Tuesday, March 24, 2009

Euthanasia, Murder and Medical Ethics

Early this morning I read a student essay on "End-of-Life Care" for this week's medical ethics class at Harvard Medical School. The student made a thoughtful argument that (a) when physicians stop life sustaining treatments like respirators they are "killing" patients, not simply "allowing them to die," and that (b) with proper safeguards it is ethically acceptable for physicians to participate in euthanasia.

I agree with the positions the student took.

Then I turned to the New York Times, and found an article about whether a medical student in Sweden who had served time for murder should be allowed to become a doctor.

In 2000, Karl Svensson was convicted of killing Bjorn Soderberg. Soderberg had complained to his employers about neo-Nazi materials a co-worker had displayed. The co-worker, a friend of Svensson's, was fired. Svensson himself had been under surveillance for his own neo-Nazi activities.

Svensson was sentenced to 11 years in prison, but was paroled after 6 1/2 years, as is common in Sweden. While in prison he took many web-based courses and did well enough to meet the Karolinska entry requirements. When Karolinska belatedly discovered Svensson's history it found grounds for expelling him.

Now it emerges that Svensson was subsequently admitted to Uppsala medical school!

When I wrote about Svensson's expulsion from Karolinska a year ago (see here) I concluded:
People convicted of murder can be outstanding physicians. In 2001 a medical specialist to whom I had referred many patients, including a member of my own family, was sent to prison for the 1999 murder of his wife. (He maintains his innocence.) He did more than provide excellent technical care - he gave outstanding human attention as well. I was moved by my patients' description of his skill and compassion and was proud to have him as a colleague.

But the Hippocratic Oath articulates another value - "In purity and holiness I will guard my life and my art."

The classmates who wanted Svensson to stay in Karolinska were half right. People who have done their time should have the opportunity to build a new life. For all we know Svensson may have had wanted to make amends for the crime he had been convicted of. But for me the Hippocratic value is the deciding point here. Medicine has its anthropological roots in religion. Many of the prophets in all religions were healers of the body as well as the soul. The obligations the privilege of being a physician entails go beyond what we do in the office and hospital.

I hope that Svensson is committed to making up in the rest of his life for the murder the court concluded he had done. But Karolinska Institute, which expelled him last week, did the right thing.
If I'm prepared to embrace a physician who has participated in euthanasia as a respected colleague, is it consistent to favor expelling Svensson from medical school?

I believe it is. The compact between clinician and patient is central to ethical assessment of an action. When competent patients (or their surrogates) make a clear request for termination of life support, following their wishes reflects respect for their right to self determination. And although physician assistance in dying (as the process is called in Oregon and Washington, which authorize it) is controversial, with many physicians (though not a majority) opposing it, even opponents recognize that physicians of intelligence and integrity can see assistance in dying - in carefully defined circumstances - as ethically warranted.

Opponents of physician participation in euthanasia can argue that if we allow euthanasia we can't turn around and keep Svensson out of medical school. But I believe this argument is fallacious.

Removing life support, carefully defined voluntary euthanasia and murder all involve actions that bring about the end of life. But just as we can distinguish between a physical exam and sexual assault, we can distinguish between ethically justifiable actions that hasten the end of life and murder.


Anonymous said...

I have reservations regarding your comparison of physical exams to sexual assault with ethical euthanasia and murder.

Sexual assault is an embarrassing misdemeanor and penalties or discipline are (according to my observation) frequently imposed where applicable. Society has little tolerance for these kinds of acts.

On the other hand, an act of involuntary euthanasia can easily be seen as an act of mercy, which society certainly tolerates. The pressures of covert rationing strategies, which might have subtly encouraged the act, might never be recognized by anyone.

Moreover, the charge for involuntary euthanasia is homicide, and the penalty is so harsh that it is highly unlikely to be imposed unless the situation is extreme.

I believe that this represents the fear of the vulnerable with respect to euthanasia.

Jim Sabin said...

Dear Anonymous -

Thank you for the thoughtful comment.

The concerns you raise are real. Covert rationing (or malevolent intent) could utilize the mechanism of physician assisted death as a vehicle. Voters in Oregon and Washington have concluded that the potential risks can be contained (though not eliminated!) and are outweighed by the potential benefits. And experience in Oregon with the Death with Dignity Act has not raised much controversy or concern.

Nevertheless, this is certainly an issue where people of intelligence and integrity can weigh the competing values differently.