Euthanasia, ethics, and the Gordian Knot: is the Hippocratic Code obsolete?

A PHILOSOPHICAL CONTINUUM

The Enlightenment itself was built on centuries of development of European philosophy that argued its issues, not from theology but from reason, dredging the accessible, antecedent philosophies to seek universals that characterise human aspiration. This had little to do with pontiffs or secular powers. It derived rather from philosophies of the classical ages, and writings of Rabbinical and Islamic scholars, being assimilated into the mediaeval universities. This eclectic mix has been called Scholasticism: the philosophy of ‘the schools’. It upheld that faith had to be accompanied by reason in the reflective pursuit of fundamental values that appear to be innate to humanity.⁴ It eschewed dogmatism in favour of disputation around universal, reasoned precepts, such as the inviolability of life. Thus, historic morality is not the invention of particular churches or religions. Society can set these aside easily enough, but to marginalise natural law ethics is about more than personal decision or choice derived from contemporary experiences.⁵ Natural law constitutes a millennial heritage, essentially separate from positive law, the legislative power of the State. Societies can legislate for the deliberate ending of a life at any stage of its course, as states have always done. But what sets the limits to these powers if there is no transcendent principle? Legislators must demonstrate ethical awareness on behalf of society, and not merely reflect public opinion, especially when considering matters of life and death, setting limits to pragmatism and respecting principle. Sometimes where taking of life is deemed essential for the social good, society legitimately appoints agents, specifically authorised, and conscientious objection is respected.

We are still, to a great degree, in European society, rooted in this continuing philosophical tradition, even in the sciences which were re-branded from natural philosophy. The new capabilities of biomedical sciences pose challenges for the time-honoured universals of ethics, notably concerning the elements and meaning of life, death, and suffering. As practitioners of the art and science of medicine, doctors have a duty to expand their capability to confront death, enhance health, prevent disease, and minimise suffering in the light of reason, with respect for the historical contribution of natural law to our code of medical ethics. There is a subsidiarity here: ethics, like positive law, is not static. Both evolve through challenge; natural law seeks to represent fundamental principles.

ETHICS AND DILEMMAS ARE INSEPARABLE

Situations arise that confront the application of reasoned principle with feelings of pity, empathy, guilt, responsibility, and the sheer capacity to override the dilemmas that arise through suffering and death. If we rely on freedom of choice or the exercise of autonomy to inform legislation in order to facilitate pragmatic solution of each tough case, we are manipulating and subjectivising the system of law, which must weigh all things in its balance. By the nature of medicine we encounter people who are suffering, some extremely so. Sometimes the problems that arise are, in the words of ‘my old chief’ in psychiatry, ‘Too difficult for me’. Our heart and head refuse to mesh. The gravity of the issues decline to be weighed in our scales. The best solution under the circumstances is often not the simplest one. Indeed the best solution may not be identifiable until a period of time has elapsed and in retrospect, sometimes ruefully. Doctors at the sharp end are then disadvantaged by the imperative to ‘do something’. This makes them interested parties; principled therapists and informed advocates, but not objective arbiters of universal rules. The exercise of clinical judgement involves limitation of clinical freedom. We need to respect the framework within which we are authorised to act, while exerting every legitimate means to alleviate suffering and circumstance. While upholding the dignity of human life, without ‘striving officiously to keep alive’ and lapsing into technologically-driven over-treatment, the capacities to intervene, care, prevent, and palliate have never been greater.

DIGNITY, AUTONOMY, AND CHOICE

What does this say about choice, autonomy, ‘burdens on society’, and ‘dying with dignity’? Patient-centredness demands the genuinely listening ear (mind and heart as well). An authentic response requires consideration of these within a framework of understanding that, at the same time, includes ethical judgement. Bearing burdens is what society does and dying with dignity is not simply a matter of aesthetics. Dignity is an intrinsic human quality, respect for the living person, even when quality of life is lamentably low. Law is subject to winds of change. A code of ethics, especially when venerable, ought to be more durable. When the legal and ethical frameworks conflict, are challenged by extreme circumstances, what is the moral equivalent of the GPS satellites that hover remotely above the detail of immediate topography? Their very remove lends perspective that can guide the wayfarer through local confusion and urgent directional choices. Such pressing decisions, however perplexing, are not just about autonomy. In a legendary approach to complexity, Alexander the Great, a warlord with blood on his hands, solved the problem of the Gordian Knot by obliterating it with his sword. Unreflective, especially for a pupil of Aristotle, the great natural philosopher.

A RUBICON DECISION

We may yet be called on to relinquish a historic humanistic principle, the inviolability of life. Should doctors allow themselves to become authorised agents of society in ending life? To allow even some to act thus would damage the integrity of the profession. Even the authorised experts in the US penal system are not very good at administering the lethal dose. We should not accede to becoming the bedside analogue of this, but persevere in the spirit of our College motto, Cum Scientia Caritas, applying intellect and compassion, to address the tangled circumstances that are inevitable, if occasional, in clinical practice and to uphold our ethical tradition. To make euthanasia available would radically shift the balance, even if that option were never used. Furthermore, making an action lawful does not automatically make it ethical. Medical ethics is too important to be dictated by pressure groups, lobbyists, personal testimonies from celebrities, or opinions of media commentators.

Those who are facing the immediacy of their own suffering are entitled to request anything they wish, and their voice must be listened to respectfully. But compassion, that of doctors and the compassionate society, is just one of the elements that contribute to decision making in extremis. Other elements, including time-honoured values and transcendent principle, should not be set aside if ever we approach a crossroads of decision that may compel us and our medical successors to become social agents in direct action to end life. There is, admittedly, much disputation and conscientious divergence concerning natural law, and the inviolability of life, among moral philosophers.⁶,⁷ However controversial, if we do not uphold the special value of human life what values can we respect? Ethics cannot exist in a moral vacuum. There are some Rubicon boundaries from which, once crossed, retreat is not possible. The profession should continue to uphold its ethical stance, while redoubling efforts to achieve optimal terminal care for all.