Chapter XVII: do we treat all patients, or may we refuse to help some of them?

• Author: Fenigsen, Richard
• Position: Other People's Lives: Reflections on Medicine, Ethics, and Euthanasia

Mount Taigetos. In Sparta all newborn children had to be presented to the Ephors of State, who selected the ones they considered robust and healthy. All other children were left on the slopes of Mount Taigetos as prey for wild dogs and predatory birds. The mothers were not allowed to display grief. (108)

The Physician on the Rocks of Taigetos. I use the term "Taigetian mentality" to denote the philosophy of life claiming that society should free itself of its weak and "useless" members. This philosophy is often called "social Darwinism," which, however, misrepresents the views of Darwin and the genuine social Darwinists. Darwin described natural selection and the "survival of the fittest" as the way blind nature operates; he never proposed that society consciously regulate human affairs in that manner. The original social Darwinists, William G. Sumner, Herbert Spencer, and Walter Bagehot, did indeed postulate survival of the best adapted as a principle of social organization, but exclusively on the socio-economic level. The proposition to exterminate the biologically weak, and to entrust doctors with the task, has its source in later writers, especially Ernst Haeckel, Karl Binding, and Alfred Hoche. (109) With these reservations, I will be using the terms "social Darwinism," "Taigetian mentality," and "biological cleansing" interchangeably.

Dr. Isaac van der Sluis traced the history of biological social Darwinism in his excellent book. (110) I will limit myself to manifestations of this mentality with which I was confronted in the last twenty years of my medical practice.

* A young woman doctor opposes the implantation of a pacemaker in a 75 year old patient suffering from heart block, and states that, as a matter of principle, she is against the implantation of pacemakers in people over 75 and that society should not be burdened with keeping the elderly alive.

* A team of anesthesiologists at a university hospital decide to refuse to provide anesthesia and thereby to prevent surgery for congenital heart disease in children with Down syndrome.

* In Rotterdam, a cook in a hospital kitchen is suffering from progressive kidney failure. An internist at that same hospital refuses to make use of renal dialysis and allows the patient to die because the patient is a bachelor and has no immediate family.

* A family physician sends our hospital in Den Bosch two women patients, both suffering from pulmonary edema (a buildup of fluid in the lungs due to heart failure: this is a sudden and life-threatening condition, but one which usually can be quickly relieved), and, in both cases, stipulates by phone that these women were "too old" and should be refused treatment. In the second of these two cases, the doctor even demanded that the woman be refused admission to the hospital.

* When transferring a patient with acute myocardial infarction and pulmonary edema to me, an internist colleague warns me "not to make overly vigorous attempts to save this man since he is a widower and without family."

* Another doctor tells me that "as a family physician" he opposes the implantation of a pacemaker to his patient since she is 86 years old. The woman had fainted due to a heart block, striking her head on the kitchen stove as she fell, and was found on the floor in a puddle of blood.

To form an idea of how widespread this attitude is, and how many sick people are refused treatment, one has to multiply these observations made by a single specialist by several thousand.

Holland is not the only country infected with Taigetian attitudes; the specter seems to loom over the part of the world around the North Sea. In the early seventies, I heard the opinion that pacemakers should be denied to older people, expressed by a doctor in Aalborg, Denmark (the view was found inadmissible by the head of cardiology). In Copenhagen, doctors at the only hospital doing the coronary bypass surgery at that time refused to do it in patients over 60, not because of less favorable results expected in them, but on principle, as a self-conceived rationing. An American poet living in Copenhagen, Mr. Robert H., 64, had severe coronary disease, but was refused surgery because of his age and soon died of a heart attack.

Thus, there are doctors who think they have the right to deny life-saving treatment to adult, competent patients asking for help. This is such a striking phenomenon and I was so much shocked when I was confronted with such attitudes and practices that I decided to analyze them in every detail and from all sides.

Before we pass judgement on such conduct, it would be useful to answer the question of whether such actions are indeed medical, that is, one of the doctor's tasks.

They are not, according to the accepted definition of "medicine," which is "the learned calling concerned with treatment and prevention of disease." (111) Such actions have also been explicitly placed outside the bounds of medical practice in the International Code of Medical Ethics, (112) in the Declaration of Tokyo adopted by the World Medical Association (113), and in the 1984 U.S. Public Law 98-475.

The Taigetian Philosophy. The system of concepts and arguments used by Taigetian physicians to justify their actions is largely inauthentic in nature since it almost never mentions its essential social-Darwinist motivation. Nevertheless, those arguments will be examined here.

First of all, let us examine an argument frequently (though not always) used by Taigetian physicians: that when they deliberately allow certain people to die, they are doing this for the person's own good, in his own best interest.

Even before it is examined in detail, this argument arouses mistrust because the same assertion was made by the ideologues of genocide (it will be better for the Untermenschen themselves if they die1 (114) and by their precursors ("the kindest thing one can do for a native is to let him die" (115).

Are the Taigetian doctors speaking the truth when they assert that they are acting for the patient's own good? And were it true, would this argument be valid?

It does not follow from any of the cases cited that the doctor was acting in the patient's best interest. Any doubts on the question cease to exist when one considers the way those people had to die.

* If a person afflicted with acute pulmonary edema is not immediately treated, several hours or sometimes a few days of torture ensue; the patient, in mortal fear, his throat rattling, desperately gasps for breath, coughing up bloody foam.

* If a person in severe kidney failure is not put on dialysis, the poisoning by the waste products of his own body will gradually increase and the patient, bleeding from his nose and covered with bloody spots on his skin, will vomit hundreds of times; so-called Kussmaul's respiration, a strained gasping for breath due to excess of acids in the blood, will utterly exhaust the remainder of his strength; dying takes months.

* If a person suffering from heart block or other form of very slow heart beat is not provided with a pacemaker, the patient will suddenly lose consciousness, but never dies during the first attack; no, he will faint dozens of times, falling on the floor, injuring his head, breaking an arm or a leg; finally he will die in one of these fainting attacks.

Indeed, considering the way all these people had to die we can clearly see that the doctors were not acting in the patient's best interest, nor did they even consider the patient's good or personal interest.

We must further examine whether the argument of "acting for the patient's good" is in principle valid; whether one person (the doctor) has the right and the ability to judge on behalf of another person that it is in the person's interest to end his life.

To sustain the assertion of "acting for the patient's good" the Taigetian doctor must know better than the patient himself what the patient's good is. The entire line of reasoning is patent nonsense. What a person feels, desires, and values are by definition that person's subjective attitudes, and no one can know better about them than he. Secondly, one cannot claim to be acting in the interest and for the good of another person if to so act means destroying all that person's interests once and for all. The right to decide on behalf of another person "in his own interest" that he must die cannot exist either morally or logically.

In none of the cases described here did the Taigetian doctor ask the patient if he or she wanted to live. And yet he was aware that most older persons want to live "as long as possible," that people with mental disabilities do not commit suicide; that the majority of people who are alone in the world have adapted to that way of life and chose it themselves. (116) When making their decisions, the...