Essay two: medical explanation.

• Author: Hoche, A.
• Position: 'Permitting the Destruction of Unworthy Life: Its Extent and Form,' first published in 1920 by Verlag von Felix Meiner in Leipzig, Germany

The points raised in the preceding legal analysis do not all require the same degree of medical elaboration. The legal status of suicide and the legal circumstances regarding the killing of consenting persons are issues which will not concern us further. But all the rest is of great interest to physicians, for whom the whole range of ideas about punishable or nonpunishable infringements on others' lives is of very active concern on professional grounds. Therefore, the relationship of physicians to killing in general requires explicit analysis.

Admittedly, everyone is legally entitled to infringe on the lives of others under narrowly defined circumstances (such as self-defense or a state of emergency) without facing punishment. And, of course, a doctor's relationship to the lives of others is also constrained by legal restrictions. But doctors' actions in this area really emanate from their code of medical ethics. Most people do not realize that this code of medical ethics is nowhere explicitly established. To be sure, there are isolated books about it, but these are unknown to most doctors and merely present the private theories of their authors. There is no medical moral law set out in paragraphs, no Moral Service Regulations. The young physician enters practice without any legal delineation of his rights and duties--especially regarding the most important points. Not even the Hippocratic Oath,(74) with its generalities, is operative today. What serve as guidelines for the novice are the example of one's teachers and university, occasional discussions stimulated by particular cases, learning during one's internship, the influence of general medical opinion as expressed in the literature, and one's own conclusions arising from the particular character of one's duties. In some respects (though not the decisive ones), restrictions arise through legal codes, dealings with insurance companies, etc.; and, at a certain distance, the physician notices certain paragraphs of the criminal code and the opinion of one's colleagues on the medical review board. But for the most part, all these cases concern negative restrictions about what the physician must avoid, rather than positive guidelines for action. What the physician may do, or ought to do, emanates from peer opinion, which holds (as a general presupposition) that physicians are obligated to observe the universal ethical norms, and (as additional professional obligations) to heal the sick, eliminate or mitigate pain, and preserve and prolong life as much as possible.

This most universal principle is not without exception. In practice, physicians are compelled to destroy life (killing a living child during delivery for the purpose of saving the mother, terminating a pregnancy for the same reason). These interventions are never expressly permitted; they remain free from punishment only because they are carried out in the interest of serving a higher good and only on the conditions that (1) they are preceded by conscientious deliberations, (2) they are carried out according to the appropriate medical procedures, and (3) the necessary agreement has been reached with the patient or his legal representatives or family.

Even the surgeon's professional acts of wounding the body are nowhere expressly permitted. They too remain free from penalty only where appropriate norms are followed--both by demonstrating the necessity of the procedure and by carrying it out carefully. At the same time, in all surgical procedures, one tacitly counts on a certain percentage of fatal outcomes. Medical science's most ardent concern is to hold such deaths (again including cases in which human life is destroyed as a result of the physician's actions) to the minimum, but they can never be wholly avoided. Our moral sensibility is completely reconciled to this. The higher legal good of restoring the majority to health makes the sacrifice of the minority necessary; in individual cases, the patient is protected by requiring his (or his representative's) prior consent. This usually assumes that the physician has explained, to the best of his knowledge, the probability of recovery and of danger to life.

Further, beyond these kinds of questions, the physician frequently faces the problem of intervening in lives under ethically questionable circumstances. In cases of incurable illness or incurable mental deficiencies, one not infrequently hears the family express the wish "that it could be ended quickly."

Just recently, for the first time, I was asked by the relatives of a deeply comatose suicide who was the "black sheep of the family" not to do anything to revive her. In fact, some families become so agitated that they reproach the physician who refuses actively to shorten a lost, pain-filled life. Nevertheless, it is a big step from such emotional outbursts to a family decision to take that life or even just to give their explicit consent to having it taken. As people are now, the physician who shortens a life today (even at the persistent entreaty of the relatives) cannot be safe tomorrow from the strongest reproaches or even from a criminal indictment.

Sometimes, specific circumstances can tempt a physician to intervene in a human life out of scientific interest. I remember this sort of temptation (which, finally, I successfully resisted) from my first internship. A child lay dying with a rare and scientifically interesting brain disorder, and conditions were such that the end could be expected within twenty-four hours. If the child had died at the hospital, we would have been able to get a desirable look at this condition by means of an autopsy. But the father made an urgent plea to take the child home with him; we would thereby lose the chance (which we could easily obtain if the child died before being discharged) for a dissection. It would have been very easy and completely undetectable for me to hasten the absolutely certain death by a few hours by means of a morphine injection. In the end, however, because my personal wish for scientific insight did not provide sufficiently weighty legal grounds for overriding the physician's obligation not to shorten life, I did nothing.

How one should decide in a...