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Editorials

Assisted dying

BMJ 2012; 344 doi: https://doi.org/10.1136/bmj.e4075 (Published 13 June 2012) Cite this as: BMJ 2012;344:e4075

Rapid Response:

Re: Assisted dying

In her editorial dedicated to the question of so-called “assisted death”, Fiona Godlee (1) proposes, with particular delicacy and notable balance, an essentially equidistant position between the attitudes of those who have for some time been arguing the legitimacy of such an approach to the patient, and those who on the other hand have insisted on its impossibility: for Godlee, legislators should resolve the question once and for all and the healthcare professionals should remain neutral, avoiding involvement in this theme of multitudinous moral implications, with varied and contrasting understandings.

Not without purpose, Godlee suggests parallels to the debate that took place prior to the introduction of the UK Abortion Act, in distant 1966. We note how on this argument she in essence simply follows in the footsteps of Thomas More, who in Utopia foresaw a future legislated scenario in which “magistrates and priests” would exhort the suffering and incurably ill to “abandon this earth” (2).

In any case, we hold that the proposed “neutralist” view deserves refutation under other considerations.

First, while uninformed on British events of 1966, but having first-hand experience of what took place in Italy ten years later, we do not believe that one can trace parallels between abortion and euthanasia. Yes, at least apparently, in both cases there is the conflict of the right to freedom (of the woman or the patient) with the right to life (of the unborn or the patient himself). But in fact, in the one case, the right to freedom, although perhaps sometimes limited by conditions of vulnerability (of financial or social nature), is still exercised by a person (the pregnant woman) who is fully autonomous, while in the second case the right to freedom would be invoked by a person not only rendered vulnerable by illness and suffering, but also at that point deprived of effective autonomy; who in the final phases of an existence debilitated by illness, has become dependent on the others who offer assistance at the level of his most essential acts (eating, getting dressed, washing, etc.).

In the first case, retrospectively, it is almost certain that the current of thought favourable to abortion had centred its argument on the right of women’s self-determination, in the conviction that the choice of interrupting pregnancy (a choice often much suffered, and thus vulnerable) could in practical fact be taken by the woman alone, and thus only the lack of formal (legal) recognition of the full autonomy of the woman could, up until that time, present an obstacle to the full expression of such right of freedom.

Yet in the second case, can we be so certain of the actual “freedom of expression” of the terminally-ill patient?
Whoever has read Dependent Rational Animals, by Alasdair MacIntyre, can well understand how much the fact of vulnerability and, above all of dependence, can present an obstacle to liberty in self-determination (3).

It appears still more debatable to call for the adoption of neutrality, almost as if the medical world need not take interest in the theme of so-called “assisted death”, instead requesting that all decisions be made by the law-makers.

The “euthanasia question” has accompanied the practice of medicine since its earliest days. And the answer, since earliest times, has not in the least been neutral.

In fact, in the Hippocratic Oath (5th century BC), we read: “I will neither give a deadly drug to any one, even if asked, nor suggest any such counsel”.
“Primum non nocere” (First, do not harm!): the objective of medical practice, for all times.

How could such a precept ever be reconciled with so-called “assisted death”?

The answer will be – or rather already is: “but you’re just blocking the wishes of a patient who doesn’t want to suffer!”

And here we enter into a dialectical fiction: meaning treatment of pain (and/or the anguish of living), we attempt to substitute provision of death.

But it is one thing to give a drug with the intention of treating pain, with the side-effect – never originally sought – of shortening the patient’s existence (primum non nocere), and another to administer it with the exclusive aim of provoking rapid death, even if it is collaterally painless.

This is not morality in play here; it is the nature of medical practice itself.

It was Epimetheus (the everyman), not Asclepius (a doctor) who closed – late as it was – Pandora’s box, leaving only the spirit of hope entrapped within: something we could never again offer the patient if the legislator Epimetheus were to close the box of suffering, applying the lid of assisted death.

And it isn’t only the nature of medical practice that is in play here.

The independence of the physician is also in play: both in respect to the patient, before whom everything must give, including the non-harmful nature of our art, and under the laws of the nation.

Here we could cite the WMA’s resolution on euthanasia, adopted at the 53rd General Assembly in Washington, 2002, which indicates “the firm conviction that euthanasia is in conflict with the fundamental ethical principles of medical practice”, and encourages all national medical associations to abstain from participating in euthanasia, even if national laws permit or do not sanction it.

But in our judgment, such a call is insufficient: a doctor cannot be a mere enactor of the will of the state, being able or, more truthfully, sometimes obliged to put the interests of the individual patient before those of the state. In fact, the 2002 declaration calls on the physician not only to abstain, or to cite conscientious objection, but to attempt to change the law.

Finally, we might accept the principle that the physician, confronted by legislated intervention on the theme of so-called “assisted death”, could only accept to apply the law. But at that point, what right would we ever have in the future, to resist the imposition of a state that, in carrying out the death penalty, requires the presence of a doctor to assist in the lethal injections? (4)

References

1. Godlee F. Assisted dying. BMJ, 2012; 344: e4075;
2. More T. Utopia. 1516; II, 5;
3. MacIntyre A. Dependent Rational Animals: Why Human Beings Need the Virtues. Chicago: Open Court, 1999;
4. Tanne J H. US anaesthesiologists are told not to take part in executions by lethal injection. BMJ 2010; 340: c2432.

Competing interests: The authors work in a Catholic institution.

28 June 2012
Giuseppe Vetrugno
Pathologist
Antonio G Spagnolo, and Fabio De Giorgio
Medical Directorate
Policlinico Universitario "A. Gemelli", L.go "A. Gemelli", 8 - 00168 Roma (Italia)