cle is unpardonable and could easily be prevented in the future. The CMA should instruct physicians to first ask all new patients "Are you a Jehovah's Witness?" If the answer is Yes he or she should tell the patient to find a physician who is a Jehovah's Witness and then refuse to see the patient under any circumstances. When medical principles come up against religious fanaticism the honest physician has no choice but to refuse further involvement. Douglas Harvie, MD 227 Minnesota St. Collingwood, Ont
Questioning the taboo
Or are ethics meant to explain and justify the most expedient action in a particular situation? Those who hold this view are nominalists, utilitarianists or consequentialists. The circumstances in which the problem occurs serve as the framework for deciding about the matter. The outcome serves as the criterion by which an action is judged. Words such as humanism, person and dignity are often used as key words to support a particular viewpoint in the euthanasia debate. Like the concept of ethics these words take on different meanings depending on their source. Humanism is not the same to the atheist as it is to the theist. These people would acknowledge different points of reference and develop radically different ideas about what to do in a given situation. The concepts of kindness and caring are related to one's understanding of humanism whether they are based on the idea of a spiritual being or on man makes a difference. The concept of person is also important. Nowhere is this more clear than at the beginning and end of life. The article "Giving death a helping hand" (ibid: 358359), by Mina Gasser Battagin, suggested that a person in a vegetative state was no longer a person. A traditionalist would disagree with that and connect personhood to the living body, regardless of its defects. In the same article the author implied that her grandmother had lost dignity because she had aged, no longer dressed fashionably and had a spot on the back of her dressing gown. This raises the idea that the quality of life has greater value than life itself. In his article "Euthanasia and
CAN MED ASSOC J 199 1; 144 (11)
An anemic patient receiving blood dies of heart failure. The two physicians who recommended the transfusion were motivated to relieve the suffering of the patient. One of the physicians intended the patient to die as a result of fluid overload. The other wanted the patient to live, but the patient nevertheless died as a result of the treatment.
The motive (to relieve suffering) was the same for the two physicians and led to a similar act but not with the same intent. Indeed, good motives may coexist with either good or bad intent: here, the ending or the saving of a life. It is important to distinguish between intent and motivation. Kluge makes a similar error when he equates passive euthanasia with natural death. This issue ties in with the difficulty of knowing when to treat and when not to treat. There are times when services, equipment or a specific treatment are unavailable or seen as offering nothing to the survival of the patient. But a decision against a mode of treatment because it will offer the patient no appreciable benefit must not be confused with a decision to withhold further treatment because a patient should no longer live. The former decision is based on the fact that the treatment, not the continuation of life, will be burdensome. Such decisions are not examples of euthanasia. The latter decision is passive euthanasia. If euthanasia is defined as the death of a human being purposely brought about as part of the treatrelated taboos" (ibid: 359-360) ment given, then passive euthanaKluge alludes to the fact that sia results when treatment that physicians who give painkillers to would in all probability save the
nce a trend begins it be() comes very difficult to argue reasonably against it. Once a taboo is questioned the damage is done. Such is the case in the trend toward exploring the acceptability of euthanasia. Recent articles in CMAJ have done just that (1991; 144: 358360). Dr. Eike-Henner Kluge, CMA director of ethics and legal affairs, has asked that the subject of euthanasia be aired and explored. It is more than a theoretical issue: in the Netherlands euthanasia is an established practice, and in North America it is present in more clandestine ways. Some central issues ought to be made clear from the start. They are not just medical matters but touch the corpus of thought and reflect the philosophy underlying euthanasia. First, one's ethical base must be clearly understood. Are ethics preformed guidelines that serve as the structure and support of the decision-making process? Such would be the case in the traditional medical model. Certain absolutes exist for example, forbid- terminally ill people really do so ding the murder of the innocent. with the expectation that they will 1382
kill themselves. He asserted that this is equivalent to passive euthanasia. However, he does not distinguish between motivation and intent in an act. Consider the following example.
patient's life is withheld. The confusion of ideas and LE I er JUIN 1991
the differences in the meanings of words, glibly used, reflects a more stark reality: most physicians do not know what to believe or what to base their beliefs upon. The new discussions on euthanasia reflect this all too accurately. Suffering is at the centre of the issue. Most people want to relieve suffering; the question concerns not our feelings about suffering but, rather, whether suffering should be relieved by willed or assisted death. This is at the heart of euthanasia. Discussion that approaches euthanasia as an option recklessly attacks what ought to be one of the first principles of care in medicine: all life is inviolable. Life continues* to have equal worth throughout its existence. Worth is not lost when function and condition change or when death is impending. There is no right to die but, rather, a right not to be killed. Life is of incalculable value. This ought to be the central principIe of medical care. This value, and no other, can protect the tradition of medicine, which is first to do no harm and then to care and heal.
a desire to die? Is it different from what physicians do when they know a patient is hoarding medication with the intention of taking an overdose, and yet they take no steps to prevent it? These questions are part of the general topic of euthanasia that was given by General Council to the CMA Committee on Ethics for discussion. I gave them as examples of what the committee will have to deal with. I did not offer a judgement or state what I think is the case. Second, the distinction between intent and motivation and, incidentally, between these and the concepts of reason and purpose - is not quite as clear as Jansen makes out. Abundant legal and philosophic discussion on the subject was generated a few years ago when the doctrine of double effect became a central issue in the debate surrounding abortion.
It resurfaced in the discussion on active and passive euthanasia. The author might want to consider that literature before going further. Third, I did not equate passive euthanasia with natural death. To do so would have been to prejudge at least part of the issue General Council asked the Committee on Ethics to discuss. I have my own position on euthanasia (active and passive); precisely because of this and because I have published extensively in the area I have removed myself from the Committee on Ethics' discussion of the subject, even though I am the coordinator of the committee and the director of ethics and legal affairs. I do not want there to be even the slightest hint that my position would in any way influence the committee's decisions. I have given the task of coordinating this part of the com-
Donald G. Jansen, BA, MD, CCFP PO Box 250 Campbell's Bay, Que.
[Dr. Kluge responds.] I would like to set the record straight. First, I emphatically did not say that "physicians who give painkillers to terminally ill people really do so with the expectation that they will kill themselves." What I did was to raise two questions: Is what Dr. Kevorkian did - made it possible for a patient to kill herself by providing the necessary means - different from what physicians do when they prescribe narcotic analgesics that are appropriate and should last the patient for a week in the full knowledge that he or she will take all of them at once because of JUNE 1, 1991
. . . . smz
FOR THE HIDDEN CAUSES OF INFECTION IN COMMON DERMATOSES CAN MED ASSOC J
1991; 144 (11)
1383
Questioning the taboo
Or are ethics meant to explain and justify the most expedient action in a particular situation? Those who hold this view are nominalists, utilitarianists or consequentialists. The circumstances in which the problem occurs serve as the framework for deciding about the matter. The outcome serves as the criterion by which an action is judged. Words such as humanism, person and dignity are often used as key words to support a particular viewpoint in the euthanasia debate. Like the concept of ethics these words take on different meanings depending on their source. Humanism is not the same to the atheist as it is to the theist. These people would acknowledge different points of reference and develop radically different ideas about what to do in a given situation. The concepts of kindness and caring are related to one's understanding of humanism whether they are based on the idea of a spiritual being or on man makes a difference. The concept of person is also important. Nowhere is this more clear than at the beginning and end of life. The article "Giving death a helping hand" (ibid: 358359), by Mina Gasser Battagin, suggested that a person in a vegetative state was no longer a person. A traditionalist would disagree with that and connect personhood to the living body, regardless of its defects. In the same article the author implied that her grandmother had lost dignity because she had aged, no longer dressed fashionably and had a spot on the back of her dressing gown. This raises the idea that the quality of life has greater value than life itself. In his article "Euthanasia and
CAN MED ASSOC J 199 1; 144 (11)
An anemic patient receiving blood dies of heart failure. The two physicians who recommended the transfusion were motivated to relieve the suffering of the patient. One of the physicians intended the patient to die as a result of fluid overload. The other wanted the patient to live, but the patient nevertheless died as a result of the treatment.
The motive (to relieve suffering) was the same for the two physicians and led to a similar act but not with the same intent. Indeed, good motives may coexist with either good or bad intent: here, the ending or the saving of a life. It is important to distinguish between intent and motivation. Kluge makes a similar error when he equates passive euthanasia with natural death. This issue ties in with the difficulty of knowing when to treat and when not to treat. There are times when services, equipment or a specific treatment are unavailable or seen as offering nothing to the survival of the patient. But a decision against a mode of treatment because it will offer the patient no appreciable benefit must not be confused with a decision to withhold further treatment because a patient should no longer live. The former decision is based on the fact that the treatment, not the continuation of life, will be burdensome. Such decisions are not examples of euthanasia. The latter decision is passive euthanasia. If euthanasia is defined as the death of a human being purposely brought about as part of the treatrelated taboos" (ibid: 359-360) ment given, then passive euthanaKluge alludes to the fact that sia results when treatment that physicians who give painkillers to would in all probability save the
nce a trend begins it be() comes very difficult to argue reasonably against it. Once a taboo is questioned the damage is done. Such is the case in the trend toward exploring the acceptability of euthanasia. Recent articles in CMAJ have done just that (1991; 144: 358360). Dr. Eike-Henner Kluge, CMA director of ethics and legal affairs, has asked that the subject of euthanasia be aired and explored. It is more than a theoretical issue: in the Netherlands euthanasia is an established practice, and in North America it is present in more clandestine ways. Some central issues ought to be made clear from the start. They are not just medical matters but touch the corpus of thought and reflect the philosophy underlying euthanasia. First, one's ethical base must be clearly understood. Are ethics preformed guidelines that serve as the structure and support of the decision-making process? Such would be the case in the traditional medical model. Certain absolutes exist for example, forbid- terminally ill people really do so ding the murder of the innocent. with the expectation that they will 1382
kill themselves. He asserted that this is equivalent to passive euthanasia. However, he does not distinguish between motivation and intent in an act. Consider the following example.
patient's life is withheld. The confusion of ideas and LE I er JUIN 1991
the differences in the meanings of words, glibly used, reflects a more stark reality: most physicians do not know what to believe or what to base their beliefs upon. The new discussions on euthanasia reflect this all too accurately. Suffering is at the centre of the issue. Most people want to relieve suffering; the question concerns not our feelings about suffering but, rather, whether suffering should be relieved by willed or assisted death. This is at the heart of euthanasia. Discussion that approaches euthanasia as an option recklessly attacks what ought to be one of the first principles of care in medicine: all life is inviolable. Life continues* to have equal worth throughout its existence. Worth is not lost when function and condition change or when death is impending. There is no right to die but, rather, a right not to be killed. Life is of incalculable value. This ought to be the central principIe of medical care. This value, and no other, can protect the tradition of medicine, which is first to do no harm and then to care and heal.
a desire to die? Is it different from what physicians do when they know a patient is hoarding medication with the intention of taking an overdose, and yet they take no steps to prevent it? These questions are part of the general topic of euthanasia that was given by General Council to the CMA Committee on Ethics for discussion. I gave them as examples of what the committee will have to deal with. I did not offer a judgement or state what I think is the case. Second, the distinction between intent and motivation and, incidentally, between these and the concepts of reason and purpose - is not quite as clear as Jansen makes out. Abundant legal and philosophic discussion on the subject was generated a few years ago when the doctrine of double effect became a central issue in the debate surrounding abortion.
It resurfaced in the discussion on active and passive euthanasia. The author might want to consider that literature before going further. Third, I did not equate passive euthanasia with natural death. To do so would have been to prejudge at least part of the issue General Council asked the Committee on Ethics to discuss. I have my own position on euthanasia (active and passive); precisely because of this and because I have published extensively in the area I have removed myself from the Committee on Ethics' discussion of the subject, even though I am the coordinator of the committee and the director of ethics and legal affairs. I do not want there to be even the slightest hint that my position would in any way influence the committee's decisions. I have given the task of coordinating this part of the com-
Donald G. Jansen, BA, MD, CCFP PO Box 250 Campbell's Bay, Que.
[Dr. Kluge responds.] I would like to set the record straight. First, I emphatically did not say that "physicians who give painkillers to terminally ill people really do so with the expectation that they will kill themselves." What I did was to raise two questions: Is what Dr. Kevorkian did - made it possible for a patient to kill herself by providing the necessary means - different from what physicians do when they prescribe narcotic analgesics that are appropriate and should last the patient for a week in the full knowledge that he or she will take all of them at once because of JUNE 1, 1991
. . . . smz
FOR THE HIDDEN CAUSES OF INFECTION IN COMMON DERMATOSES CAN MED ASSOC J
1991; 144 (11)
1383
