Abstract
The current article deals with the ethics and practice of physician-assisted suicide (PAS) and dying. The debate about PAS must take the important legal and ethical context of medical acts at the end of life into consideration, and cannot be examined independently from physicians’ duties with respect to care for the terminally ill and dying. The discussion in Germany about active euthanasia, limiting medical intervention at the end of life, patient autonomy, advanced directives, and PAS is not fundamentally different in content and arguments from discussions led in other European countries and the United States. This must be emphasized, since it is occasionally claimed that in Germany a thorough discussion could not be held with the same openness as in other countries due to Germany’s recent history. Still, it is worthwhile to portray the debate, which has been held intensively both among experts and the German public, from the German perspective. In general, it can be stated that in Germany debates about questions of medical ethics and bioethics are taking place with relatively large participation of an interested public, as shown, for instance, by the intense recent discussions about the legalisation of advanced directives on June 18 2009, the generation and use of embryonic stem cells in research or the highly difficult challenges for the prioritizing and rationing of scarce resources within the German health care system. Hence, the current article provides some insights into central medical and legal documents and the controversial public debate on the regulation of end-of-life medical care. In conclusion, euthanasia and PAS as practices of direct medical killing or medically assisted killing of vulnerable persons as “due care” is to be strictly rejected. Instead, we propose a more holistically-oriented palliative concept of a compassionate and virtuous doctor-cared dying that is embedded in an ethics of care.
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Notes
The jurisdiction in Germany used to refer to the concept of indirect active euthanasia with respect to cases when palliative medical measures have had an unintended (side-) effect such as shortening the patient’s life. Treatment with pain killers in high doses had often been given as an example, yet, modern palliative medicine has exposed the concept of indirect active euthanasia as inapropriate and obsolete. For a circumstantial discussion see Materstvedt et al. 2003; Sahm 2006.
The forum reports some 2,500–3,000 attendees for each of the biennial meetings and a membership of approx. 7,000. The draft concerning assistance in suicide was voted on by only 110 attendees, who are not representatives of the forum, but are a group of “interested” members (Deutscher Juristentag 2006).
Germany is a federal state. Health care is an affair of the individual federal states (Bundesländer), of which there are 17. Physicians are required to become members of the State Chamber of Physicians of their respective state. The State Chambers are public-law institutions and bodies of self-administration. Physicians elect delegates to the German Medical Assembly. The German Medical Association (Bundesärztekammer) is a consortium of all the State Chambers of Physicians. The assemblies of the respective states elect members to represent their chamber in the nationwide German Medical Assembly of the German Medical Association.
For example, the assertion that in some cases doctors would be confronted with conditions that cause unbearable suffering not amenable to palliative treatment. In such a state of emergency termination of life or PAS would be justified, or even more, be obligatory. The assumption of a state of emergency is the very reason behind the Dutch ruling (which is frequently mistaken), as opposed to the reference to autonomy. In fact, the concept of a state of unbearable suffering restricts autonomy, because this diagnosis lies with the doctor. In addition, modern palliative care has disproven it long ago (for circumstantial discussion see Oduncu 2007b, Sahm 2006).
That is, of course, also an argument against physicians being involved in the execution of the death penalty, for example (or to be exact: it is an argument against death penalty per se).
In case studies, literature, movies and no doubt even in the real-world there are settings where persons commit sucide with the intention to save the life of others. Of course, here suicide may be ethically justified, or even regarded as a highly appreciated opus supererogativum. Yet the act is not free in the above-mentioned sense. Hence, the ethical judgement of these cases depends on the circumstances. If circumstances are brought forth to justify the suicide, then they are ethically reprehensible. The first obligation is to change those circumstances. In highly developed countries, avoiding high costs of medical care can never justify suicide as an act of altruism. Altruism here is out of place (as opposed to e.g. Fenner 2007). To be clear, this is not meant to denounce those who commit suicide because of their particular motives; the point is that this cannot justify assisting patients with suicide.
Others have pointed out that there is a disproportion between the prohibition of sexual relationships of doctors with their patients and the relaxation and individualisation which accompanies the promotion of PAS (Barilan 2003).
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The authors are indebted to Mrs. Bernadette Fisher who helped to prepare the manuscript, and to Mrs. Kathy Muller-Schertler for native language correction of the manuscript.
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Oduncu, F.S., Sahm, S. Doctor-cared dying instead of physician-assisted suicide: a perspective from Germany. Med Health Care and Philos 13, 371–381 (2010). https://doi.org/10.1007/s11019-010-9266-z
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DOI: https://doi.org/10.1007/s11019-010-9266-z