be effectively alleviated in many cases, even though in patients
with pleural mesothelioma this may require frequent punctures of the effusion. Fear
of suffocating is a different and difficult problem, raised mainly by patients with throat
malignancy and those with disabling neuromuscular disorders (in particular, amyotrophic
lateral sclerosis). We must address it very seriously and show complete understanding
and firm determination not to let the patient suffocate in full consciousness. Binding
promises should be given and kept. Choking on one’s own saliva can be easily prevented;
a simple (dentist’s) suction device should be available, and demonstrated to the patient.
Complete Sedation, that is, inducing a patient’s total unconsciousness, seems to be
more frequently used in the U.S. while the British practitioners only exceptionally resort
to this method.457 It may be applied at a patient’s insistence. It may also be the only
solution in the infrequent case of terminal anguish (ascribed to unresolved emotional
problems, conflicts, and unhappy memories with guilty content.)458 The terminal anguish manifests with restlessness, thrashing about, moaning, and crying out, and does
not respond to sedatives in the usual dosage.
The Basic Material Care consists in the provision of nourishment, liquids, shelter,
and a warm hygienic environment.459 None of these must be deliberately denied to
our fellow human beings in need, whether conscious or unconscious, “terminal” or
otherwise. Good clinical judgment, the determination to help and never do harm, and
plain common sense guide our actions. Fluids can be provided to the very end, if not
by mouth then by intravenous drip which is almost no burden for the patient. As long
as the patient is at least intermittently conscious, fluid supply is of utmost importance
because dehydration badly aggravates the suffering, causing thirst, dryness of the mucosae, difficulties with speaking and swallowing, restlessness, and mental confusion. When
an unconscious patient pulls the I.V. line out, this should not be interpreted as refusal.
Not everything that is said about water applies to feeding. Many gravely ill patients
with heart disease or emphysema can be fed, and ask for food, till their last few hours,
but the situation is often different with patients who have cancer.
It is my impression that gastrostomies are sometimes performed in patients who
could be spoon-fed. Spoon feeding is laborious and may tax the patience of the auxiliary
personnel; it is therefore stopped, or not attempted, and a tube is inserted. This is not
a good policy.
Once the tube has been inserted, this way of feeding is not a burden, becomes
part of “ordinary care” and can be continued for a long time. Feeding by mouth or tube
should be stopped when the patient with a malignancy can no longer tolerate food and
L. Gormally, Palliative Treatment and Ordinary Care, in PROCEEDINGS OF THE FIFTH ASSEMBLY OF THE
PONTIFICAL ACADEMY FOR LIFE 252-66 (2000).
458
R. G. Twycross & J. Lichter, The Terminal Phase, in OXFORD TEXTBOOK OF PALLIATIVE MEDICINE 659
(D. Doyle, G.W.C. Hanks & N. MacDonald, eds. 1993).
459
Gormally, supra note 457, at 263-66.
457
298
Issues in Law & Medicine, Volume 28, Number 2, 2012
no longer benefits from it, at the stage which Twycross and Lichter460 called terminal
phase. Patients at this stage are profoundly weak, essentially bedbound, drowsy for
extended periods, disoriented as to time, and have a severely limited attention span;
they are disinterested in food, and find it difficult to swallow medication.
Staying at the Patient’s Side. Of all the physician’s duties one is of utmost importance:
to be present. Continuity of contact with the same attending physician is very important
for the gravely ill patient. He should not be exposed to a string of ever changing doctors.
For a longtime it had been known that doctors tended to withdraw from the bedside of a “hopeless” patient, or limited their visits. They knew they could not expect
medicine’s greatest rewards, the cure, or improvement in patient’s condition; they also
felt they would be wasting their time, being unable to apply their skills. This attitude,
now partly conquered, was not only ethically wrong, but also intellectually untenable.
Intellectually, terminal care did not seem interesting because doctors knew too little
about it. As any other field, it becomes absorbing and challenging when our knowledge
of the subject expands.
Moreover, doctors are not “experts,” but helpers. Their relation to the patient is
of the nature of a covenant, binding them to the patient for better or worse. They have
no right to abandon the patient when he runs a downhill course.
Chapter XXVII. Death in the Gray Zone
The Death of Gene McC.461 Shalom Newman was on the phone.
Shalom: I can hardly believe what Halina told me about Gene’s last days. Do you
think it can be true?
Richard: I see no good reason to doubt the story. Unfortunately, nowadays those
things are being done.
S: But if this is true, it was murder!
R: You can call it so, but it would be difficult to prove. The doctors and the nursing
home personnel say they had to stop the feeding and the fluids because it was no
more benefit to the patient and his body no longer accepted it.
S: This is a lie! The feeding ran smoothly, Gene was in good mood, making plans for
the summer vacation – and then the feeding bag and the stomach tube were removed.
On the next day Halina found him dull and mumbling, a few hours later she could
no longer awaken him. He was comatose for another two days, and then he died.
R: Yes, after the removal of the tube he was heavily sedated, and they will say that
since fluids had been stopped they had to sedate the patient to prevent suffering
due to dehydration. Of course, you know Halina was remonstrating, begging, and
Twycross & Lichter, supra note 458, at 651.
This is a verbatim account of my January 2002 telephone conversation with Mr. Shalom Newman,
psychologist, in Cambridge, Massachusetts.
460
461
Other People’s Lives: Reflections on Medicine, Ethics, and Euthanasia
299
shouting, but all that was no avail. She had no standing, being just a friend, while
Gene’s children repeatedly called from Florida insisting that their father “be allowed
to die.” They had demanded that again and again: five years ago, when he had his
first surgery for bursting aorta, and when the aneurysm recurred. When another
recurrence of aneurysm compressed Gene’s esophagus, the children tried to prevent
the insertion of stomach tube.
S: A remarkable man he was! He used to joke about his tube, said his usual portion
of white wine should be added to the meals.
R: Oh, he was a great guy. Quietly proud of his war-time colonel’s rank, on first
name terms with all Boston’s politicians, his shirts always impeccably white, his belt
buckle a work of art, his car perhaps a little battered but always a Cadillac; and while
keeping up all those appearances he remained such a simple and friendly man, and
so patient and brave while facing his illness. I shall miss him badly.
S: But say, why did the children wish his death? He had adopted this boy and this
girl, raised them, supported them all his life. Inheritance? Gene hardly left anything
worth while.
R: I think they wanted to get rid of the psychological burden, the sick father lingering somewhere in a Boston nursing home. And, above all, power! Power! There is
no greater sense of power than that derived from putting a human being to death.
They now know how to express such wish in socially acceptable terms, they speak
in modern lingo.
S: You know, Richard, I am all for the right of a competent person, acting under no
constraint, to choose the time of his own death and to be assisted in committing
suicide. But that was not what happened to Gene. He did not want to die, he was
murdered!
R: What you support is an ideal concept. What happened to Gene is the reality.462
What is happening to elderly persons in hospitals and nursing homes has alarmed
public opinion in several countries. In hundreds of cases there have been clear indications
that medical personnel acted to cause or at least hasten old people’s deaths.
In Britain, the deaths of fifty elderly hospital patients were being investigated
by police and health officials in January, 1999, “amid allegations of a creeping tide of
backdoor euthanasia.”463 At least five hospitals were at the center of police inquiries as a
Mr. Eugene McC died on Christmas Eve 2001. I explained to his friend, Mrs. Halina Nelken, of
Cambridge, Massachusetts, that in my opinion she could not expect an inquiry to be launched, but the
public should be warned and a record of the circumstances of Gene’s death preserved. She reported what
happened to the Boston chapter of Massachusetts Citizens for Life and, since Gene was a Roman Catholic
whose will and beliefs were violated, to attorney Daniel Avila, then director of medical ethics at the Massachusetts Conference of Catholic Bishops.
463
M. Horsnell, Police Check Hospitals Over “Backdoor Euthanasia,” THE TIMES (London), Jan. 6, 1999,
at 1.
462
300
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result of relatives’ complaints or nurses’ whistle blowing. The number of deaths under
inquiry soon increased to sixty.464 The published reports and case histories illustrate
the various ways the deaths of older people were induced by the staff. The nurses at
Kingsway Hospital in Derby claimed that forty people with dementia were starved and
dehydrated until they became so weak that they died from infections. Nurses alleged
that their senior colleagues were withdrawing food and water from patients; they placed
them, without proper authorization, on “nil-by-mouth” regimes, claiming that they were
at risk of choking.465 Mrs. L.C. was admitted to Eastborne Hospital with a mild stroke:
her left arm was somewhat floppy. She was fully conscious. The next day her daughter discovered above the patient’s bed a sign saying “nil-by-mouth.” “I’m gasping for
something to drink, my mouth is so dry,” said Mrs. L.C., and drank avidly the orange
juice brought by the daughter. The next day the daughter was told not to disobey the
“nil-by-mouth” regime. The drinking cup had been confiscated. An I.V. drip was started
but it caused swelling in the arm. The drip was removed and never replaced. Still no
doctor had seen the patient. Three days later Mrs. L.C. died.466 After several strokes,
Mrs. O. was in stable condition and could swallow quite well small gulps of liquid food.
But then Dr. K.T. ordered withdrawal of the high-protein supplement essential for her
nourishment. Mrs. O began to lose weight “until she looked like a victim of Belsen”; she
died weighing fifty-four pounds.467 Mr. W.H., 78, was admitted to Royal Oldham Hospital after falling and cutting his head. He quickly began to lose weight; “when nursing
staff brought his food they left it out of his reach and did not help him cut it up or eat
it.” When the family complained, hospital staff told them: “Your father is not the first
priority on this ward.” Mr. H’s death, five weeks after admission to the hospital, was
apparently not due to his injury or any disease but to starving and neglect.468
“I have witnessed doctors who want to keep the bed clear by withdrawing treatment
or actively assisted in deaths,” Dr. Rita Pal told the London Times. “An 89 year old stroke
patient was unable to speak . . . [He] was actually conscious and could hear us. The
doctor said, “We need the bed – stop all his medication.” They stopped the medication
and about 9:30 p.m. he started getting short of breath. I held his hand and said, “You
will be all right.” I was sickened by the whole episode.”469
Once families of elderly patients came forward, relatives of young British patients
with disabilities also began to speak out. When 12 year old David G., who has cerebral
palsy, was admitted to St. Mary’s Hospital in Portsmouth with chest infection, doctors
M. Horsnell, Police Investigate More “Backdoor Euthanasia,” THE TIMES (London), Jan. 28, 1999, at 8.
M. Horsnell & P. Foster, Euthanasia Claims Sow Doubt in Families’ Minds, THE TIMES (London), Jan.
6, 1999, at 9.
466
M. Horsnell & P. Foster, Grieving Families Seek Answers, THE TIMES (London), Jan. 6, 1999, at 8.
467
M. Horsnell, Doctor Guilty of Starving Patient: GP Faces Being Struck Off After Ruling Over Euthanasia
Order to Nurses, THE TIMES (London), Mar. 26, 1999; M. Horsnell, Relatives Fear Rising Tide of Euthanasia,
THE TIMES (London), Mar. 26, 1999.
468
L. Townsend, British Health Service Doctors Accused of Involuntary Euthanasia, NAT’L RIGHT TO LIFE
NEWS, June 2000, at 14.
469
Id.
464
465
Other People’s Lives: Reflections on Medicine, Ethics, and Euthanasia
301
ordered that he should be given diamorphine and a DNR order and left to “die with
dignity.”470 The doctor’s expectations (or hopes?) did not come true: David survived his
hospital stay and his mother is taking care of him at home.
In February, 2000, the British Medical Association issued guidelines intended to
prevent “back-door euthanasia.”471
Austria. The heart of darkness seems to have reached Austria, at Vienna’s Lainz
Hospital, where four nursing aids killed forty-nine,472 and possibly 200 elderly patients.473
The preferred method was administering high doses of the sedative and anti-hallucinatory
drug Rohypnol or what the nurses called “oral hygiene” (“Mundpflege”): the murderess
poured large amounts of water into the helpless patient’s mouth while the accomplice
held tight the victim’s nose.474 The killings were going on for several years and at least
some doctors and hospital officials must have been aware of them: autopsies were
mandatory, and the test of lung floating, routinely done at the post-mortem, must have
shown that the patients died of drowning.475 During the inquiry, some suspects claimed
to have acted out of compassion; there were, however, clear indications of malevolence.
One of the nursing aids was known to have boasted that “there is no such thing as ‘no
beds available’ at my ward.”476 The code words for killing were “sending him up to the
Lord” or “down to the cellar” (where the morgue was located).477 One of the suspects
admitted that she resorted to killing when a patient aggravated her.478 At the trial, two
defendants were sentenced to life in prison, one to twenty years, and one to fifteen
years.479 The psychologist who studied the events at Lainz Hospital came to the conclusion that society and the medical profession are now more tolerant of euthanasia and
that has influenced the barely literate nursing aids who had very insufficient schooling
as caregivers. Having witnessed some doctor’s decisions to let patients die, they lost all
ability to discern what was permissible and what was not.480
In the Netherlands, a number of deceased patients’ families complained in 1997
that their loved ones had been deliberately starved and dehydrated to death in nursing
Id.
D. Charter, BMA Guide to Halt “Backdoor Euthanasia,” THE TIMES (London), Mar. 1, 2001.
472
Vienna in Turmoil as Story of 49 Hospital Slayings Unfolds, INT’L HERALD TRIB., Apr. 1989, at 2.
473
Mogelijk 200 doden in Weens ziekenhuis [Possibly 200 died in Viennese hospital], BRABANTS DAGBLAD,
Apr. 24, 1989.
474
Murder, Not Mercy, TIME MAG., Apr. 24, 1989.
475
Vienna in Turmoil, supra note 472.
476
T. van den Brand, Is dit een moordenares of eenbehulpzaame verpleegster? [Is she a murderess or a
nurse ready to help?], BRABANTS DAGBLAD, Apr. 15, 1989.
477
Murder, Not Mercy, supra note 474.
478
R. Drost, Psycholoog over vijf “Weense verpleegsters”: “Doden patienten geen incident” [Psychologist on
the five “Viennese nurses”: “Killing patients hasn’t been accidental”], BRABANTS DAGBLAD, Apr. 11, 1989.
479
Levenslang voor Oostenrijkse verpleegsters [Austrian nurses sentenced to life in prison], BRABANTS
DAGBLAD, Mar. 30, 1991.
480
Drost, supra note 478.
470
471
302
Issues in Law & Medicine, Volume 28, Number 2, 2012
homes ’t Blauwbörgje, De Plantage, and De Weerde;481 the police and the public prosecutors launched inquiries in some cases, but often were reluctant to intervene.482 The
study conducted by nursing home physician, Dr. E. Fischer, showed that twenty-two
percent of non-demented persons dying in nursing homes, and forty-six percent of
the demented die as a result of “versterving”;483 the word had been used in a variety of
meanings but now came to denote deliberate withholding of food and liquids with the
aim to cause death. Targeted are patients who seem to refuse eating and drinking, those
who are unconscious or otherwise unable to feed themselves, and often those who crave
food and drink, but are too weak to demand it loudly. The list does not include tube-fed
patients because this method of feeding is virtually never used in Dutch nursing homes.
As a rule, families are not informed of the intended withdrawal of food and fluids, but
in some cases the relatives noticed or suspected what was going on. Since the personnel
are feeling righteous about this policy, assured that they are helping the sufferers die an
easy death, remonstrations and protests of the families are usually disregarded. Some
ethicists justified the versterving, arguing that “quality of life outweighs its duration,”484
while others protested.485 It was pointed out that people dying by dehydration suffer
terribly.486 In many cases the starving and dehydration are instituted abruptly, which
in the very aged usually leads to death within a few days; or else the portions of food
and drinks of water offered the patient are gradually reduced until a “zero-regime” is
reached and the patient dies.487 The latter method is identical with the policy of gradually diminishing feeding, which had caused the death of almost half of all hospitalized
German psychiatric patients during and immediately after World War I,488 and with
the so-called “wild euthanasia” in German psychiatric wards after August 1941, when
481
M. Bouwmans, Moeder lieten ze bewust uitdrogen [They deliberately allowed mother to dehydrate],
BRABANTS DAGBLAD, Aug. 8, 1997; Justitie nalatig in zaak dood bejaarde: Aanklacht tegen Eindhovens verpleeghuis [Prosecutors’ neglect in the case of elderly person’s death: Complaint against nursing home in
Eindhoven], BRABANTS DAGBLAD, Aug. 8, 1997; Klachten na onvrijwillige levensbeeindiging: “Verpleeghuis in
Brielle schoot tekort in zorg” [Complaints in connection with involuntary termination of life: “Nursing home
in Brielle failed to provide due care”], REFORMATORISCH DAGBLAD, Aug. 8, 1997.
482
Justitie nalatig, supra note 481; Klachten, supra note 481.
483
Helft dementerende overlijdt door versterving [Half of demented persons die by deprivation of food
and water], REFORMATORISCH DAGBLAD, July 29, 1997.
484
J. van Delden, J. Konings, P. Froeling, & M. Ribbe, Kwaliteit leven moet zwaarder wegen dan duur
[Quality of life should outweigh its duration], DEVOLKSKRANT, Aug.7, 1997.
485
Ch. Rutenfrans, Versterving is in strijd met eisen van zorgvuldigheid [Deprivation of food and water
violates the rules of due care], DE VOLKSKRANT, Aug. 7, 1997; M. van Driel, Versterven is in buitenland onacceptable [In foreign countries deprivation of food and water is considered unacceptable], DE VOLKSKRANT,
July 31, 1997.
486
G. Wolvers, Op een gegeven moment komt het einde [At a certain point the end comes], REFORMATORISCH DAGBLAD, Aug. 8, 1997.
487
Id.
488
R.N. PROCTOR, RACIAL HYGIENE: MEDICINE UNDER THE NAZIS 178 (Harvard Univ. Press, Cambridge
- London 1988).
Other People’s Lives: Reflections on Medicine, Ethics, and Euthanasia
303
the Nazi program of active euthanasia was revoked, but doctors continued starving the
patients to death.489
In America the public is informed of cases in which judges and courts are involved.
This happens when there is a conflict between an unconscious patient’s next of kin and
the hospital, or within the patient’s family, about continuing life-sustaining measures.
When behind the patient’s back an “agreement” is reached between the next of
kin, the doctor, and the nursing home personnel to put an end to the patient’s life – as
was the case with Gene McC – the event receives no publicity.
The following published case illustrates what can happen to older people who
have the misfortune to fall into the hands of indoctrinated caregivers: This 97 year old
lady from Albany, Oregon, lived in a retirement complex, which was perfect for her
independent spirit and sharp mind. She took a tumble and was taken to the hospital to
check for possible fractures. No injuries were found. She was released to a nursing care
facility for physical therapy. After close to two weeks there, the lady no longer seemed
to recognize her family. It was not easy to rouse her from sleep. The few words she
spoke were difficult to understand. Her roommate told the family that the lady did not
eat or drink and was asleep at meal time. The personnel explained that she wasn’t very
cooperative with her therapy, and that older people facing a change in circumstances
may decide that they are no longer going to make an effort to live; and that it is their
right to make that choice. The family did not agree and checked her out. She became a
resident in an “assisted living” complex and seemed to make a little progress, but spent
most of each day asleep and took in little food. A nurse/administrator said that she did
not think the lady would live, and that she had the right to refuse food and water. The
home visitation health care workers offered the same perspective. The on-call doctor
repeated the mantra about the right to die.
The despairing family took the lady to the emergency room, and she was admitted
to the hospital. She was given fluids and calories intravenously and improved almost
immediately. The lady left the hospital to live with her family. She is now better than
ever. She recently spent three hours shopping with her granddaughters to find a dress
to wear at her great-granddaughter’s wedding.490
What a travesty of care, a parody of medicine! A doctor and a whole host of “health
workers” who kept repeating the “right-to-die” gibberish, and didn’t even try to diagnose
that patient’s condition! That’s how we are being driven to our graves!
A wave of rabid aggression against the lives of older people is rising all over the
Western industrialized world. The darkest past of mankind, the bags in which old people
were thrown from Greek island’s cliffs to the sea, pillows used to smother the elderly
on Chukchi Peninsula to let them join the ancestors – all this is being resurrected in
modernized form, in the name of human rights and freedoms.
Id. at192-93; R.J. LIFTON, THE NAZI DOCTORS: MEDICAL KILLING AND THE PSYCHOLOGY OF GENOCIDE
96-99 (1986).
490
J. Schwarze, The “Right” to Die Became the Duty to Die in Oregon, PCC/PHYSICIANS FOR COMPASSIONATE
CARE (Portland, Oregon), vol. 4, no. 2, 2001, at 7.
489
304
Issues in Law & Medicine, Volume 28, Number 2, 2012
Chapter XXVIII. American Assisted Suicide
A Family Conversation in Sarasota.491 I have always liked best the West Coast of
Florida, with its wonderful abundance of birds, egrets, sandpiper and plunging brown
pelicans. Gina’s first cousin Irving and his wife Mary used to spend the winters in their
condominium on Lido Key. When we met them at a restaurant there, Mary inquired
about our previous visits to Florida. “Last year we were in Palm Beach on business,” said
Gina. “Tell her how you appeared in the court room with a terrible flu.”
Richard: Dr. MacIver sued the State of Florida,492 he wanted to be allowed to help a
patient to commit suicide but Florida’s law prohibits such acts. I testified in the case.
Mary: And are you for or against assisted suicide?
R: I fight it.
M: Why?
R: Are you for?
M: Once we had dinner with a nice elderly couple who later committed suicide. He
was a retired doctor and she was quite senile or had Alzheimer’s disease and was
totally dependent on him. They were members of some kind of society.
R: Hemlock.
M: Yes, and them being so old and frail and as they wanted to die. I don’t see why
not. They invited their children and friends, had a farewell dinner, and then he gave
her the pills and later took the pills himself; and they both died. To go together, that
was what they wanted.
R: They acted on delusion.
M: What do you mean?
R: They were together as long as they lived. There is no togetherness after death.
Irving: You may be right, in a sense.
M: But did you hear of that woman in New York who gave pills to her mother and
so helped her to die? She would never have got in trouble had she not told the story.
But she published a book about it and Morgenthau . . .
Gina: Which Morgenthau?
R: The district attorney.
491
A verbatim account of a February, 2000, conversation between Mr. and Mrs. Irving Volk of Sarasota, Florida, Mrs. Eugenia Shrut of Cambridge, Massachusetts, and myself.
492
McIver vs.Krischer, Case No. CL-96-1504-AF, Palm Beach Circuit Court, supra note 401.
Other People’s Lives: Reflections on Medicine, Ethics, and Euthanasia
305
M: Yes. He arrested her. She had to take the oath and tell how sick her mother had
been, and that the mother herself had badly wanted to die. The daughter got away
with it but only after this whole ordeal.
R: The ordeal? Do you think one should be able to dispatch the mother, period, no
questions asked?
M: No, but you know . . .
R: And I wonder when the idea of writing a book entered the lady’s mind. If this
occurred to her before the act, she couldn’t help minding the future book while she
pondered and prepared the mother’s suicide.
M: That is a nasty thing to say!
R: Perhaps. But the problem deserves attention. I mean, what are the real motives of
family members who hasten death of a loved one? It is generally assumed that their
motives can only be noble: empathy, love, desire to free the loved person from suffering. Is it always so? It is amazing that those noble explanations are unqualifiedly
accepted. After all, human lives are at stake; shouldn’t we be more inquisitive?
M: Maybe. Still I think people should be free to choose their own death, and if they
are unable to do it themselves they should be helped. You haven’t yet told me why
you are against it.
R: No, I haven’t. Remember, the law in this state prohibits helping another person
to commit suicide. So I am under no obligation to justify my position. The burden
of the proof is on those who want to change the status quo. But I’ll try to explain my
reasons. I could not expect much of your attention in the restaurant, over excellent
food, with all that talk and music around us. Let’s now go for a walk, and postpone
the rest of the discussion till our next meeting.
We haven’t resumed that conversation, and now we shall not be able to do so: of
the four persons, two are no longer living.
The Assisted Suicide Story. Physician’s assistance with suicide is all we hear nowadays, and the impression is created that this is and always has been the aim of the
American “right-to-die” movement. It doesn’t take a very long memory to know that
physician-assisted suicide is a recent invention. Historically, the American movement
has always promoted active euthanasia, lethal injections administered by physicians,
with (or, sometimes, without) consent of the patient. In 1938 the American Euthanasia
Society submitted a bill to the New York legislature that would permit voluntary active
euthanasia.493 The American promoters of euthanasia in the nineteen forties, Dr. Foster
493
Mercy Death Law Ready for Albany, N.Y. TIMES, Feb. 14, 1938.
306
Issues in Law & Medicine, Volume 28, Number 2, 2012
Kennedy,494 W.G. Lennox,495 and Dr. Abraham Wolbarst,496 Rev. Joseph Fletcher,497 the
champions of euthanasia in the 1970’s,498 and the Hemlock Society up to 1994499 – all
of them proposed euthanasia by lethal injection and nothing else.
But it turned out that American society was not ready to accept lethal injection
administered by physicians. The measures proposing legalization of active euthanasia
could not be put on the ballot in California in 1988, nor in Oregon in 1990, because
the activists were unable to collect the required number of signatures.
In 1991, a bill that would legalize voluntary active euthanasia was put on the
ballot in Washington state. That fall, the situation seemed to portend a victory for the
supporters of the bill. The state’s Medical Association took an equivocal position. The
pre-referendum polls indicated that the majority of respondents favored the bill.
When November 5th came, the day of the ballot, the voters rejected the euthanasia
bill by a majority of fifty-four percent.500 Analyzing the result, some observers pointed
out that new medical killings revealed by Dr. Kevorkian had deterred voters. Moreover,
the newly published Dutch governmental survey of euthanasia, which showed that involuntary euthanasia was practiced on a large scale, was promptly faxed from Holland,
presented at a press conference in Seattle, and may have influenced the vote. But first
and foremost the ballot’s result was due to the highly informative educational campaign
led by a group of talented and dedicated activists, Mrs. Mary-Jo Kahler, Miss Eileen
Brown, R.N., Dr. Robert Bernhoft, and Dr. Dorsett Smith.
The next year, 1992, a bill to legalize active euthanasia was rejected by the voters
of California.501
The new Board of the Hemlock Society learned a lesson from these experiences. It
was decided to suspend the campaign to legalize active euthanasia. Instead, the Society
would now aim at the legalization of physician-assisted suicide.
Physician-Assisted Suicide: Is It Any Better than Active Euthanasia? Physician-assisted
suicide is more easily accepted by the public because it is believed to be an arrangement in which the patient remains in full control. This is of course an illusion. The
overwhelming influence of the doctor, the sick person’s swinging moods, the attitude
Foster Kennedy, The Problem of Social Control of the Congenitally Defective: Education, Sterilization,
Euthanasia, 99 AM.J. PSYCH. 13 (1942).
495
W.G. Lennox, Should They Live? Certain Economic Aspects of Medicine, 7 AM. SCHOLAR 454 (1938).
496
R.N. PROCTOR, RACIAL HYGIENE:MEDICINE UNDER THE NAZIS 380 (1988) (quoting A. Wolbarst).
497
J. Fletcher, Ethics and Euthanasia, in TO LIVE AND TO DIE: WHEN, WHY, AND HOW 113, 118 (R.H.
Williams, ed., 1973); J. Fletcher, The “Right” to Live and the “Right” to Die, in BENEFICENT EUTHANASIA 44
(M. Kohl., ed., 1975).
498
BENEFICENT EUTHANASIA (Marvin Kohl, ed. 1975).
499
Initiative 119: An Act Relating to the Natural Death Act; amending R.C.W. § 70.122.010 et seq.
(Wash. State ballot measure, Nov. 5, 1991).
500
R. Knox, Washington State Voters Reject a Proposal to Legalize Euthanasia, BOSTON GLOBE, Nov. 7,
1991.
501
Lethal Injection Will Be on the Ballot in California, Secretary of State Says, NAT’L RIGHT TO LIFE NEWS,
Apr. 28, 1992; D. Andrusko, Assisted Suicide Measure Defeated in California, NAT’L RIGHT TO LIFE NEWS,
Nov. 16, 1992.
494
Other People’s Lives: Reflections on Medicine, Ethics, and Euthanasia
307
of the family, the propaganda that is infecting a person’s language and thinking – all
these factors are part of a patient’s suicidal decision.
It is the doctor who informs the patient on the diagnosis and prognosis, and, unfortunately, in this country some doctors do it in a callous or brutal way that may destroy
the patient’s will to live.502 But also soft-spoken doctors who believe that suicide can be
a rational solution, and discuss it in all seriousness, may induce the patient to put an
end to his life. The patient thinks he can discuss it “safely” – after all, he’s talking to his
doctor! Some doctors impermissibly encourage dreams of delights that await the patient
in the other world. Holland’s leading practitioner of euthanasia, Dr. Pieter Admiraal, told
the interviewer that before injecting the patient with drugs that paralyze the heartbeat
and the respiration, he wished him “a very good journey to an unknown you’ve never
seen.”503 The American pioneer of assisted suicide, Dr. Timothy Quill, tells in his report
how his patient announced her intention to meet him after her suicide at her favorite
spot on the shore of Lake Geneva, and they would watch dragons playing at sunset; and
the doctor acquiesced.504 Such doctors lure the patient into a trap.
The role of families calls for scrutiny. My heart goes out to families who with
devotion take care of their loved ones, and so it is in most instances. But things may
be different. A talented journalist published in The New Yorker an article in praise of
euthanasia and in this article he told the story of his own family.505 It is a frightening
tale. We read how four educated, enlightened people caught the lingo of the Hemlock
Society, and in a few years mutually exciting each other, reached a kind of murderous
frenzy. After her surgery grandma was less interested in other people, and also her sense
of humor had suffered. Seeing her so changed, the mother exclaimed: “If I knew how
to do it, I’d go up there and shoot her!” Finally the mother herself fell ill; they helped
her to commit suicide. She had not used the whole supply of the drug, and the healthy
ones – the father and two sons – wrested the remaining tablets from each other’s hands.
In Manhattan, Mr. D, an editor, helped his sick wife to commit suicide; he instantly
became a hero, and received many invitations for public appearances. Then the journal
he had kept was found, and revealed what happened. “You are sucking my life out of
me like a vampire and nobody cares,” Mr. D wrote in his journal. He called his wife
B. LOWN, THE LOST ART OF HEALING 61-89 (1996).
F.X. Clines, Dutch Tacitly Adopt Mercy Killing: Law Condemns It But Doctors Help 5,000 Die Each Year,
INT’L HERALD TRIB., Nov. 1, 1986) (quoting P. V. Admiraal).
504
T.E. Quill, Death and Dignity: A Case of Individual Decision Making, 324 NEW ENG. J.MED. 691
(1991).
505
A. Solomon, A Death of One’s Own, NEW YORKER, May 22, 1995, at 54.
502
503
308
Issues in Law & Medicine, Volume 28, Number 2, 2012
“a burden” and “not wanted,” and kept telling her so, until she agreed to swallow the
lethal dose of amitriptyline.506
In 1993, Mrs. Judith C. filed a complaint against her husband in Pembroke, Massachusetts, accusing him of physical and mental abuse. A few years later this very same
husband brought her to Dr. Kevorkian and was present at her “suicide.” Mrs. C had
no life-threatening disease, she had been treated for chronic fatigue syndrome, muscle
pain, and depression.507 Another of Dr. Kevorkian’s “patients,” Mrs. Loretta P., had been
confined to a wheelchair. She had told her support group that her husband regularly
took long walks and she didn’t know where he was during these walks. The husband,
Mr. Joseph P., remarried three months after his wife’s death. Susan N., the woman he
married after Loretta’s suicide, lived only two blocks away.508
In Oregon, Mrs. Kate C., 85, diagnosed with “terminal cancer,” applied for assistance in committing suicide in accordance with the Oregon law. Since she suffered
from memory loss, she was referred to a psychiatrist to determine her ability to make
this decision. Her daughter, Ms. Erica G., accompanied her during the consultation.
The psychiatrist found that Mrs. C “[did] not seem to be explicitly pushing for this.”
But the daughter did push, and shopped for another doctor. This consultant, a clinical
psychologist, worried about familial pressure, and wrote that Mrs. C’s decision to die
“may be influenced by her family’s wishes.” Nevertheless, the psychologist determined
that Mrs. C was competent to kill herself and approved the writing of the lethal prescription.509 The story of Mrs. Kate C’s suicide seems rather typical of a whole class of cases.
Groups “supporting the patient’s own decision” can act very effectively. One suchgroup led by Unitarian minister Mr. Ralph Mero in Seattle invited a journalist to attend
the preparations for what they called “Good Death for Louise.” The story then appeared
506
H.W. Batt, DeLury Defense Fund Established by Hemlock Society of New York, TIME LINES, Mar.-Apr.,
1996 (Hemlock Society newsletter); “I Deserve to Enjoy a Little Rest I Have Left and a Chance to Do Something
for Myself,” THE FORWARD, July 21, 1995, at 1; A. Shafran, When Life is Measured by Quality, Not Sanctity,
NAT’L RIGHT TO LIFE NEWS, Feb. 6, 1996; July 4, 1995 Was “LiberationDay” for Fifty-Two Year Old Myrna Lebov, FIRST THINGS, Apr. 1996, at 75-76; L. Townsend, New York Authorities Investigate “Mercy Killing,” NAT’L
RIGHT TO LIFE NEWS, Oct. 11, 1995; D. Andrusko, Manhattan Editor Pleads Guilty in “Assisted Suicide” Case,
Will Serve Minimum Time in Prison, NAT’L RIGHT TO LIFE NEWS, Apr. 12, 1996; Lagnado, Welcome to the Era
of Euthanasia Chic, NAT’L RIGHT TO LIFE NEWS, May 20, 1996.
507
J. Forman, Doctors Say Her Case Treatable, Nonfatal, BOSTON GLOBE, Aug. 17, 1996; Bai & R. Chacon,
Spouse Says He Told Wife: “Don’t Quit,” BOSTON GLOBE, Aug. 18, 1996; Amid Questions, A Life Taken, BOSTON
GLOBE, Aug.18, 1996; K. Zernike, New Case May Cost Kevorkian, BOSTON GLOBE, Aug. 19, 1996; K. Zernike & D.J. Vigue, Kevorkian Patient Was Addicted to Drugs, Doctor Says, BOSTON GLOBE, Aug. 20, 1996; K.
Zernike, State Board Eyes Doctor’s Role in Wife’s Assisted Death, BOSTON GLOBE, Aug. 21, 1996; J. Rakovsky,
Suicide Patient Discussed Suing Husband, Sources Say, BOSTON GLOBE, Aug. 24, 1996; I.A.R. Lakshmanan,
& D.I. Vigue, Death Ended a Troubled Relationship, BOSTON GLOBE, Aug. 25, 1996; P. Terzian, Appointment
With Dr. Jack, PROVIDENCE SUNDAY J., Aug. 25, 1996; R. Saltus, Questions Persist Following Suicide, BOSTON
GLOBE, Sept. 2, 1996.
508
Assisted Suicide Case Takes Bizarre Twist, DETROIT NEWS, May 16, 1997.
509
THE OREGONIAN, Oct. 17, 1998; W.J. Smith, Suicide Unlimited in Oregon, WEEKLY STANDARD, Nov.
8, 1999.
Other People’s Lives: Reflections on Medicine, Ethics, and Euthanasia
309
in New York Times Magazine510 and was widely read throughout the country. One of the
best experts in the field, director of the American Foundation for Prevention of Suicide,
Dr. Herbert Hendin, a psychiatrist, has carefully analyzed the story and disclosed what it
really showed: “Louise’s hesitations, fear, reluctance to take her own life, her attempts to
postpone the decision, and how the group, craving for “action” and publicity, inexorably
pushed “Louise” into committing suicide.511
So much for the patient’s autonomous decision. As we can see, in this respect the
physician-assisted suicide isn’t much better than active euthanasia.
The Oregon Law. As mentioned before, around 1993-94 the Hemlock Society and
other right-to-die groups decided to no longer promote active euthanasia; now the aim
was to legalize physician-assisted suicide.
The change had not come easily. It was opposed, first of all, by the founder of
Hemlock Society, Mr. Derek Humphry, who argued that legalizing assisted suicide would
not attain the Society’s real goals. He also pointed out that suicide by oral intake of drugs
was an unreliable method and would fail in a number of cases. But the new project was
better adapted to the American public mood, and proponents of the new strategy have
prevailed. The State of Oregon, to which Hemlock’s headquarters had recently been
moved, was chosen as the first battleground.
This campaign led to the passage of the first American law allowing physician-assisted suicide. On November 8, 1994, the Oregon voters enacted this law by a slight
majority of 51 percent. The law allows the doctors to prescribe lethal drugs to willing
adult patients who have a “terminal disease,” that is, a disease which in the opinion of
two doctors is incurable and irreversible, and would lead to death within six months’
time. The patient has to be informed of the diagnosis and the prognosis, and has to repeat his request after an interval of 15 days; then another 48 hours should lapse, giving
the patient a last opportunity to change his mind. If one of the doctors suspects that
the patient suffers from a depression that might influence his judgment, a consultation
with a psychologist or psychiatrist is required.512
A lawsuit was immediately filed at the U.S. Federal Court in Eugene, Oregon by
the law firm of Bopp, Coleson and Bostrom on behalf of a group of Oregon’s doctors,
patients, and healthcare workers. I was involved in this case as an expert witness.
The plaintiffs asserted, first of all, that the new law violated the Constitution of the
United States by creating legal inequality: persons who are poor, less educated,uninsured
and/or have insufficient command of the English language, and for these reasons do
not receive adequate treatment to relieve their suffering, would be under much stronger pressure to ask for assistance in suicide than the rest of the population. The other
important group who would be discriminated against by the new law are people with
grave disabilities. Carol J. Gill, Ph.D., an expert on the rights of people with disabilities,
L. Belkin, There is No Simple Suicide, N.Y. TIMES MAG., Nov. 14, 1993.
H. HENDIN, SEDUCED BY DEATH: DOCTORS, PATIENTS, AND THE DUTCH CURE 35-43 (1997).
512
THE OREGON DEATH WITH DIGNITY ACT: A GUIDEBOOK FOR HEALTH CARE PROVIDERS 56-61 (K.K. Haley & M. Lee, eds., The Center for Ethics in Health Care, Portland, OR 1998).
510
511
310
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presented the situation of this group in her affidavit. They need both their own will and
strength, and the help and acceptance of the society just to go on with their lives, and
would now find themselves under disproportionate pressure to give up.
Affidavit of Expert Witness. My affidavit submitted to the federal court in Eugene,
Oregon, is rendered here with a few abbreviations:
I am submitting this affidavit as a physician faithful to my profession’s vows of absolute respect for human life, and as a physician who during 40 years of hospital
work has attended to many gravely ill and dying patients. I also base my opinion on
my 20 years’ first hand experience, and my detailed knowledge, of euthanasia and
physician-assisted suicide practiced in the hospitals and by family physicians in The
Netherlands.
It is my deep conviction that the statement in the Declaration of Independence that
Life is a Right which is unalienable means literally what it says, and, therefore, the
Law allowing the terminally ill to obtain prescriptions for lethal drugs, passed in the
State of Oregon in the referendum of November 8, 1994, is contrary to the spirit in
which the United States and all free societies were founded.
Moreover, I am convinced that the Oregon law is flawed because it contains erroneous
assumptions and not properly considered provisions. As a consequence, this law, if
enacted, must produce effects unforeseen by the voters, dangerous to the people of
Oregon, and contrary to the State’s duty to extend equal protection of the law to all
citizens.
1. Medical diagnoses often prove wrong. The necessary fallibility
The Oregon “Death with Dignity Act” states that the patient should be informed of his
or her medical diagnosis and requires this diagnosis to be confirmed by a “consulting
physician, qualified by specialty or experience to make a professional diagnosis…
regarding the patient’s disease.”
The Oregon law failed to take into account, and to inform the involved persons,
that medical diagnoses, also those established by specialists and in special hospital
departments, when confronted with the ultimate diagnostic standard, that it, the
findings at post-mortem examinations, prove wrong in a high percentage of cases.
There is ample evidence to prove this point. In 1985, an editorial in New England
Journal of Medicine513 stated that the discrepancies between clinical diagnoses and those
established at the post-mortem, as documented in over 100 publications, ranged from
20-40 percent. A study was quoted in which lung cancer proved misdiagnosed in 49
percent of the cases. In the Connecticut study of 272 deaths, Kircher et al. reported
in 29 percent of cases major disagreements, and in further 26 percent of cases less
striking yet substantial disagreements between clinical diagnoses and post-mortem
513
Editorial, The Problematic Death Certificate, 313 NEW ENG. J. MED. 1285 (1985).
Other People’s Lives: Reflections on Medicine, Ethics, and Euthanasia
311
findings.514 Anderson et al. reviewed studies from U.S., Britain, and Scandinavia, encompassing more than 50,000 autopsies over a period of 48 years (1930-1977), and
found that the ability of clinicians to diagnose rheumatic heart disease and leukemia
improved since 1930 but the accuracy of diagnosing several other diseases (pulmonary
tuberculosis, peritonitis, cancers of the lung, liver, biliary tract, and stomach) had
deteriorated in 48 years.515 In one series, analyzed by these authors, 66 percent of
gastric/peptic ulcers found at post-mortem had been missed by clinicians. Britton and
Hartvelt (quoted by Anderson et al.) found that post-mortem examinations showed
a different disease in 35 to 45 percent of cases in which the clinician was uncertain
of the diagnosis and in 19 to 25 percent of cases in which the clinician was certain.
Anderson et al. emphasized that diagnostic errors are not incidental but on principle unavoidable; the errors have not been and will not be eliminated by progress in
medical science; the authors speak of “necessary fallibility.”
Goldman et al. analyzed 100 randomly selected autopsies from each academic year
1960, 1970, and 1980 at one of the nation’s best hospitals, the Brigham and Women’s
Hospital in Boston, and found that the percentage of wrong clinical diagnoses has
not changed in 20 years (22 percent in 1960, 23 percent in 1970, and 21 percent
in 1980).516 The authors found that the introduction of modern diagnostic tools
(radionuclide scans, ultrasounds, computerized tomography) has not eliminated the
wrong diagnoses; in some cases, excessive reliance on these procedures contributed
to diagnostic errors.
In Holland, Boers found in 1988, in his series of 147 autopsies, that clinical diagnoses were wrong in 32 percent of the cases.517 In the series published in 1989 by
Wubeke et al., in 40 percent of the cases the clinical diagnoses proved wrong at the
post-mortem examinations.518
In Britain, Rees et al. reported a series of four patients who were referred to a hospice
for “terminal care” as having untreatable cancer.519 One of these patients had the diagnosis of cancer established (from pleural biopsy) by two pathologists and confirmed
by a third. Further observation showed that none of these patients was “terminal,”
and none of them had cancer.
514
T. Kircher, J. Nelson & H. Burdo, The Autopsy as a Measure of Accuracy of the Death Certificate, 313
NEW ENG. J. MED. 1263 (1985).
515
R.E. Anderson, R.B. Hill & C.R. Key, The Sensitivity and Specificity of Clinical Diagnostics During Five
Decades: Toward an Understanding of Necessary Fallibility, 261 JAMA 1610 (1989).
516
L. Goldman et al., The Value of the Autopsy in Three Medical Areas, 308 NEW ENG. J. MED. 1000
(1983).
517
M. Boers, Obduceren is vooruitzien: Detoekomst van obductie [Performing autopsies means looking
ahead: The future of the post-mortem], 134 NED. TIJDSCHRIFT V. GENEESKUNDE 1346 (1990).
518
E. Wubeke et al., Obducties in een verpleeghuis [Autopsies in a nursing home], 133 NED.TIJDSCHRIFT
V. GENEESKUNDE 765 (1989).
519
W. D. Rees, S.B. Dover & T.S.Low-Beer, “Patients with Terminal Cancer” Who Have Neither Terminal
Illness Nor Cancer, 1987 BRIT. MED. J. 488 (monthly Dutch ed.).
312
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Even some doctors are unaware of these data, and the general public certainly has
very little knowledge thereof. The voters in Oregon who accepted the “medically confirmed diagnosis” believing it to be a safeguard against mistakes, did not realize that
a medically confirmed diagnosis carries a risk of error ranging from 20 to 40 percent.
It is an irrational and negligent act to cause a patient’s death on the grounds of a
diagnosis that may prove faulty. And yet such acts will be legal in Oregon if the law
in question is enacted.
2. Fit and active people would qualify as “terminally ill.”
The new Oregon law defines “terminal disease” as “an incurable and irreversible disease
that will, within reasonable medical judgment, produce death within six months.”
Here I will discuss the part of the definition that contains the terms “incurable and
irreversible.”
It is a faulty definition, due to which many millions of Americans, and hundreds of
thousands of fit and active Oregonians, would qualify as “terminally ill.”
Insulin-dependent diabetes mellitus, pernicious anemia, severe hypothyroidism with
myxedema, and adrenocortical insufficiency (Addison disease) are incurable diseases
and the underlying pathological changes in the body are irreversible. These diseases,
if untreated, would inexorably lead to death (which in many cases would follow
within a few months of the diagnosis). However, patients with these diseases who
receive the proper substitution therapy (respectively,insulin, vitamin B12, thyroid
hormone, and cortisone) lead normal lives and have a life span close to normal. The
same is true of other incurable, irreversible, and potentially lethal diseases treatable
with symptom-suppressive drugs (severe form of high blood pressure, polycythemia
vera, and many others).
This grave flaw in Oregon law would have been avoided if the law’s authors defined
terminal disease as incurable and irreversible disease that would produce death
within as certain time regardless of treatment. However, the law fails to list the latter
crucial condition.
As a result, people with incurable, but perfectly treatable, diseases, who, as any of
us, may be subject to transient suicidal moods, will receive prescriptions for lethal
drugs from doctors whose misjudgment, or reverence for people’s right to die, will
apply to them the letter of paragraph 1.01 (12) of Oregon law.
3. Accurately predicting death “within six months” is impossible.
According to the new Oregon law patients qualify for obtaining the prescription for
lethal drugs if they suffer from a “terminal disease which will produce death within
six months.”
Other People’s Lives: Reflections on Medicine, Ethics, and Euthanasia
313
This provision unreasonably assumes the doctors’ ability to exactly predict a patient’s
life expectancy.
Doctors who venture to predict that a patient would die within so many months or
years either base their predictions on their own experience, and personal impression
of the patient, or on scientific publications in which the survival of patients with this
disease was reported.
In the former case, small data sample, vagaries of recollection, failure to account for
data dispersion (the number of survivals that were much shorter or much longer than
the average), and, quite often, emotional bias of the doctor, invalidate the prediction.
Predictions based on published scientific data are free from most of the above listed
errors. However, a double and fundamental methodological error is committed when
probabilities based on published studies are translated into a precise prediction of
expected survival of a new individual patient.
A well documented study reports the number of patients within every class and subclass of the disease, their average survivals, the standard deviation (being a measure of
prevailing dispersion), and also the actual dispersion, that is, the numbers of patients
who survived much shorter, shorter, longer, and much longer than the average.
When a new individual patient is considered, and correctly ranged as to the class and
subclass of the disease, the chances are that he will do as well as those in the group
of average survival, or as badly as the ones who survived much shorter, or as well as
those with much longer survival. There is also a lesser but real chance that he will
exceed the hitherto known survival range. For example, in one published study the
survival of patients with breast cancer and tumor cells found in more than four lymph
nodes was four years on the average, but some patients survived ten to twenty years
and few even longer.520 We simply cannot know this beforehand.
Doctors who precisely predict when a particular patient is going to die engage in
imprudent and unprofessional conduct. Spectacular blunders, as when a patient, told
that he would die within two months or two years, is still alive and well many years
later, occur very often and are publicized by daily press.
Concluding, I state that predicting a patient’s death within six month is in practice
fallible and in principle erroneous.
Unavoidably, some patients who otherwise would live longer or much longer than
six months will obtain prescription for lethal drugs if the Oregon law is enacted.
4. The waiting period is unreasonable because too short and arbitrary.
520
C. Henderson, Breast Cancer, in HARRISON’S PRINCIPLES OF INTERNAL MEDICINE 12TH ED. 1612-21 (J.D.
Wilson et al., eds., 1991).
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The new Oregon law makes provision for a mandatory 15 days’ waiting time and
a further delay of 48 hours. During all this time the patient had the opportunity to
rescind his request.
Thus, the authors of the Oregon law have recognized the obvious fact that people’s
suicidal moods are often transient, and that the person taking such a fatal and irreversible step should be given the opportunity to change his or her mind.
However, the 17 days’ time given the patient to make up his mind is unjust and
unreasonable because:
(a) It is too short. There is a much better chance that a person’s suicidal tendency
would clear away within 2 months than in 17 days.
(b) It is arbitrary. Why is a person who would change her mind on the 17th day given
a chance to rescind her request and stay alive, but persons who would change their
minds on the 25th or 18th day are deprived of such a chance? The latter persons are
denied equal protection of the law.
The objection that this last criticism would apply to any, even much longer, waiting
time, is correct but irrelevant. This criticism, indeed, applies to any waiting time that
would be required to precede a fatal and irreparable step.
5. Patients will receive prescriptions for suicide instead of treatment for depression.
The Oregon law states that the patient should be referred for counseling to a psychiatrist or psychologist if one of the physicians is of opinion that the patient may be
suffering from a psychological disorder or depression causing impaired judgment.
Thus, the Oregon law correctly recognized that there is a danger of granting requests
which may be submitted under the influence of depression. But the decision whether
to refer the patient for counseling is left to psychologically untrained physicians.
Such physicians often fail to suspect depression, to think of it, in particular when
the depression is “masked,” that is, when the patient utters only somatic complaints.
As a consequence of this fault in the law, inevitably patients who submit requests
for lethal drug due to a (treatable) depression will be wrongly assisted with suicides.
6. Botched suicide attempts may force expansion of the law.
The Oregon law is also flawed because the method of ending life it allows does not
ensure the intended result, and is bound to fail in some cases, leaving the victims
injured but not dead. Mr. Derek Humphry, founder of the association that was instrumental in persuading the voters to approve the Oregon law, is well aware of the
insufficient effectiveness of oral drug intake: In his book, Final Exit, he advises the
suicide candidates who take lethal drugs by mouth to suffocate themselves at the same
Other People’s Lives: Reflections on Medicine, Ethics, and Euthanasia
315
time with a plastic bag.521 In the Netherlands, in a number of cases the procedures
started as physician-assisted suicides had to be ended by means of lethal injections
administered by physicians.522 Physicianassisted suicide is, therefore, the least frequently used method of ending patients’ living in that country.523 It is understandable
that the physicians, if they at all consent to be involved in intentionally causing a
patient’s death, are reluctant to choose a method carrying a considerable risk of
failure. They are afraid of being called again, only to find a half-conscious patient
who vomited the tablets, aspirated the stomach contents into his airways, struggled
off the plastic bag he had on his head, and does not die. Such patient is, moreover,
exposed to further complications, aspiration pneumonia, severe blistered skin lesions
due to barbiturates, etc. The provision that the information on acts committed in
compliance with the law in question “may not be made available for inspection by the
public” (paragraph 3.11 of the Oregon Death with Dignity Act) will slow down the
spreading of the horrors of the botched suicides. The latter will create acute medical,
moral, and legal problems, necessitating further action in every such case and new
expanded legislation in the future.
7. To end’s somebody’s life upon his own request is to do him an injustice.
The voters in Oregon have assumed that a sick person’s own request, submitted
voluntarily and under no constraint, justifies giving him or her a prescription for
lethal drugs.524
I maintain that this is a fallacy, and that to end somebody’s life upon his own request
is to do him injustice.
Let us note that according to the new Oregon law the patient’s own request is a necessary but not by itself sufficient ground to give the patient the lethal prescription. Such
request will only be granted if reasons other than the patient’s request are present,
i.e., a disease that is incurable and irreversible and is, moreover, supposed to cause
death within six months. The law still protects, in particular against prescriptions for
deadly drugs, the lives of citizens who do not suffer from “terminal disease,” even if
they themselves voluntarily request such prescription. However, such protection is
not extended to persons who in the opinion of two physicians do have a “terminal disease.” The legislators consider their lives to be less worthy of protection, less valuable
than the lives of others. This is an injustice done to these people, an injury to their
dignity, and a failure to extend equal protection of the law to all citizens of the state.
D. HUMPHRY, FINAL EXIT 96-98 (The Hemlock Society, 1991).
REPORT II, supra note 199, 179; “Als het drankje niet werkt, dan ligt de spuit al klaar” [If the drink does
not work, the syringe is ready], NEDERLANDS DAGBLAD, July 6, 1994.
523
REPORT I, supra note 199, 13.
524
Such assumption is, indeed, in accordance with the Roman law’s principle volenti non fit iniuria.
But both in the medical tradition and according to laws pertaining to medical practice the validity of this
principle is strictly limited. E.g., no doctor would, or should, grant a patient’s voluntary request to mutilate
him.
521
522
316
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Cambridge, MA, November 27, 1994
When I presented my criticism of the Oregon law at a meeting in Warwick, Rhode
Island, somebody in the audience asked: “How come they have written such a faulty
law?! Couldn’t they do better?”
“I’m sure they’ve had the very best advisers” – was my answer – “and I think they
are at least as bright as we are” (there was some merriment in the audience at this point).
“But there is no right way to make the wrong law.”
Federal Judge Michael Hogan struck down the Oregon Death with Dignity Act as
flawed and unconstitutional.525 In his decision Judge Hogan cited several of our arguments. This decision was subsequently reversed by the United States Court of Appeals
for the Ninth Circuit.526 In an unrelated case, the U.S. Supreme Court held that citizens
do not have a constitutional right to assistance in suicide, but the decision whether to
ban or approve such acts was left to the states.527 In a second referendum the voters in
Oregon confirmed their assisted-suicide law.528 This law remains in force in Oregon, and
a number of persons have ended their lives using drugs obtained from their physicians,
or, quite often, from a doctor belonging to a small group of “activists.”529
From the very beginning it was clear that the Oregon assisted-suicide law would
get into conflict with federal law. Oral drugs used to commit suicides are federally controlled substances, and the 1979 federal Controlled Substances Act limits the use of
such drugs to legitimate medical purposes.530 On April 30, 1997, while signing the bill
that forbids any federal agency or health program to fund assisted suicide, President
Clinton reaffirmed his long-standing opposition to euthanasia and assisted suicide; yet
his administration did not speak in one voice on the issue of using federally controlled
drugs for these purposes. The director of Drug Enforcement Administration Mr. Thomas
Constantine decided to take steps against the violation of federal law, but was overruled
525
Lee v. Oregon, 891 F. Supp. 1429 (D.Or. 1995) (No. 94-6467-HO); J. Bopp & R.E. Coleson, Judge
Strikes Down Oregon Assisted Suicide Law, NAT’L RIGHT TO LIFE NEWS, Sept. 7, 1995; Editorial, Protect the
Dying: Even if Assisted Suicide is Constitutional, Measure 16’s Flaws are Fatal, THE OREGONIAN, Aug. 5, 1995.
526
Assisted-Suicide Challenge Rejected, BOSTON GLOBE, Feb. 28, 1997.
527
Fifteen States File Joint Brief in Support of N.Y.’s Appeal to the U.S. Supreme Court, IAETF UPDATE, 1996,
vol. 10, no. 3, at 1; L Asseo, Scalia Takes a Stand Against “Right to Die,” BOSTON GLOBE, Oct. 29, 1996; D.G.
Savage, U.S. Urges Court to Ban Doctor-Assisted Suicide, BOSTON GLOBE, Nov. 13, 1996; J. Biskupic, Suicide
Issue Hits High Court, PALM BEACH POST, Jan. 9, 1997; T. Mauro, Court Wary of Suicide Right: Debate Suggests
Issue Could Be Left to States, USA TODAY, Jan. 9, 1997; D. van Biema, Death’s Door Left Ajar: The Justices Deny
a Sweeping Right to Assisted Suicide But Might Entertain More Modest Claims, TIME MAG., July 7, 1997, at 30;
High Court Seen as “Skeptical” on Suicide Right, LIFE AT RISK, 1997, vol. 7, no. 1, at 1.
528
Oregon Votes Not to Repeal Assisted Suicide Law, NAT’L RIGHT TO LIFE NEWS, Nov. 18, 1997.
529
Oregon Death With Dignity Act: The First Year’s Experience, Oregon Dept. Of Human Resources, Feb.
18, 1999; K. Foley & H. Hendin, The Oregon Report: Don’t Ask, Don’t Tell, HASTINGS CENTER REP., May/June,
1999, at 37; C. Hamilton, The Oregon Report: What’s Hiding Behind the Numbers? Physicians for Compassionate Care, 2000, vol. 3, no. 1, at 2; J. Holan, Fear of “Burden” Major Reason for Oregon Assisted Suicides,
NAT’L RIGHT TO LIFE NEWS, Mar. 2001, at 5; B. Johnston, Assisted Suicide in Oregon: Deaths More Widespread,
NAT’L RIGHT TO LIFE NEWS, Apr. 2003, at 29.
530
Controlled Substances Act of 1970, with Amendments (1984).
Other People’s Lives: Reflections on Medicine, Ethics, and Euthanasia
317
by Ms. Janet Reno, U.S. Attorney General, who declared that she wouldn’t enforce the
federal Controlled Substances Act in cases of assisted suicide in the state of Oregon. Ms.
Reno did not make clear whether hers was a pragmatic decision, taken to avoid conflict
and further legal complications, or a decision on principle, a recognition of states’ right
to determine what is a legitimate medical purpose in their state. Well, states do have the
right to regulate medical practice within their jurisdiction, but do they have the power
to regulate or change medicine itself? To change medicine’s aims? This would seem to
extend the states’ rights too far: Medicine is a learned discipline with an all-American
and global reach, has existed for a few millennia, and has established its own standards.
The new Attorney General Mr. John D. Ashcroft issued the directive to apply the
Controlled Substances Act to all actions in violation of this federal law, including actions
committed in compliance with the Oregon assisted suicide law.531 The directive was suspended by a judge,532 and the chain of appeals ended in the U.S. Supreme Court’ refusal
to hear the case. Meanwhile, a vigorous campaign was started in the media; frightening
pictures were presented, federal agents spying on doctors, some doctors in jail, others
afraid of prescribing painkillers to their patients, etc. As a matter of fact, nobody can be
put in jail by virtue of Controlled Substances Act because the only sanction it provides
is suspension of the right to prescribe controlled substances;533 spying on doctors is
superfluous because those prescribing drugs to commit suicide are supposed to report
their actions to Oregon’s Health Division;534 and treating pain is not involved in the
issue at all, since the method of suicide (modeled on the Dutch prescription) consists
in ingesting an overdose of sleep-inducing barbiturate,535 not painkillers.
Of course the enactment of assisted suicide law in Oregon has been an event
of extremely grave importance. Moreover, it can lead to further changes in American
jurisprudence. If a category of persons is entitled to assistance in committing suicide,
the courts may – or will have to – adjudge the same right to paralyzed patients unable
to take the poison, and to unconscious persons and minors represented by guardians.
Thus, by virtue of the 14th Amendment to the Constitution, which guarantees equal
protection of the law to all citizens, the law permitting physician-assisted suicide may
lead to legalization of voluntary and involuntary active euthanasia; there is little doubt
that these are the further prospects. But first, the acceptance of assisted suicide would
have to expand, Oregon must no longer be the sole exception.
531
D. Eggen & C. Connolly, Ashcroft Blocks Oregon Assisted-Suicide Law: Participating Doctors Face Loss
of Rx License, BOSTON GLOBE, Nov. 7, 2001.
532
Judge Blocks a U.S. Bid to Halt Assisted Suicides, BOSTON GLOBE, Nov. 9, 2001; W. McCall, Oregon
Suicide Law Gets Longer Reprieve: Court Allows U.S., State 5 Months to Ready Arguments, BOSTON GLOBE, Nov.
21, 2001; B.J. Balch, Federal Judge Overturns Ashcroft Assisted Suicide Ruling, Appeals Expected, NAT’L RIGHT
TO LIFE NEWS, May 2002, at 11; L. Denniston, Ruling Protects Assisted Suicide, BOSTON GLOBE, Apr. 18, 2002;
D. Kravets, U.S. Again Challenges Ore. Suicide Law, BOSTON GLOBE, Sept. 24, 2002.
533
Controlled Substances Act, supra note 530.
534
The Death with Dignity Act, supra note 512, at secs. 3.09 & 3.11.
535
Foley & Hendin, supra note 529.
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To achieve such expansion has proved difficult. Bills modeled on the Oregon law
were submitted to the legislatures of thirteen states, and were rejected by, or died in,
various committees. Putting such bills on the ballot was tried in two states; the initiative failed to pass in Maine,536 and was rejected by a huge majority of 71 percent in
Michigan.537
What’s the future going to bring? Will the indomitable “libertarian” drive persuade
more and more states to legalize physician-assisted suicide? I hope not.
It takes an undercurrent of tribal eugenics, and a very persistent, predominant,
monopolistic propaganda to overcome a country’s taboo on killing; and it takes a
“pragmatic disregard of the law” to make euthanasia an established practice ahead of
any legislation. This is what happened in the Netherlands. The U.S., with its respect for
the law, with its multitude of independent centers of thought and action, its wonderful
ethnic and cultural diversity, is too great a country to succumb to such an assault.
Some of my readers will not rejoice at the prospect. Will the government tell us
how long we have to suffer? Will there be no escape?
Dear friends, life is not a trap. Life is all you have. You will not be given another
chance. Distrust people too willing to let you go. Don’t trust their hearts, and even less
their wisdom. Live and die among people who love you, lament you when the worst
has come, and like to keep you with them forever.
Chapter XXIX. The Shaping Of Public Opinion
In Holland, the opinion polls conducted in the last three decades have shown
an increasing acceptance of euthanasia by the public: in 1986, 76 to 77 percent of the
respondents supported euthanasia (whether voluntary or involuntary),538 in 2001 the
percentage rose to 82.539 The consolidation of the present overwhelming majority must
be seen as a remarkable phenomenon in the very diversified Dutch society where so
many religious denominations coexist and no less than eleven political parties compete
in the elections.
One of the influences that has contributed to creating those exceptionally high
percentages in favor of euthanasia was the way the polls were conducted. With social
acceptance of euthanasia known to be on the rise, asking solely the positively construed
questions of the type “Do you agree with . . .,” as all the questionnaires did, was bound
to elicit many quick and less than thoroughly considered affirmative answers. The results
Maine on the Way to the Ballot in 2000, PRO-USA REP., Spr. 1999, at 1 (Newsletter of the Hemlock
Society); B. Daley, Taking the Initiative: Mainers Weigh Tough Issues at Ballot Box, BOSTON GLOBE, Nov. 3,
2000; Suicide Voted Down, WALL ST. J., Nov. 10, 2000.
537
Measure to Legalize Assisted Suicide in Michigan on November Ballot, IAETF UPDATE, 1998, vol. 12,
no. 3, at 1; Michigan Buries Proposal B, LIFE AT RISK, 1998, vol. 8, no. 8, at 1; Michigan Rejects Euthanasia
Initiative, 71% - 29%, NAT’L RIGHT TO LIFE NEWS, Nov. 17, 1998
538
Meer Nederlanders voor actieve euthanasie [More Dutchmen favor active euthanasia], NRC HANDELSBLAD, Jan. 13, 1986.
539
G. VAN DER WAL, A. VAN DER HEIDE, B.D. ONWUTEAKA-PHILIPSEN, & P.J. VAN DER MAAS, MEDISCHE BESLUITVORMING AAN HET EINDE VAN HET LEVEN: DE PRAKTIJK EN DE TOETSING PROCEDURE [Medical decision making at the end
of life: The practice and verification procedure] 69 (tbl. 7.3) (De Tijdstroom, Utrecht 2003).
536
Other People’s Lives: Reflections on Medicine, Ethics, and Euthanasia
319
could be different had the questionnaires been drawn up in a way that would induce
the respondents to consider both the pros and cons of euthanasia.540
The selective information supplied to the Dutch public was of utmost importance
in shaping opinion on the issue of euthanasia. In the last thirty years a great number of
books, monographs, official documents, press reports and scientific papers on the subject
have been published in Holland, and symposia have been exceedingly frequent. Among
those thousands of publications and telecasts a few were open-minded on the issue of
euthanasia, most favored it, and discussed euthanasia as an established practice beyond
any dispute. From 1982 to 1985, 166 items concerning euthanasia were published in
a large circulation moderate Dutch daily, Brabants Dagblad; only two of these opposed
euthanasia. Of the eleven existing TV corporations, only one telecasts programs allowing
the opponents of euthanasia to explain their point of view. The Dutch opponents of
euthanasia who wish to state their views in print do so in small bulletins read only by
themselves or in little known periodicals. As a rule publishers reject manuscripts that
oppose euthanasia. The very well researched critical history of the euthanasia movement
written by Dr. Issac van der Sluis was rejected by eight publishers and finally printed
by the author at his own expense. My book opposing euthanasia had been rejected by
four publishers before Van Loghum Slaterus in Deventer decided to publish it. The
Dutch press, usually eager to pick up every piece of news on euthanasia, did not report
that the European Committee of Medical Ethics and the World Medical Association
condemned Dutch euthanasia.
How does the situation in America compare with that in Holland? Of course the
U.S. is much less accepting of euthanasia, there is no national consensus on the issue
(yet), and the resistance to euthanasia is more powerful than in Holland. But similar
developments have begun.
The Dutch advocates of euthanasia emphasize that making the issue debatable was
the first step on their way to victory.541 In the United States euthanasia became debatable
long ago. The next step to follow, according to the Dutch, is the stroomversnelling, “the
rapids.” This is now beginning in the United States. Key media are approached and easily
won. It is in the nature of the media to seize upon genuine news. “Thou shall not kill”
was news 3,500 year ago, it isn’t any more. Legal, logically justified, morally approved
killing is news. Printable matter is supplied in abundance by the pro-euthanasia movement. There is little opposition from the other side: The opponents of euthanasia still
put too much confidence in the stability of traditional values, and they find it awkward
to expound publicly the truths that in their view are self-evident.
540
Undoubtedly, in the U.S., questionnaires composed in a more balanced way would also have
changed the results of opinion polls.
541
Some years ago, in the Dutch press, there was an open discussion of pedophilia, in which several
debaters argued that children derive psychological and physical advantages from sexual intercourse with
adults. Not everything should be open to debate. There are topics which, for the sake of our common
safety and sanity, should never be discussed.
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The intervention of courts has become an important factor, helping to persuade
the public that allowing, hastening, even causing death is a matter of justice. Doctors are
told by judges when to stop treating their patients, and some of them have been ordered
to act against their professional judgment. Of course we all have to live under the law.
However, we should realize that law and medicine are governed by different principles
and defend different values. Law and medicine are two great achievements of our civilization. We should try to prevent the one from overwhelming and destroying the other.
Test cases of mercy killing are boldly publicized. Terrible examples that strike the
imagination, such as the man paralyzed from his neck down who somehow managed
to set his own bed afire, are cited to convince the reader of the necessity of euthanasia.
We know that it is improper to use uncommon cases to promote a change that would
affect millions of people and society as a whole, but this kind of argumentation helps
shape public opinion.
Horrific hospital scenes are depicted, and the language used, those “people
slumped in wheelchairs,” “decaying bodies,” “patients hooked on machines,” is such
as to evoke not sympathy but revulsion, and the feeling that the world should be rid
of such abominations.
Unconscious persons, who stay alive are called “biologically tenacious,” as if they
were not people whom we cherish, whose illness pains us, but noxious creatures resistant to insecticides. The lives of newborns and of people with substantial disabilities
are verbally abused and devalued. Their very humanity is questioned so as to make
euthanasia an imperative. They are termed “monsters,” “post-human beings,” and we
are asked if they are “still persons, or only things”?542
An insidious attack is directed at people who do their best to help fellow humans
in distress. Not the death and disease but doctors and their machines are depicted as
the enemies of mankind.
The right to die is forcefully emphasized, as if dying were indeed a right and
not a sad necessity. The theme of dignity is widely exploited. We are told that to be
assisted by medical technology entails loss of dignity, as if the dignity of honest, caring,
courageous people, our parents and spouses, could somehow be drained out of them
through medical devices. And we are told that the way to die in dignity is to let yourself
be killed by a professional.
A special, soothing language is used to make it easier for the public to accept
euthanasia. Documents intended to hasten death are given the name of “Living Wills”
and killing patients with injections is called “Aid in Dying.” The term “euthanasia” is
carefully avoided, and “physician-assisted suicide” is substituted, though there is no
moral difference between the two, and the factual difference is negligible.543
542
J. Fletcher, The “Right” to Live and the “Right” to Die, in BENEFICENT EUTHANASIA 44-53 (M. Kohl, ed.
1975).
543
See chapter XXVIII, subsection entitled Physician-assisted Suicide: Is It Any Better Than Active Euthanasia?
Other People’s Lives: Reflections on Medicine, Ethics, and Euthanasia
321
In Holland, doctors unimpressed by the quasi-legalization, and all the rhetoric in
praise of voluntary euthanasia, go on exterminating children with disabilities544 and sick
elderly people who never asked for death.545 Similar exterminatory practices, though
on a smaller scale, occur in the United States546 along with the movement in favor of
assisted suicide. Indeed, two different currents mix and intertwine in the euthanasia
movement: the libertarian and the exterminatory. Watching this alliance of the honest
and sincere with the ruthless and fanatical, I have little doubt who will use whom and
whose agenda will prevail. The striving of libertarians for expanded rights and unlimited
freedom of the individual will produce the opposite: compulsion to die, denial of the
right to live, and replacement of human community we know by a new Killing Society.
Chapter XXX. The Society That Has Embraced Euthanasia547
In the last three decades euthanasia has become one of the main issues, and the
most discussed issue in Dutch public life, politics, and national conscience. Euthanasia
is supported by all major Dutch political parties and by a majority of Dutch Catholics,
Protestants, and agnostics and has found a way to express and unify important and
disparate social moods and tendencies.
The anti-intellectual and anti-technological rebellion in the years after World War
II, and the triumphant technological society’s certitude that all problems (including
death) can and must be solved, met and intertwined in the movement in favor of euthanasia. The movement was begun by people who believe in abolition of all taboos and
joined by those observant of the new taboos protecting autonomy and selfishness. The
movement in favor of euthanasia succeeded in unifying at the same time the modern
abhorrence of death, disease, dependence, and disfigurement, and the new national
fascination with death.
People intent on improving the human race by extermination of weaklings form
an important current in the movement in favor of euthanasia. They mute their rhetoric
to conform with the official platform, but when euthanasia is considered for infants
with disabilities, and people who are mentally retarded or demented, or the policy of
allowing certain groups to die out is promoted, the supporters of extermination reveal
their presence in an unmistakable way.
The supporters of free choice and “the right to die” form an even more important
current. This group includes both libertarian intellectuals who proclaim the individual’s
See chapter XVIII.
See chapters XIX and XX, Tbl. 1, and subsections entitled More Information on Active Involuntary
Euthanasia and Active Involuntary Euthanasia in 1995/1996 and 2001/2002.
546
C.E. KOOP, KOOP: THE MEMOIRS OF AMERICA’S FAMILY DOCTOR 240-61, 251-52 (1991); Gross et al.,
Early Management and Decision Making for the Treatment of Meningo-myelocele, 72 PEDIATRICS 450 (1983).
547
Physician-assisted suicide has only been practiced in Oregon since 1998, on a limited scale, and a
considerable part of the public and majority of the medical profession oppose or ignore the practice. Some
corruption due to unpunished killing can already be seen: coercion by family members (see, supra, n.
509), “shopping” for doctors willing to prescribe lethal drugs, and hard-core activists rallying to promote
and facilitate death. However, Oregon has not yet become the place where one could watch the full-blown
societal effects of euthanasia. Holland is such a place.
544
545
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unlimited right to self-determination and people who simply are afraid of suffering, feel
that they have the right to escape it, and want to have the means. The libertarians have
shaped the present official platform of the movement.
Active euthanasia has been openly practiced in the Netherlands for over thirty
years, a time probably too short to expose all the changes it brings about in society, but
long enough to reveal some of the consequences. Indeed, the practice of euthanasia has
perceptibly affected the position of the individual in relation to society, society’s very
nature and purpose, law, government, judicial system, the practice of medicine, family,
the expectations of older persons, and the prospects of newborn citizens.
Some knowledge of the Dutch health care and welfare system is needed for a
correct understanding of Dutch euthanasia. It is important to realize that among the
industrialized nations Holland has developed one of the best, and arguably the best,
health care system, and an excellent system of care for older persons and people with
disabilities.548 Practically all of the country’s residents have health insurance – money
plays no role in a patient’s decisions concerning medical treatment. A high percentage
of physicians practice family medicine, which makes health care eminently accessible.
There are no crowded emergency rooms. Nursing homes and institutions for mentally
retarded persons are modern, well equipped, and manned by skilled and dedicated
workers.
Does economy influence Dutch euthanasia? Having closely watched the scene of
Dutch euthanasia for many years, I am quite certain that the Dutch pro-euthanasia movement, its mainstream, has never been economically motivated. When some defenders
of euthanasia assume a no-nonsense attitude putting forward economic arguments, it
is felt this is a rationalization serving to conceal motives more difficult to avow.
The Intolerant Majority. In the very open Dutch society an exception is made for
euthanasia: The majority does not tolerate dissident views on this issue, and opposing
acts are strongly condemned. In numerous articles and declarations those who object
to euthanasia have been accused of trying to impose their own views on other people,
excluded from the community of reasonable persons,549 and depicted as fanatics prone
to outbursts of rage.550 When the pediatricians, the surgeons, and the parents denied
surgery for duodenal obstruction to a baby with Down syndrome and let the child die,
the only person whose conduct was found to be at fault was the family physician who
did not agree with the decision and called the district attorney. He was said to have
grossly violated the privacy of his patient and of the parents and to have transgressed
R. Fenigsen, Physician-Assisted Death in the Netherlands: Impact on Long-Term Care, 11 ISSUES IN LAW
& MED. 283 (1995); R. Fenigsen, Euthanasia in the Netherlands, in ENCYCLOPEDIA OF U.S. BIOMEDICAL POLICY
72 (R.H. Blank & J.C. Merrick, eds. 1996).
549
J.C. Molenaar, Het nalaten van medisch handelen [The omission of medical treatement], 132 NED.
TIJDSCHRIFT V. GENEESKUNDE 1926 (1988).
550
H.M. Dupuis, Patienten in coma: Een oplosbaar probleem [There is a solution to the problem of comatose patients], 132 NED. TIJDSCHRIFT V. GENEESKUNDE 1927 (1988).
548
Other People’s Lives: Reflections on Medicine, Ethics, and Euthanasia
323
his duty to preserve professional confidentiality.551 The nurse who protested against
euthanasia of a child with disabilities and, together with her husband, offered to adopt
the baby, saw her offer rejected, and received an official reprimand because by involving
her husband in the adoption offer she violated professional confidentiality.552 In the
affair of the doctor who killed several residents of a senior citizens’ home without their
request, consent, or knowledge, a high ranking lawyer, the Board of the Royal Dutch
Society of Medicine, and the president of the Dutch Society for Voluntary Euthanasia
declared that the person to be blamed was the district court judge who unduly made a
criminal of the defendant, and by sentencing the doctor adversely influenced the practice of euthanasia in the country.553 Critics of euthanasia are sued by the Dutch Society
for Voluntary Euthanasia;554 and those opponents of euthanasia who are Jewish are
implicitly555 and explicitly556 met with the reproach that their personal reminiscences
of the Nazi era and the resulting bias disqualify them from pronouncing any judgment
on euthanasia.557 Hostile acts follow, aimed at undercutting the opponents’ income
and professional existence. A dermatologist in Amsterdam, known for his learned and
incisive publications opposing euthanasia,558 was silenced when family physicians, to
punish him, stopped referring patients to his office.559 In recent years, physicians who
oppose euthanasia encounter considerable difficulties when they apply for post-graduate
training, try to obtain residency, or open a family practice.560
A Deputy Secretary General of the Royal Dutch Society of Medicine found it
suitable to declare that doctors who refuse to carry out euthanasia “open the door to
Auschwitz.”561 Such absurd and over aggressive utterances of the promoters and practitioners of euthanasia betray how insecure they feel.
551
J.C. Molenaar, K. Gill & H.M. Dupuis, Geneeskunde dienares van barmhartigheid [Medicine, servant
of charity], 132 NED. TIJDSCHRIFT V. GENEESKUNDE 1915 (1988).
552
B. Versteeg, De wens van de ouders en het recht op het leven van een kind [The wish of the parents and
the child’s right to life], 4 IN PERSPECTIEF 12 (1991).
553
Jurist kraakt proces tegen arts De Terp [Lawyer victorious at the trial of De Terp doctor], BRABANTS
DAGBLAD, Aug. 17, 1985; and Artsen bezorgd na vonnis De Terp: Euthanasie in kwaad licht [Doctors express
concern because of De Terp verdict: Euthanasia put in an unfavorable light], BRABANTS DAGBLAD, Aug. 7,
1985.
554
The Board of the Dutch Society for Voluntary Euthanasia, Letter to the Editor, HASTINGS CENTER REP.,
Nov./Dec., 1989, at 49.
555
H.H. van der Kloot Meijburg, Letter to the Editor, HASTINGS CENTER REP., Nov./Dec., 1989, at 48.
556
I. Jungschleger, Interview with Prof. C.I. Desaur, VOLKSKRANT, Jan. 14, 1986.
557
C.I. DESAUR & C.J.C. RUTENFRANS, MAG DE DOKTER DODEN? [Is the doctor allowed to kill?] 26 (Querido, Amsterdam 1986).
558
I. VAN DER SLUIS, HER RECHT OM GROOTMOEDER TE DODEN [The right to kill grandma] (Editions St.
Jacques, Amsterdam 1979).
559
Interview with Dr. Herbert Cohen, in H. HENDIN, SEDUCED BY DEATH: DOCTORS, PATIENTS, AND THE DUTCH
CURE 105 (1997).
560
Nederlands Artsenverbond [Dutch Physicians’ League], Aan de Tweede Kamer Der Staten Generaal,
t.a.v. de vaste commissie voor Justitie, 14 oktober 1999 [Letter to the Second Chamber of Parliament, attention
of the Permanent Committee on Justice, Oct. 14, 1999].
561
E. Vullamy, Life or Death? THE GUARDIAN (London), Feb. 17, 1988.
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Human Life and Other Trivia. From the government-ordered study562 one can calculate that on an average day in 1995 ninety-seven persons died in Holland as a result of
deliberate actions of physicians.563 This is a large figure; it shows that physician-induced
death is no exceptional event, almost everybody must hear of such occurrences in one’s
neighborhood, if not in one’s own family, once in a while.
Physician-induced death has become commonplace, and is treated accordingly.
How are such events arranged? To many patients the lethal injection is administered
almost immediately after the request.564 On the other hand, quite often euthanasia is
postponed for several weeks because the patient desires to spend another Christmas
with her family. This raises doubts about the rationale for euthanasia: If it can wait, if
it is not urgent, is it really necessary? Euthanasia may be postponed till after Easter or
a birthday, or to enable family members living in other parts of the country, or coming
from Australia, to take leave of the departing one. In a published case, a patient’s family
came from Canada because of planned euthanasia; then the patient said: “No, not to-day,
I don’t want it any more,” but everybody pressed him saying “Look, the family came
from Canada, they cannot do it again.”565
Dr. Karel F. Gunning, family physician in Rotterdam, reported that one of his fellow
physicians was approached by a man who requested euthanasia for his old and ill father.
The son wanted euthanasia performed so that he could bury the father before leaving
for vacation. The request was granted, but the euthanasia was botched.566
In the U.S. the mentality of similar kind is not unknown. In a hospital in California a friend of mine witnessed a request for euthanasia of an old lady, submitted by
her daughter. Confronted with the doctor’s refusal, the daughter argued that she had
already disposed of the mother’s belongings at a yard sale.
Years after the death of King George V, the notes of the monarch’s personal physician, Lord Dawson, were published and revealed that in January 1936, when the king
neared death, Dr. Dawson gave him a lethal injection. “It was important,” noted the
G. VAN DER WAL & P.J. VAN DER MAAS, EUTHANASIE EN ANDERE MEDISCHE BESLISSINGEN ROND HET LEVENS
[Euthanasia and other medical decisions at the end of life] 181 (Sdu Pub. House, The Hague 1996).
563
Id. According to this nationwide survey, on an average day in 1995, nine persons died by voluntary
euthanasia, one was assisted by a doctor in committing suicide, and seven who never asked for death were
deliberately terminated by lethal overdose of pain killers or with an injection paralyzing the heart beat and
respiration. Lethal overdoses were also administered to five consenting people. Life-prolonging treatment
of seventy-five people was withheld or withdrawn with intention to cause death.
564
G. van der Wal, Th.M. van Eijk, H.J.J. Leenen, & C. Spreeuwenberg, Euthanasie en hulp bij zelfdoding door artsen in de thuissituatie [Euthanasia and physician-assisted suicide at the (patient’s) home], 135
NED. TIJDSCHRIFT V. GENEESKUNDE 1593 (1991).
565
B. Zylicz, in K. Birchard, Dutch Authorities Consider Exempting Docs from Euthanasia Laws, MED. POST
(Toronto), May 4, 1999.
566
Dutch Physician, Dr. Karel Gunning, Warns Canadians to Oppose Euthanasia, COMPASSIONATE HEALTHCARE NETWORK (Surrey B.C.), Fall 1994, No. 8, at 1-2; R. Wigod, Pitfalls of Euthanasia Cited: Ailing Father
Death Target, VANCOUVER SUN, Oct. 4, 1994, at B1-2.
562
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Other People’s Lives: Reflections on Medicine, Ethics, and Euthanasia
325
doctor, “to let this death occur in time to be announced in the morning newspapers,
and not in the less appropriate evening journals.”567
Professor Margaret Somerville of Toronto, whose opposition to euthanasia is well
known, was invited by the Dutch Medical Law Association to give an address to mark the
group’s 25th anniversary. At the reception that followed the meeting, the Dutch doctor
approached professor Somerville and said: “Look, I’ll give you a case of euthanasia with
which I’m sure you will agree.” The lady expected to hear of a terminally half-suffocating
patient with amyotrophic lateral sclerosis or a similar case of hopeless suffering. What
she heard was a very different story. An eighty-three-year old highly educated woman
became very lonely after the death of her diplomat husband with whom she had lived
a wonderful life in various parts of the world. She said she had nothing to live for. Her
husband, the center of her life, had died. All her friends had died. She had no children.
Her only company was her doctor who visited every week and with whom every week
she would plead, “Please give me an injection.” After about three months the doctor
obliged. Professor Somerville paused for a moment, and then asked: “Did you think of
buying her a cat?” The doctor looked at her and, with complete serousness, said: “What
a good idea!”568 Professor Somerville’s remark was adorable, witty and to the point, but
it is the Dutch doctor’s reply that I find even more interesting. To him, killing the lady,
or buying her a cat, were, indeed, options. Buying a cat could even be preferable.
Making death trivial might perhaps be a good thing, but it has an inherent obverse
side: life is also made trivial. Whether somebody lives or dies has become just one of
these trivia.
What Has Changed? Can one notice anything particular in the cities and villages of
the nation that has embraced euthanasia? Not much. There is work as usual, business
as usual, politics, sports, and entertainment as usual.
But something has changed. Instead of the message a humane society sends its
members – “Everybody has the right to be around, we want to keep you with us, every
one of you” – the society that embraces euthanasia tells people: “We wouldn’t mind
getting rid of you”; and this message reaches the elderly, the sick, and all the weak and
dependent. It is now up to them to justify their existence. The Superior Public Prosecutor
T.M. Schalken stated in 1984 that “the elderly are now under pressure to begin talking
about euthanasia, and even under pressure to request it.”569 In 1988 a group of adults
with significant disabilities, from Ammersfoort, stated in their letter to the Parliamentary
Committees on Health Care and Justice: “We feel our lives threatened …. We realize that
567
J. Lelyveld, Euthanasia Performed on King George V, Physician’s Notes Reveal, INT’L HERALD TRIB., Nov.
29-30, 1986, at 2.
568
B. Tobin, Did You Think About Buying Her a Cat? Some Reflections on the Concept of Autonomy, 11 J.
CONTEMP. HEALTH L. & POL’Y 417 (1985).
569
T.M. Schalken, Counsel for the Prosecution’s Address to the Appeals Court in Amsterdam, 1984 NEDERLANDS JURISTENBLAD 38. See also analyses of this address: J.A. van der Does de Willebois, Een Magna Charta
voor de verdedigers van het menselijk leven [A magna charta for the defenders of human life], 11(1) VITA HUMANA 3 (1984); and A.J. Colijn, Euthanasie en de rechtspolitieke betekenis van het gewetensconflit [Euthanasia
and politico-legal significance of conscience conflict], 11(1) VITA HUMANA 12 (1984).
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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 frightening and very dangerous
if the new medical legislation includes euthanasia.”570
If asked, many people will tell you they find it comforting to know that when they
fall hopelessly ill they may ask a doctor for euthanasia. True, there is also at the back
of people’s mind an awareness that if a doctor puts an end to your life without your
consent, he won’t be punished.
Clearly, the feelings and attitudes of people depend on the degree of real risk they
run. Young and middle-aged healthy people – that is, the majority of the population –
support voluntary and involuntary euthanasia in the polls571 and often show a cavalier
attitude toward their own lives. It is these people who easily and well in advance sign
declarations saying that “when I get in a bodily and mental condition from which no
recovery to a reasonable and dignified life can be expected, it is my wish that euthanasia
be performed on me.”572 Meanwhile, feelings of anxiety and uncertainly lurk among
the members of vulnerable groups. In their fears, people do not distinguish “voluntary”
from “involuntary” euthanasia. A study of attitudes of the elderly done by Dr. J. Segers
showed that 66 percent of those living in their own homes, and 95 percent of those
living in homes for senior citizens opposed the legalization of euthanasia. Fifty to 60
percent of older people interviewed by Dr. Segers were afraid that their lives could be
terminated against their will by others.573 There were scattered reports that some older
people, afraid of involuntary euthanasia, avoided visiting doctors’ offices,574 and, when
admitted to a hospital, refused to take any medicines and even orange juice.575 The Dutch
Patients’ Association (N.P.V.), an anti-euthanasia group, stated in 1985 that “in recent
months the fear of euthanasia among people considerably increased.”576 Eight years later,
the Christian Protestant Association of the Elderly (P.C.O.B.), an organization that in
principle accepts euthanasia, surveyed 2,066 senior citizens and found that many feared
they would be subject to euthanasia if admitted to a hospital. Some older people, out
of fear of involuntary euthanasia, delayed their admission to nursing or senior citizens’
Letter of a group of severely disabled adult persons to the Parliamentary Committees on Health Care and
Justice, NEDERLANDS DAGBLAD, Apr. 1, 1988.
571
Meer Nederlanders voor actieve euthanasie [More Dutchmen favor active euthanasia], NRC HANDELSBLAD, Jan. 13, 1986; P. Van der Eijk, Euthanasie en ‘de mensen’ [Euthanasia and “the people”], in DESSAUR &
RUTENFRANS, supra note 557, at 31.
572
NED. VERENIGING VOOR VRIJWILLIGE EUTHANASIE [Dutch Association for Voluntary Euthanasia], LEVENSTESTAMENT/EUTHANASIEVERKLARING [Living Will/Declaration of Request for Euthanasia] (1982).
573
J. Segers, Elderly Persons on the Subject of Euthanasia, 3 ISSUES IN LAW & MED. 407 (1988).
574
Euthanasievrees belet gang naar arts [Fear of euthanasia keeps (patients) from visiting doctors’ offices), DE MEDICUS, 1985, vol. 3, no. 93.
575
R. FENIGSEN, EUTHANASIE, EEN WELDAAD? [Charitable euthanasia?] 87 (Van Loghum Slaterus, Deventer
1987).
576
NIEUWSBULLETIN NEDERLANDSCHE PATIENTENVERENIGING [News bulletin of the Dutch Patients’ Association], 1985, vol. 3, no. 1, at 8.
570
Other People’s Lives: Reflections on Medicine, Ethics, and Euthanasia
327
homes, even when they could no longer care for themselves at their own homes.577
When the new regulations concerning euthanasia, passed by the Parliament in 1993,
officially acknowledged the practice of “active termination of patients’ lives without their
request,”578 the news increased the anxiety among the elderly.579 The Association found
it necessary to warn the Secretary of Health about the alarming results of the study.
The image of the family began to change. Some published case histories revealed
the role of family members who pushed older persons to request death.580 The study
of elderly hospital patients done by Ms. Marion Wagner showed that many feared their
own families as people who at a critical moment could decide on euthanasia.581
At the same time, dramatic changes were occurring at the other end of society’s age
spectrum, afflicting those newborn and children who need special help to survive and
grow. The care for bodily or mentally disabled children flourished in the Netherlands
in the 1960s and early 1970s; “if there were limits to the extension of care, they only
could be due to limited funding, never to lack of commitment.”582 The participation of
parents was important and necessary to the success of these endeavors.
Euthanasia of newborns and children with disabilities began in the mid-1970s,
and triggered (or revealed) a sea change in society’s attitude toward its weaker members.
Since the advent of euthanasia, the limits of community’s commitment became visible,
restrictions to funding multiplied, and the parents have often been denied assistance.583
But the parents who undertake to raise a child with disabilities, and those who have for
years nursed, loved, and protected their disabled son or daughter, can no longer expect
support or even understanding of other members of the community. What they now
hear are utterances expressing surprise, incomprehension, repugnance, or even hate;
warnings and threats. The following are examples collected by professor J. Stolk of the
Free University in Amsterdam, an authority on mental retardation, and his collaborators: “What? Is this child still alive?” “How can one love such child?” “Nowadays such
577
Ouderen bang voor onvrijwillige euthanasie bij ziekenhiusopname [Elderly afraid of involuntary euthanasia in case of admission to a hospital], DE VOLKSKRANT, June 9, 1993.
578
R. Fenigsen, The Netherlands: New Regulations Concerning Euthanasia, 8 ISSUES IN LAW & MED. 167
(1993).
579
Ouderen bang, supra note 577.
580
W. VAN DEN LINDEN, ZIJ MOEST EERST ... HET DOSSIER VAN BOMMELEN: EEN GEVAL VAN EUTHANASIE? [She had
to go first ... The van Bommelen file: A case of euthanasia?] (Strengholt Pub., Naarden 1984); Waarom heeft
Wibo niet ingegrepen? [Why the (TV journalist) Wibo van den Linden did not intervene?], ZONDAG (Beusichem), Jan. 22, 1984; G.A. Lindeboom, Een z.g. euthanasie-drama [The drama of the so-called euthanasia],
11 VITA HUMANA 100 (1984);H. TEN HAVE & G. KIMSMA, GENEESKUNDE TUSSEN DRROM EN DRAMA [Medicine between dream and drama] 83-87 (Kok-Agora Pubs., Kampen 1987); and G.F. Koerselman, Hoe mondig zijn
moderne patienten? [How mature are modern patients?], 130 NED. TIJDSCHRIFT V. GENEESKUNDE 2017 (1986).
581
M. Wagner, Stervenshulp: Wensen van patienten [Assisted death: The wishes of patients], 49 MEDISCH
CONTACT 1569 (1984).
582
J. Stolk, Euthanasie en de waarde van het leven van verstandelijk gehandicapte kinderen [Euthanasia
and the value of life of mentally challenged children], in GEBROKEN WERELD: ZWAKZINNIGENZORG EN DE VRAAG
NAAR EUTHANASIE [The broken world: Care of the mentally retarded and the demand for euthanasia] 32 (J.
Stolk, ed., J.H. Kok, Kampen 1988).
583
Id.
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a being need not be born at all.” “With such a child you put your own future at risk.”
“Such a thing should have been given an injection.”584 No, this is no longer the same
society as thirty years ago.
How do the parents react? As they told the researcher, after such encounters they
were left “speechless,” “crying and sleepless for several days and nights,” “paralyzed,”
or “totally crushed.”585 A father said: “We feel that people let us down.”586
Sandra, a spastic and mentally disabled girl of eight, developed a menacing growth
on her neck. The mother brought her to a hospital, but the doctor said: “I won’t do anything. It’s meaningless, anyway.” “We fled from that hospital, weeping,” says the mother.587
In the view of professor Stolk, “the killing of handicapped children denotes the
end, or in any case the beginning of the end of care for the mentally retarded.”588
Mr. Bottelier, president of the Dutch Association for Care of the Disabled, demanded from the government an assurance that the lives of mentally retarded will be
respected.589 No such assurance was given.590
A lady from Australia told me at a conference: “You and your colleagues argue
that we should let children born with Down syndrome live, but nobody is concerned
about the mother. And yet it is the mother who will have to raise such a child, not you.
It is the mother who will have to live with this burden.” In a New England family of
my acquaintance a child had a medical problem soon after birth and the prognosis was
still uncertain: the trouble could prove insignificant and disappear, or it could turn out
to be the first sign of a permanent disability. The grandmother confided to me that in
the latter case it would be better if the child died. The lady’s motives were unselfish:
the person she cared for was her son. She was terrified at the thought that her son’s life
could be marred by raising a disabled child. Every time I had a conversation of this kind
I thought how wonderful it would be if the traditional medical ethics, its unbending
maxim, Salus aegroti suprema lex, “the good of the sick one is the highest law,” were
taken over by society at large. The sight of the weak and vulnerable would not incite us
to trample them to death, but to help and protect them. This ethic would place us on
the side of the Hippocratic ideal, of the great imperatives of Kant, of what is most precious in the Judeo-Christian tradition, on the side of utmost respect for the individual,
Id. at 33-34; G.E. van Breukelen, Leven met een gehandicapte kind is een leerschool [Living with a
handicapped child teaches you lessons] in GEBROKEN WERELD: ZWAKZINNIGENZORG EN DE VRAAG NAAR EUTHANASIE
[The broken world: Care of the mentally retarded and the demand for euthanasia] 99 (J. Stolk, ed., J.H.
Kok, Kampen 1988).
585
Stolk, supra note 582, at 33.
586
Id. at 34.
587
Id. at 33.
588
Id. at 36.
589
Voorzitter Bottelier van Vereniging Gehandicaptenzorg: Nooit euthanasie op mensen met verstandelijke
handicap [President of the Association for Care of Handicapped (Mr.) Bottelier: The mentally handicapped
must never be subjected to euthanasia], BRABANTS DAGBLAD, Mar. 26, 1992.
590
L. Cornelisse, Euthanasie wordt onder voorwaarden legaal [Euthanasia becomes legal, with some
reservations], TROUW, Feb. 3, 1993; F. Vermeulen, Pragmatisme kenmerkend voor euthanasie wet [The distinguishing feature of the bill on euthanasia is its pragmatism], NRC HANDELSBLAD, Apr. 3, 1993.
584
Other People’s Lives: Reflections on Medicine, Ethics, and Euthanasia
329
every individual. I am not portraying a utopia, but what in my quite recent memory
used to be the reality, what at every decent place was considered the only conceivable
attitude. Dostoyevsky proclaimed that if salvation of humankind required torturing a
child to death, humankind should not be saved;591 and we, his readers, agreed without
discussion. This firm stand seems to have been abandoned by a large segment of the
community. The ladies I quoted were willing to sacrifice children’s lives for purposes
much more limited than mankind’s salvation. And tumultuous voices call for the extermination of “non-persons,” “monsters,” and “subhumans.”592 How so many civilized
people can be so insensitive and short-sighted as to welcome this hideous new world
is beyond my comprehension.
It takes a visitor to Holland quite a while to realize that he has entered a new and
different world. It is a world of reversed values, surprising standards and strange emotions. Life is pitied, death is sought and envied. A leading ethicist launches an appeal
in praise of death.593 “No euthanasia for little Joris!” weeps the author of an article
about a sick child.594 A court ruled that being bored with life is not a sufficient reason
for euthanasia, and the media lament: poor elderly are denied an escape from life!595
Virtuous people, significant people are those who help us die. Three men can claim a
really important place in a woman’s life, says the country’s best novelist: the obstetrician who brings her into the world, the man who deprives her of her virginity, and the
doctor who helps her die.596
There still are people who criticize euthanasia, who refuse to do it; these are wicked,
cruel people who open the door to Auschwitz!597
Persons and institutions doing the reverse of their calling raise nobody’s eyebrows,
it has become the norm. Doctors supplying sick children with poison to enable them to
commit suicide,598 official lists of drugs to be used to kill patients,599 official guidelines
591
F.M. Dostoyevsky, Brat’ya Karamazovy [The Brothers Karamazov], in 9 SOBRANIYE SOCHINENIY [Collected Works], GOS. IZD. KHUD. LIT. 308 (Moscow 1958).
592
J. Fletcher, The “Right” to Life and the “Right” to Die, in BENEFICENT EUTHANASIA 44 (M. Kohl, ed. 1975).
593
Bijzonder hoogleraar medische ethiek dr. Heleen Dupuis: “Dood wordt te negatief gewaardeerd” [Professor extraordinary of medical ethics, Dr. Helen Dupuis: “Death is being evaluated in too negative a way”],
BRABANTS DAGBLAD, Nov. 1, 1985.
594
R. Huggenberg, Geen euthanasie voor kleine Joris [No euthanasia for little Joris], BRABANTS DAGBLAD,
Apr. 27, 1984.
595
P. van der Mije, Euthanasievonnis zet lijdende ouderen klem [Ruling on euthanasia pushes suffering
elderly into a devil of a fix], BRABANTS DAGBLAD, Dec. 27, 2002.
596
H. MULISCH, DE ONTDEKKING VAN DE HEMEL [The discovery of heavens] 93 (De Bezige Bij, Amsterdam
2002).
597
Vullamy, supra note 561 (quoting Secretary of the Royal Dutch Society of Medicine, Dr. Theo V.
Berkesteijn).
598
Arts geeft jongens dodelijke pil mee [Doctor supplies boy with deadly pills], BRABANTS DAGBLAD, Oct.
10, 1987.
599
The first list of euthanasia drugs of the Royal Dutch Society of Pharmacy was published in 1987
and some years later this Society published a corrected version: KONINKLIJKE NEDERLANDSE MAATSCHAPPIJ TER
BEVORDERING DER PHARMACIE [Royal Dutch Society], TOEPASSING EN BEREIDING VAN EUTHANATICA [Application and
preparation of drugs to carry out euthanasia] (The Hague, 1994).
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advising to perform euthanasia on a child’s request even when the parents protest,600
citizens’ committees founded in defense of doctors who kill unsuspecting elderly,601
public symposia debating over ways to justify euthanasia of “patients unable to express
their will,”602 government’s investigators shifting the responsibility for involuntary euthanasia on the victims603 – eyeing this sheer nightmare, I exclaimed at a meeting of the
Dutch Patients’ Association: “But this is the world upside down!”
Mastery of life, domination over people604
Michael Schooyans
Euthanasia, the Rule of Law, and the Future of Democracy in the Western World. For
more than thirty years euthanasia has been practiced in the Netherlands in open defiance of the law. The entire Dutch establishment, the Royal Society of Medicine, the
Health Council, the judiciary, the Supreme Court, the ministers of Health and Justice,
and the Parliament devoted themselves to working out ways to bypass the law of the
land. The euthanasia bill passed by the Parliament in 2001 is the final act of contempt
for the law: euthanasia remains a punishable crime, but doctors who carry it out are
granted immunity.605
Killing sick people without their consent is murder pure and simple. Yet thousands
of such acts were committed in Holland every year,606 and the perpetrators, many of
whom were known to the authorities, were never punished.
Standput Gezondheidsraad: Geen veto ouders als kind euthanasie wil [The Health Council’s Standpoint:
Parents have no veto right when the child wants euthanasia], BRABANTS DAGBLAD, Mar. 31, 1987; see also
Gezondheidsraad [The Health Council], Advies inzake zorgvuldigheidseisen euthanasie [Opinion on careful
conduct’s requirements (concerning) euthanasia], 131 NED. TIJDSCHRIFT V. GENEESKUNDE 1207 (1987).
601
Euthanasie-dokter! Comité steun huisarts D.W. Bakker [Euthanasia doctor! Committee for support of
family doctor D.W. Bakker], AMSTERDAM STADSBLAD ZUID, Aug. 14, 1985.
602
BESLISSEN OVER LEVEN EN DOOD: DILEMMA’S BIJ WILSONBEDWAME, ERNSTIG GEHANDICAPTE PASGEBORENEN, COMA-PATIENTEN, ZWAKZINNINGEN EN PSYCHOGERIATRISCHE PATIENTEN [Deciding about life and death: Dilemmas with
patients unable to conceive and/or express their will, newborns with severe disabilities, patients in coma,
with mental retardation, and psycho-geriatric patients] (L. Boon, ed., Stichting Sympoz, Amstelveen
1989).
603
G. VAN DER WAL & P.J. VAN DER MAAS, EUTHANASIE EN ANDERE MEDISCHE BESLISSINGEN ROND HET LEVENS EINDE
[Euthanasia and other medical decisions concerning the end of life] 237 (Sdu Pub. House, The Hague
1996); G. VAN DER WAL ET AL., MEDISCHE BESLIUITVORMING AAN HET EINDE VAN HET LEVEN: DE PRAKTIJK EN DE TOETSING PROCEDURE [Medical decisionmaking at the end of life: The practice and the verification procedure] 201
(De Tijdstroom, Utrecht 2003).
604
M. SCHOOYANS, MAÎTRISE DE LA VIE, DOMINATION DES HOMMES [Mastery of life, domination of people]
(Éditions Lethielleux, Paris-Namur 1986).
605
Article 293 of the Dutch Penal Code (Wetboek van Strafrecht) makes euthanasia a crime punishable
by up to 12 years’ imprisonment. Article 294 prohibits assisting a person in committing suicide; the punishment for this crime is three years in jail. Articles 293 and 294 remained on the books throughout the
more than three decades of open practice of euthanasia in the country and even the euthanasia law passed
in 2001 has not abolished these articles. It is remarkable that the Dutch, so proud of their free practice of
euthanasia, ultimately have not dared to fully decriminalize it.
606
See Table I, Ch. XX, supra, and REPORT I, supra note 199, at 15.
600
Other People’s Lives: Reflections on Medicine, Ethics, and Euthanasia
331
Not only in Holland,607 but also in the U.S.,608 and other Western countries,609 some
health care workers do their best to remove elderly people from society. As yet, limiting
the citizens’ life span is nowhere adopted as a national goal; but a number of community
leaders promote such a policy. A former governor of Colorado, member of the board
of the Hastings Center,610 a prominent journalist,611 and a former president of Boston
University612 exhort the aged to die quickly; a director of the most important center
for bioethics has proposed to stop lending medical help to people beyond a certain age
limit.613 An essential feature of such schemes is that they are conceived in the abstract,
without their authors trying to imagine how the project would work. A frightened old
lady would be brought to the emergency room with a massively bleeding duodenal ulcer,
and the doctor would say, “How old are you, madam? 86? Sorry, we cannot take care of
you. The ambulance will take you back home.” A nurse would call and say: “Doctor, Mr.
X is so breathless and coughs up pink foam, I think he’s got a pulmonary edema, I gave
him oxygen, may I inject morphine and lasix?” “No, nurse, he’s 87, let him suffocate.”
Do we want such scenes to occur in our hospitals? Do we want our doctors to act in
this way? Would we entrust such doctors with treating our spouses, our children? Do
we want a society that would instruct the doctors to act in such a way?
Some old people may long for death, but most entertain the hope of living a few
more years. When they break their hips they wish to have them fixed and be able to walk
again. When they faint and fall because of a slow heart beat, they cherish the freedom
and security offered by a pacemaker. If we were to stop offering them this kind of help,
not only our feelings, values, and habits of thinking would be reversed, but considerable
social change would be involved.614 The elderly are lifelong taxpayers, they do not, as
a group, support age limits to medical help, and in our present system of government
they have the right to vote. They may be supported by their families and by all of those
worried about their own future. Barring old people from medical assistance cannot be
put into effect with democratic means. A society that undertakes to effectively limit the
life span of its members must evolve into a totalitarian state.
Euthanasia seems to have a peculiar power to undermine the Rule of Law. Those
“passports to life,” pitiful papers which some Dutch people carry to ward off involuntary euthanasia,615 signal that for the protection of their lives people no longer rely on
the rule of law. The courts have granted virtual impunity to doctors who kill patients
See Ch. XXVII, supra.
Id.
609
Id.
610
W. Slater, Latest Lamm Remark Angers the Elderly, ARIZ. DAILY STAR, Mar. 29, 1984, at 1.
611
J. Paterson, Something Needs to be Done About the Quality of Dying, INT’L HERALD TRIB. Jan. 15, 1988.
612
R. Saltus, Silber Attacks Health System, BOSTON GLOBE, Apr. 30, 1991.
613
D. CALLAHAN, SETTING LIMITS: MEDICAL GOALS IN AN AGING SOCIETY (1987); D. CALLAHAN, WHAT KIND OF
LIFE: THE LIMITS OF MEDICAL PROGRESS (1990).
614
R. Fenigsen, Most of Them Would Rather Live, INT’L HERALD TRIB., Jan. 29, 1988.
615
Codicil tegen euthanasie [Codicil against euthanasia], BRABANTS DAGBLAD, June 19, 1985; NPV/Stichting Schuilplaats, Levenswensverklaring [Declaration of the will to live].
607
608
332
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without their consent.616 The regulations passed by the Parliament in 1993 acknowledge
the practice of “actively terminating patients’ lives without their request” and encourage
doctors who do it to report these cases.617 The official acknowledgment of the practice
of involuntary euthanasia means that article 1 of the Statutes for Batavian People and
article 4 of the Dutch Constitution (Grondwet), protecting everybody’s life and person,
have been de facto abolished. Yet no amendment to the Constitution was ever passed.
The actual practice and the momentary state of public opinion have prevailed over the
law and due democratic process.
The creation of a group empowered to kill with impunity has introduced an essential
feature of most oppressive dictatorships618 into the very heart of one of the world’s best
democracies. Democratic Holland is on its way to become a society where the lives of
all will be in the hands of a few.619
A Dutch social scientist proposes adopting the extermination of disabled newborns
as society’s policy; the society’s decision would overrule the wishes of the parents.620
At present, 400 children are put to death in Holland every year because of congenital
defects or sequels of birth trauma.621 This means that doctors, working, as they do everywhere, under government supervision, issue permits to live to some newly arrived
citizens, and destroy the others. To exist, a human being must be approved by the
authorities. This is a reversal of the democratic principle that governmental authorities
must be approved by people.
As a result, the country’s population will never become the Demos, The People,
respectful of every individual, the sovereign in a democracy, but must remain a herd,
selected by breeders for some desirable characteristics and then repeatedly culled according to biological criteria.
A number of causes has been given to explain the surge of the pro-euthanasia
movement. There is no doubt, however, that the ultimate cause of this movement is the
Huisarts vrijgesproken van moord [Family physician acquitted of murder], BRABANTS DAGBLAD, Nov.
13, 1986; Geen straf arts voor euthanasie: van Ooijen wel schuldig van moord [No punishment for the doctor
who performed euthanasia, but the court did find (Dr.) van Ooijen guilty of murder], BRABANTS DAGBLAD,
Feb. 22, 2001.
617
R. Fenigsen, The Netherlands: New Regulations Concerning Euthanasia, 9 ISSUES IN LAW & MED. 167
(1993); J. Bruinsma, Euthanasie-compromis onduidelijk voor arts: Grens tussen levensbeeindiging op verzoek en
niet op verzoek zal vervagen [The compromise on euthanasia is not clear to the doctor: The line between
termination of life upon request and without request will become blurred], DE VOLKSKRANT, Feb. 2, 1993.
618
The Gestapo in Nazi Germany, Tontons Macoutes in Papa Doc’s Haiti, and “Angka” organization in
Pol Pot’s Cambodia are the well known examples.
619
R. Fenigsen, Op naar een samenleving waarin levens in handen van somigen zijn [Toward a society in
which the lives of all will be in the hands of a few], VITA HUMANA, Apr. 2, 1989.
620
Summary of the doctoral thesis of Mrs. M.J. Zwiers, in W. Houtman, Laten leven als een gunst [Letting live as a favor], NEDERLANDS DAGBLAD, Nov. 14, 1998.
621
G. VAN DER WAL & P.J. VAN DER MAAS, EUTHANASIE EN ANDERE MEDISCHE BESLISSINGEN ROND HET LEVENS
EINDE [Euthanasia and other medical decisions concerning the end of life] 188-89 (Sdu Pub. House, The
Hague 1996).
616
Other People’s Lives: Reflections on Medicine, Ethics, and Euthanasia
333
great tragedy of man. I don’t mean the physical suffering which is remediable. What I
mean is our true tragedy: the awareness of unavoidable death.
People of lucid mind and strong character face it with calm. Many find solace in
religion. Most learn to live with awareness of death by shoving it away to the margins
of consciousness and to a vague future. The modern way of informing patients of their
diagnosis and prognosis has all but closed this escape.
For individual human beings, the solution proposed by the euthanasia movement
is no solution at all. It only satisfies a certain psychological need, well summed up in
the German proverb: “Better terrible end than terror without end.”
To society, euthanasia brings with it an ominous transformation.
Chapter XXXI. Who Is Leading Us There?
The right-to-die movement, a great popular movement sweeping half the globe
couldn’t develop without organization, paid workers, newsletters, access to the media,
PR specialists, traveling speakers, campaign headquarters active before every referendum, national and international congresses,622 and very large donations. In the U.S.,
the organizations which promote assisted suicide receive money from George Soros’
Open Society Institute,623 the Columbia Foundation, Greenwall Foundation, Water &
Ellis Haas, Nathan Cummings, Robert Wood Johnson, Fan Fox, and Leslie R. Samuels
Foundations, and the extremely generous Wallace Alexander Gerbode Foundation.624
Many capable and dedicated people are working for the movement’s organizations,
activists little known to the public. But the movement also needs prominent leaders
able to catch popular imagination. Since these are the people who plan to lead us into
the New Society, it may be useful to know who they are.
The Unemployed Pathologist. Dr. Jack Kevorkian helped more than 130 persons to
commit suicide, gained enormous publicity through all media, won thousands of ardent
supporters all over the U.S., and successfully fought several attempts to prosecute him
– until the misstep of showing on “60 Minutes” the video showing him administering
a lethal injection to a patient. This led to conviction and a jail sentence that prevented
Dr. Kevorkian from continuing his activities.
Dr. Kevorkian was an ascetic figure. He was never married. Before his imprisonment he lived modestly on a social security check, in a basement, playing his flute. His
doctor’s licenses in Michigan and California were revoked, but even before that, he was
unemployed. Trained as a pathologist, he never was a practicing physician. It is underCf. EUTHANASIA EDUCATION FUND, THE RIGHT TO DIE WITH DIGNITY (1971) (Excerpted remarks and discussion from the First Euthanasia Conference of the Euthanasia Education Fund held in New York on Nov.
23, 1968); Transcripts from the Fifth Biennial Conference of the Word Federation of Right to Die Societies,
Nice (France), Sept. 20-23, 1984; World Conference on Assisted Dying, Boston, Mass., Sept. 1-3, 2000.
623
R. Marker, Dying for the Cause: Foundations Funding for the “Right-to-Die” Movement, PHILANTHROPY,
Jan./Feb., 2001, at 26.
624
Id., P. Reilly, Subsidizing Despair: Gerbode Foundation Funds Advocates for Assisted Suicide, FOUND.
WATCH, Jan. 1999, at 1 (A publication of Capital Research Center).
622
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Issues in Law & Medicine, Volume 28, Number 2, 2012
standable, therefore, that he made mistakes, arranging for suicides of people who did
not have the diseases he thought they had.625
A fixation on a single subject can be traced from the beginning of Dr. Kevorkian’s
career. As a young resident, he used to ask the hospital nurses to notify him whenever
a patient was nearing death: he wanted to watch people’s eyes at the moment of death.
Painting had been one of his hobbies, and on the paintings he exhibited there were
broken human bones, dead people’s skulls showing red tongues, skin peeling off of a
head and hanging there, eyes protruding from the skulls’ eye sockets.626
The American Medical Association and medical associations in most states prohibit doctors’ involvement in executions, but in the articles Dr. Kevorkian published,
he argued that it is the physicians’ duty to administer lethal injections to persons condemned to death.627 He proposed the option of death to all prisoners sentenced to long
jail terms.628 Other of Dr. Kevorkian’s ideas are a macabre travesty of “utility ethics.” He
argued that medical experiments should be conducted on people sentenced to death,
and organs or transplantation ought to be harvested before executions.629 Also other
people approaching unavoidable death, those who decide to commit suicide, or to
undergo euthanasia, should not be wasted, but used for experiments and as a source
of organs for transplantation.630
Dr. Kevorkian also announced that he would offer for transplantation the organs
of people he was helping to die,631 and on at least one occasion stealthily delivered
somebody’s kidney to a hospital. Apparently he did not know that the diseases that his
“patients” had, or claim to have had, disqualified them as organ donors; nor that organs
for transplantation must be harvested, preserved, and transported according to strict
rules which assure their viability and prevent infection.
All his life Dr. Kevorkian has been obsessed with the dying, the killing, and the
macabre aspects of death. His ideas of “utility” place him firmly outside the circle of
our civilization. Dr. Kevorkian was a bizarre psychopath. I shudder at the thought of a
society organized according to his precepts.
The British Journalist. Contrary to Dr. Kevorkian, who often turned verbally and
even bodily violent in courtrooms and while confronting the police, Derek Humphry is
a very composed person. On many (though not all) occasions he proved a courtly debater. He was not very successful as a journalist and became interested in other activities.
A.P., 2 Kevokian Patients Weren’t Dying, Coroner Testifies, BOSTON GLOBE, Apr. 20, 1996; R. Mishra, A
Study of Deaths Raises Questions on Kevorkian Image, BOSTON GLOBE, Dec. 7, 2000.
626
A. Martin, “I Am Not Afraid”: Oakland County Tried to Pin a Murder Rap on Him, and His Peers Still
Think He’s Nuts, DETROIT FREE PRESS MAG., Feb. 3, 1991.
627
J. Kevorkian, Medicine, Ethics, and Execution by Lethal Injection, 4 MED. & L. 307 (Berlin 1985); J.
Kevorkian, Opinions on Capital Punishment, Executions and Medical Science, 4 MED. & L. 515 (1985).
628
J. Kevorkian, A Comprehensive Bioethical Code for Medical Exploitation of Humans Facing Imminent
and Unavoidable Death, 5 MED. & L. 181 (Berlin 1986).
629
Id.
630
Id.
631
Kevorkian Offers Patients’ Organs, BOSTON GLOBE, Oct. 23, 1997.
625
Other People’s Lives: Reflections on Medicine, Ethics, and Euthanasia
335
His first wife Jean was diagnosed with cancer, was undergoing chemotherapy, and for
several months the couple discussed her possible suicide. To the end, Jean looked for
Derek’s guidance; when she asked him, “Is this the day?” Derek said “Yes,” and served
her the lethal dose.
Together with his second wife, Ann, Humphry published “Jean’s Way,” an account
of Jean’s death. Emphasizing his resolve, Derek stated that he had prepared pillows;
“I decided that with the first stirring of life I would smother her with them. It did not
matter to me that I would be breaking the law.”632 But he declared pillows were not
needed, Jean died peacefully. An inquiry was launched, but was dismissed for lack of
evidence. The couple moved to the U.S. After one year, when Humphry’s contract with
the Los Angeles Times was not renewed, Mr. and Mrs. Humphry decided “to make death
their life work.”633 They founded the Hemlock Society; Ann was a prolific writer on
“right-to-die” subjects and Humphry took part in many TV debates and international
meetings. He later published a best-selling suicide manual, “Final Exit.”
They did not stop at words. In 1986, in Belmont, Massachusetts, Derek and Ann
helped Ann’s parents commit suicide. The mother did not die promptly, and Ann had
to hold a plastic bag over the mother’s mouth.
Haunted by the experience, Ann tried to talk about it to her husband, but he forbade it. Ann argued that they did talk about Jean’s death. “Well, that’s different,” Derek
replied, “We made a business out of Jean.”634
When Ann, too, was found to have breast cancer and was receiving chemotherapy,
Humphry left her. When she complained, Humphry decried her as an insane person,
and persuaded the Hemlock Board to fire her. At a certain point, Humphry threatened
to inform Ann’s family that she criminally helped in her mother’s suicide, which would
lead to a prosecution and deprive Ann of her inheritance.635 Ann, sick, abandoned, and
jobless, would also be evicted from her home which had been bought with inheritance
money.
Embittered Ann revealed a number of details of Derek’s career, and declared that
he had lied about Jean and those pillows: in fact, Derek had smothered Jean.636 Ann’s
late friendship with Mrs. Rita Marker, a prominent anti-euthanasia activist, furthered
many confessions. Finally, Ann committed suicide; in her suicide note she repeated the
accusation that Derek was a killer.
Some people see Humphry as a talented crusader for a cause. Others think he is
a cynical dealer who is using other persons’ deaths for his own aggrandizement and to
free himself from cumbersome family ties.
632
633
D. HUMPHRY, JEAN’S WAY 113 (1984).
R. MARKER, DEADLY COMPASSION: THE DEATH
OF
ANN HUMPHRY
AND THE
TRUTH ABOUT EUTHANASIA 38
(1993).
Id. at 75 (quoting Ann Humphry).
Ann Humphry and Derek Humphry on “Larry King Live,” Feb. 20, 1990.
636
W. Bole, Ann Humphry’s Final Exit: Abandoned by Her Husband and Sick With Cancer, The Co-Founder
of the Hemlock Society Went into the Oregon Woods and Took an Overdose of Pills, OUR SUNDAY VISITOR, Nov. 17,
1991; see also MARKER, supra note 633, at 35, and 230 (the facsimile of Ann’s suicide note).
634
635
336
Issues in Law & Medicine, Volume 28, Number 2, 2012
The Leader From Down Under. Dr. Philip Nitschke is a late medical bloomer: He
graduated as M.D. at the age of 42, and almost immediately got involved in medicine’s
“new specialty.” He started a vigorous campaign for the legalization of euthanasia,
and as soon as Australia’s Northern Territory allowed it, he ended a patient’s life. The
short-lived Northern Territory’s law was abolished by Australia’s Federal Parliament,
but Dr. Nitschke continued his campaign. He founded the euthanasia society “EXIT
Australia,” organized “how-to” workshops teaching the public the techniques of painless
suicide, and constructed a number of machines to deliver the lethal drugs. Dr. Nitschke
is working on an important project: to make “The Peaceful Pill,”637 a concoction that
would be reliably lethal, yet consisting of products available at a supermarket. If successful, the project, which breaks no laws, would open the way to mass suicides. The
American Hemlock Society is said to have invested large sums in “The Peaceful Pill,”
and right-to-die organizations in various countries became interested in the project. Dr.
Nitschke has been the star of right-to-die congresses on three continents.
Yet some of his acts, and certain details of his biography aroused doubts as to his
character. He did not show very good judgment when he declared that assisted suicide
should be available to everybody wishing to end his or her life, also to “troubled teens.”
Unable to find two doctors who would endorse a planned euthanasia, Dr. Nitschke
declared that his candidate, Mr. B, would go on hunger strike if not permitted to end
his life. But Mr. B, interviewed by journalists, stated that he does not have and never
had the intention to go on a hunger strike.638
Aware that a single individual, a hopelessly ill, terribly suffering person with name
and address, may become a symbol around which one can build a powerful campaign,
Dr. Nitschke embraced the cause of Mrs. Nancy C. The lady said she had inoperable
bowel cancer and wanted to die. A large popular movement developed to help her achieve
this goal. Nancy was supplied with poison and committed suicide in the presence of Dr.
Nitschke and twenty-one witnesses. Then the bomb exploded: at the autopsy no cancer
was found.639 There was a “twisted bowel,” a condition which had caused Nancy’s abdominal complaints and could have been cured surgically or improved with conservative
treatment. And it turned out that for some time both the patient and Dr. Nitschke had
known she did not have cancer;640 but Nancy was a depressed suicidal woman who
wished “to do it for the cause,” and Nitschke was loath to disavow the campaign, and
decided to conceal the truth. This was a short-sighted decision. He should have known
that authorities would require an autopsy.
W.J. Smith, Australia’s Dr. Death Supported by the Hemlock Society, USA.ITFEAS UPDATE 2003, vol.
17, no. 1, at 6.
638
G. Alcorn, Profile: Philip Nitschke: Death Becomes Him, SYDNEY MORNING HERALD, Oct. 12, 1996.
639
M. Devine, The Death Knell for Euthanasia, SYDNEY MORNING HERALD, May 30, 2002.
640
R. Yallop, Truth and Consequences, THE AUSTRALIAN, May 30, 2002; Special Report: The Death that
Backfired on the Right-to-Die Movement, ITFEAS UPDATE, 2002, vol. 16, no. 2, at 1; L. Townsend, Nitschke
Assists in Death of Non-Terminal Patient, NAT’L RIGHT TO LIFE NEWS, June 2002, at 7.
637
Other People’s Lives: Reflections on Medicine, Ethics, and Euthanasia
337
But there were some deeper flaws in Philip Nitschke’s character, ones that were
manifest in his youth. As a 15-year old, Philip shocked the city of Adelaide: he slaughtered
a dog, cutting its throat with a kitchen knife.641 He was referred to a psychiatrist who said
“You’ve got to realize that the idea of knives and blood and throats puts a certain chill
through...(the) residents of Adelaide.”642 It also turned out that previously the boy “had
cut the throats of rabbits all the time.”643 But killing a dog was unacceptable, a much
more serious matter. And Dr. Nitschke seems to understand this now; anyway, he now
understands the “difference.” Reminded of the incident, he said “I was very young … I
just didn’t have enough world experience . . . to make good judgments. I was arguing
… that there’s no difference between a dog and some contemptible animal that no-one
would care if you cut its throat.”644
Before taking on humans, Jack the Ripper liked to accompany hunters and butcher
and disembowel freshly killed deer. I wonder what he would be doing if he were alive
in our time.
The French Statesman. Dr. Bernard Kouchner created and for many years presided
over the most important humanitarian non-profit organization which brings medical
assistance to the sick and wounded in areas of war and disaster around the globe. He
personally led a number of such expeditions: to Ethiopia, Jordan, Lebanon, Kurdistan,
Sudan, Vietnam, Armenia, and Yugoslavia. Dr. Kouchner’s merits and organizational
skills have been appreciated by French and international authorities: he was appointed
chief of the U.N. administration in war-devastated Kosovo, and served as minister of
health in the socialist government of France. It is in this last position that he supported
Miss Christine Malevre, nurse at the hospital in Mantes-la-Jolie. Miss Malevre killed 30
gravely ill elderly patients. She did it sometimes upon a patient’s or his family’s request,
and sometimes on her own initiative. When she was charged with murder, Minister
Kouchner warned against “hasty moral judgment” and declared that what Miss Malevre
needed was help; “she should not feel as lonely as her patients had been.”645 The next
day the minister, reportedly upon president Chirac’s insistence, took back his words.
But when circumstances allowed, Dr. Kouchner proceeded to action. Interviewed
by foreign journalists, he said: “I’ve seen many wars and many sufferings, and if my
patients suffered terribly and nothing could be done to save their lives, I helped them
leave this world.”646
Thus, Dr. Kouchner does not practice euthanasia in his own country, where he
would risk his high position, might be prosecuted, perhaps even jailed. No, but in some
war-torn Third World countries, where the authorities, the people, and the patients’
Yallop, supra note 640.
Alcorn, supra note 638.
643
Id.
644
Id.
645
A French Debate About Death, THE ECONOMIST (London), Aug. 15, 1998.
646
E. Korotayeva, Priznaniye s posledstviyami: Bernar Kushner ubival iz miloserdiya [An admission with
consequences: Bernard Kouchner killed out of mercy], IZVIESTIYA (Moscow), July 26, 2001.
641
642
338
Issues in Law & Medicine, Volume 28, Number 2, 2012
families with gratitude and in full confidence receive the life-saving help of Doctors
Without Borders, where it would not occur to anyone to control their actions – there
Dr. Kouchner feels free to end his patients’ lives. I wouldn’t even ask whether, and in
what language, he obtained valid consent for euthanasia from Sudanese tribesmen. Let
us not agree to be led by Dr. Kouchner. He is a coward.
Two Leaders of the German Euthanasia Movement. Articles by Professor Werner Catel,
promoting euthanasia of sick and disabled children, and his book Borderline Situations
in Life, published in 1962,647 have significantly contributed to the revival of the German
pro-euthanasia movement after World War II. The scientific credentials of Dr. Catel,
former chair of the department of pediatrics at the University of Leipzig, and after the
war, professor of pediatrics in Kiel, helped restore the movement’s legitimacy. Scientists
and university professors are much revered in Germany.
But then the public was reminded of professor Catel’s past. He was a member of
the select Nazi committee on euthanasia648 and one of the initiators, the main designer,
and a hands-on manager of the Nazi program of child euthanasia in which five thousand disabled German children were murdered. Dr. Catel personally read the reports
on children with congenital defects and marked with crosses the papers of children to
be killed.649 One of the euthanasia centers for children functioned at Leipzig University’s
Pediatric Department led by Professor Catel.650 At that department, starvation combined
with administration of morphine and scopolamine were used to kill children with
congenital defects, while starvation and barbiturates were used in many other centers.
The revelation that Professor Catel was a Nazi murderer of children led to his
withdrawal from a prominent role in the modern German euthanasia movement. Other
people were promoted to leading positions, wiser ones, and with an untainted past. Mr.
Hans Henning Atrott was deservedly chosen to chair Deutsche Gesellschaft für Humanes
Sterben, the German Society for the Humane Way of Dying. He effectively countered
allegations of a link to Nazi euthanasia, and kept the movement firmly on the side of
legality. Mr. Atrott decidedly rejected euthanasia by lethal injection as a Nazi legacy.
The aim of the German movement under Mr. Atrott’s leadership was to legalize physician-assisted suicide. Neither suicide nor helping a person to commit suicide are crimes
in Germany, therefore, the aims of the movement chosen by Mr. Atrott were perfectly
legal. What remained to be achieved was the legal involvement of doctors, and a wider
social acceptance of aid-in-dying.
But the movement was in for a sorry setback. To a young lady posing as a suicide
candidate Mr. Atrott sold a dose of quick acting deadly poison, potassium cyanide, for
647
648
W. CATEL, GRENZSITUATIONEN DES LEBENS [Borderline Situations in Life] (Bayreuth, 1962).
H. FRIEDLANDER, THE ORIGINS OF NAZI GENOCIDE: FROM EUTHANASIA TO THE FINAL SOLUTION 44, 46
(1995).
R.N. PROCTOR, RACIAL HYGIENE: MEDICINE UNDER THE NAZIS 187 (1988).
M. BURLEIGH, DEATH AND DELIVERANCE: “EUTHANASIA” IN GERMANY, c. 1900-1945 101 (1994); FRIEDLANDER, supra 648, at 47.
649
650
Other People’s Lives: Reflections on Medicine, Ethics, and Euthanasia
339
3,000 D Marks, and was arrested by Hamburg police;651 selling poison for the purpose of suicide is illegal in Germany. It was revealed that for some time the police had
watched Mr. Atrott’s actions on suspicion that trafficking in cyanide was the source of
his apparently high income.
The list is depressing. Why do the leaders of a popular international movement turn
out to be psychopaths, Nazis, petty criminals, or at best, persons of flawed character?
Is it just the movement’s bad luck? Or does the prospect of causing people’s death with
impunity attract persons of a certain kind?
Chapter XXXII. Toward a Killing Society
An Abstract Discussion of a Concrete Issue. The extensive debate on euthanasia and
assisted suicide has been surprisingly abstract. The actual deaths from euthanasia, the
reality of death and of putting people to death, have almost never been mentioned.
This has partly been due to the broad range of the discussion: stands have been taken
by ethicists, theologians, lawyers, sociologists, journalists, citizens writing letters to the
editor; very few of them have ever had the misfortune to see how people put a person
to death, most have never seen a human being die, and many have never seen a dead
body. The debate on euthanasia has been conducted in such a way that the reality of a
person’s death, and the way it is seen and experienced by those present, has never been
revealed. A human being B though he be sick or paralyzed, but a living person, a unity
of structure and function incomparable in its complexity and precision, a spirit capable
of feeling, hoping, and suffering, reacting to everything in the world, a mind that knows
no limits, a world unto himself and a world different from all others, irreplaceable, one
of us, loving and loved, bound with innumerable ties to us all – ceases breathing, turns
gray and blue, and is no more; after a few hours, cold, rigid, with red blotches on his
back, he begins to decay.
After a lifetime of medical practice this is just as difficult to bear as it was at the
beginning. There is the same sense of loss, guilt, self-doubt, and the recurrent questions
of whether this had to happen, whether I had neglected or overlooked something. The
fact that sooner or later we all must go down that road changes nothing, the fragility of
human life makes it all the more precious, every day becomes precious, and every hour.
Alas, I can no longer say the same about all my colleagues, but all doctors educated in
the same spirit that I was feel the same as I do.
It was more than thirty years ago that I first heard of doctors who, motivated
by logical reasoning and noble considerations, deliberately caused the death of their
patients; but I still find it difficult to believe, despite the obvious evidence. I always
have the impression (though I know it to be mistaken) that only genetic mutation can
explain such deviant acts. Unlike many who have taken part in the debate, I have had
the misfortune to see people being killed: In 1943, along with all the other soldiers
in my infantry regiment, I was compelled to witness the execution of two so-called
deserters. After that experience, for the rest of my life I have remained convinced that
651
Czlowiek z cyjankiem [The man with cyanide], GAZETA WYBORCZA (Warsaw), Jan. 30-31, 1993.
340
Issues in Law & Medicine, Volume 28, Number 2, 2012
to deliberately put a defenseless person to death, regardless of the reasons, is the most
terrible act that one can commit on this earth and the worst evil he can do to himself,
to those who aid him, and to all helpless eye-witnesses.
The debate on euthanasia has avoided the specific realities of death and killing.
Emotion should indeed be excluded from rational debate, thus images that rouse emotion must be excluded as well. But purely rational debate, excluding all emotions, is
not the right way to solve all human problems. This is not the best way to decide to get
married, for example; nor is it the right way to consider matters of life and death. We
must also know when to trust our emotions. This does not rule out rational thought,
but leads to lines of reasoning that differ from those purely abstract ones.
The Ugly Reality. Euthanasia has been praised as an act of charity governed by truth
and wisdom. However, the reports from the country where euthanasia is practiced on
a large scale do not confirm these claims.
Doctors are the ones who carry out euthanasia, and the medical profession, as any
other, has its share of neglectful, intellectually inferior, amoral, or emotionally unstable
members. In the past, such doctors now and again failed in their professional duties;
but as long as a strong taboo and an absolute legal prohibition protected human life,
they did not intentionally kill anyone. With the advent of euthanasia, these inferior
doctors seem to have been particularly attracted to this new branch of medical practice.
A neurologist prescribed lethal increases of morphine injections to a 63 year old
incompetent patient, had neither explained his intentions to the nurses, nor informed
the doctor on duty or the patient’s family, left for the weekend and could not be reached
when the patient was dying.652 The doctor who terminated the life of Mrs. H in “a sloppy way”653 was a drug addict and had previously been disciplined for forgery and for
administering treatments beyond his competence.
Doctor B, suspected of having killed twenty inhabitants of the De Terp home for
the elderly in The Hague,654 admitted having performed euthanasia on five persons
without their consent or knowledge.655 Witnesses testified that some of the victims were
not even ill, but only senile and querulous, and that the doctor was impatient with older
people, reluctant to treat them, frequently absent, and left many decisions to the male
head nurse. The latter carried out the killings (using untraceable intravenous injections
of insulin) and threatened other De Terp inhabitants with euthanasia.656
Bedoelingen arts waren good: Voorwaardelijke celstraf voor “slordige” euthanasie [The doctor had good
intentions: Probation for “sloppy” euthanasia], BRABANTS DAGBLAD, Oct. 22, 1995.
653
F. Abrahams, De huisarts die het niet zo nauw nam [The family doctor who was not too scrupulous
(about consent to euthanasia)], NRC HANDELSBLAD, May 23, 1995.
654
Verzorgingshuizen in opspraak: Het onnodig sterven [Rumors about nursing homes: The unnecessary
deaths], ELZEVIERS MAG., Apr. 20, 1995.
655
Arts bekent vijfmaal euthanasie [Physician admits having performed euthanasia on five persons],
BRABANTS DAGBLAD, Apr. 17, 1985.
656
“Euthanasie” vertaald in viervoudig moord [“Euthanasia” turns out to be murder of four people],
BRABANTS DAGBLAD, July 24, 1985.
652
Other People’s Lives: Reflections on Medicine, Ethics, and Euthanasia
341
With euthanasia, as with other daily activities of practitioners, expediency may
dictate the course of action. A family physician, called to the home of a sick woman,
immediately asked her to choose between hospitalization and euthanasia. When the
stunned patient could not reply, he gave her one hour to think it over because he had
other patients to see.657 A study conducted by Health Inspector Gerrit van der Wal showed
that when patients requested lethal injections, their wish was sometimes granted with
unseemly haste. In 11% of cases, euthanasia was carried out within one hour after the
request; and in 59% of cases, on the same day.658 The government-ordered survey of
euthanasia revealed that a few hospital doctors, when asked why they had given lethal
injections to very gravely ill patients, explained that they needed the beds.659
The awareness that a person had been coerced to request death has not deterred
some physicians from performing euthanasia. When a husband coerced his healthy 72
year old wife to ask for euthanasia, and a wife forced her sick husband to request death,
the physicians, aware of the coercion, nevertheless administered lethal injections to the
two victims.660
Explicitly stated wishes of patients weigh little with some doctors. In chapter XXIV,
there is the story of the “Impatient chest physician” and his young patient who was killed
though he “clung to life and did not even want to discuss” the matter. More such cases
have been published. An 85 year old sick woman had told her family and the family
physician that she wished to live and did not want euthanasia. Nevertheless, when the
doctor found her unconscious and incontinent, he gave her a lethal injection.661
In chapters XXIII and XXIV are more examples of criminal contempt for human
life and human rights. The incidents cited in this book are only those published and the
ones of which I was an eyewitness. They are no more than the tip of an ugly iceberg.
Gross mistakes, lies, fraud, criminal scheming, brutal coercion, people using the
death of others to arrange their own affairs, killers indulging in outbursts of anger, human life in the hands of psychopaths, fanatics, negligent fools – those are not “abuses”
but regular occurrences in a society that allows unpunished killing. People who had
the misfortune to spend the years 1939-1945 in Central and Eastern Europe know it
all too well.
F.T. DIEMEN-LINDEBOOM, DE DOOD, UITKOMST VOOR HET LEVEN? [Death as deliverance from life?] 109-10
(Buyten & Schipperheyn, Amsterdam 1987).
658
G. van der Wal et al., Euthanasie en hulp bij zelfdoding door artsen in de thuissituatie [Euthanasia and
physician-assisted suicide at the (patient’s) home], 135 NED. TIJDSCHRIFT V. GENEESKUNDE 1593 (1991).
659
REPORT II, supra note 199, at 64 (tbl. 6.7).
660
W. VAN DEN LINDEN, ZIJ MOEST EERST . . . HET DOSSIER VAN BOMMELEN: EEN GEVAL VAN EUTHANASIE? [She had
to go first . . . The van Bommelen file: A case of euthanasia?] (Strengholt Pub., Naarden 1984); Waarom
heeft Wibo niet ingegrepen? [Why (the TV journalist) Wibo (van den Linden) did not intervene?], ZONDAG
(Beusichem), Jan. 22, 1984; H. TEN HAVE & G. KIMSMA, GENEESKUNDE TUSSEN DRROM EN DRAMA [Medicine between dream and drama] 83-87 (Kok-Agora Pubs. Kampen 1987); G.F. Koerselman, Hoe mondig zijn moderne patienten? [How mature are the modern patients?] 130 NED. TIJDSCHRIFT V. GENEESKUNDE 2017 (1986).
661
Geen straf arts voor euthanasie: van Ooijen wel schuldig van moord [No punishment for the doctor
who performed euthanasia but the court did find (Dr.) van Ooijen guilty of murder], BRABANTS DAGBLAD,
Feb. 22, 2001.
657
342
Issues in Law & Medicine, Volume 28, Number 2, 2012
Involuntary Euthanasia. It is the acceptance of euthanasia – be it voluntary, or in the
form of assisted suicide – that pushes a human community in the direction of a killing
society. The practice of involuntary euthanasia completes the transformation.
The subject of involuntary euthanasia has been extensively discussed in this book.662
Here I’ll reflect on two questions: why doctors resort to involuntary euthanasia? And
can this be avoided?
Why are there doctors who without the patient’s consent cut short their lives?
Are they all cold-blooded, mean-motivated murders? Of course not. True, some of
them are irresponsible, casual killers. Most, however, are men with a mission. Like all
people supporting euthanasia, they sincerely believe that good results may sometimes
be produced by causing a person’s death.663 And once this is assumed, there are several
compelling reasons to end some sick people’s lives without their knowledge. It seems
equally justified as doing so with patients’ consent, and more humane.
Involuntary mercy killing is dictated by the very logic of euthanasia. If we are
serious in our belief that a patient in a sad condition benefits from being put to death,
we have no right to deny this benefit to some patients just because they are unable, or
not wise enough, to ask for it. Any hesitation on this point would raise doubts whether
the doctors practicing euthanasia are as certain of its beneficence as they claim.
Moreover, euthanasia done without the patient’s knowledge is less cruel. Humane
killing done without the knowledge of the patient was the prevailing idea among the
proponents of euthanasia in the first half of the 20th century. It has been an important
consideration for Dutch physicians practicing involuntary euthanasia.664 This was also
the reason why professor Fritz Lenz whom the German government commissioned in
1940 to write the draft euthanasia law, included in Article I the proviso that euthanasia
should be performed without the patient’s knowledge.665
There is also a point of seemingly minor importance yet in fact influencing some
doctors’ decisions: covert medical killing is easier. Adding a lethal mixture to the I.V. drip,
or simply quickening the potassium drip from six to ninety-nine drops per minute will
soon put the patient out of his misery, and spares the doctor the emotional torment of
proposing death and discussing it with the patient.
There is one more factor that often determines the course of events. Not all people
in the movement in favor of euthanasia are libertarians, sincere supporters of self-determination and death by choice. There are also adherents of a different ideology, one
that is much deeper rooted in people’s subconscious and appeals to more ancient tribal
ties: exterminatory eugenics.
Chapters XVIII - XX, XXIII - XXIV, and XXVII.
D. Meerman, Goed doen door dood te maken [Doing good by making one dead] (Kok Pubs., Kampen
1991) (Doctoral dissertabion defended at the Catholic University of Nijmegen).
664
H.W.H. HILHORST, EUTHANASIE IN HET ZIEKENHUIS: ZACHTE DOOD VOOR ZIEKENHUISPATIENTEN [Euthanasia in
the hospital: Mild death for hospital patients] 99 (De Tijdstroom, Lochem-Poperinge 1983).
665
B. MÜLLER-HILL, MET WETENSCHAP ALS EXCUUS: DE ROL VAN PSYCHIATERS, ANTHROPOLOGEN EN GENETICI IN
NAZI-DUITSLAND [Science was their excuse: The role of psychiatrists, anthropologists and geneticists in Nazi
Germany] 18 (Anthos/Epo Pubs., Baarn-Antwerpen 1986).
662
663
Other People’s Lives: Reflections on Medicine, Ethics, and Euthanasia
343
Can We Legalize Voluntary Euthanasia or Assisted Suicide and Avoid Involuntary Euthanasia? Unfortunately, no. The facts are that in all countries where the pro-euthanasia
movement has been active, and throughout the movement’s history, the extermination
of undesirables has been promoted, and whenever feasible, practiced. In Great Britain,
Gillian Tindall most forcefully stressed the connection between the pro-euthanasia
movement and compulsory extermination: she proclaimed voluntary euthanasia and the
individual’s right to self-determination, and in the same breath, in the same press article
called for the killing of demented elderly against their will.666 In Australia, Peter Singer
and Helga Kuhse promoted the killing of hemophiliac babies and other sick children and
unwanted infants,667 “non-voluntary” euthanasia for sick adults who have not asked for
death,668 and voluntary euthanasia for those willing to die.669 In France, along with the
campaign in favor of voluntary euthanasia led by Messrs. Atali and Schwartzenberg, legislative and propagandistic activities are deployed by Ligue pur la prévention d’une jeunesse
handicappée of Senator Caillavet who proposes to prevent disabilities by killing disabled
infants.670 In Germany, the Humanist Union, the Green Party, and the German Society
for the Humane Way of Dying (Deutche Gesellschaft für Humanes Sterben) campaign for
the legalization of physician-assisted suicide,671 and at the same time the mass media,672
prominent lawyers,673 and philosophers674 question the severely disabled persons’ right
to live, and justify the killing of disabled infants. Again, it is noteworthy that often the
same persons and publications support voluntary euthanasia and involuntary killing of
people with disabilities.675 The link has existed from the very beginning of the German
movement: the early champions of German euthanasia, Jost, Haeckel, Binding and
G. Tindall, It’s My Life and I’ll Die If I Want To, THE INDEPENDENT (London), Sept. 18, 1987.
H. KUHSE & P. SINGER, SHOULD THE BABY LIVE? THE PROBLEM OF HANDICAPPED INFANTS (1985); P. SINGER,
PRACTICAL ETHICS 181-90 (1st ed. 1979).
668
SINGER, supra note 667, at 191.
669
Id. at 193-200.
670
Wetsvoorstel in Frans parlement: Debaat over euthanasie op misformde baby’s [Bill submitted to the
French parliament: The debate on euthanasia for babies with (congenital) defects], BRABANTS DAGBLAD, Nov.
7, 1987; Franse r-k kerk verontwaardigd over voorstel euthanasie [French Catholic Church indignant about
the euthanasia bill], IN PERSPECTIEF (Ede), no. 6, 1988, at 16.
671
HUMANES LEBEN B HUMANES STERBEN (No. 4, 1984); FRANKFURTER RUNDSCHAU (May 9, 1984).
672
H. Schuh, Haben schwerstbehinderte Neugeborene ein Recht auf Leben? [Do the worst-handicapped
newborns have a right to life?], DIE ZEIT, June 16, 1989; R. Merkel, Die Streit um Leben und Tod [The dispute
on life and death], DIE ZEIT, June 23, 1989; A. Meyer, Mutter Courage und ihren Kindern [(The heroine of
Bertold Brecht’s play) Mother Courage and her children], WIENER, May, 1987.
673
I. Müller, Furchtbare Juristen: Die unbewältige Vergangenheit unserer Justiz [Frightful lawyers: The
un-mastered past of our justice], MUNICH 1987, at 250.
674
Mitleid allein begründet keine Ethik. Interview mit Hans Jonas [Compassion alone is not basis for ethics. Interview with Hans Jonas], DIE ZEIT, Aug. 25, 1989.
675
DER SPIEGEL, Apr. 30, 1984, and the series of articles: Tötung auf Verlangen [Killing upon request],
Behilfe zum Selbstmord [Assistance in suicide], Tötung behinderter Neugeborener [Killing of handicapped
newborn], published in the following weeks in the same magazine.
666
667
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Issues in Law & Medicine, Volume 28, Number 2, 2012
Hoche, advocated both the voluntary euthanasia and the compulsory extermination of
incurable psychiatric patients, “idiots,” and disabled newborns.676
In Holland, the country much praised for its practice of voluntary euthanasia, the
lives of 400 disabled newborns are terminated every year by denial of medical assistance,
dehydration/starvation and lethal injections,677 and the reports of government-ordered
studies revealed that every year lethal injections are given to one thousand gravely ill
persons who had never asked for death,678 but have a “low quality of life” or “no prospect of improvement”;679 some were killed “because the families could not take it any
more,”680 or even because their beds were needed.681 Thus, along with the voluntary
euthanasia that is going on,682 we witness the extermination of persons that embarrass
their families, are undesirable for society, or arbitrarily judged unfit by doctors. There
is a broad professional, institutional, and public support for these policies.683
Of course, the United States is less “advanced” than Holland in practicing euthanasia. There is little doubt, however, that developments similar to those seen in Holland
are taking place. Along with the campaign for the “right to die,” for the legalization of
assisted suicide, incessant pressure has been exerted to allow the killing of persons who
are a material and psychological burden to their families and society: very sick chil-
A. JOST, DAS RECHT AUF DEN TOD [The right to die] 17, 32, 37, 47, 52 (Göttingen 1895); E. HAEDIE LEBENSWUNDER: GEMEINVERSTÄNDLICHE STUDIEN ÜBER BIOLOGISCHE PHILOSOPHIE [The wonder of life:
Commonsense studies on biological philosophy] 131-35, 456-58, 472 (Stuttgart 1904); K. BINDING & A.
HOCHE, DIE FREIGABE DER VERNICHTUNG LEBENSUNWERTEN LEBENS (2nd ed. Leipzig 1922) (available in English in
Permitting the Destruction of Unworthy Life, 8 ISSUES IN LAW & MED. 231 (P. Derr & R. Salomon, eds. 1992).
677
VAN DER WAL & VAN DER MAAS, EUTHANASIE EN ANDERE MEDISCHE BESLISSINGEN ROND HET LEVENS EINDE [Euthanasia and other medical decisions concerning the end of life] 188 (tbl. 17.2), & 194 (tbl. 17.5) (Sdu
Pub. House, The Hague 1996).
678
REPORT I, supra note 199, at 15; VAN DER WAL & VAN DER MAAS, supra note 677, at 92; VAN DER WAL
ET AL., supra note 603, at 67 (tbl. 7.1) & 68.
679
REPORT II, supra note 199, at 51 (tbl. 6.7).
680
Id.
681
Id.
682
VAN DER WAL ET AL., supra note 603, at 67 (tbl. 7.1).
683
J.H. VAN DEN BERG, MEDISCHE MACHT EN MEDISCHE ETHIEK [Medical power and medical ethics] 27-30
(G.V. Callenbach, Nijkerk 1969); J. Ekelmans, De mondige sterveling [The mature mortal], 1971 MEDISCH
CONTACT 791; M. Krop, Letter to the Editor, 26 MEDISCH CONTACT 1164 (1971); GENERALE SYNODE DER NEDERLANDSE HERVORMED KERK [General Synod of the Dutch Reformed Church], EUTHANASIE, ZIN EN BEGRENZING VAN
HET MEDISCH HANDELEN. PASTORALE HANDREIKING [Euthanasia: the meaning and the limits of medical actions.
Manual for ministers] (The Hague 1972); DE DOOD KOMT SOMS TE LAAT, EEN BROCHURE V.D. STICHTING VRIJWILLIGE
EUTHANSIE [Sometimes the death comes too late: A Pamphlet of the Foundation for Voluntary Euthanasia
20 (De Tijdstroom, Lochem 1975); Hoofdbestuur KNMG, Reactie op vragen Staatscommissie Euthanasie
[The Board of the Royal Dutch Society of Medicine, Answer to the questions asked by the State Committee
on Euthanasia], 31 MEDISCH CONTACT (Official Section) 1002 (Aug. 3, 1984).
676
CKEL,
Other People’s Lives: Reflections on Medicine, Ethics, and Euthanasia
345
dren,684 people who are mentally retarded,685 disabled newborns,686 and those persons
in a persistent, presumably unconscious state.687
In no way can the American libertarian movement in favor of assisted suicide
dissociate itself from the supporters of extermination. The two wings of the American pro-euthanasia movement share the same basic philosophy688 and a good deal of
the same rhetoric, and plainly are led by the same people. Prominent personalities in
the movement in favor of assisted suicide, members of the Board of Choice in Dying
Society,689 promoters of free choice of their own death,690 are also on record for recommending euthanasia as a means to reduce the world’s overpopulation,691 supporting the
extermination of disabled newborns,692 the compulsory euthanasia of mentally retarded
persons,693 the destruction of people who are comatose,694 and the societally imposed
reduction of citizens’ life span.695 The twin goals, the libertarian and the exterminatory,
have been pursued throughout the movement’s history.
There was an uproar among the members of the Euthanasia Society of America
when on January 25, 1939, the Board proposed legislation that would only allow voluntary euthanasia. Mr. Charles E. Nixdorf, Esq., the Society’s treasurer, had to reassure
the members that this was just the first step, the only bill that had a chance to pass, but
D.C. MAGUIRE, DEATH BY CHOICE 173-79 (1977); G. Williams, Euthanasia and the Physician, in BENEFIEUTHANASIA 154-57 (M. Kohl, ed. 1975); H.T. Engelhardt, Jr., Ethical Issues in Aiding the Death of Young
Children, in BENEFICENT EUTHANASIA 180-82 (1975).
685
E.W. Lusthaus, Involuntary Euthanasia and Current Attempts to Define Persons with Mental Retardation
as Less Than Human, 23 MENTAL RETARDATION 148 (1985).
686
J. Lachs, On Humane Treatment and the Treatment of Humans, 294 NEW ENG. J. MED. 838 (1976);
J. Fletcher, Ethics and Euthanasia, in TO LIVE AND TO DIE: WHEN, WHY, AND HOW 113 (R.H. Williams, ed.
1973); and J. Lorber, Selective Treatment of Myelomeningocele: To Treat or Not to Treat, 53 PEDIATRICS 308
(1974).
687
Cruzan v. Harmon, 760 S.W.2d 408, 412 (Mo. 1988); Cruzan v. Director, Missouri Dept. of Health,
497 U.S. 261 (1990); and L. Matchan, Court Upholds a State’s Limit on Right to Die: A Father Joins Ethicists’
Outcry, BOSTON GLOBE, June 26, 1990; L. Greenhouse, Request to End Feeding of Comatose Woman is Turned
Down, N.Y. TIMES, June 26, 1990, at A1, A19.
688
BINDING & HOCHE, supra note 676; P. SINGER, supra note 667; J. FLETCHER, SITUATION ETHICS: THE NEW
MORALITY (1966).
689
R.E. Cranford, see CHOICE IN DYING NEWS, 1992, vol. 1, no. 2, at 6.
690
Governor Richard D. Lamm’s book endorsement on the jacket of DEREK HUMPHRY, FINAL EXIT (1991);
J. Fletcher, supra note 686; R. Williams, Number, Types and Duration of Human Lives, NW MED., July 1970,
at 493.
691
R. Williams, supra note 690.
692
J. Fletcher, The “Right” to Live and the “Right” to Die, in BENEFICENT EUTHANASIA 44-53 (1975).
693
Id., J. Fletcher, supra note 686, at 118.
694
R.E. Cranford, A Hostage to Technology, HASTINGS CTR. REP., 1990, vol. 20, at 9-10; R.E. Cranford,
Helga Wanglie’s Ventilator, HASTINGS CTR. REP., 1991, vol. 21, at 23-24.
695
W. Slater, Latest Lamm Remark Angers the Elderly, ARIZ. DAILY STAR, Mar. 29, 1984 (quoting Gov.
Lamm); R.D. Lamm, A Debate: Medicare in 2020, in MEDICARE REFORM AND THE BABY BOOM GENERATION, PROCEEDINGS OF THE SECOND ANNUAL CONFERENCE OF AMERICANS FOR GENERATION EQUITY 77-88 (Washington, 1987);
R.D. Lamm, Columbus and Copernicus: New Wine in Old Wineskins, MT. SINAI J. MED. 1989, vol. 56, at 1-10;
R.D. Lamm, Saving a Few, Sacrificing Many B at Great Cost, N.Y. TIMES, Aug. 8, 1989, at A23.
684
CENT
346
Issues in Law & Medicine, Volume 28, Number 2, 2012
that “the Society hoped eventually to legalize putting to death of non-volunteers who
are beyond the help of medical science.”696
A few weeks later the President of the Euthanasia Society of America, Dr. Foster
Kennedy, called for a law permitting “euthanasia in cases of born defectives.”697 In the
ominous year 1942, Dr. Kennedy expounded in more detail his plan to exterminate
“defective” children. At the age of five, the child, upon application of the guardian, would
be examined, and a medical board would decide on the killing.698 A Gallup poll showed
in 1937 that forty-five percent of Americans supported euthanasia of defective infants.699
Members of the Harvard chapter of Phi Beta Kappa heard a plea for the “privilege of
death for the congenitally mindless and for incurable sick who wish to die”700 – indeed,
the two goals were also inseparable in this lecturer’s mind.
World War II and the discovery of Nazi atrocities caused a twenty year lull in the
American euthanasia movement, but no change of ideas. In 1973, the leading theorist
of American euthanasia, Joseph Fletcher, called for “direct and voluntary” euthanasia
for those willing to die, and euthanasia that is “direct but involuntary… as when an
idiot is given a fatal dose.”701
How about the present leaders of the American movement in favor of assisted
suicide? The Hemlock Society and related groups such as Choice in Dying, Compassion
in Dying, etc., “are committed to support the rights of the terminally ill to choose death
with dignity, and to support the rights of the terminally ill to choose death with dignity,
and to support personal control and autonomy in end-of-life decisions.” Yet on December 3, 1997, Ms. Faye Girsh, the executive director of Hemlock Society USA, issued a
statement that “a judicial determination should be made when it is necessary to hasten
the death of… a demented parent,”702 and supported mercy killing of “people… who
are not competent to make this decision.”703 Answering the many alarmed reactions,
Ms. Girsh clarified that her statement “was not approved by the Hemlock Board.”704
Perhaps, but it revealed what a leader of Hemlock really wanted.
In the Netherlands, for more than thirty years every authority, a dozen courts,
the Supreme Court, several governmental committees, the Parliament, the ministries
of Justice and Health, the Health Council, the Royal Society of Medicine, were busy
polishing, expanding, and improving the “rules” and laws of euthanasia, and have not
Minutes of the Meeting of the Euthanasia Society of America, N.Y. TIMES, Jan. 27, 1939.
Mercy Death Law Ready for Albany, N.Y. TIMES, Feb. 14, 1940.
698
F. Kennedy, The Problem of Social Control of the Congenitally Defective: Education, Sterilization, Euthanasia, 99 AM. J. PSYCHIATRY 13-16 (1942).
699
1937 Gallup Poll, quoted in PROCTOR, supra note 649, at 180.
700
W.G. Lennox, Should They Live? Certain Economic Aspects of Medicine, 7 AM. SCHOLAR 454-66 (1938).
701
J. Fletcher, supra note 686, at 118.
702
F. Girsh, Executive Director, Hemlock Society USA, Statement on Mercy Killing, Dec. 3, 1997.
703
Id.
704
F.J. Girsh, Clarification of Hemlock Statement on Mercy Killing, TIME LINES B THE HEMLOCK SOCIETY USA,
Winter 1998, no. 75, at 4; Hemlock Executive Director Seeks to Pull Bank From Endorsement of Nonvoluntary
Euthanasia, NAT’L RIGHT TO LIFE NEWS, Feb. 11, 1988.
696
697
Other People’s Lives: Reflections on Medicine, Ethics, and Euthanasia
347
succeeded in keeping euthanasia voluntary.705 Every law is and will be circumvented in
the secrecy and intimacy of the doctor-patient-family relationship and by arbitrary and
virtually uncontrollable actions of physicians.
It is a tragic mistake of the sincere supporters of euthanasia that they believe they
can create safeguards against the killing of sick people who have not asked for death.
The Killing Society. Preserving the lives of its members is what a society is for. A
society that kills people contradicts its own reason for being and sooner or later must
fail or disappear. Indeed, that’s what happened to killing societies in both the distant
and recent past.
In this chapter, I have argued that the acceptance of euthanasia brings to being a
Killing Society. Such society will use medical means to eliminate its weakest members.
Incredible as it may seem, there are in the United States physicians willing to carry out
such programs, and not some freaks, but influential members of California’s medical
profession who expounded their program in a medical journal. What follow are broad
excerpts from their manifesto:
A New Ethic for Medicine and Society
The traditional western ethic has always placed great emphasis on the intrinsic worth
and equal value of every human life regardless of its stage or condition. This ethic
had the blessing of the Judeo-Christian heritage and has been the basis for most of
our laws and much of our social policy. The reverence for each and every human
life has also been a keystone of Western medicine and is the ethic which caused
physicians to try to preserve, protect, repair, prolong, and enhance every human life
which comes under their surveillance. This traditional ethic is still clearly dominant,
but there is much to suggest that it is being eroded at its core and may eventually
even be abandoned.
There are certain new facts and social realities which are becoming recognized … and
seem certain to undermine and transform this traditional ethic. They have come into
being and into focus as the social by-products of unprecedented technologic progress
and achievement. Of particular importance are, first, the demographic data of human
population expansion which tend to proceed uncontrolled and at a geometric rate
of progression; second, an ever growing ecological disparity between the numbers
of people and the resources available to support these numbers in the manner to
which they are or would like to become accustomed; and third, and perhaps most
important, a quite new social emphasis on something which is beginning to be called
the quality of life, something which becomes possible for the first time in human
history because of scientific and technologic development….
What is not yet so clearly perceived is that in order to bring this about hard choices
will have to be made with respect to what is to be preserved and strengthened and
705
REPORT I, supra note 199, at 15; VAN DER WAL & VAN DER MAAS, supra note 677, at 90 (tbl. 9.1), 237;
VAN DER WAL ET AL., supra note 603, at 201.
348
Issues in Law & Medicine, Volume 28, Number 2, 2012
what is not, and that this will of necessity violate and ultimately destroy the traditional
Western ethic…. It will become necessary and acceptable to place relative rather than
absolute values on such things as human lives…. This is quite distinctly at variance
with the Judeo-Christian ethic and carries serious philosophical, social, economic,
and political implications for Western society and perhaps for world society….
It seems safe to predict that the new… realities and aspirations are so powerful that
the new ethic of relative rather than absolute and equal values will ultimately prevail
as man exercises ever more…effective control over his numbers, and uses his always
comparatively scarce resources to provide the nutrition, housing, economic support,
education and health care in such ways as to achieve his desired quality of life and
living …. This may be expected to reflect the extent that quality of life is considered
to be a function of personal fulfillment; of individual responsibility for the common
welfare, the preservation of the environment, the betterment of the species; and of
whether or not, or to what extent, these responsibilities are to be exercised on a
compulsory or voluntary basis.
The part which medicine will play as all this develops is not yet entirely clear. That it
will be deeply involved is certain. Medicine’s role with respect to changing attitudes
toward abortion may well be a prototype of what is to occur. Another precedent may
be found in the part physicians have played in evaluating who is and who is not to
be given costly long-term renal dialysis. Certainly this has required placing relative
values on human lives and the impact of the physician to this decision process has
been considerable. One may anticipate further development of these roles as the
problems of birth control and birth selection are extended inevitably to death selection and death control, whether by individual or by society, and further public and
professional determinations of when and when not to use scarce resources.
Since the problems which the new demographic, ecologic and social realities pose
are fundamentally biological and ecological in nature and pertain to the survival
and well-being of human beings, the participation of physicians and of the medical
profession will be essential in planning and decision-making at many levels. No other
discipline has the knowledge of human nature, human behavior, health and disease,
and of what is involved in physical and mental well-being which will be needed. It
is not too early for our profession to examine this new ethic, recognize it for what
it is and will mean for human society, and prepare to apply it in a rational development for the fulfillment and betterment of mankind in what is almost certain to be
a biologically oriented world.706
Thus, it will be the task of the medical profession to exert death selection and death
control and reduce the numbers of human beings for the betterment of the species and
in order to improve the quality of life of those chosen to be preserved; and this will be
the policy of the society, applied, if needed, on a compulsory basis.
706
Editorial, A New Ethic for Medicine and Society, 113 CAL. MED. 67 (1970).
Other People’s Lives: Reflections on Medicine, Ethics, and Euthanasia
349
The “Killing Society” is not a bogey man that I invented to frighten my readers.
It is the program of a group that will put it into effect if allowed to do so. Democracy,
which has protected us against so many dangers, will not protect us against this one.
Democracy will cease to exist. There is no democracy where everyone has the right to
vote, but not everyone has the right to live.
Too deeply-rooted to collapse overnight, the institutions of democracy will keep
functioning for some time, amidst the unspeakable gloom and oppressiveness of the
Killing Society.
350
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Appendix 1
Nazi Euthanasia
The modern movement in favor of euthanasia has been often accused of trying
to repeat the practices of the Nazis, and with equal insistence its representatives have
repudiated these allegations. Due to inaccuracies in arguing, and thinking, the dispute
has trailed for a long time without a conclusion. People tend to assume that to show a
Nazi precedent of an action is enough to condemn it. It is not. Due to the same mental
short circuit, the modern proponents of euthanasia feel obligated to repudiate every
allegation of a Nazi link without examining whether it is true.
From October, 1939, till August 24, 1941, doctors involved in “Aktion T4”707 and
their collaborators killed 70,273 inmates of German psychiatric hospitals and asylums.708
Some estimates came up with a higher figure, of 80,000 persons killed.709 In the same
period, in occupied Poland, German medical and military personnel took over the
psychiatric hospitals and killed all patients; the number of victims was about 20,000.710
Five thousand disabled German children perished in the so-called Kinderaktion.711
The extermination of people with physical and mental disabilities under the Nazi
regime has been thoroughly researched, and a good deal of what happened has been
described: people dying in chambers filled with carbon monoxide, misleading letters
sent to families, false death certificates, infernal scenes during the abduction and transportation of patients, doctors involved in Kinderaktion who read the “reporting forms”
and decided every child’s fate, and professors who provided the scientific rationale.
Is Nazi euthanasia relevant to our present problems? According to the representatives of the modern movement in favor of euthanasia or assisted suicide, it is not.712 Our
movement is an assembly of decent, humane, highly conscientious people concerned
with the rights and dignity of the individual. What we do, or intend to do, cannot have
anything in common with what the Nazis did. We campaign for the freedom of choice
while the Nazis carried out a compulsory extermination of the sick. Nazi euthanasia was
brought about by the inhuman totalitarian state, carried out by a bunch of degenerate
criminals, and ended with the crushing of the Third Reich. It is lunacy to think that our
democratic society could ever repeat such horrors.713
This is reassuring, but some of its assumptions are not entirely correct, and some
are entirely incorrect.
PROCTOR, supra note 649, at 189.
FRIEDLANDER, supra 648, at 109; BURLEIGH, supra note 650, at 160.
709
FRIEDLANDER, supra 648, at 110.
710
Zaglada chorych psychicznie w Polsce, 1939-1945: Die Ermordung der Geisteskraken in Polen, 19391945 [The annihilation of the mentally ill in Poland, 1939-1945] 4-7 (Z. Jaroszewski, ed. PWN Pub.
House, Warsaw 1993).
711
PROCTOR, supra note 649, at 188.
712
Vullamy, supra note 561 (Interview with the Secretary of the Royal Dutch Society of Medicine, Dr.
Th. van Berkestijn); Tindall, supra note 666.
713
Vullamy, supra note 561.
707
708
Other People’s Lives: Reflections on Medicine, Ethics, and Euthanasia
351
“Nazi euthanasia was carried out by a bunch of cynical criminals.” This is true enough
of many of those directly involved in the killings, the likes of Victor Brack, Dr. Hermann
Pfannmüller, and their assistants.
But the psychiatrists, pediatricians, and anthropologists who conceived and
planned the euthanasia program, professors at Berlin’s Kaiser Wilhelm Institute, and
at the universities of Heidelberg, Göttingen, Halle, Leipzig, and München, including
Eugen Fischer, Otmar von Verschuer, Ernst Rüdin, Fritz Lenz, Carl Schneider, Hans F.K.
Günther, Werner Catel, and others were the country’s intellectual elite, comparable with
the faculty and the top researchers of ivy-league schools in America. In fact, the status
of these German intellectuals was even loftier, due to the nation’s unwavering faith in
and reverence for scientific authorities.
No, not a bunch of lowly criminals, but Germany’s best and brightest presided
over Nazi euthanasia.
“Our intentions are good and charitable while the motives of those who organized and
carried out Nazi euthanasia were vile.” A half-truth again. What were the Nazis’ intentions?
The Nazi propagandists spent several years persuading the public that “elimination of
useless eaters” would spare so many tons of flour, marmalade, margarine, and vegetables.714 Only a very superficial observer would buy this argument. Mass murders are
not committed in order to gain some flour and marmalade.
Hitler did reveal his true motives in killing the handicapped and mentally ill: It
was hate, contempt, and repugnance.715 After the war, a prominent Nazi gave a similar
explanation.716 On the other hand, some doctors involved in the Nazi euthanasia program believed that they were doing charitable work.717
How about our own intentions? We are sincerely convinced they are noble. But have
we considered all known facts? What were, for instance, the motives of the Oregon lady
who pushed so hard for the suicide of her sick mother that she aroused the suspicions
of two examiners?718 And a husband who had been on record for verbally and physically
abusing his wife, what were his motives when a few years later he brought his wife to
PROCTOR, supra note 649, at 184.
A. HITLER, MEIN KAMPF [My Struggle] 134-35, 285, 289 (Am. ed. 1943).
716
PROCTOR, supra note 649, at 299-300 (quoting N. Weiss).
717
Th. Degener, Tödliches Mitleid schützt vor Strafe [Deadly compassion wards off punishment], in O.
TOLMEIN, GESCHÄTZTES LEBEN [Estimated (value of) life] 121 (Konkret, Hamburg 1990).
718
W.J. Smith, Suicide Unlimited in Oregon, WEEKLY STAND., Nov. 8, 1999; THE OREGONIAN, Oct. 17,
1998.
714
715
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Dr. Kevorkian?719 What were the motives of that “support group” that pushed hesitant
and reluctant “Louise” to commit suicide, and invited a New York Times journalist to
publicize the matter?720 The motives of that Manhattan editor who wrote in his diary
that his sick wife was “sucking his life out of him like a vampire,” repeated to her every
day that she was a burden, and helped her to commit suicide?721
The Dutch are proud of their euthanasia, practiced “in the best interest of the sufferers.” However, when we turn to individual cases, other motivations are often revealed.
Euthanasia was carried out because of gross blunders and unpardonable negligence,722
because of a woman’s callous attitude toward a sick spouse,723 in insolent contempt for
a patient’s clearly stated wish,724 as a result of criminal scheming,725 for mere expedi-
J. Forman, Doctors Say Her Case Treatable, Nonfatal, BOSTON GLOBE, Aug. 17, 1996; M. Bai & R.
Chacon, Spouse Says He Told Wife: “Don’t Quit,” BOSTON GLOBE, Aug. 18, 1996; Amid Questions, A Life Taken,
BOSTON GLOBE, Aug. 18, 1996; K. Zernike, New Case May Cost Kevorkian, BOSTON GLOBE, Aug. 19, 1996; K.
Zernike & D.J. Vigue, Kevorkian Patient Was Addicted to Drugs, Doctor Says, BOSTON GLOBE, Aug. 20, 1996;
K. Zernike, State Board Eyes Doctor’s Role in Wife’s Assisted Death, BOSTON GLOBE, Aug. 21, 1996; J. Rakovsky,
Suicide Patient Discussed Suing Husband, Sources Say, BOSTON GLOBE, Aug. 24, 1996; I.A.R. Lakshmanan, &
D.I. Vigue, Death Ended a Troubled Relationship, BOSTON GLOBE, Aug. 25, 1996; P. Terzian, Appointment With
Dr. Jack, PROVIDENCE SUNDAY J., Aug. 25, 1996; R. Saltus, Questions Persist Following Suicide, BOSTON GLOBE,
Sept. 2, 1996.
720
L. Belkin, There is No Simple Suicide, N.Y. TIMES MAG., Nov. 14, 1993; H. HENDIN, SEDUCED BY DEATH:
DOCTORS, PATIENTS, AND THE DUTCH CURE 91 (1997).
721
H.W. Batt, DeLury Defense Fund Established by Hemlock Society of New York, TIME LINES, Mar.-Apr.,
1996 (Hemlock Society newsletter); “I Deserve to Enjoy a Little Rest I Have Left and a Chance to Do Something
for Myself,” THE FORWARD, July 21, 1995, at 1; A. Shafran, When Life is Measured by Quality, Not Sanctity,
NAT’L RIGHT TO LIFE NEWS, Feb. 6, 1996; July 4, 1995 Was “Liberation Day” for Fifty-Two Year Old Myrna Lebov, FIRST THINGS, Apr. 1996, at 75-76; L. Townsend, New York Authorities Investigate “Mercy Killing,” NAT’L
RIGHT TO LIFE NEWS, Oct. 11, 1995; D. Andrusko, Manhattan Editor Pleads Guilty in “Assisted Suicide” Case,
Will Serve Minimum Time in Prison, NAT’L RIGHT TO LIFE NEWS, Apr. 12, 1996; L. Lagnado, Welcome to the Era
of Euthanasia Chic, NAT’L RIGHT TO LIFE NEWS, May 20, 1996.
722
C. Innemee, Commissie Remmelink krijgt zes gevallen voorgelegd: NPV geeft voorbeelden van ongebraagde levensbeeindiging [Six cases presented to the Remmelink Committee: N.P.V. (The Dutch Patients’ Association) presentes examples of termination of life without request], 8(4) ZORG (Veenendaal) 4-6 (1990); R.
FENIGSEN, EUTHANASIE, EEN WELDAAD? [Charitable euthanasia?] 12 (Van Loghum Slaterus, Deventer 1987); F.
Abrahams, De huisarts die het niet zo nauw nam [The family physician who was not too scrupulous], NRC
HANDELSBLAD, May 23, 1995; Bedoelingen arts waren good: Voorwaardelijke celstraf voor “slordige” euthanasie
[The doctor had good intentions: Probation for “sloppy” euthanasia], BRABANTS DAGBLAD, Oct. 22, 1995.
723
G.F. Koerselman, Hoe mondig zijn moderne patienten? [How mature are the modern patients?], 130
NED. TIJDSCHRIFT V. GENEESKUNDE, 2017 (1986).
724
Geen straf arts voor euthanasie: van Ooijen wel schuldig van moord [No punishment for the doctor
who performed euthanasia, but the court did find Dr. van Ooijen guilty of murder], BRABANTS DAGBLAD,
Feb. 22, 2001. The seemingly paradoxical ruling (doctor guilty of murder, no punishment) is typical of
the Dutch legal situation.
725
W. van den Linden, Zij moest eerst . . . Het dossier van Bommelen: een geval van euthanasie? [She had
to go first . . . The Van Blommelen file: A case of euthanasia?] (Strengholt Pub., Naarden 1984); G.A. Lindeboom, Een z.g. euthanasie-drama [The drama of the so-called euthanasia], 11 VITA HUMANA 100 (1984).
719
Other People’s Lives: Reflections on Medicine, Ethics, and Euthanasia
353
ency,726 to relieve, not the patient, but his family,727 out of social-Darwinist bias against
people with disabilities,728 and even out of doctor’s impatience, in a burst of anger.729
And in the United States? What exactly were the intentions of the obstetrician
and the parents who decided to let a baby with Down syndrome die?730 Was the best
interest of the child (however, they understood that interest) their sole consideration?
Wasn’t there an intention to spare the parents, and the community, the psychological
and material burden of raising a child with disabilities?
And when some of us plead for putting the comatose persons or the severely
disabled infants out of their misery, are we absolutely certain that only compassion and
concern about their dignity are our motives? Isn’t there a component of repugnance?
And of instinctive fear and hate?
What were the motives of the spiritual father of American euthanasia, professor
Joseph Fletcher, when he demanded that “an idiot” be given a lethal injection?731 When
he recommended death for those he called “monsters,” “subhumans,” and “no more
persons”?732
Nazi euthanasia was the work of people motivated by hate and repugnance,
although some people involved had misguided good intentions. The tenor of the present-day pro-euthanasia movement in the Western nations is the noble striving to liberate
the sufferers; in reality, however, a multitude of motivations and intentions is revealed,
often less noble, and sometimes despicable. Thus, as far as intentions are concerned,
there is a difference, but, alas, no clear-cut boundary between Nazi euthanasia and our
own can be drawn.
“The Nazis killed sick people against their will; what we want is exactly the opposite:
Death by an individual’s own free choice.” Only the first part of this assertion is true.
Though many American proponents of assisted suicide do not realize it, the international
and American movement in favor of the “right to die” has always been, and remains,
strongly linked to the striving for involuntary euthanasia (the subject is discussed in
detail in Chapter XXXII). Nothing indicates that they would give up this goal after their
victory. In Holland, Great Britain, and the United States, health-care workers deliberately cause the deaths of older persons who never expressed such a wish. This is being
done by denying food to them and dehydrating them to death (see Chapter XXVII). In
REPORT II, supra note 199, at 64 (tbl. 6.7).
Id.
728
J.C. Molenaar, K. Gill & H.M. Dupuis, Geneeskunde, dienares van barmhartigheid [Medicine, servant
of mercy], 132 NED. TIJDSCHRIFT V. GENEESKUNDE 1913, 1914 (1988); J.C. Molenaar, Het nalaten van medisch
handelen [Refraning from medical interventions], 132 NED. TIJDSCHRIFT V. GENEESKUNDE 1925 (1988).
729
H.W.H. HILHORST, EUTHANASIE IN HET ZIEKENHUIS: ZACHTE DOOD VOOR ZIEKENHUIS-PATIENTS [Euthanasia in
the hospital: Mild death for patients] 175 (De Tijdstroom, Lochem-Poperinge 1983).
730
C.E. KOOP, KOOP: THE MEMOIRS OF AMERICA’S FAMILY DOCTOR 240-61 (1991).
731
J. Fletcher, Ethics and Euthanasia, in TO LIVE AND TO DIE: WHEN, WHY, AND HOW 113, 118 (1973).
732
J. Fletcher,The “Right” to Live and the “Right” to Die, in BENEFICENT EUTHANASIA 44-53 (M. Kohl, ed.
1975).
726
727
354
Issues in Law & Medicine, Volume 28, Number 2, 2012
modern Holland, involuntary euthanasia is practiced openly, and on a very large scale
(see Chapters XIX and XX).
“A massacre like the Nazi euthanasia could only happen in a totolitarian state.” Indeed,
only in a totalitarian state a mass euthanasia program ordered by a vicious leader could
be put into effect in such a brutal way, in full contempt of the law and public opinion.
But even in the totalitarian system Hitler’s powers were not unlimited. A euthanasia
bill was prepared but Hitler did not dare to introduce it to the Reichstag.733 Neither did
he dare to start the mass euthanasia in peace time; he waited until the beginning of the
war, hoping that “among all this dying” euthanasia would become more acceptable.734
Hitler’s euthanasia program could only proceed because it was eagerly supported by
groups that had pre-existed the totalitarian state and were at least partly independent of
it: the German scientists,735 doctors,736 parents of disabled children,737 and the believers
in the purity of the tribe.
Nor was the pressure exerted by the totalitarian state necessary to go on with
euthanasia. In August, 1941, when Hitler ordered a halt to euthanasia on psychiatric
patients,738 psychiatrists, hospital pediatricians, and doctors in private practice went on
with the killings, without orders, on their own.739
This spontaneous nation-wide action, known as “wild euthanasia,” did not stop
with the abolition of the Nazi regime. After the end of the war, in some German hospitals, euthanasia was continued, and was only stopped when the allied forces suppressed
the practice.740
No, no totalitarian regime is necessary to orchestrate hate and aggression against
the weakest members of society.
“Nazi euthanasia was a freak, monstrous incident. It cannot happen again in our civilized
part of the world.” It was no “freak accident.” Nazi euthanasia must be seen, first of all, as
a chapter in the long history of German euthanasia. The country’s tradition of destroying
“defective” children was ancient and persistent. In several of the German Länder laws
permitting such infanticide subsisted till the nineteen century,741 and the practice was
H. FRIEDLANDER, THE ORIGINS OF NAZI GENOCIDE: FROM EUTHANASIA TO THE FINAL SOLUTION 112 (195).
Id.
735
MÜLLER-HILL, supra note 665; PROCTOR, supra note 649, at 10-45.
736
PROCTOR, supra note 649, at 64-94.
737
Id. at 185-86; FRIEDLANDER, supra note 733, at 39; H. Eherhardt, Euthanasie and Vernichtung “Lebensunwerten Lebens” [Euthanasia and the destruction of “unworthy life”] 28 (Ferdienand Enke Verlag,
Stuttgart 1965).
738
FRIEDLANDER, supra note 733, at 61.
739
Id. at 151; PROCTOR, supra note 649, at 192-93.
740
FRIEDLANDER, supra note 733, at 61; PROCTOR, supra note 649, at 192-93.
741
I. VAN DER SLUIS, HER RECHT OM GROOTMOEDER TE DODEN [The right to kill grandma] 10 (Editions
Saint Jacques, Amsterdam 1979) (quoting C.J.A. Mittermaier, in A.v. FEUERBACH, LEHRBUCH DES GEMEINEN IN
DEUTSCHLAND GLTIGEN PEINLICHEN RECHTS [Handbook of common penal right in force in Germany] 217-19
(Giessen 1836)).
733
734
Other People’s Lives: Reflections on Medicine, Ethics, and Euthanasia
355
still well remembered in German Silesia in modern times.742 The exterminatory ideas
of Ernst Haeckel743 have strongly influenced intellectuals, and the deprivations of First
World War made some of the public receptive to the view that “useless eaters” ought
to be eliminated. Therefore, in the years 1914-1918, the food rations of the inmates of
German psychiatric hospitals were reduced in such a drastic way that up to fifty percent of all patients, about 140,000 persons, died of starvation.744 This first large-scale
assault on the lives of people with mental illness did not occur in a totalitarian state,
but in the German constitutional monarchy. The appeal to “release the destruction of
lives unworthy of living,” launched by professors Binding and Hoche in 1920,745 evoked
many supportive reactions in the post World War I democratic republic of Germany.
A motion to kill off the town’s mentally ill was considered by a municipal council.746
In 1925, seventy-three percent of parents of mentally retarded children, polled by
Meltzer,747 desired euthanasia of their offspring. The initial destruction of children with
disabilities in 1938 was not imposed by the Nazis, it was the parents and grandparents
who on their own initiative submitted applications for euthanasia to the Landregierung
of Prussia and to Hitler’s chancellery.748
The attitudes that led to Nazi euthanasia have never been totally rejected by German
society, and persist in many circles.749 The academe has sown particular understanding
for those who had inspired and directed Nazi euthanasia. After World War II, Eugen
Fischer continued as the editor of scholarly journals,750 Otmar von Verschuer was appointed professor of human genetics in Münster,751 and Werner Catel was invited to
chair the department of pediatrics in Kiel.752 If Verschuer’s assistant Dr. Josef Mengele
was not offered an academic post, it was apparently due only to the fact that he was
out of the country.
Id. (quoting H. Ploss, Das Kind in Brauch und Sitte der Vlker [The child in the nations’ customs
and morals] 162 (Th. Brieben Verlag, Leipzig 1911)).
743
HAECKEL, supra note 676, at 132, 134-35, 456-58, 472.
744
M. BURLEIGH, DEATH AND DELIVERANCE: “EUTHANASIA” IN GERMANY 1900-1945 142 (1994); PROCTOR,
supra note 649, at 178.
745
BINDING & HOCHE, supra note 676.
746
PROCTOR, supra note 649, at 179.
747
E. MELTZER, DAS PROBLEM DER ABKRZUNG “LEBENSUNWERTEN” LEBENS [The problem of cutting short the
“unworthy” life] 56, 90 (Carl Marhold Verlag, Halle 1925).
748
BURLEIGH, supra note 744, at 93; FRIEDLANDER, supra note 733, at 39; PROCTOR, supra note 649, at
185-87.
749
But we should not forget that Germany is not only that; Germany is also the country of Dr. Christoph Wilhelm Hufeland who in 1804 published the most prophetic warning against euthanasia ever
written; of The Rev. Franz Walter who in 1935 warned that “mercy killing” of the sick would become the
first step toward the extermination of entire ethnic groups and races. Germany is the country where public
indignation, voices of protest from the church, the army, and the very Nazi party, forced Hitler in 1941 to
order the end of the euthanasia program; the country where in 1989 public protests put a stop to professor
Peter Singer’s lectures in which he promoted the killing of handicapped infants.
750
PROCTOR, supra note 649, at 300.
751
Id.
752
Id.
742
356
Issues in Law & Medicine, Volume 28, Number 2, 2012
The judges in Frankfurt, Cologne, Tübingen, and at the Federal Court of Justice,
who tried the Nazi doctors responsible for gassing more than 2,000 psychiatric patients,
found that the defendants “believed they were performing genuine euthanasia,”753
“acted out of idealism,”754 and were motivated by “that most noble of human impulses:
compassion.”755
People with disabilities are still under assault in Germany, both from their educated foes (see Chapter XXXII), and from the skinheads who kick and punch them to
death,756 throw them down the stairs,757 and, armed with clubs, attack them at mental
institutions and schools for the deaf.758
Having determined the place of Nazi euthanasia in German history, we must also
locate it in space, as one of the manifestations of the eugenic craze and exterminatory
drive widespread at the end of the nineteenth and in the first half of the twentieth century in the Western world. A large section of intellectuals, scientists, social thinkers,
and politicians in Northwestern Europe and North America, Theodore Roosevelt, Oliver
Wendell Holmes, Jr., Calvin Coolidge, and John D. Rockefeller III, found themselves
under the sway of Sir Francis Galton’s theory that the quality of the human species (or
of the race, or nation, as the case might be) should be improved by barring entrance,
preventing the procreation, and eliminating “defectives,” “morons,” and “asocial individuals.” Human rights were trampled upon and innumerable human tragedies
ensued, all that for “the betterment of the species.” Henry Herbert Goddard and his
ladies “trained to recognize a moron at sight” on Ellis Island and ordered hundreds of
deportations “for mental deficiency.”759 U.S. immigration quotas, based on Goddard’s
finding that up to 87 percent of Jewish, Hungarian, Italian, and Russian immigrants
were “morons,”760 reduced the immigration from Eastern and Southern Europe to a
trickle.761 Twenty-seven states adopted legislation permitting surgical sterilization of
the “feeble-minded” and “defectives.”762 In Vermont, the sterilization law, promoted by
professor Henry Farnham Perkins, was passed in 1931,763 two years ahead of Germany
where such law was only adopted under Chancellor Adolf Hitler in 1933. From 1924
to 1972, over 7,500 “feeble-minded” and “antisocial” persons were surgically sterilized
Deneger, supra note 717, at 126.
Id. at 121.
755
Id.
756
German Skinheads Held in Beating, INT’L HERALD TRIB., Jan. 23-24, 1993.
757
The Return of German Facism, BOSTON GLOBE, Dec. 4, 1992.
758
J. Kaufman, New Wall of Hate Tilts Germany to Right, BOSTON GLOBE, Nov. 15, 1992; J. Kaufman, Man
Fights Disability of Hatred, BOSTON GLOBE, Dec. 14, 1992.
759
S.J. GOULD, THE MISMEASURE OF MAN 165, 168 (1981).
760
Id. at 166.
761
Id. at 232.
762
S. KHL, THE NAZI CONNECTION: EUGENICS, AMERICAN RACISM, AND GERMAN NATIONAL SOCIALISM 16-18
(1994); A.L. Stoskopf, Confronting the Forgotten History of the American Eugenics Movement, FACING HISTORY
AND OURSELVES NEWS, Winter 1995, at 3-9; J. Bandler, Facing Vermont’s Dark Past: UVM Exhibit Sheds Light
on Sterilization Project, BOSTON GLOBE, Sept. 3, 1995.
763
Bandler, supra note 762.
753
754
Other People’s Lives: Reflections on Medicine, Ethics, and Euthanasia
357
in Virginia: “unwed mothers, prostitutes, petty criminals and children with disciplinary
problems”!764 Victims were not told what was done to them. Farther-reaching projects
were abundant. Even the older ones among us tend to forget how openly the plans of
exterminating whole groups of population were discussed in the nineteen thirties, how
respectable it was to discuss the topic, how the revered leaders of the Western world
committed their names and talents to the programs of extermination. Dr. Alex Carrel,
winner of Nobel prize in medicine, proposed in 1935 that “the criminal and insane”
be “humanely and economically disposed of in small euthanasia institutions supplied
with proper gasses.”765 George Bernard Shaw, a great playwright and a revered sage, in
1944 and again in 1949 called for the extermination of “hopeless idiots” and “dangerous
crazy people.”766 Another moral authority of the Twentieth Century, the philosopher
Bertrand Russell, pondered whether Negroes should be exterminated, and concluded
that this was undesirable because they were indispensable for work in a hot climate.767 I
presented in Chapter XXXII the exterminatory projects of Dr. Foster Kennedy and other
activists of the euthanasia movement in the United States. At the Nuremberg trial, Dr.
Karl Brandt, Hitler’s personal physician and one of the initiators of Nazi propaganda,
argued, alas, in part correctly, that he only put into effect what many prominent Americans had proposed.768
We shall never understand Nazi euthanasia unless we admit that it was a monstrous
product of our Western civilization.
Does this mean that it can happen again? That it can happen in the United States?
I’m sure it won’t. But this is a qualified denial. The mass horrors of Aktion T4, the blatant
murder of tens of thousands will not be repeated; but a quieter, case by case elimination
of undesirables, either covert or surrounded by a cloud of rhetoric, will occur – and is
already occurring – in our democratic society.
Every morning democracy must be recreated anew by our deeds, and every day it
must be defended against thousand attempts to undermine it. If we don’t put up forceful
resistance, democracy may crumble as a result of legalized killing.
GOULD, supra note 759, at 335.
A. CARREL, MAN THE UNKNOWN 296 (London 1936).
766
W.L. Sperry, The Case Against Mercy Killing, 70 AM. MERCURY 274 (Mar. 1950) (quoting G.B. SHAW,
EVERYBODY’S POLITICAL WHAT’S WHAT 281-86 (London 1944) (Interview given to the Associated Press, Aug.
24, 1949)).
767
PROCTOR, supra note 649, at 179 (quoting B. Russell, 1927).
768
KHL, supra note 762, at 101.
764
765
358
Issues in Law & Medicine, Volume 28, Number 2, 2012
Appendix 2
Voices from Mensa
Mensa is an association of the best and the brightest, persons with an “IQ” so
high that it places them in the top two percent of the population. In 1994, American
Mensa Ltd. had 55,000 members, 2,000 of them in the Los Angeles area. At the end of
that year, two remarkable articles appeared in Lament, the newsletter of Lost Angeles
Mensa. The authors called for the extermination of “defective” people and the creation
of a “master race.”
Jason G. Brent, a lawyer, wrote that “society must face the concept that we kill off
the old, weak, the stupid and the inefficient.” Brent supported the creation of a “master
race,” and regretted that Adolf Hitler’s actions prevent a rational discussion of this topic.769
Answering journalists’ questions, Brent said, “We cannot continue to have population
explosion. We better face that we have to kill people. There are not unlimited amounts
of resources.”770
Another Mensa member, Jon Evans, called for liquidation of the homeless. “What
good are they? The vast majority are too stupid, too lazy, too crazy, or too anti-social to
earn a living…. Granted, there are a few people who have fallen beneath the blow of
circumstances and are unable to afford any place to live, but they are few and far between.
The rest of the homeless should be humanely done away with, like abandoned kittens.”771
The same, according to Evans, should be done with people who are mentally or
bodily deficient: “A piece of meat in the shape of man but without a mind is not a human
being whether the body be deathly ill, damaged by accident, mentally blank because of
brain deficiency, or criminally insane.”772
One could easily dismiss the articles by Brent and Evans as the excesses of some
freaks. But these two gentlemen were not isolated in their opinions. The editor of Lament
newsletter, Nikki Frey, was unapologetic, and surprised that anybody would be offended. “I wouldn’t print anything I thought was truly harmful or offensive. I didn’t think it
was harmful. I don’t think it’s even that offensive – nobody wants to have a deformed
child.”773 The chair of Mensa’s Los Angeles chapter, Ms. Gowen, and the chapter’s board
supported Frey.774 Ultimately, however, the editor of Lament had to resign from her post.
There were many indignant reactions from other members of Mensa and from outsiders.775 A member of American Mensa’s national board condemned the publication of
769
J.G. Brent, in LAMENT, Nov. 1994 (Newsletter of the Los Angeles Mensa); J. Bone, Outcry Over Mensa
Call for Master Race, THE TIMES (London), Jan. 12, 1995.
770
N. Zamichow, Newsletter Articles Stir Furor in High-IQ Group: Writers in Mensa Publication Spark
Outrage by Advocating Killing of the Old, Infirm, and Homeless, Board Backs the Editors and the Author’s Right
to Express Their Views, LOS ANGELES TIMES, Jan. 10, 1995.
771
J. Evans, in LAMENT, Nov. 1994; Bone, supra note 769.
772
J. Evans, in LAMENT, Nov. 1994; Bone, supra note 769.
773
Zamichow, supra note 770.
774
Id.
775
Id., D.J. Sauders, Death Instead of Taxes, SAN FRANCISCO CHRONICLE, Jan. 13, 1995.
Other People’s Lives: Reflections on Medicine, Ethics, and Euthanasia
359
“hate material.”776 The director of British Mensa said that “one Adolf Hitler was enough
for this century.”777
For our own safety, we should not forget what ideas ferment in a certain faction
of the West Coast’s intellectual elite.
776
Zamichow, supra note 770; Associated Press, Mensa Newsletter Editor Ousted for Eugenics Views,
CONTRA COSTA TIMES, Jan. 14, 1995.
777
Bone, supra note 769.
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