Comparison of Dutch & Nazi German euthanasia programmes (Dr John Larsen)
Submission to the South African Medical Association
Euthanasia is a subject, which has repeatedly entered public debate in South Africa in recent years. There are countries where doctor-assisted suicide and euthanasia with consent are legal practices. That is not the situation in South Africa. The South African Law Commission did consider introducing legislation on euthanasia but shelved the idea in 2000. However, the subject continues to crop up regularly in the press. It is usually presented as a compassionate idea, but is it?
The term euthanasia may mean one of two things:
It may be used for doctor-assisted suicide. This means a doctor provides a person with the means of killing himself or herself at his or her own request.
It may mean true euthanasia, in which the doctor kills the patient, usually by administering a lethal dose of a drug. That may be done at the request of the patient, so-called voluntary euthanasia; or a doctor may kill at the request of the relatives of the patient or on his own initiative without the patient’s consent – involuntary euthanasia.
We understand that if a patient refuses treatment which is burdensome or which has a poor chance of helping her, that is not suicide or euthanasia. That person is simply using her right to choose.
Also, when a doctor and the patient’s relatives decide to stop trying to cure an illness because treatment has become useless, and instead give palliative (comfort) care, that is not euthanasia. There is a very real difference between allowing the illness to take its natural course and giving a patient a lethal dose to kill her.
OUR FOREFATHERS DID NOT CONSIDER EUTHANASIA AN OPTION.
Euthanasia is a huge departure from the norms of Western medicine for the past 2400 years. It was the followers of Hippocrates who first took an oath, which included these words: “I will keep (the sick) from harm and injustice. I will neither give a deadly drug to anybody if asked for it, nor will I make a suggestion to this effect.” Christian and Muslim doctors followed their lead. Before Hippocrates, patients could never be sure whether a doctor intended healing them or harming them!
It is very significant that German doctors stopped taking the Hippocratic Oath some years before the Nazi regime took power. Under the Nazis, doctors lent their skills to the design of the death chambers of the notorious concentration camps where millions of Jews and others died. Other doctors carried out experiments on prisoners which often led to death or disfigurement.
Nuremburg War Crimes Trials Report: Leo Alexander – NEJM, 1949
“… it became evident to all who investigated that they (the crimes) had started from small beginnings. The beginnings at first were merely a subtle shift of emphasis in the attitudes of physicians. It started with the acceptance of the attitude, basic in the euthanasia movement, that there is such a thing as a life not worthy to be lived. This attitude in its early stages concerned itself merely with the severe and chronically sick. Gradually, the number of those included in this category was enlarged to encompass the socially unproductive, the ideologically unwanted, the racially unwanted, and finally, all non-Germans. It is important to realize that the infinitely small wedge – the lever from which this entire trend of mind received its impetus – was the attitude toward the non-rehabilitable sick.”
HOW GERMANY PROGRESSED DOWN ‘SLIPPERY SLOPE’:
* 1920’s: Eugenics before the Nazis – killing of the suffering and terminally ill
* 1935: Killing the mentally ill, aged, disabled ‘weaklings’
* 1939: GENOCIDE
So it is not surprising that Linda Emanuel, MD PhD, wrote about American law makers considering allowing euthanasia in their country: “This is a defining moment in medicine. If doctors are allowed to kill patients, the doctor-patient relationship will never be the same again. If killing you is an option, how can you trust me to do all I can to heal you?”1
WORLD MEDICAL ASSOCIATION AND EUTHANASIA:
1987: The following motion was passed by a vote, which was unanimous except for Holland:
“Euthanasia, that is the act of deliberately ending the life of a patient, even at the patient’s own request or the request of close relatives, is unethical. This does not prevent a physician from respecting the desire of a patient to allow the natural process of disease to follow its course in the terminal phase of illness.
“Physician-assisted suicide, like euthanasia is unethical and must be condemned by the medical profession; where the assistance of the physician is intentionally and deliberately directed at enabling an individual to end his/her own life, the physician acts unethically.”
That position was reaffirmed in 1987, 2002 and 2005.
HOW HOLLAND HAS PROGRESSED DOWN THE ‘SLIPPERY SLOPE’:
* 1973 – A physician gave a lethal injection to her mother.
* 1981 – Criteria for voluntary euthanasia for people with terminal illnesses were promulgated.
* 1982 – Voluntary euthanasia was made available for people with chronic illnesses.
* 1985 – Non-voluntary euthanasia became tolerated by the justice system.
* 1989 – Infanticide was then permitted.
* 1994 – Euthanasia allowed for mental suffering.
* 1997 – No penalties for not obeying the rules.
* 2001 – Euthanasia made legal. 16 year olds allowed to make decision without parental consent.
* 2005 – Criteria for legal infanticide proposed.
Holland has since lagged seriously behind other European nations in its delivery of terminal care.
It is important that we South Africans take note of Holland’s rapid slide, because, unlike Germany in the 1930’s, it is a stable nation.
South Africa is not yet stable politically. We have just emerged from the 40 years of Apartheid and the severe political violence, which that spawned. Political assassinations are still common, and we have a long way to go before we can be assured that legalizing euthanasia in this country would not be used as a tool for political oppression.
We are also a population who are culturally unstable. 80% of our people are being required to make the transition to modernism in about 80 years. That transition was made by Western nations over a period of about 300 years. We are a people experiencing serious cultural confusion. It is almost certain that our slide down the slippery slope would be very fast, and it is likely that it could take our whole nation into very serious suffering, even some forms of genocide.
WHY THEN, ARE PEOPLE NOW TALKING ABOUT EUTHANASIA?
What has led some people to attempt to abandon over 2400 years of wisdom?
The first thing seems to be our modern culture’s preoccupation with personal autonomy. That has spawned the idea that control over the timing and way in which I die is the ultimate autonomy. Proponents of euthanasia use the same language about choice used by those supporting abortion. But that is a deeply flawed idea.
Firstly, a belief like that cannot foster a sense of community and the common good, with their values of self-sacrifice and of doing things simply because they are right and just.
It would be disastrous for our civilisation if many people began to live according to an ethic rooted in autonomous individuality. It would mean, for instance, that the police officer who is faced with a man who wishes to throw himself from a 12 storey building has not got any authority to intervene and stop him.
Every meaning given to community would be reduced if each person exists as an end in himself. Such an idea promotes uncontrolled selfishness. That is true on a secular level as well as a religious level.
Secondly, no man is an island, and that is true of this situation too. The person desiring to take his life will be drawing others into that decision whether he intends to do that or not. Doctors will be faced with a crisis of conscience, not only when they are asked to assist a suicide, but in looking after every critically ill patient.
What doctor has not wished in our worse moments at 2:00 a.m. that a critically ill patient would die quickly so we could be relieved of the duty of providing difficult treatments or surgery? When we start to push back the boundaries of the sanctity of human life in that way, will it not become easier to give up? Ambivalence in motivation in medical practice is a very serious thing, and is the reason we health care practitioners take an oath not to consider the patient’s race, religion or creed in our efforts to save him – why we still take an oath equivalent to the Hippocratic Oath.
Then consider the situation of the patient herself. When a man or woman senses they have become a burden to others, will not the availability of voluntary euthanasia soon become the duty to ask for it and die?
Myrna Lebov suffered from Multiple Sclerosis. 1 week before her death, however, she was able to swim 28 lengths of their swimming pool. Her husband, George de Lury, loathed her disability and repeatedly urged her to commit suicide, because, he said, she was ‘sucking the life from him like a vampire.’ He wrote in his diary that he ‘had work to do, people to see and places to travel,’ which he could not do as long a Lebov burdened him with her existence. In 1995, she finally succumbed to de Lury’s pressure and agreed to kill herself. He mixed a poisonous concoction using her medicines. That only put her to sleep, so he smothered her with a plastic bag. He found support from Dr Kevorkian’s PRO and the Hemlock Society and is a popular speaker in pro-euthanasia circles in the USA.
Unending tragedy can result when assisted suicide interrupts the process of dying. Most of us find near death that there is still plenty of work to be done in our relationships if we are to die in peace, and leave those who love us in peace. When that process is interfered with, the possibility of severe depressive reactions in the survivors becomes very real, and other suicides may then be added to the tragic sequence of events.
Suicide contagion is ‘the process by which a previous suicide facilitates the occurrence of a subsequent suicide.’ In addition to contagion through exposure to media reports of suicide, contagion can occur through exposure to suicide or suicidal behaviour within family or peer groups. Suicide contagion affects individuals already at risk for suicide and is linked to increases in suicidal behaviours, especially in adolescents and young adults.
Sources: National Institute for Mental Health: ‘Frequently asked questions about suicide.’ www,nimh.nih.gov and Canterbury Suicide Project: Bulletin No. 10 February 1997 www.chmeds.ac.nz
It is easy to see how legalizing euthanasia will create a harsh society showing little compassion. ‘This will cause a quagmire of litigation between family members and make it enormously difficult to know who has been coerced or even killed against their will.’ (New York Attorney General Vacco.)
Western medicine has gradually moved away from the idea that medicine is an art, which combines skills and a moral commitment based on the standards Hippocrates taught. We too easily think of medical care as a series of techniques and as a means only of satisfying what the consumer wants. This crisis of meaning in medical circles puts additional pressure on health care workers when patients request assisted suicide.
WHY WOULD A PERSON ASK HIS DOCTOR TO END HIS LIFE?
Most people assume that unbearable pain, perhaps from cancer or AIDS, is the usual reason. That is not true. To begin with, 95% of all pain can be satisfactorily controlled by a doctor who will take the trouble to listen to the patient and follow common procedures of pain control. When pain is controlled, most such patients (97% in some series) change their minds. The medical profession has never had such powerful means of pain control as we have in our generation.
Depression and other mental illnesses are the commonest reasons a patient wants to end his life. Depression can be a difficult diagnosis to make, and it should thus be considered if any person begins to talk about suicide.
Researchers conclude that “Suicidal thoughts appear linked exclusively to mental disorder.”2 These are also treatable conditions, and the vast majority of patients who receive proper treatment and counselling, change their minds about taking their own lives. It is therefore not surprising that major studies in the United States, United Kingdom, Sweden and Australia found that only 2-4% of victims of suicide were terminally ill when they died.7
The third reason people may give for wanting to end their lives is the fear of losing control and becoming dependent – of perhaps becoming incontinent or developing a dementia. These are real fears, especially for people with no strong supportive family group. But when such people are introduced to skilled hospice care where their fears are listened to and solutions are found – when they are given loving care – they too change their minds.
Most patients expressing a desire to die want to know whether they are still worthwhile. So often the suicide request is really asking the question, “Does anyone care?” Such questions arise in patients’ minds because of the fear of being a financial burden or an emotional burden. The worst thing doctors can say in such circumstances is to agree that physician-assisted suicide in a ‘good’ option. JAMA, 235, 2660.
Fearful and dependent people can learn that the frailty of terminal illness or of old age can be the place where they at last face up to the deep existential questions of life – questions about the meaning of life and the possibility of eternal life. They have the time to find that there are satisfactory answers to those questions, which will let them die in peace. This should also be the time when we put all our relationships right – when we face up to all the unfinished business of our lives. It should be a time of spiritual and psychological maturing. It is a tragedy when people are deprived of this important life work. It leaves behind scars in others who should have been able to use those times for healing family wounds.
One thing that becomes clear as we consider this information is that the patient is not the best person to decide about euthanasia!! In the depths of depression he may want it, but a week or so later, he will be glad no one had the right to take his life when he asked them to do so.
Are doctors any better than patients at judging whether a patient should be helped to die?
Holland’s guidelines require that patients requesting assisted suicide must be mentally competent, that they voluntarily repeat the request for death and that they experience unbearable suffering from an irreversible illness. They also require that the doctors always report their intentional involvement in a patient’s death. It was hoped that such guidelines would protect dependent, disabled or elderly persons from family members and doctors who no longer think their lives are worth living.
Two studies 4 years apart have proved that those were vain hopes. 31% in 1990 and 22,5% in 1995 of the patients were killed without their consent, and in 1995, 21% of them were mentally competent at the time.3,4 The same researchers found that cases of involuntary euthanasia were rarely reported to the authorities.5 In other words, doctors are murdering patients, the numbers of murders are not really known and there is no recourse to the law in that situation.
Predictably, many Dutch patients now carry cards instructing that they should not be killed and some even hire people to guard them while they are in hospital. The trust between doctor and patient has substantially broken down, and legal safeguards have proved useless.
Then consider the fact that doctors are not nearly as good at predicting the outcome of an illness as they wish they were and as the lay public believes. Errors of diagnosis and prognosis are common, even in end of life situations.
It is an extreme irony that the Netherlands does not permit the death sentence for convicted serial killers for fear of the court’s making a wrong judgment, but they do permit it for innocent citizens who happen to be terminally ill. They do that even though there is certainly a greater chance of a doctor making a wrong decision than there is of one of their courts doing so in crimes, which might have carried the death penalty in the past.
There is also evidence that doctors in any nation are not good at assessing the patients’ feelings about the quality of their lives. Patients are generally more comfortable with the quality of their lives than the doctors think they are.6
In the private medical sector in South Africa, doctors would be open to a conflict of interest if euthanasia became legal, especially when they are offered financial incentives in managed care programmes to keep the costs of patient care down. Euthanasia is now an option offered to patients with a diagnosis of a terminal disease in Holland. It is a great deal cheaper to put an end to patients’ lives if they have a serious illness, than to treat them.
In the public sector, the situation is no better. Our hospital services are overwhelmed by large numbers of very ill people as a result of the HIV/AIDS pandemic. These patients are often very poor and ill informed. Staff providing after hours cover in particular suffer from high levels of compassion fatigue and burnout. One can confidently predict that the introduction of euthanasia into such a situation will lead to very serious levels of abuse of any legal safeguards, which might be attempted.
Doctors should not be given the responsibility and power of euthanasia or doctor-assisted suicide.
Neither should patients’ relatives be given that power, for a number of reasons. The first is that they are often drawn into the problems experienced by the one they love. Caring for them can cause exhaustion and burnout. That combination often causes profound depression. A depressed state of mind is not one in which to make any life and death decisions. That became clear in a recent celebrated case in this country. Then too, if relatives are in financial difficulties, their interests will be divided if the old man has money they hope to inherit, or if caring for the old lady is leading to increasing costs. And of course, not all families have good relationships. Euthanasia could be a good way of getting a troublesome old lady out of the way.
And how does a person who has helped to decide to kill someone close to them ever complete their grieving, especially when they come to see the circumstances through different eyes when the pressure is no longer on them?
Thus relatives should not be given the responsibility of deciding about euthanasia or of helping with doctor-assisted suicide.
Indeed, no one is suitable for that responsibility, which is why our fathers wisely chose to leave the timing of death to the processes of nature and the mercy of God.
“THE VALUE OF HUMAN LIFE CANNOT BE MEASURED: IT IS THE MEASURE ITSELF.” Former Pennsylvania Governor Robert Casey.
There is one other issue, which we must look at before we ask how we should respond to a loved one or a patient who is so desperate that he asks for help in ending his life.
In our culture, we tend to give value to people according to their usefulness. This is called a utilitarian view of people. It has been used to justify all sorts of destructive attitudes toward others. Thus the first step the Nazi government took was to declare the mentally retarded as useless and a drain on the economy of Germany. It was to exterminate large numbers of mentally retarded people that the gas chambers later used in Auschwitz and Buchenwald were first developed.
What Robert Casey was saying is that persons have value apart from their usefulness. Theologians say that it is because they have the image of God on them. When my dear old mother of 88 had a stroke and lost her speech and ability to walk, she was still my mother. Her eyes still lit up when I came to visit. She could still love, though she could not talk or walk. She was still my mother. My sense of compassion for her in her distress grew me, made me a better person, taught me more about love.
Our reverence for humanity must extend far beyond usefulness. It is the quality which allows mothers and fathers to behave sacrificially toward their young, soldiers to risk themselves for a critically injured colleague, spouses to pour themselves out in caring for each other into old age, health care workers to roll out of bed for an emergency. It is the essential basis of all quality of life.
Relationships are the one thing that remain when we are incapacitated. Our reverence for human life must extend to being prepared to accept that hardship and pain are not necessarily always bad. Our growth towards emotional and spiritual maturity often needs them. We can do much harm by demanding that we always be allowed to take the easy way out.
CARING, NOT KILLING.
How then, should we care for people with terminal disease?
We should do 3 things:
Provide comfort. That means helping those they love to come in close emotionally, and not to run away. It means learning to talk the truth in love, and learning when to stay silent. It means helping one another to face our mortality and find ways through our grief. It means good food, safe and comfortable accommodation, kind and sensitive carers. It may mean speaking up for a patient’s rights, interpreting her needs. It means finding adequate solutions for symptoms such as nausea and thirst. It means ensuring dignity. It may mean gathering expertise to solve financial problems. It usually means finding appropriate spiritual ministry and nurture.
Treat pain properly. That is seldom very difficult, but some patients do need the help of doctors or nurses with special expertise in that area of care.
Treat depression energetically. That usually means medication is required, but so is sensitive help in facing the existential issues in life.
For many of our patients in South Africa, some of these things are not easily achieved. The provision of adequate comfort in a shack in an informal settlement for a patient dying of AIDS or cancer can be extremely difficult.
That implies that we, as a society, must be prepared to invest heavily in developing Hospice Services, which are easily accessible to all our people. That is a much better and more compassionate solution than considering euthanasia in all its forms.
“There are no ordinary people. You have never talked to a mere mortal.”
C. S. Lewis.
1. Linda Emanuel, MD, PhD, Vice President for Ethics Standards, American Medical Association, New York Times Magazine, July 21, 1996.
2. Brown JH, Hentleff P, Barakat S, Rowe CJ: Is it normal for terminally ill patients to desire death? 1986, American Journal of Psychiatry, 143:2, 208-211
3. van der Maas PJ, van Delden JJM, Pijenborg L: Euthanasia and other medical decisions concerning the end of life: An investigation performed upon request of the Commission of Inquiry into the medical practice concerning euthanasia. 1992. Amsterdam: Elsevier Science Publishers. p 178-182.
4. van der Maas PJ, van der Wal G, Haverkate I, de Graaff CLM, Kester JGC, Onwuteaka-Philipsen BD, van der Heide A, Bosma JM, Willems DL: Euthanasia, physician-assisted suicide, and other medical practices involving the end of life in the Netherlands, 1990-1995. 1996; New England Journal of Medicine 335, 1699-1705.
5. van der Wal G, van der Maas PJ, Bosma JM, Onwuteaka-Philipsen BD, Willems DL, Haverkate I, Kostense PJ: Evaluation of the notification procedure for physician-assisted death in the Netherlands. 1996. New England Journal of Medicine, 335, 1706-1711.
6. Callahan D: Minimalist Ethics. 1981, The Hastings Centre, October, p 19-20.
7. Clark DC: ”Rational” suicide and people with terminal conditions or disabilities. 1992: Issues in Law and Medicine, 8, 147-166.
I wish to acknowledge the help I received from publications by Focus on the Family as I prepared this document.
Dr J V Larsen MB, ChB, FRCOG