The Sciences: Medicine:
The Medical Profession and Euthanasia
by Professor Dr. António Gentil Martins
Pediatric Surgeon, Pediatric Oncologist and Plastic, Reconstructive
and Aesthetc Surgeon
Summary: The problem of Euthanasia is approached in the light of the Hypocratic principles, considered not to have changed with times, but only having been adapted to the new scientific and social developments. The concept of Euthanasia is clarified as well as the need to avoid that semantic mutations might manipulate ideas so much so that, what is certainly wrong, does not appear as apparently right. The uniqueness and individuality of the Human Being is emphasized, as well as the Medical Professionals commitment to the wellbeing of their Patients, altough, at times, a balance is required in relation with some apparently conflicting interests between them and Society, as a whole. Also stressed is the importance of the Patient/Doctors relationship, particularly in the final stages of terminal disease. Decisions concerning life or death, although preferably to be shared, still remain most often on the Doctor’s shoulders, alone. The respect for the wishes of the Patients, their right to know the truth and its limits, the use of the Living Will, the right to die in dignity, the use of ordinary or extraordinary means of treatment, the concept of brain death and the rules for ressuscitation, are commented upon. In all cases, the need for a global and individualized approach is mandatory before any final decision is made. Total respect for Human Life, from its beguining to its end, is emphasized; intentional killing, for whatever reason or motivation, is firmly rejected. Reference is made to National and International Codes of Ethics, as well as to Statements and Declarations of the World Medical Association. Finally reference is made to a subtle form of Euthanasia, of a political nature, when the necessary funds are not allocated for Health Care.
As a rule for human behaviour, and as a factor of social conduct, the Christian Civilization recomends that “one should love others as he loves himself”. We could speculate that medical ethics goes far behyond that, imposing that, in situations of dilema, the Medical Professional places the interests of his Patients before its own interests.
We believe that Natural Morals, and Laws, do not really change with the winds of history or politics. And also that do not change the basic principles and values, that should be the base of “Medical Ethics”. Those Principles are already well established in the Hypocratic Oath, that as been adapted to the Culture, tradition and general trends of the Societies and their historical evolution; but without , by that, being altered in their fiundations. The Hypocratic Oath contains inalterable principles such as the “Right to Life” and that all actions of the Medical Professional are directed to the health of all men, without exception, independently of their religion, ethnicity, sex, political options or social status, to whom he consecrates himself.
It is the Professional commitment of Medical Doctors to the individual and to Society, that makes the true nobility of Mediicne, so wide in moral terms as restrited in legal ones, imponsing a constant search for perfection, both in conduct and in medical and ethical knowledge, runing from the more sublime aspects of human activity to the smallest daily life activities in the practice of the art. And the truth is, that. most of the time, the medical professional will only be guided by his own conscience, that one expects well formed, considering that only himself will be the true and only judge In his Oath, Hypocrates, promises not to give to anyone, even if requested, any mortal medicine and not to sugest such advice, as well as promising not to give to women anything that may lead to abortion.
the same way wrote
Moises Maimonides, in the XII century, Tomas Percival in 1803 and,
more recently the World Medical Association, that, in
Already more than 25
centuries ago, Hypocrates, freed himself from the
primitive magic medicine of the
The concept of Hypocratic Medicine, which has prevailed over centuries, is a cultural concept, steming from the conviction that the individual Human Being, when considered facing the whole of Humanity, has a unique and inimitable destiny and is thus not a mere component of a Society, who can be subsituted at any moment or circunstances. So, its fundamental purpose, will always be the safeguard of the Human Being and his survival as an individual.
It is obvious that Medical Ethics, while primarily concerned with the individual Person, can not forget Society as a whole, and seecks to find an equilibrium between the interests of both. Nevertheless, it would be utterly regretable that Hegel’s Theses, of rational utility, would overcome moral, ethical and religious values, with a Consumers Society overcoming a Society of Values.
It is important to stress that situations of progressive degradation, do not arrise suddenly and it is often the small opening that leads, latter on, to the most regretable enormities. A Society that is not able, does not want or can not maintain its moral values, is necessarily condemned to dehumanization. Medical Doctors themselves have always been, globaly, unsurpassable defenders of the perenial moral values of their profession, (within which, one can surely find, “the Right to Life”).
But, is it true, that only Medical Doctors are worried about this problem?. Certainly not.
Universal Declaration on Human Rights, approved by the
United Nations, in 1948, states that “all man has the right to life, to freedom,
and to security as a person”. And the European Convention on Human Rights, of
In fact, in the modern world, two great theses clash: one, that believes that there exists a natural moral and law, fundamental and unalterable base of human Dignity, and another, that believes that moral and law are no more than progressive and conjunctural principles, in constant alteration, in order to serve the apparent momentary interests of each Society. It is obvious that we share the first one, and repudiate the second.
The defence of Life has always represented an essential and basic principle, when considering the respect that human dignity merits to Medical Doctors, be it in its beguining or at its final stages. It is this way, that abortion and euthanasia, are the extreme ends of the same phylosophy, and that they do not respect the dignity of man, as a global, material and spiritual, Human Being.
Medical Science as for long demonstrated that Human life is a continuum, in which only artificially, one can establish divisions. That extremely complex, and many times dramatic, problems may exist, is certainly not deniable. Dilemas confront often the Medical Doctors conscience: but, to deny the principles, will surely be more dramatic and socially more serious..
New breaches in the moral principles, already so much confounded in our modern Society, must surely be avoided, and one thing will be to try to understand an human error, stemimg from extreme situations, another will be to legitimate or consider apparently correct, something that can never be so: the intentional threat to a Human Life.
When speaking about Euthanasia, the first thing that has to be defined very clearly, is the concept. Etimologically Euthanasia signifies, soft death, sweet death or quiet death. Nevertheless, for what concerns us today, it really means necessarily the deliberate intension of anticipating death in relation to what could be expected from the natural evolution of things. If that intention does not exist, there will be no Euthanasia. It is thus irrelevant, and even unreasonable, to speak about “Passive Euthanasia”, as to abstain from a hopeless therapy, in a terminal Patient, can not be considered as Euthanasia. On the other end, voluntary Euthanasia, even at the Patient’s request, will be no less than homicide by request ou assisted suicide, always unethical under the viewpoint of Medical Ethics.
Could it ever be that any Human Being, wether or not medically qualified, has the right to dispose of the life of other Human Beings? We would reject seing the medical professional, today still regarded and worshiped according to the respect his actions merit, to become looked at with sentiments of suspition or fear, of even aversion or danger, of suspicion of abuses or errors, of involvement in material gains, or being victim of the collusion of greedy relatives ( thus interested .in the desappearance of inept, but simultaneously wealthy, relative).
What would a Patient feel about the possibility of finding himself surrounded by a group of men, in principle knowledgable and of sound judjement, but from whose Meeting might follow a induced death sentence? Certainly, one of the effects of such a possibility would the destruction of a true Patient/Doctor relationship, an essential pré-requisite for an efective support, particularly in the period which preceeds death..
The acceptance of voluntary Euthanasia would leed to na increase of the number of requests. And, worst of all, could bring about, also, the quick acceptance of non-voluntary Euthanasia. At a time that the more sophisticated so-called “modern States”, become more powerfull and burocratic, again, quite easily, could emerge an almost compulsary Euthanasia, for the disabled, the deformed and the incurable, similarly to the Nazi Holocaust.
We can not forget that, even recently, in the United Sates of América, for a “more easy” death, it was proposed that it should be a Doctor ( by the use of drugs, as opposed to the classical electric chair ), the one to execute the capital punhisment, - a suggestion that was clearly rejected in a Document of the World Medical Association.
In daily practice it may happen that a Patient, when under intolerable physical suffering, may ask, as a supreme mercy, that everything is granted to him, even death. Nevertheless, some days later, when suffering has quietened, either sponaneously or by therapy, the Patient has already forgotten his previous request and makes projects for the future. Can one take as granted, what has been expressed under the coercion of apparently untolerable pain? Has the Medical Professional the right to satisty that wish, dictacted by the anguish of continuous suffering, but can no longer be such, later on? The answer, for us, is surely negative. The Patient may, if he so wishes and is beliefs allow it, end is own life; but he should never ask any Medical Professional to do that for him.
modern Societies, egoism tends to prevail. And so, numerous movements in Holand, in
we returning to the times of Esparta, when weak and
malformed children were
thrown over the clifs of the Taigeto? Or that in old Germânia,
old or very sick people were buried, death or alive.?
Or that in Índia, the incurable diseased were thrown
In cases of prolongued, painfull and hopeless disease, suggestions to approximate the end, do not come generally from the Patient, still lucid, and they do not appear, spontaneously, in the Doctors mind. They come generally from relatives, that call upon the Doctor about the inconvinience of prolonguing an already condemned life. The Doctor’s answer can be no other than to aliviate suffering,, support the Patient, but never to precipitate his death. It is common to say that to alliviate pain is God’s work: that has been, and still is, true. But the administration of the same therapeutic elements, may represent na abysmal difference: the difference between the defense of human dignity at the time of death or homicide. It is surely correct that the Medical Professional administers the drugs that kill pain, even when he knows that that might, unwillinlgy, shorten the life of the Patient, in a double effect situation. To run a calculated risk when using a therapy is surely different than to have the deliberate aim to provoque death by an overdose.. .
Behind a request for Euthanasia, expressed by the Patient, there is almost always an anguished request for support and affection, a need for human warm and of supernatural. For a humanized death to occur, it is important that pain be kept within bearable limits. The resistance to pain, is a variable cultural phenomenon, apart from individual, influenced by the level of motivation, the significance atributed to it, and also by the atitude of Society. Human suffering is not only a biological phenomenon, thus becoming essential not only to fight pain, but also that anguish and anxiety inherent to the situation of those that see, threatened, their body and integrity. It is particularly, in that situation, that a personalized Patient/Doctor relationship becomes of paramount importance. Nevertheless, one can not forget, when analyzing this problem, that this relationship with the very sick or dying Patient, is also traumatic for the Person who treats them,:and this is, so more so, when death becomes closer and suffering is not relieved enough by medication.
If the Medical Professionel has the duty of fighting for life, that does not imply that he should be compeled to use extraordinary means of therapy, when they, in borderline situations and according to scientific knowledge at that time, would only serve to prolong death or when, on the other end, the Patient has manifested , without any shadow of a doubt, that he does not want, those means to be applied to himself.
The distinction between extraordinary or disproportionate means and normal, ordinary or proportionate means, are here fundamental and obviuosly will vary according to scientific development, with the existing ressources and with the concrete circunstances of each case. If, on no account, can be questioned the use of normal means ( which include, particularly, the basic human confort care, like nutrition, higiene,and the psycological and moral support ), on the contrary, the use of extraordinary means can only be justified, when the prespectives of their utilization, can give to the Patient a usefull prolongation of life, and not only an absurd prolongation of suffering and of death. In this latter ciscunstances, the non utilization of extraordinary means is not, and will never be considered Euthanasia, similarly to what happens when a ventilator is disconected in a Patient already in cerebral death.
If Society, one day, hopefully never, believes that it is licit to kill a Patient or a criplled, then it will have to choose na executioner, but could never pretend that a Medical Professional would perform such a role.
In Holand, the political power decided to cease punishing Euthanasia on demand.and, unfortunately, the Royal Ducht Medical Association accepted to subscribe such a priniciple, altough with reservations. That led, immediately and healthily, to the appearance of another Association, respecting the basic principles of traditional, and perenneal, Medical Éthics. Unfortunately one can foresee that, namelly in Holand, with times going by, after acceptance and widening of those concepts it will not be only the one that has requested it, but also the troublesome relative (because incapable of caring for himself), or the relative suffering from advanced câncer, that can become the victims of provoked death, with alleged good intentions. For us, “no penalization”, is no more than a coward and hypocritical way of not wanting to assume legalization and to demonstrate agreement.
In the Dutch legislation, it is expected that the Medical Professional that refuses to practice Euthanasia on demand, due to “consciencious objection” , should assume the responsability of refering his Patient to another Medical Professional, willing to do it. That is, for us, a chocking situation, to repudiate firmly. But that can not surprize all those that have accepted such a principle, namelly in relation to the problem of abortion (atitude of which we have always disagreed, but from what discussion, at international level, we came loosers but not convinced.
The most dangerous is to start opening the doors, because soon they will become wide open.That is what has happened, namelly in the United States of América, with the question of Abortion, where around 98% of them are now performed just on psycological grounds. The true Medical Professinals, that have sworn to defend life and and to respect the sacred principles of their profession, will have always to say no, to Euthanasia. The interest of the Patients and the safeguard of the most elementary human rights, so require.
When discussing the problem of Euthanasia the problem of quality of life has been raised. It is quite clear that a consumistic mentality and a culture based on profit, ends up considering quality of life, only on quantitative critéria, measuring the worth of a person existance only upon its efficacy or economical value.. Facing such a concept, the lives of deficient or older people become necessarily precarious, as only with difficulty can they be utilized for production and profit. To that mentality one has to oppose the implacable faith in the intrinsic Human Dignity, as the fundamental bases for evaluation of quality of life. If this is already valid for mosto f those who believe in a laic society, , more evident it becomes for those that firmly believe that life is a God’s gift.
Inclusively, scientific techology risks, to place in the shadow, the unique human value of the Patient that is being treated. The Health Machine, with its Institutions and ressources, of a ever increasing efficacy ( but also with theis tortures…. ), may tend to ignore the the personality of the Patient, then reduced to a number or a file, composed of faceless indices and factors, without a story, relation or problems. It is essencail to remember that the Patient, before being a disturbed organism, is a displaced Person, searching for a lost equilibrium. How often, in Medical pratice, one is not confronted with the question when should death be fought against , even at a high price, or when it will be our duty to get familiar to it, to confront it and to accept it.
The Medical Professional that renounces to therapeutic obstination because he believes that the means available are desproportionate to the results and benefits he will be able to give to the Patient, is certainly justified. In the impeding of an unavoidable death in spite of all the measures taken, it is licit to take,. in all conscience, the decision to renounce to tratments that would only allow for a precarious, and that could almost be said, artificial prolongation of life.
The Right to Life is surely undisposable, but it is normal to admit that also exists the Right to Die, conceived as the dignified end of that life. The Right to Life and the respect for the Right to Die.The concrete possibility that Medicine now offers to prolong life, raises the problem of what are the limits, imposed by Morals and Reason, for such a prolongation, to how far should one have the right to go. It would be to take out any sense to his fight, to reduce Medical Action, to simple therapeutic obstination, with no regard for the dignity of the Person.
The problem of those limits, relates also to the respect for the Patient’s wish, and that will stand out in the Code of Medical Ethics; In view of that, the eventual Patient’s refusal of a proposed therapy , frees the Medical Professional from any responsability, not only in relation to his own conscience, but also in the face of Morals and the Law. It will be in the intimacy of his conscience that, at a last resort, the Medical Professional will decide to stop his fierce fight against death.
Life being a primary possession and the biggest we have, it is normal that it is to be defended to the very end. However, to keep alive na organism, does not mean to maintain only its vegetative functions but to assure, at least at a basic level, the cognitive functions which constitute the Person’s ego, and consequently, give him his unique dignity and personality. The cessation of all cortical activity removes, by defenition, any sense, to try to prolong human life.
Apart from brain death, the existence of a persistent vegetative state, with total loss of cognitive function, but with maintenance of the functions needed for a vegetative life, raises the problem of an eventual cessation of means of artificial vital support. Pratice has shown that after 12 months of such a situation, it is pratically none the risk of mistake, about the irreversability of the situation, and the problem can arrise about the proportionality between the inconvenients and benefits of maintaining extraordinary means of ressuscitation: from that will be taken the final decision, and again, in this case, an accusation of Euthanasia , not being sustainable.
The personalized relationship Patient/Doctor, we have always fought for, stems naturally from the freedom of choice that is left to the first one, being the best assurance that, in the situation of terminal illness, there will be no major surprizes or difficulties. Mutual knowledge and the established trust, will allow for anticipating situations and the finding of solutions. The Patient will always have a word to say,, as no treatment can be imposed on him by the Medical Professional, who is, fundamentaly, defender, friend, and councellor and not owner or judge.. But also it will not be the Patient or anyone else that could impose to the Medical Professional to violate the Ethical Code of his Profession.. The fundamental difference between Euthanasia and to renounce to prolong death through useless treatments, lies fundamentaly in the intention of the atitude and in the fact that one represents a direct assault to life and the other the right to die in peace. It is the difference between homicide and the dignity in life, even in death..
Knowing that the Medical Professional, as any Human Being, is falible, decision such as these, altough taken in science and conscience, should preferably be shared ( even if , in his daily actions, it is almost always the Medical Professional alone, who as to assume total responsability for the final decision ). It is thus fundamental that in their judgement, Medical Practitioners do not cease to consider, above all, the interests of the Patients and the respect for their professional Ethics.
The phrase “to die in dignity” must be reserved to describe the obligation to give care to the dying, with sensibility,compassion and ethics and never as a means to hide Euthanasia. The decision to kill by the use of any letal agent, even when death is iminent, is a decision that can be made by anyone , not requiring medical knowledge and the letal agent can as well be a bullet, an electric chock or a poison. What is certainly unacceptable is to pretend that it should be a Medical Professional the instrument of such action, that in fact means murder..
The Patient has the right to know all the truth concerning his real health situation, the care and interventions he needs and the riscks in which he will be involved, because only to himself and to no other, belongs to dispose of himself and consequently exercise his own freedom, in an extremely critical vital situation. The knowledge of the truth inspires many times in the Patient, the legitimate wish to fullfil certain religious or moral duties, to complete certain civil formalities or to determine the succession, in the best interest of the survivors.. Nevertheless, even if the Patient has the right to know the truth, the Medical Professional is not precluded from abstaining to tell him all the truth, when he believes that he will suffer a shock that may be detrimental to his physical or psychological health. In this case, the Medical Professional should give proof of sensibility, intuition and compassion, revealing the truth with tact, progressively and causciously, but always maintaining some hope. The Medical Professional’s atitude must always take into account the cultural level, the inteligence, the character and the personality of the Patient.. The Medical Professional will not be compeled to give a Medical Course to each Patient: nevertheless he must give him the basic elements, indispensable to allow him the choice between the various possible options, refering to risks, as well as to the possibilities for success. Only this way the Patient will be capable to weight prós and cons, and to take the decison he feels it is best for himself. This personalized Patient/Doctor relationship is one of the best safegards for de defense of man, his dignity and is survival as na individual,, against the ever increasing weight of those for whom Society is all powerfull and wants to substitute the Patient/Doctor relationship, by a relatioship Beneficiary/State ( in which the role of the Medical Professional is regulated by burocartic/administrative critéria ). Easy is, thus, to understand that the problem of Euthanasia envolves also a choice about the type of Society in which one wishes to live.
The International Code of Medical Ethics of the World Medical Association, promulgated in 1969 and revised in 1983, reafirms the duty of the Medical Professional “to have always in mind the obligation to preserve Human Life”. In 1950 the World Medical Association again declared that “Voluntary Euthanasia was against to the spirit of the Geneva Declaration”, and thus non-Ethical. The same Association, in its Declaration of Tóquio, in 1975, concerning the problem of torture, reafirmed in the preamble, that “the utmost respect for human life must be maintained, even under threat, and that no use of medical knowledge shall be made that would be contrary to the laws of Humanity”. It also explicits that, if a prisoner refuses feeding and the Medical Professional has certified that he is able of conscient and rational reasoning concerning the consequences of that voluntary refusal, he or she, should not be fed artificialy. This abstention, by the Medical Professional, in the respect for the Patient’s will, will never be considered as Euthanasia.
More recently, the World Medical Association, noticing the existence of voices advocating Euthanasia in cases of incurable disease, decided to clearly reafirm its stand, that is, that active Euthanasia is a act of murder, and thus, fundamentaly against the basic Oath, sworn by the Medical Professional. Simultaneously states that “that position does not preclude the Medical Professional to respect the Patient’s wish that the natural dying process to follow its way, in the terminal fases of ilness”.
The European Code of Medical Ethics ( in which drafting we had the honour to participate), says, in its Article 12º, about support to the dying, that Medicine implies, in all circunstances, the respect for life and also for the moral autonomy and freedom of choice, of the Patient. Nevertheless the Medical Professional can, in cases of incurable and terminal disease, limit himself to aliviate the Patient’s physical and psychological suffering, giving him the appropriate treatment and maintaining, as much as possible the quality of the life that is ending. The Declaration of Lisboa, in 1981, about the Rights of the Patients and drafted during the first Portuguese Presidency of the World Medical Association, after declaring that the Patient has the Right to accept or reject treatments after having been duly informed, states that the Patient has the Right to die in Dignity and to receive or reject the moral and/or spiritual confort, from a Minister of the appropriate Religion. The Declaration of Venice, of 1983, on Terminal Ilness, says that it is the duty of the Medical Practitioner to cure, and whenever possible to alliviate suffering, as well as to act in the best interests fo the Patient, with no exceptions to that principle, even in the event of incurable disease or malformation. This principle implies that the Medical Professional must follow certain rules ( as to alleviate the agonizing Patient’s suffering or abstaining to use extraordinary means which are proved to be of no real benefice ) and, at the same time, allows him to use artifitial means, needed to maintain organs active for transplantation ( when the Patient is already incapable to invert the final process of cessation of vital functions.
The Declaration of Sidney, of the World Medical Association,, in 1968, related to the certification of Death, revised in Venice in 1983, reinforced the need that the certification of death must be the responsability of a Medical Professional, emphazizing that two activities of modern Medicine have raised the need to more deeply study the moment of death: in the first place , the capacity to maintain, by artificial means, the circulation of oxigenated blood thoughout the body tissues ( that may already be irreversibly damaged ), and, in the second place, particularly in what concerns the quickness of that detrmination, the problem of harvesting cadaveric organs ( like the heart or the kidneys, for transplantation )
Death being a gradual process at celular level, the importance of determining the moment of death, lies not in the state of preservation of isolated cells, but in the Person’s destiny:from that stems the concept of cerebral death, today universaly accepted. The moment of death of different cells or organs, is not so important as the certainty that the process has become irreversible, no matter what ressuscitation techniques are imployed. What is essential is to determine when there is irreversible cessation of all cerebral functions ( including the brain stem ), determination to be accomplished through clinical examination , to be supplemented , as required, by auxiliatry diagnostic methods. Nevertheless , in the present state of Medicine, , no single tecnological criteria is entirely satisfactory and the technology can not be a substitute for the global appreciation of the Medical Professional.
It is a current finding that the law lags behind in defining parameters e thus should not, in the concretesituation of cerebral death, go beyond the recognition that such a concepts exists.
It should be the Medical Profession ( in the concrete case of Portugal, the “Ordem dos Médicos” , based on the advice of a specif Sub-Committee, dependent of the Council of Medical Ehtics ), to maintain constantly up-dated the techno-scientífic criteria that will allow for defining, in each period, the true existence of cerebral death.
Refering now to national norms, we find that the “Ethical Code of the Ordem dos Médicos ( Portuguese Medical Association and Council ), of 1949, refuses Euthanasia and specifies in a specific paragraph of Article 12º, that the incurability of the desease does not justify abandoning the Patient, and that the Medical Professional, that would do so, would incur in a severe fault, because he would compromise one of the most wonderfull assets of the profession: to confort and to mitigate, when one can not cure. In Article 19º it states that itshould be avoided, in an incurable Patient, any treatment that is not aimed at, or does not contribute to smooth his existence. In Article 20º it say that moderation in thearpy is a quality always valuable and that the choice of the simplest and cheapest means constitutes a moral obligation, when the state of the Patient allows it.
The present Code of Medical Ethics of the Ordem dos Médcios is very clear in its Article 50º, about the duty of the Medical Professional to keep the utmost respect for human life since its beguining and reafirms that the pratice of Euthanasia is totally forbidden, not bein considered as such the abstention of any non initiated therapy when resulting from the conscient and free will of the Patient or its legal representative except, for what is stated in Article 41º nº3, where it is said that in the case that life is in danger, the refusal of immediate treatment required by the situation, whenever possible, can only be made personally and freely, by the Patient himself.
same position of rejection for Euthanasia can be found in numerous Codes of
Medical Ethics (quotes from 1991): Brasil - (Medical
Federal Council) – Article 57;
The Parliamentary Assembly of the Council of Europe, in its Recomendation 777, of 1976, concerning the Rights of Patiens and of the Dying, invites the Governments of the Member States to take all necessary measures so that Patients are relieved of their suffering as much as present medical knowledge allows it, and to guarantee that all Patients have the chance to prepare themselves, psychologically, for death, foreseeing the necessary support to that aim. It also suggests the establishment of National Committees, able to elaborate ethical rules for the treatment of the dying, to determine the ethical principles to be respected in what concerns the use of special measures aiming at prolonguing life and to examine the situation in which the Medical Profession can find itself when they abstain to use artificial means to prolong the process of dying., in Patients in whom agony has already started and life can not be saved, in the present state of medical knowledge.
side remark, we would like to state that, for us, those National Committees will
have very little to teach to the Ethical Councils that the organized medical
profession, has always kept funcioning. I tis curious to find that those Committees firstly appeared
The Recomendation 777, to which we have already refered, also atributes to the National Committees the evaluation of the writen statements, done by juridically capable Persons, authorizing Medical Professionals to abstain to use measures to prolong life. It is the case of the Declarations of expressed wishes or “Living Will”, of the anglo-saxonics. That “living will” can never be more than another factor to be evaluated by the Medical Professional, whom, above all, will have to use his clinical judgement (evaluating all the multifactorial complexity of advantages and desadvantages for the Patient, of the established diagnoses and the concrete circunstances in which he practices.
It is also important to consider that the rules of “ressuscitation or no-ressuscitation”, established in Intensive Care Units ( do not ressuscitate or DNR, of the anglo-saxónic authors ) can never be interpreted whithin a rigid frame, as the Scientific Method is fundamentally a statistical method and we all know that there are no Diseases but Patients, and that statistics, as D’Israely stated, are one of the greatest types of lies. Each individual case must thus be taken in its own mérits and any basic rules, even scientifilly established, can be no more than stand points to be incorporated in a more complex picture, which is the overall evaluation of the Patient by the Medical Professional.
The History of Medicine is full of difficult problems that required clear ethical rules for their resolution. On the other end one must be conscious of the limitations of Medical Science, and of human nature itself. The defenders of Euthanasia ( in the middle of whom one can find some medical graduates, that we do not wish to consider has true Medical Professionals ), try to disguise, with atractive words such as Rights, and Compassion , the most barbaric ideas, so to give them a certain apprearance of respectability.
Through a skilful adulteration of speech, is produced the manipulation of contents, of the real issues and of the ethical principles.. The clever manipulation of new forms of persuasion, made possible through the experience gained in comercial publicity and in political propaganda, leeds often people to accept, atraumatically, new expressions that make tolerable, or establish as needed,what previously was rejected as unworthy or repugnant. That is exemplified with what happened when the concepet of the inviolability of life was destoyed, to allow for the legalization of abortion.
The social acceptance of the new morality is made easier through the alteration in significance of many words, like contraception, voluntay interruption of pregancy, death with dignity., etc.. Through simple semantic mutation, the new words not only appear as ethically neutral but also surrounded with an aura of innocence. One is not facing simple synonims of old words, but neologisms that represent the deliberate manupulation of Ethics. One day phylologists will tell the story of this enourmous error, with which a large part of Society has condoned, with a certainly not tottaly innocent complicity.
Can’t we remember that
a pill was advised that would eliminate old people ?
( John Goundry –
It is important to note that degrading situations, in general, do not appear out of the blues and it is often the small opened wedge that leads later to the worse atrocities. A Society that does not know or is not able to keep its ethical values is necessarily condemned to inhumanity. The Medical Professionals, on their own, have always been inflexible in the defense of the perennial values of the profession, in which, certainly stands, de defence of life. Is is in fact the importance they atribute to it, that conditions their stand.
The Patients perpective about death and suffering is clearly dependent of the laic or religious vision about the value of suffering and about life beyond death. It is up to the Medical Professionals, here again, to respect the Patient’s options and help him, directly or through someone appropriate, friend or priest, to acomplish his own death.
It is common to say that Ethics should respect law: I would say that medical ethics can be above the law. How often have we not found that the Laws of Princes are against Ethics: is is the case of hand amputations, for thieves, in Islamic Countries, the use of Psychiatry in the Soviet Union, the death penalty in the United States of América, the exsanguination of prisoners condemned to death in Iran, etc. The jurists, with cleverness, have found a solution for these and other problems in a pluralistic Society: the “consciencious objection”Only this one, nowadays, allows the Medical Professional to fully respect his Code of Honour and namelly one of its most basic principles: you shall not kill. But will consciencious objection be enough? Wouldn’t it also be required that the Medical Professional gets involved in the defense of the values he believes in? For us, there are no doubts that he must do so.
The right to a smooth and dignified death necessarily implies that, in those last moments, the Patient is accompanied by his most loved ones, what is usually very difficult in the hospital settings and particularly in the Intensive Care Units. It should be a well established rule, in the last ones, the possibiity of the presence of at least one family member , particularly when death becomes imminent.
Is spite of the sad reality of our times, with frequent family break up and the working conditions not being favorable to that support, the truth is that every day one finds the multiplication of acts of solidarity and union, at the side of those that life is abandoning. How often a kind word, a gesture of affection, are better than a new dose of analgesics? To die in his home, in his bed, near his loved ones, the basic care and particularly the relief of pain, being assured, is for us the best solution. And when that is not possible, it will have to be the health personnel – Medical Professionals, Nurses ou even Voluntary hospital workers, who, at the time of death, must fill that emptiness.
If the decision to stop vital life support should, in principle,, be shared with the ones who have a better knowledge of all the problems involved and the existence of an hierarchic chain justifies the agreement of the more responsible Professional, it is generally on the shoulders of the Patient’s Doctor that must lie the responsability of the final decision. It is that individual responsability of the Medical Professional, one hopes correctly develloped, that at the end, will take the decision on which depends the life or the death of the Patient. It is that individual responsability that consecrates the true greatness of the profession, and which the great majority of Medical Professionals has, since Hypocrates, been able to respect and strenghten.
We do not share the concept that only one parameter can define priorities in the choice of a therapy, particularly when ressources are limited.Thus, it can not be age the simple reason to connect or disconnect a ventilator, to do or not to do, dyalises. There is nothing that allows one man to decide if a life is more worthy than another. Thus, it is not acceptable to deny to one Patient the means of vital support just because another Patient arrives, perhaps with better chances of recovery, but for whom no longer are there vital support means available. En exception might nevetheless be, if one has to consider very particular circunstances, and, in which case, after overall analyses, it is clearly found a manifest disporportion of the chances of recovery and survival of both Patients.
This brings us to a final consideration on what we can call Political Euthanasia, resulting from the insuficiency of the health budget. From those insuficiencies results too often the unnecessary death of many Patients, but, apparently, nobody seeming to notice it….. On the Medical Profession stays the ónus of denouncing it and to fight so that the existing ressources can be enough and available to all.
this respect it is interesting to quote, as an example, what happened many years
ago in the
The Medical Professionals refused such a task, suggesting to the politicians that they should be the ones to decide, based on individualized Medical Reports.The politicians where thus confronted with really, taking direct and personal knowledge that a waiting list, in dyalises, would mean a deth sentence for many Patients, for whose death the politicians had to take full responsability.. The pratical result was the immediate availability of the required number of dyalisers, according with the number of renal insuficiency Patients in that área.
This example constitutes an important lesson, which should encourage us to fight for better working conditions and allows to make clear to whom belongs the major responsability for the existing deficiencies: to the Medical Professionals or to Society. This one, represented by those that have been elected, seems often to be more worried about pleasure and confort, and to forget vital needs, what the Medical Profession will never do.
António Gentil Martins
Rua D. Francisco Manuel de Melo 1 3º Dto Lisboa
Pediatric Surgeon, Pediatric Oncologist and and Plastic, Reconstructive and Aesthetc Surgeon
Former invited Professor of Pediatric Surgery at the
Former President of the Ordem dos Médicos (Portuguese Medical Associationand Council ) and
former President of the World Medical Association.
Published in Portuguese in Acta Médica Portuguesa 1991;4:147-153
Note: This paper was written by us in 1991,
and we still believe in every word we wrote. Nevertheless, in 2006, the WMA
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