Medical Ethics

Medical Ethics

The moral basis for practice of medicine has developed gradually over several thousand years and has its expression through what is commonly termed medical ethics.

  • Pain-relief treatment that could shorten life, if it does not involve a primary intention to kill the patient, is not euthanasia.
  • Refusals of treatments are morally and ethically different from euthanasia, and should remain legally different.
  • The drive by bioethicists to have euthanasia become part of medical practice is unwelcome to many doctors.
  • "Physician-assisted suicide, like euthanasia, is unethical and must be condemned by the medical profession." (WMA)
From early times, the medical profession has had a strong commitment to ethical behaviour in professional practice. The Hippocratic Oath dates from around the 4th Century BC:
"I swear by Apollo the physician, by Æsculapius, Hygeia, and Panacea, and I take to witness all the gods, all the goddesses, to keep according to my ability and my judgement, the following Oath. To consider dear to me as my parents him who taught me this art; to live in common with him and if necessary to share my goods with him; to look upon his children as my own brothers, to teach them this art if they so desire without fee or written promise; to impart to my sons and the sons of the master who taught me and the disciples who have enrolled themselves and have agreed to the rules of the profession, but to these alone the precepts and the instruction. I will prescribe regimen for the good of my patients according to my ability and my judgement and never do harm to anyone. To please no one will I prescribe a deadly drug nor give advice which may cause his death. Nor will I give a woman a pessary to procure abortion. But I will preserve the purity of my life and my art. I will not cut for stone, even for patients in whom the disease is manifest; I will leave this operation to be performed by practitioners, specialists in this art. In every house where I come I will enter only for the good of my patients, keeping myself far from all intentional ill-doing and all seduction and especially from the pleasures of love with women or with men, be they free or slaves. All that may come to my knowledge in the exercise of my profession or in daily commerce with men, which ought not to be spread abroad, I will keep secret and will never reveal. If I keep this oath faithfully, may I enjoy my life and practice my art, respected by all men and in all times; but if I swerve from it or violate it, may the reverse be my lot." In more recent times, a medical practitioner is more likely to use the Declaration of Geneva at the time of being admitted as a member of the medical profession. The Declaration Of Geneva was adopted by the 2nd General Assembly of the World Medical Association, Geneva, Switzerland, September 1948, and was most recently amended and reaffirmed by the 46th WMA General Assembly in Stockholm, Sweden, in September 1994.

DECLARATION OF GENEVA

I SOLEMNLY PLEDGE myself to consecrate my life to the service of humanity;
I WILL GIVE to my teachers the respect and gratitude which is their due;
I WILL PRACTICE my profession with conscience and dignity;
THE HEALTH OF MY PATIENT will be my first consideration;
I WILL RESPECT the secrets which are confided in me, even after the patient has died;
I WILL MAINTAIN by all the means in my power, the honour and the noble traditions of the medical profession;
MY COLLEAGUES will be my sisters and brothers;
I WILL NOT PERMIT considerations of age, disease or disability, creed, ethnic origin, gender, nationality, political affiliation, race, sexual orientation, or social standing to intervene between my duty and my patient;
I WILL MAINTAIN the utmost respect for human life from its beginning even under threat and I will not use my medical knowledge contrary to the laws of humanity;
I MAKE THESE PROMISES solemnly, freely and upon my honour

The basis of the moral framework for medical practice has been developed gradually over several thousand years, and is therefore well established, whereas guidelines for professional behaviour must reflect the changing social environment in which doctors practise.

The moral basis for practice has its expression through what is commonly termed medical ethics. Integral to an ethical basis for professional practice is the overriding acceptance of an obligation to patients, and recognition of their autonomy.

The World Medical Association provides an international code of practice for all doctors, and in New Zealand we have the Code of Ethics of the New Zealand Medical Association, most recently updated in 2002, which delineates the standards of ethical behaviour expected of doctors in New Zealand.

It contains eleven Principles of Ethical Behaviour:

NZMA CODE OF ETHICS
All medical practitioners, including those who may not be engaged directly in clinical practice, will acknowledge and accept the following Principles of Ethical Behaviour:
  1. Consider the health and well-being of the patient to be your first priority
  2. Respect the rights of the patient
  3. Respect the patient's autonomy and freedom of choice
  4. Avoid exploiting the patient in any manner
  5. Protect the patient's private information throughout his/her lifetime and following death, unless there are overriding public interest considerations at stake, or a patient's own safety requires a breach of confidentiality
  6. Strive to improve your knowledge and skills so that the best possible advice and treatment can be offered to the patient
  7. Adhere to the scientific basis for medical practice while acknowledging the limits of current knowledge
  8. Honour the profession and its traditions in the ways that best serve the interests of the patient
  9. Recognise your own limitations and the special skills of others in the prevention and treatment of disease
  10. Accept a responsibility for assisting in the allocation of limited resources to maximise medical benefit across the community
  11. Accept a responsibility for advocating for adequate resourcing of medical services
The Principles are followed by fifty-three recommendations or guidelines, designed to convey an overall pattern of professional behaviour consistent with the principles set out in the Code of Ethics.

The NZMA, as the representative of the medical profession, must also measure its actions against these codes of practice. (Source: www.nzma.org.nz)

Dr Tricia Briscoe, Chairman of the New Zealand Medical Association, addressing the Medical Law Conference on 30 May 2004 said:
"It is very important not to confuse euthanasia with other conduct that is ethically and legally acceptable in treating terminally ill patients. There is a world of difference between using appropriately prescribed very strong pain relief that may also shorten life and deliberately killing someone.

Necessary pain-relief treatment, even that which could shorten life, does not involve a primary intention to kill the patient; euthanasia does. Profound legal and ethical differences hinge on whether such an intent is present.

Similarly, refusals of treatments are morally and ethically different from euthanasia, and should remain legally different. The right to refuse treatment flows from a right to inviolability ? a right not to be touched, including by continuing treatment, without one's consent ? not from a right to die.

Withdrawal of treatment will mean death, but it will result from the patient's underlying illness. Causing a patient's death through administering a lethal injection is different, not in degree but in kind, from death following refusal of treatment."
Bioethicists
The drive by bioethicists to have euthanasia become part of medical practice is unwelcome to many doctors and is seen as sinister by opponents of euthanasia.
  • One of the fears is that it will undermine the doctor patient relationship and corrupt the character of doctors
  • Medical associations around the world have taken a firm stance against euthanasia, calling it unethical
  • There are fears that economics and healthcare rationing will dictate who can live and who must die
  • Doctors enter medicine out of a desire to save lives and relieve suffering, not to have to kill their patients
  • Doctors may feel pressured to agree to a patient's wish for euthanasia even when they know they can alleviate pain or treat depression
Bioethics is a relatively new field of philosophy that engages in debate in the areas of morality in the context of health care and biotechnology. Bioethicists have enormous influence over policy makers in medicine, law and government who try to grapple with highly complex moral issues.

John Harris, a director of the Institute of Medicine, Law and Bioethics at the University of Manchester in England and a leading voice in the bioethics movement wrote:
"Many, if not most of the problems of health care ethics presuppose that we have a view about what sorts of beings have something that we might think of as ultimate moral value. Or, if this sounds too apocalyptic, then we certainly need to identify those sorts of individuals who have 'the highest' moral value or importance (emphasis added): a moral value or importance comparable to that to which we believe ourselves entitled."
Wesley J. Smith is a senior fellow at the Discovery Institute of Seattle, Washington, an attorney and consultant for the International Task Force on Euthanasia and Assisted Suicide, an award winning author, and a special consultant to the Center for Bioethics and Culture. Smith points out:
"Had Harris written that health-care ethics presupposes a view about "which race has the highest moral value or importance, " he would be dismissed as a mindless bigot. Mainstream beliefs in bioethics are just as discriminatory -- they merely threaten different victims.
Here's the nub of the problem: Many bioethicists believe that basing moral value and legal rights solely upon being human is capricious, religion-based and irrational. Many go so far as to contend that granting special status to humans simply because they are human is itself an act of discrimination against animals, a concept that has been given the bizarre name "species-ism."

To avoid the odour of species-ism, bioethicists often assert that what counts morally is not being "human" but being a "person," a status earned by possessing identifiable mental capabilities such as being self-aware or having the ability to engage in rational behavior. While the exact criteria for determining who is and who is not a person are still being debated, most bioethicists agree that there are human beings who are not persons."

Many of those who are labelled by bioethicists as "non-persons" are also those whose medical care would be the most expensive. In a day and age when most hospitals are facing budget blow-outs and are calling for cost-cutting measures, bioethics poses a danger not only for the terminally ill, but also for the elderly, those with physical or mental disabilities, and the chronically ill.

Doctor Patient Relationship
Opponents of euthanasia say that one of the first casualties of euthanasia and physician assisted suicide (PAS) will undoubtedly be the doctor/patient relationship. Dependent on mutual trust they believe this bond will become increasingly fragile as doctors find their boundaries in the issue over life and death changing.

Doctors worldwide are against euthanasia and PAS this statement from the World Medical Association (1992) outlines their position.
"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 or her own life, the physician acts unethically. However the right to decline medical treatment is a basic right of the patient and the physician does not act unethically even if respecting such a wish results in the death of the patient."
Further the WMA recommends to National Medical Associations and doctors to refrain from practising euthanasia even if national laws allow or decriminalise it.

1988 British Medical Association Working Party Report
Published in 1988, the Report concentrated almost exclusively on the ethics of clinical practice.

The seven members of the Working Party were all doctors and had access to advice on legal and philosophical questions from three 'observers', and was established in response to an urging that the BMA 'reconsider its policy on euthanasia'. It held 15 meetings in as many months before publishing the Report in May 1988.

The Working Party reached the conclusion that, for several ethical considerations, euthanasia should not be made legal.

Para 56: The view that someone would be 'better off dead' is linked to being 'discriminatory about the kind of worth that attends a life'.

Para 62: The 'conviction that human life is of inestimable value and ought to be protected and cherished' leads one to embrace the arduous task of of finding value in the lives of patients suffering pain and severe disability; to end those lives would be a comparatively easy option.

Para 72: In being asked to kill patients doctors are being asked to abandon the conviction that human life is of inestimable value and ought to be protected and cherished.

Para 238: A sense of the inestimable value of individual human life is essential if doctors are to 'maintain a dedication to care of patients and the preservation of life'.

Select Committee Report
102. The existence of a trusting and open relationship between doctor and patient is of particular importance when the patient is terminally ill and decisions must be made for care towards the end of life. The VES (Voluntary Euthanasia Society) suggested that "any change making it easier for doctors openly to carry out their patients' wishes can only reinforce confidence on both sides". Some other witnesses agreed.

103. More witnesses however felt that the relationship between doctor and patient would be undermined if the doctor was empowered to practise euthanasia, even under the strictest of controls. The BMA said "if doctors are authorised to kill or help kill, however carefully circumscribed the situation, they acquire an additional role, alien to the traditional one of healer. Their relationship with all their patients is perceived as having changed and as a result some may come to fear the doctor's visit".

104. The Linacre Centre suggested that the practice of euthanasia would corrupt the character of doctors, and encourage them to view some patients as lacking inherent worth. This would undermine "a disposition indispensable to the practice of medicine: the willingness to give what is owing to patients just in virtue of their possession of basic human dignity" .

Advances in Medical Science
105. The VES cited developing medical technology as a factor fuelling support for euthanasia. "Having created the situation in which lives are routinely saved, transformed or prolonged by medical intervention, we can hardly pretend that the process of dying, and that alone, must be left to nature".

Mr Ludovic Kennedy suggested that advances in medical techniques meant that "the dominant fear today is of being denied release from a prolonged period of painful, distressing and undignified dying". This point was supported by a number of individual members of the public who wrote to us, particularly those who had witnessed the difficult death of a family member.

"Slippery Slopes"
106. The so-called "slippery slope" argument was clearly put by the BMA. They said that "by removing legal barriers to the previously 'unthinkable' and permitting people to be killed, society would open up new possibilities of action". They said that "any moral stance founded on the permissibility of active termination of life in some circumstances may lead to a climate of opinion where euthanasia becomes not just permissible but desirable.

Once active termination of life is a matter of choice for competent people, the grounds for excluding non-competent people from such treatment become harder to defend". A number of other witnesses made a similar point. Sir Robert Kilpatrick observed that "one of the great problems is always to work out the implications of a change, because they may be much more far reaching than one can see".

He cited abortion as an example, saying that the number of abortions performed each year far exceeded that expected at the time legislation was passed. Dr David Cook made a similar point: "What began in 1968 as offering permission for doctors to perform abortions under certain restricted terms has now become an expectation ... that abortion is available on demand ... there has been a slippery slope when legislation about justified killing has been introduced". He also spoke of the human inclination always to go beyond any established limit.

107. The Reformed Presbyterian Church of Ireland feared that voluntary euthanasia would lead to a descent of the "slippery slope" because of the need for concurrence by the doctor. "The ultimate decisive factor is the patient's perceived quality of life - ie that his life is not worth living - not his request for death... there is no logical reason, once voluntary euthanasia is allowed, why the practice may not be extended to cases where no request has been made, if in the doctor's judgement that is the best course of action for all concerned". (1)

See also Position of Medical Associations Worldwide

Economic Aspects
The fear of becoming a financial burden on loved ones is the second most important reason people want to die by euthanasia claim ?right to die' advocates. However a survey in Oregon where assisted suicide is legal claims the figure to be as high as 66 percent.

Inadequate funding for palliative care means that many who reach old-age feel the despair of frustrating physical limitations and endure debilitating conditions that could be treated with proper care.

Opponents claim the demand for euthanasia could be eliminated totally with high quality nursing care available across society.

Big budget blow-outs in health spending means that health-care providers will be forced to make budget cuts and this will result in less funding being made available for nursing staff and hospital beds. As the ageing population grows there will be increasing pressure to look at euthanasia and assisted suicide as a means of cost containment.

Economic cutbacks in health spending pose a major threat to those who are medically marginalised. If assisted suicide or euthanasia became legal, once the public had be de-sensitised to the whole idea it would then increasingly become a method of cost-cutting for health care providers.

In Oregon where assisted suicide is legal there are already cost-caps on health care provisions and while some life-saving surgery is considered too expensive the same company will front up with the money for a much cheaper alternative, assisted suicide. The same company can then claim the patient ?chose' this option.

The Coalition of Concerned Medical Professionals condemns this practice as "death squad medicine".(2)

Obviously a major illness can wreak havoc on family finances. As the public debate about assisted suicide and euthanasia grows there will be increasing pressure placed on the sick to move towards death - what is now known as a "duty to die". This may not only come through the major institutions but may insinuate itself in the most precious one, the family, as relatives see their inheritance being eroded by high health costs.

These figures speak volumes: The cost of drugs for assisted suicide $35.00. The cost of proper health care $35,000-40,000.

Christian Perspective
The difficulty Christians have with euthanasia is that it involves killing another human being which is a blasphemous act to a Christian because life is a gift from God and is sacred because mankind is made in the image of God. (Genesis 9:6) So too is Physician Assisted Suicide a similar act in that human beings strive to kill themselves with doctors becoming accessories to that act.

The Christian ethic is indeed to relieve suffering but not above all else. The death of Jesus on a cross is an explicit display of the burden he chose to bear. In so doing he challenged all Christians to join him in carrying that burden and entering his suffering by taking up their cross everyday. Human life even at its most difficult has meaning because of God's eternal purpose for each person.

Lack of suffering is of course a good thing which is why Jesus asked to be spared from his ordeal in the garden of Gethsemane. But he then chose the greater good, the path that resulted in suffering and pain with the ultimate prize as his reward.

They cite more practical reasons for their stance as well in that the barriers to killing exist to protect doctors and surrogate decision makers who may make a hasty or wrong decision. This could have repercussions on their mental and emotional health in future years.

In a conference for Catholic health workers at the Vatican Pope John Paul stated:
"Euthanasia is among the dramas of an ethic that presumes to establish who can live and who must die. Compassion, when devoid of the willingness to confront suffering and stand by those who are suffering, puts an end to life where it aims to end pain, thus distorting the ethical statutes of medical science." (3)

Summary from LifeSite Website - English Based Medical Ethics Site
The British house of lords has responded to a Private Members Bill promoting legalised suicide in Britain by taking an unprecedented step of investigating the proposed Bill. At the core of the investigation lie claims by Lord Joffe, who presented the Bill, that 80% of people support euthanasia.

Doctors however are clearly not in favour of euthanasia. Results based on a UK Opinions Research Business survey (2003) showed 74% of doctors would refuse to perform euthanasia on patients. A clear majority 56% also consider euthanasia an area of unclear boundaries.

The survey also found palliative doctors totally opposed to the practice of euthanasia and assisted suicide.

Patient response to the question of euthanasia was also considered. Forty-eight percent of doctors reported that in the previous three years not one of their patients had requested euthanasia while only two percent gave figures higher than ten.

Doctors found requests for euthanasia were generally "cries for help that have been resolved with good symptom control...they invariably want relief from distress."

Dr Stevens director of the Christian Medical and Dental Society (CMDS) is quite outspoken about what he believes is the slippery slope of euthanasia.

"One in five cases of assisted suicide occurred in Holland without the patient's consent, and in 17 percent of the cases, other treatment options were available. The survey also revealed that almost two-thirds of the euthanasia cases in 1995 were not reported. With this kind of irresponsibility and neglect, who will even know what really went on between a doctor and a patient when a patient is dead?" Find this site on www.lifesite.net (4)

Second Thoughts From Dutch Euthanasia Doctors
The vanguard of the euthanasia practice are registering their doubt over committing the practice of euthanasia to their patients. These doctors are specially trained euthanasia consultants from whom a second opinion is required before a life can be terminated.

Doctor Groen-Evers stated at a gathering of these consultants:

"Look here, I have a statement to make. When I started on euthanasia, I got hold of the wrong end of the stick. So I am going to stop as a euthanasia counsellor. I cannot in all conscience accept the responsibility any longer. The law requires us to explore all avenues before we give euthanasia. But I see now that this happens only too infrequently."(5)

Other possibilities have been overlooked in the cases of many. Dr Willem Budde claims a blind spot resulting in euthanasia becoming THE solution to many conditions that could have been treated in a more pro-active manner. Dr Budde admits:

"There are some who died through euthanasia that now make me realise that, with my present knowledge, things would have gone a very different way." (6)

Little is known in the Netherlands about palliative care and some family doctors are now leading a counter movement against euthanasia learning from hospice programs in other countries.

Another doctor now opposed to euthanasia Dr Van Coevorden, claims patients are very suggestible and that if euthanasia is proposed a patient will go for it and if palliative care proposed they will go for that. She is pleased to have been able to offer palliative care as an alternative to euthanasia and has virtually stopped performing euthanasia.

Dr Budde states further: Palliative care gives me back the confidence...to say no, (to euthanasia) and yet have something to offer." He remembers the early days of euthanasia:

"There you were, out on the streets with your euthanasia bag; it had something: a mixture of caring and power. But that vanguard feeling has certainly gone now. Maybe it has to do with one's age" Budde explains. "I am fifty-three now: then you begin having other thoughts about death. Would I want euthanasia? No." (7)

More Concerns about the lippery Slope
All the concerns that were voiced when euthanasia was legalised in the Netherlands have, unfortunately, been realised. In August 2004, the Dutch judiciary legalised euthanasia for children under the age of 12. This means from birth onwards, anyone can be euthanised, often without the informed consent of the person involved.

Opponents to euthanasia say that this is "the voluntary murder of a human being who cannot speak for himself -- the voluntary murder of a human being who cannot express what he is thinking."

Now the doctor, together with the parents, might decide to eliminate the children who, according to the former, should not live. Several press articles report the statements of a Dutch doctor who says that it is a procedure that will be applied with much rigor. The Nazis also proceeded to practice euthanasia with extreme rigor.

In the early 1990s at a world meeting of neurosurgeons discussed what should be done when a child is born with a certain serious neurological illness. Two opposite positions arose from the debate. On one hand, an Israeli doctor who operated on children with excellent results. The patients needed follow-up treatment, but had a relatively normal life.

On the other hand, a Dutch doctor explained how, in the clinic where he worked, the children affected by this sickness were eliminated by being injected with a lethal substance.

Not many people know that Hitler's euthanasia program was at first rigorously reserved for Germans; only later was it extended to other ethnic groups.

The Nazi program was directed to children born with sicknesses that, according to its point of view, threatened physical integrity.

The first case of euthanasia was practised on a boy who had a harelip. It occurred at the request of the parents who, fearing that he would have an unhappy life, asked the doctors of the Hitlerian regime for help; they advised euthanasia.


(1) BMA Website - policy http://www.bma.org.uk/ap.nsf/Content/pas+project+-+select+cttee
(2) Smith W.J. Culture of Death The Assault on Medical Ethics in America. Encounter Books - San Francisco p118.
(3) http://www.sutterhealth.org/health/healthinfo/reutershome_top.cfm?fx=article&id=19354
(4) lifesite - www.lifesite.net/ldn/2004/jan/04011501.html
(5) Oostveen, "Regrets: Champions of euthanasia practice are having second thoughts",
NRC Handelsblad, 11/10/01. Translated.
(6) Ibid
(7) Ibid