- Email: [email protected]
Living testaments and medical decisions
Forensic Science International 113 (2000) 487–489
www.elsevier.com / locate / forsciint
Living testaments and medical decisions R. Wegener Institute of Legal Medicine, Faculty of Medicine, University of Rostock, St. Georg. Strasse 108, 18055 Rostock, Germany
1. Preface In the aftermath of the National Socialist era and the doctors’ trials before the US Tribunal in 1947, the ‘long shadow of Nuremberg’ has inhibited any open discussion of the legal, political and ethical aspects of euthanasia in Germany [1,4,11]. It is therefore not surprising that for decades many German doctors rejected any form of euthanasia or assisted dying if it entailed any danger of shortening life. However, the increasing capabilities of modern intensive medicine have led to growing anxiety among the public opinion, some of whom feared that the physician, acting as the controller of the patient, might seek to prolong life artificially under cruel and inhumane conditions [20]. In the mid-eighties, when German parliamentarians and lawyers were considering the ‘right to die’ or the ‘right to control one’s own death’, the German medical profession became increasingly pre-occupied with the problem of euthanasia [2]. In the ‘Principles of the German Medical Association concerning terminal medical care’ in 1998 [4], three basic propositions are laid down: the rejection of active euthanasia, refusal of any medical assessment of the value of life or quality of life and the respect for the patient’s wishes, and accordingly for the patient’s advanced declaration. For the first time, there exits an official recommendation to the medical profession in Germany, E-mail address: [email protected] (R. Wegener).
according to the relevance of patients’ ‘living wills’ [3]. Since active euthanasia – including assisted suicide – is a criminal offence in Germany, the patient’s consent is not enough to legitimize any such killing [7]. A patient capable of making decisions, when under medical care, has the right to accept or reject the doctor’s advice. The doctor is obligated to respect patient’s will, even if his / her will does not concur with the diagnostic and therapeutic measures indicated from a medical viewpoint. This also applies to the discontinuation of previously initiated life-preserving measures. What under consideration is passive euthanasia, the withholding of life-prolonging therapy from a patient who is no longer capable of expressing his or her wishes.
2. The ‘living will’ In Germany three variant forms of living testaments are at a patients disposal: advanced directives, precautionary healthcare authorizations and healthcare instructions. In the ‘Principles’ strict conditions are laid down to ensure the binding force of a patient’s ‘living will’. • it must be applicable to the existing clinical situation • it must be relevant to the existing circumstances • the seriousness of the patient’s intentions must not be in doubt.
0379-0738 / 00 / $ – see front matter 2000 Elsevier Science Ireland Ltd. All rights reserved. PII: S0379-0738( 00 )00198-5
488
R. Wegener / Forensic Science International 113 (2000) 487 – 489
At this point controversy begins. Is patient’s living will merely one among many reasons that can be used to ascertain the presumptive wishes of a patient who is no longer capable of making decisions? Does the patient’s living will give the doctor unrestricted authority to what he or she thinks is the best? There are weighty arguments against the unrestricted binding power of patients’ living wills, arguments primarily raised by doctors [5,8,17]: • It is impossible to predict the outcome of a chronic disease or of an accident followed by irreparable consequences (biological variability). • The patient’s own wishes and intentions cannot be projected into the future, as they may apply in an abstract clinical situation (changing attitudes). • Misinterpretations are conceivable, from lack of knowledge of medical realities or the unpredictability of future therapeutic possibilities (longterm prognosis is imponderable). • When the living will was originally drafted, the patient’s capacity might have been in some way impaired (substance abuse, suicidal ideas, etc.). • When formulating his or her wishes and intentions, the patient might be influenced by third persons for the benefit of themselves or others. • The gaps or deficiencies in the living will might lead to difficulties in its interpretation. These could arise from lack of clarity or from contradictory expressions of the patient’s wishes. It could therefore happen that a patient might become the victim of a living will which gave unrestricted powers. In Germany – as in most other countries – up to now there are no legislative provisions governing patients’ living wills. In the US (California) the ‘Natural Death Act’ has been in existence since 1977 in connection with the first statutory provisions governing euthanasia. However, this ‘Directive to Physicians’ – and this point is emphasized – does not come into effect unless the patient has signed it at least 14 days after the diagnosis of an incurable disease has been established (for details see Ref. [6]). A ‘Law on Living Wills’ was enacted in Denmark in 1992. When a patient with a fatal prognosis has made a decision against life-prolonging treatment,
the doctor must respect the patient’s wishes. The appropriate Danish Health Authority issues forms for the purpose. The data are stored in a central Health Register. Before deciding to withhold treatment, every doctor must enquire whether any such decision has been registered. Attention may be drawn to hospital legislation in Austria, which lays down that a patient’s wish not to be treated should be noted in the case papers [9].
3. The drafting of living wills As yet, Germany has no legislative provisions covering the field of patients’ living wills. They are therefore not confirmed to any pre-made form. Instead of hand-written documents, printed forms can be used, and in the last few years numerous versions have been published [2,12–16,18]. There must be some doubt whether these forms will cover all cases and circumstances. Irrespective of legislative and professional regulations, the following considerations apply. A patient’s living will must be drafted step by step, in keeping with the existing life situation, and in dialogue with a doctor who has the patient’s confidence. The doctor should use this possibility. The informed consent on the extent of life-preserving measures should be obtained as soon as possible [19]. Confirmation at appropriate intervals is strongly recommended. In this way a flexible response can be made, with the agreement of the doctor in charge of treatment, to the clinical situation as it develops. This will also provide documentation of the patient’s current wishes and seriousness of intent. To provide against unexpected events and unpredictable situations, it is advisable to appoint a precautionary healthcare authorization or a healthcare instruction. In Germany this authorized representative can also be appointed to give consent to medical treatment, its omission or discontinuation. Regarding measures involving a great risk for life and health, this consent must be in written form and must expressly refer to such treatment. The consent of the representative to ‘life-threatening treatment’ requires the approval of the court of guardianship (Art. 1904 German Civil Code).
R. Wegener / Forensic Science International 113 (2000) 487 – 489
4. Concluding remarks • If the patient has made a living will, the doctor has a duty to respect the patient’s life and human dignity when making decisions in an individual case. • If dealing with a chronically ill patient, the doctor has to make inquiries regarding the existence of a living will. • A patient’s living testament has greater binding force if it has been drafted with a doctor’s assistance. In this context patient’s information about nature and scope of treatment at the end of life is also a chance of the doctor to come to a dialogue. • Nevertheless: We confess ourselves, that there are also questions of the last lonely physician, which are not solvable [10].
[6]
[7] [8] [9]
[10] [11] [12]
[13] [14]
References [1] M.O. Baumgarten, The Right To Die?: Rechtliche Probleme Um Sterben Und Tod, Peter Lang, Bern, 1998. ¨ [2] Berliner Arzte, Selbstbestimmung des Patienten bis zum Tod, 9 (1997) 14. ¨ ¨ ¨ [3] Bundesarztekammer, Grundsatze der Bundesarztekammer ¨ ¨ zur arztlichen Sterbebegleitung. Dt. Arztebl, 1998;95:A2366. [4] Deibl Asta Karin, Die Mehrheit lehnt die aktive Sterbehilfe ¨ ¨ ¨ ab. Arzte befragen Arzte. Dt. Arztbl, 87 (1985) A-157 ¨ [5] U. Eibach, Patientenverfugungen – Mein Wille geschehe!? Kritische Betrachtungen der Christlichen Patientenver-
[15] [16]
[17] [18]
[19] [20]
489
¨ fugung‘ der Evangelisch-lutherischen Kirche in Bayern. Z Med Ethik 44 (1998) 201. Eisenbart Bettina, Patienten-Testament und Stellvertretung in Gesundheitsangelegenheiten. Alternativen zur Selbstbestimmung im Vorfeld des Todes, Nomos, Baden-Baden, 1998. ¨ ¨ A. Eser: in: Schonke / Schroder, Strafgesetzbuch, Kommen¨ tar, 24. Aufl. Munchen, 1991. H. Frahm, Patiententestament – nein danke!, Interview MMW 140 (1998) 44. H.G. Koch, Sterbebegleitung in Europa und den USA, in: ¨ ¨ Arztliche Sterbebegleitung. Symposium der Bundesarz¨ ¨ tekammer vom 15. Januar 1998. S. 38, Arzte-Verlag Koln, 1999. A. Laufs, Kommentar: Selbstverantwortetes Sterben? NJW 1996 (1996) 763. D. Linden, Gespenst des Biologismus. Lehren aus der ¨ Vergangenheit Dt Arztebl, 94 (1997) A-1104. ¨ ¨ Neuman Gitta, Personliche Patientenverfugung. Humanistischer Verband Deutschland. Berliner Medizinethische Schriften, Sonderdruck Heft 14 / 15a, 1998. Patienten-Testament mit Vorsorgevollmacht nach Prof. Dr. Wilhelm Uhlenbruck (1998): Verlag Klaus Vahle Berlin. ¨ Patientenschutzbrief der Deutschen Gesellschaft fur Humanes Sterben (DGHS e.V.), Augsburg, zit. bei 11. ¨ Patientenverfugung, Christliche, Evangelische-lutherische ¨ Kirche in Bayern. Gwd Hans Venus GmbH Munchen, 1996. ¨ ¨ die H.M. Sass, R. Kielstein, Vorsorgliche Verfugung fur ¨ Medizinische Ethik, Medizinischen Betreuung. Zentrum fur ¨ Bochum, 1997. Ruhr-Universitat W. Spann, Das Patiententestament, MedR 1 (1983) 13–16. W. Uhlenbruck, Selbstbestimmtes Sterben durch Patienten¨ Testament, Vorsorgevollmacht, Betreuungsverfugung, Verlag Klaus Vahle Berlin, 1997. ¨ S. Waibel, P. Novak, S. Roller, Patientenverfugungen: Der ¨ ¨ Arzt als Gesprachspartner Dt. Arztebl. 96 (1999) A-836. J. Wawersik, Reanimation und ihre Grenzen. S. 125, in: A. Eser (Ed.), Suizid und Euthanasie, Enke Stuttgart, 1976.
www.elsevier.com / locate / forsciint
Living testaments and medical decisions R. Wegener Institute of Legal Medicine, Faculty of Medicine, University of Rostock, St. Georg. Strasse 108, 18055 Rostock, Germany
1. Preface In the aftermath of the National Socialist era and the doctors’ trials before the US Tribunal in 1947, the ‘long shadow of Nuremberg’ has inhibited any open discussion of the legal, political and ethical aspects of euthanasia in Germany [1,4,11]. It is therefore not surprising that for decades many German doctors rejected any form of euthanasia or assisted dying if it entailed any danger of shortening life. However, the increasing capabilities of modern intensive medicine have led to growing anxiety among the public opinion, some of whom feared that the physician, acting as the controller of the patient, might seek to prolong life artificially under cruel and inhumane conditions [20]. In the mid-eighties, when German parliamentarians and lawyers were considering the ‘right to die’ or the ‘right to control one’s own death’, the German medical profession became increasingly pre-occupied with the problem of euthanasia [2]. In the ‘Principles of the German Medical Association concerning terminal medical care’ in 1998 [4], three basic propositions are laid down: the rejection of active euthanasia, refusal of any medical assessment of the value of life or quality of life and the respect for the patient’s wishes, and accordingly for the patient’s advanced declaration. For the first time, there exits an official recommendation to the medical profession in Germany, E-mail address: [email protected] (R. Wegener).
according to the relevance of patients’ ‘living wills’ [3]. Since active euthanasia – including assisted suicide – is a criminal offence in Germany, the patient’s consent is not enough to legitimize any such killing [7]. A patient capable of making decisions, when under medical care, has the right to accept or reject the doctor’s advice. The doctor is obligated to respect patient’s will, even if his / her will does not concur with the diagnostic and therapeutic measures indicated from a medical viewpoint. This also applies to the discontinuation of previously initiated life-preserving measures. What under consideration is passive euthanasia, the withholding of life-prolonging therapy from a patient who is no longer capable of expressing his or her wishes.
2. The ‘living will’ In Germany three variant forms of living testaments are at a patients disposal: advanced directives, precautionary healthcare authorizations and healthcare instructions. In the ‘Principles’ strict conditions are laid down to ensure the binding force of a patient’s ‘living will’. • it must be applicable to the existing clinical situation • it must be relevant to the existing circumstances • the seriousness of the patient’s intentions must not be in doubt.
0379-0738 / 00 / $ – see front matter 2000 Elsevier Science Ireland Ltd. All rights reserved. PII: S0379-0738( 00 )00198-5
488
R. Wegener / Forensic Science International 113 (2000) 487 – 489
At this point controversy begins. Is patient’s living will merely one among many reasons that can be used to ascertain the presumptive wishes of a patient who is no longer capable of making decisions? Does the patient’s living will give the doctor unrestricted authority to what he or she thinks is the best? There are weighty arguments against the unrestricted binding power of patients’ living wills, arguments primarily raised by doctors [5,8,17]: • It is impossible to predict the outcome of a chronic disease or of an accident followed by irreparable consequences (biological variability). • The patient’s own wishes and intentions cannot be projected into the future, as they may apply in an abstract clinical situation (changing attitudes). • Misinterpretations are conceivable, from lack of knowledge of medical realities or the unpredictability of future therapeutic possibilities (longterm prognosis is imponderable). • When the living will was originally drafted, the patient’s capacity might have been in some way impaired (substance abuse, suicidal ideas, etc.). • When formulating his or her wishes and intentions, the patient might be influenced by third persons for the benefit of themselves or others. • The gaps or deficiencies in the living will might lead to difficulties in its interpretation. These could arise from lack of clarity or from contradictory expressions of the patient’s wishes. It could therefore happen that a patient might become the victim of a living will which gave unrestricted powers. In Germany – as in most other countries – up to now there are no legislative provisions governing patients’ living wills. In the US (California) the ‘Natural Death Act’ has been in existence since 1977 in connection with the first statutory provisions governing euthanasia. However, this ‘Directive to Physicians’ – and this point is emphasized – does not come into effect unless the patient has signed it at least 14 days after the diagnosis of an incurable disease has been established (for details see Ref. [6]). A ‘Law on Living Wills’ was enacted in Denmark in 1992. When a patient with a fatal prognosis has made a decision against life-prolonging treatment,
the doctor must respect the patient’s wishes. The appropriate Danish Health Authority issues forms for the purpose. The data are stored in a central Health Register. Before deciding to withhold treatment, every doctor must enquire whether any such decision has been registered. Attention may be drawn to hospital legislation in Austria, which lays down that a patient’s wish not to be treated should be noted in the case papers [9].
3. The drafting of living wills As yet, Germany has no legislative provisions covering the field of patients’ living wills. They are therefore not confirmed to any pre-made form. Instead of hand-written documents, printed forms can be used, and in the last few years numerous versions have been published [2,12–16,18]. There must be some doubt whether these forms will cover all cases and circumstances. Irrespective of legislative and professional regulations, the following considerations apply. A patient’s living will must be drafted step by step, in keeping with the existing life situation, and in dialogue with a doctor who has the patient’s confidence. The doctor should use this possibility. The informed consent on the extent of life-preserving measures should be obtained as soon as possible [19]. Confirmation at appropriate intervals is strongly recommended. In this way a flexible response can be made, with the agreement of the doctor in charge of treatment, to the clinical situation as it develops. This will also provide documentation of the patient’s current wishes and seriousness of intent. To provide against unexpected events and unpredictable situations, it is advisable to appoint a precautionary healthcare authorization or a healthcare instruction. In Germany this authorized representative can also be appointed to give consent to medical treatment, its omission or discontinuation. Regarding measures involving a great risk for life and health, this consent must be in written form and must expressly refer to such treatment. The consent of the representative to ‘life-threatening treatment’ requires the approval of the court of guardianship (Art. 1904 German Civil Code).
R. Wegener / Forensic Science International 113 (2000) 487 – 489
4. Concluding remarks • If the patient has made a living will, the doctor has a duty to respect the patient’s life and human dignity when making decisions in an individual case. • If dealing with a chronically ill patient, the doctor has to make inquiries regarding the existence of a living will. • A patient’s living testament has greater binding force if it has been drafted with a doctor’s assistance. In this context patient’s information about nature and scope of treatment at the end of life is also a chance of the doctor to come to a dialogue. • Nevertheless: We confess ourselves, that there are also questions of the last lonely physician, which are not solvable [10].
[6]
[7] [8] [9]
[10] [11] [12]
[13] [14]
References [1] M.O. Baumgarten, The Right To Die?: Rechtliche Probleme Um Sterben Und Tod, Peter Lang, Bern, 1998. ¨ [2] Berliner Arzte, Selbstbestimmung des Patienten bis zum Tod, 9 (1997) 14. ¨ ¨ ¨ [3] Bundesarztekammer, Grundsatze der Bundesarztekammer ¨ ¨ zur arztlichen Sterbebegleitung. Dt. Arztebl, 1998;95:A2366. [4] Deibl Asta Karin, Die Mehrheit lehnt die aktive Sterbehilfe ¨ ¨ ¨ ab. Arzte befragen Arzte. Dt. Arztbl, 87 (1985) A-157 ¨ [5] U. Eibach, Patientenverfugungen – Mein Wille geschehe!? Kritische Betrachtungen der Christlichen Patientenver-
[15] [16]
[17] [18]
[19] [20]
489
¨ fugung‘ der Evangelisch-lutherischen Kirche in Bayern. Z Med Ethik 44 (1998) 201. Eisenbart Bettina, Patienten-Testament und Stellvertretung in Gesundheitsangelegenheiten. Alternativen zur Selbstbestimmung im Vorfeld des Todes, Nomos, Baden-Baden, 1998. ¨ ¨ A. Eser: in: Schonke / Schroder, Strafgesetzbuch, Kommen¨ tar, 24. Aufl. Munchen, 1991. H. Frahm, Patiententestament – nein danke!, Interview MMW 140 (1998) 44. H.G. Koch, Sterbebegleitung in Europa und den USA, in: ¨ ¨ Arztliche Sterbebegleitung. Symposium der Bundesarz¨ ¨ tekammer vom 15. Januar 1998. S. 38, Arzte-Verlag Koln, 1999. A. Laufs, Kommentar: Selbstverantwortetes Sterben? NJW 1996 (1996) 763. D. Linden, Gespenst des Biologismus. Lehren aus der ¨ Vergangenheit Dt Arztebl, 94 (1997) A-1104. ¨ ¨ Neuman Gitta, Personliche Patientenverfugung. Humanistischer Verband Deutschland. Berliner Medizinethische Schriften, Sonderdruck Heft 14 / 15a, 1998. Patienten-Testament mit Vorsorgevollmacht nach Prof. Dr. Wilhelm Uhlenbruck (1998): Verlag Klaus Vahle Berlin. ¨ Patientenschutzbrief der Deutschen Gesellschaft fur Humanes Sterben (DGHS e.V.), Augsburg, zit. bei 11. ¨ Patientenverfugung, Christliche, Evangelische-lutherische ¨ Kirche in Bayern. Gwd Hans Venus GmbH Munchen, 1996. ¨ ¨ die H.M. Sass, R. Kielstein, Vorsorgliche Verfugung fur ¨ Medizinische Ethik, Medizinischen Betreuung. Zentrum fur ¨ Bochum, 1997. Ruhr-Universitat W. Spann, Das Patiententestament, MedR 1 (1983) 13–16. W. Uhlenbruck, Selbstbestimmtes Sterben durch Patienten¨ Testament, Vorsorgevollmacht, Betreuungsverfugung, Verlag Klaus Vahle Berlin, 1997. ¨ S. Waibel, P. Novak, S. Roller, Patientenverfugungen: Der ¨ ¨ Arzt als Gesprachspartner Dt. Arztebl. 96 (1999) A-836. J. Wawersik, Reanimation und ihre Grenzen. S. 125, in: A. Eser (Ed.), Suizid und Euthanasie, Enke Stuttgart, 1976.