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The legalisation of voluntary euthanasia
1931.
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T h e Legalisation of V o l u n t a r y Euthanasia. Being the Presidential Address of DR. C. KILLICK M~ILLARD, Medical Officer of Health, City of Leicester, President of the Session, at his Installation on October 16th, 1931. " 0 death, where is day sting ? "--St. Paul. " No one knows but that death is the greatest of all goods to man ; but men fear it as if they knew that it is the greatest of evils."--Plato. " Death sets us free, even from the greatest evils."-Plutarch. " T h e best of rest is sleep, and that thou oft provok'st ; yet greatly fear'st thy death, which is no more."~Shakespeare. " I have often thought upon death and find it the least of all evils."--Bacon. " 0 Death! the poor man's dearest friend, the kindest and the best."--Burns. " 0 what a wonder seems the fear of death, seeing how gladly we all sink to sleep."~CoIeridge. " Sleep that no pain shall wake, Night that no morn shall break, Till joy shall overtake Her perfect peace." Christina Rossetti. The great task of Medicine is to prevent disease ; and failing that, to cure disease. If it fails in both, Science, at least, enables us to shorten the sufferings caused by disease. ] I N spite of all the advances which preventive I r a nd curative medicine have made, and of all that m o d e r n science has achieved in the alleviation of h u m a n suffering, the fact remains that vast numbers of h u m a n beings are doomed to end their earthly existence by a lingering, painful and often agonising form of death. U n d o u b t e d l y , m u c h of the " sting of death " ties in the prolonged physical suffering which so often precedes it. T h e actual death itself is often regarded by both patient and friends as a " h a p p y release." T h e very serious increase during recent years in the mortality from e a n c e r - - a notoriously painNl disea~:e---has ;iJefinitely increased the proportion of painful deaths. T h e time seems opportune, therefore, for the consideration of a subject which hitherto has been b u t little discussed. I refer to voluntary euthanasia and the question of making it legal u n d e r certain circumstances, and subject, of course, to p r o p e r restrictions and safeguards. Euthanasia ~ (tit. " easy death " ) i s defined in the Encyclopaedia of Religion and Ethics as : ~
" The doctrine or theory that in certain circumstances when owing to disease, senility or the like, a person's life has permanently ceased to be either agreeable or useful, the sufferer should be painlessly killed either by himself or another." Voluntary euthanasia, the subject of this address, clearly excludes anything but euthanasia which is desired by the person concerned. Nevertheless, to prevent misapprehension, let me make it quite clear that w h a t ~ I am proposing is not :-(a) T h a t imbeciles and mentally defectives should be painlessly deprived of l i f e ; (b) T h a t old people who have become a b u r d e n to their relatives should be quietly consigned to the lethal c h a m b e r ; (c) Or that any one who wishes to do so should be allowed, still less encouraged, to c o m m i t suicide. T h e proposition merely is that individuals, who have attained to years of discretion, and w h o are suffering from an incurabIe and fatal disease which usually entails a slow and painful death, should be allowed b y l a w - - i f they so desire, and if they have complied with the requisite c o n d i t i o n s - - t o substitute for the slow and painful death a quick and painless one. This, I submit, should be regarded not merely as an act of mercy, but as a matter of elementary human right. It is difficult to see, if properly safeguarded, that it would be in any way contrary to the highest interests of the c o m m u n i t y as a whole. I am aware, of course, that this proposition is likely to meet with opposition, in certain quarters, on so-called moral and religious grounds. T h a t is no proof, however, that it is * Tt~e word " euthanasia " is used by Bacon in his essay " De Augmentis Scientiarum " in the following passage :-" But in our times the physicians make a kind of scruple and religion to stay with the patient after he is given up, whereas in my judgment, if they would be wanting in their office, and indeed to humanity, they ought both to acquire the skill and to bestow the attention whereby the dying may pass more easily out of life. This part I call the inquiry concerning outward euthanasia, or the easy dying of the body (to distinguish it from that euthanasia which regards the preparation of the soul) ; and set it down among the desiderata,"
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in any way contrary to true morality, or that it will not ultimately be a p p r o v e d and sanctioned b y the enlightened conscience of mankind. In the case of an animal suffering f r o m some incurable and painful disease, or which has been hopelessly mutilated b y s o m e accident, c o m m o n h u m a n i t y d e m a n d s that we should " put the poor creature out of its p a i n . " T h i s is not only regarded as an act of mercy, but as a positive duty, neglect of which a m o u n t s to actual cruelty. I n India, however, where animal life is regarded as sacred, H i n d u i s m forbids the killing of sick or w o u n d e d animals, no matter what their sufferings m a y be. " G o d alone ordains," t h e y say, " w h e n death shall occur."* Such an attitude seems clearly w r o n g to W e s t e r n ideas. M a y not our o w n attitude in denying h u m a n beings the privilege of a painless death, p r o v i d e d they so desire it, be also w r o n g ? T h e proposal I a m p u t t i n g f o r w a r d is b y no means new. Sir T h o m a s M o r e , in his U t o p i a , published in 1516, over 400 years ago, represented the inhabitants of his imaginary K i n g d o m of U t o p i a as not only allowing euthanasia to those who were suffering f r o m incurable disease, b u t of actually encouraging it. T h e following is the passage (mediaeval spelling has been m o d e r n i s e d ) : - " The sick they see to with great affection, and let nothing at all pass concerning physic or good diet whereby they may be restored again to health. Such as be sick of incurable diseases they comfort by sitting by them, by talking with them, and to be short, with all manner of helps that may be. But if the disease be not only incurable, but also full of continual pain and anguish: then the priests and the magistrates exhort the man, seeing he is not able to do any duty of life, and by over-living his own death is noisome and irksome to others, and grievous to himself: that he will determine *My friend, Dr. A. S. H u m , tells me that Indian cities abound with stray dogs, often diseased or badly injured. An attempt was made by the Government of Bombay to bring in a measure for the destruction of stray dogs by the police. This was opposed on the ground that it would wound the religious susceptibilities of the Hindus. The Government representative said : " Is it a decent sight to see some poor animal disembowelled, legs broken and bleeding, in the streets of Bombay. The only humane thing is to put the beast out of misery." The reply to this was : " The framers of the Bill think that shooting an animal which is diseased and which could not be cured is much better. We, on the other hand, think that God Himself has ordained what is to come about." To overcome Hindu objection, it was proposed to exempt cows and bulls which are especially sacred, but the opposition prevailed and killed the Bill.
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with himself no longer to cherish that pestilent and painful disease. And seeing that his life is to him but a torment, that he will not be unwilling to die, but rather take a good hope to him, and either dispatch himself out of that painful life as out of a prison, or a rack of torment, or else suffer himself to be rid out of it by other. And in so doing they tell him he shall do wisely, seeing by his death he shall lose no commodity, but end his pain. And because in that act he shall follow the counsel of the priests, that is to say, of the interpreters of God's will and pleasure, they show him that he shall do like a Godly and virtuous man . . . . But they cause none such to die against his will, nor they use no less diligence and attendance about him, believing this to be an honourable death. On the contrary, he that killeth himself before that the priests and counsel have allowed the cause of his death, him as unworthy to be buried, or with fire to be consumed, they cast unburied into some stinking marsh." Sir T h o m a s M o r e was a very able man. H e succeeded Cardinal Wolsey in the office of L o r d Chancellor, and he was noted for his integrity and m o r a l courage, which qualities, indeed, cost h i m his life on T o w e r Hill. M a n y of his ideas for the good g o v e r n m e n t of m a n kind, as p u t forward in his Utopia, reveal rare prescience, good j u d g m e n t , and sound c o m m o n sense. Sir George N e w m a n , in his recently published H a l l e y - S t e w a r t L e c t u r e for 1930, after referring in detail to s o m e of M o r e ' s anticipations of m o d e r n public health (though he does not include M o r e ' s suggestions as to euthanasia) writes : - " It would be difficult to find a more succinct programme of the essentials of personal and public health than this j e u d'esprlt of a Tudor scholar and statesman . . . . During the four hundred years which have elapsed since More's U t o p i a was published, we have travelled a long way towards his ideals, but it cannot be truly said that we have yet arrived." T h e w o r d " U t o p i a n " has come to signify s o m e t h i n g which, although desirable, is impracticable or visionary. Evidently, however, m a n y of M o r e ' s ideals are far f r o m b e i n g U t o p i a n in the ordinary sense of the word. W e h o p e to show that the ideal of euthanasia is not only desirable b u t would also be quite practicable, once public opinion were converted to it. But the idea of euthanasia as s o m e t h i n g desirable dates back long before the 16th century and the t i m e of More. M a n y of the ancient philosophers were definitely in favour of it. Pliny declared that it was one of the greatest proofs of the b o u n t y of Providence that it has filled the world with herbs b y which the weary m a y find a rapid and painless death. Seneca, the Philosopher, said : - -
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" If I can choose between a death of torture and one that is simple and easy, why should I not select the latter ? As I choose the ship in which I will sail, and the house I will inhabit, so I will choose the death by which I will leave life . . . . Man should seek the approbation of others in his life ; his death concerns himself alone . . . . Why should I endure the agonies of disease . . . when I can emancipate myself from all my torment . . . . I will not depart by death from disease as long as it may be healed and leaves my mind unimpaired . . . . But if I know that I will suffer for ever I will depart, not through fear of the pain itself but because it prevents all for which I would live." Lecky, in his " History of European Morals," from which the above quotations have been taken, tells us that the younger Pliny described in terms of the most glowing admiration the conduct of one of his friends, who, struck down by disease, resolved calmly and deliberately upon the path he should pursue. H e determined, if the disease was only dangerous and long, to yield to the wishes of his friends and await the struggle ; but if the issue was hopeless, to die by his own hand. Having reasoned on the propriety of this course with all the tranquil courage of a Roman, he s u m m o n e d a council of physicians, and with a mind indifferent to either fate, he calmly awaited their sentence. T h e same writer (the younger Pliny) also mentions the case of a man who was afflicted with a horrible disease, which reduced the body to a mass of sores. His wife, being convinced that it was incurable, exhorted her husband to shorten his sufferings ; she nerved and encouraged him to the effort, and she claimed it as her privilege to accompany him to the grave. H u s b a n d and wife, b o u n d together, plunged into a lake. Epictetus, although opposed to indiscriminate suicide, considered it justifiable u n d e r certain circumstances such as incurable disease, intolerable pain, or misery of any kind. Before proceeding further, I wish to stress the point that there is a fundamental distinction between legalised voluntary euthanasia and what is ordinarily understood by the t e r m " suicide." T h e difference is just as real as the difference, say, between laying down one's life for one's friends and suicide; or between the killing of one's fellow men in war and m u r d e r ; the difference consisting in the fact that the one is legalised and approved, whilst the other is illegal and condemned. I contend that it is erroneous and unfair to describe legalised voluntary euthanasia as suicide, the latter being a t e r m which carries with it, after centuries of condemnation, the stigma of a
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revolt against religion, law, and public opinion. History of Suicide.--Having pointed out the distinction, however, it may be of interest, as certainly having a bearing upon our subject, to consider briefly the attitude towards suicide of different ages, races and religions. F o r the data which follow we are indebted principally to Westermark's great work, The Origin and
Development of Moral Ideas. Amongst some primitive peoples suicide appears to be practically u n k n o w n ; amongst others it is common. Amongst most it would seem to be deprecated, but this may possibly be attributed to the widespread belief t h r o u g h o u t the world that the spirit of a man who has died by his own hand does not rest in peace. Probably this belief accounts for the c o m m o n practice amongst so many tribes of not burying the body of a suicide in proximity to the usual burying place, but in some place apart. At the same time some forms of suicide are regarded not only as meritorious but as a positive duty. T h u s , where men are supposed to require wives in a future life it is the " correct " thing for wives to die with their husband, and women who refuse to do so are disgraced. We are told that the Kamchadales inflict death on themselves with the utmost coolness because they believe that the future life is a continuation of the present, but m u c h more complete and perfect. T h e suicides of old people, again, are in some eases due to the belief that a man enters into the next world in the same state as that in which he leaves this, and, consequently that it is better for him to die before he grows too old and feeble. Amongst many tribes the ghosts of any one who has died a violent death, and not merely those dying by their own hand, are believed to be " uneasy." Westermark says that, speaking generally, savages are seldom reported as attaching a stigma to suicide. Passing from primitive peoples to civilised races, we find that suicide has always been very c o m m o n in China. U n d e r certain circumstances it is regarded as highly meritorious, e.g., in the case of soldiers and officers of state who choose suicide rather than survive disgrace or defeat in battle. In this connection, we may observe that even amongst Christians, it is considered praiseworthy for soldiers or sailors to die fighting rather than surrender, although in a sense this is a form of suicide. It is also honourable in China for women to kilI themselves on the death of their husbands, or even of those to whom they are betrothea, and,
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in spite of imperial prohibitions sutteeism flourished until quite recent times. In Japan, admiration for suicide is carried even further, and the Japanese calendar of saints is said to be filled with canonised suicides and committers of harakiri. Harakiri, or " belly-cutting," was of two kinds, the one obligatory by command of the Emperor, as an alternative to being handed over to the execut i o n e r - t h i s was a boon granted to the Samurai or ancient military caste ; the other, voluntary, was performed from loyalty to a superior, to avoid disgrace, to restore injured honour, or as a protest when other protests were unavailing. Such cases were assured of honourable interment and a respected memory. Coming now to India, Hinduism not only sanctions but actually encourages many forms of suicide. Sutteeism, or suicide of widows, was only suppressed by the British with great difficulty. Buddhists, on the other hand, look upon suicide with much less favour, whilst Mohammedans not only condemn it but teach that it is a greater sin for a man to kill himself than to kill another. The Jews condemn suicide, and Josephus wrote strongly against it, but the Talmud sanctions the suicide of generals defeated in battle. It is noteworthy that suicide as such is nowhere forbidden either in the Old or New Testament. The attitude of the Ancients towards suicide is a little difficult to assess. A number of the ancient philosophers wrote in favour of it. Some of these we have already quoted from. Others, such as Pythagoras, condemned it on the ground that men ought not to depart from their station or guard without the order of the Commander, i.e., God. Plato held similar views, although he permitted suicide when the law required it, or when men were stricken down by intolerable calamity. Aristotle condemned it on civic grounds, as being an injury to the State. Cicero held the doctrine of Pythagoras, although he praised the suicide of Cato. Seneca, as we have already seen, strongly advocated suicide. Marcus Aurelius seems to have wavered. Speaking generally we may say that public opinion in the time of the Ancients, though opposed to suicide was much less severe than has been the case during the Christian era. Even where it was condemned little or no stigma attached to the act, and consequently the relatives did not suffer to any extent. The Romans had no law against suicide, and it was not a penal offence to attempt suicide, except
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in the case of soldiers. If an accused man, however, committed suicide it was regarded as a confession of guilt, and the same penalty followed, e.g., as regards confiscation of property, as if he had been found guilty. The Attitude of Christianity towards Suicide.Christianity has always been strongly opposed to suicide. It is true that the Earlier Fathers sanctioned it in certain cases, e,g., to avoid apostacy, to preserve the crown of virginity, or to procure martyrdom. But St. Augustine* went further and forbade it under any circumstances. He held that the Biblical injunction " Thou shalt not kill " (Ex. 20. 13) was to be interpreted as meaning neither thyself nor any other person. This doctrine was definitely accepted by the Church, and suicide was regarded as a form of murder, indeed, as the worst form of m u r d e r - - " The most grievous thing of all." Probably another reason why Christianity came to regard suicide as such a heinous sin was that it was bound up with another doctrine, that of the vital importance of absolution before death. Suicide obviously deprived a man of any chance of repentance and therefore doomed him, so it was taught, to eternal damnation. St. Thomas Aquinas definitely took this view. Hence the reason for d e n y i n g " Christian burial" to those who had died by their own hand and thus deliberately placed themselves " outside the pale." For centuries it was the custom to bury suicides at cross roads with a stake driven through the body, a practice only discontinued fifty years ago. Presumably the reason for this barbarous mutilation was the primitive superstition of the restlessness of a suicide's ghost, and the idea that this would help to keep it from wandering. The object of selecting cross roads is not so clear, unless it was to serve as a deterrent to others, as in the case of the gibbet. Certainly, such procedure must have deeply impressed on the public mind the exceptional wickedness and disgrace of suicide, which idea, as we know, still persists. Here we may pause to consider whether the Church's doctrine that suicide is self-murder is really justified ? Was St. Augustine right in teaching that the Biblical injunction " Thou shalt not kill " was intended to include suicide ? After all, there is this fundamental difference between suicide and murder, viz., that in murder we commit a serious wrong against another, in that we rob him of his most precious
The City of God. Bk. I, Chaps. XVI and XIX.
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possession, his life ; whereas, in suicide we are only destroying that which, humanly speaking, is our own, and we are not necessarily injuring another in any way. In this connection it is relevant to observe that when St. Paul says " T h o u shalt not kill " (Romans 13. 9) he couples with it other prohibitions, against adultery, stealing, bearing false witness, &c., all calculated to injure others, and he sums up with the famous sentence " and if there is any other c o m m a n d m e n t it is briefly c o m p r e h e n d e d in this saying, namely, T h o u shalt love thy neighbour as thyself." It is noteworthy, also, that in the Revised Version of Ex. 20. 13, " T h o u shalt not kill " is translated " T h o u shalt do no m u r d e r . " No doubt Christianity also disapproved of suicide on the same ground as that taken up by Pythagoras, v i z . , that it was desertion of a sacred trust without permission of God, but this would hardly have been a sufficient ground for ranking the sin of suicide with that of murder. T h e attitude of the Christian C h u r c h was reflected in that of the secular law, and suicide was, and still is regarded as a felony. In this country the confiscation of the p r o p e r t y of those who were guilty of felo de se was only discontinued as recently as 1870. Even attempted suicide is a felony in the eyes of the law, and although public opinion is coming to take a much more lenient view of this offence, we still occasionally witness the old spirit of prejudice and intolerance. In a recent case at Middles° brough, the u n h a p p y mother of fourteen children, who had attempted to put an end to herself, was sentenced to three months imprisonment ! Happily, in this case the t t o m e Secretary intervened, and the poor woman was liberated and restored to her family. T o avoid the stigma attaching to suicide modern coroner's juries usually bring in a verdict, regardless of the evidence, of " suicide whilst temporarily insane." In many cases such a verdict is doubtless quite justified, but in others it is entirely against the weight of evidence. Perjury, as Bentham said, being the penance which prevents an outrage on humanity ! F r o m time to time, however, there have been those who took a more enlightened attitude towards this question. We have already quoted from More's " U t o p i a . " Donne, a well-known Dean of St. Paul's, wrote in his younger days a book in defence of suicide. Montaigne was certainly sympathetic. Montesquieu advocated its legitimacy. Paulsen said that to refrain from suicide in great bodily or mental anguish
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might be heroic but was no definite duty. Voltaire strongly condemned the cruel laws which subjected a suicide's body to outrage and deprived his children of their heritage. Beccarla said that the State is more wronged by the emigrant than b y the suicide, in that the f o r m e r took all his property with him, whilst the suicide left it behind. Holbach said that the suicide was guilty of no outrage on nature or its Author ; on the contrary, he follows an indication given by nature when he pa~ts from his sufferings through the only door which has been left open. H u m e wrote a famous essay on suicide, in which he said : - " Suppose that it is no longer in my power to promote the interests of society ; suppose that I am a burden to it; suppose that my life hinders some person from being much more useful to society. In such cases, my resignation of life must not only be innocent but laudable." He also suggested that it is no more a sin to shorten life than to try to lengthen it beyond the natural span. Dr. Inge, the present Dean of St. Paul's, is distinctly sympathetic. In his last book, Christian Ethics and Modern Problems, in a chapter on Suicide, he sums up as follows : - " Some of the arguments against suicide are losing their force . . . . It seems anomalous that a man may be punished for cruelty if he does not put a horse or a dog ' out of its misery,' but is liable to be hanged for murder if he helps a cancer patient to an overdose of morphia . . . . I confess that in this instance I cannot resist the arguments for a modification of the traditional Christian law which absolutely prohibits suicide in all circumstances. I do not think we can assume that God willed the prolongation of torture for the benefit of the soul of the sufferer. Nor do I judge other suicides so severely as is the custom of Christian moralists." Dean Inge adds, however: " At the same time I hope, inconsistently, perhaps, that if I were attacked by a painful illness, I should have patience to wait for the end, and I do not think I should wish anyone near and dear to me to act otherwise... " M y own feeling about the ethics of suicide is that it depends almost entirely upon the motive prompting the act. Excluding that large group of cases where the mind is unhinged and which should only call for pity, suicide is usually resorted to as an easy way out of difficulties, financial or otherwise. It then too often represents an act of moral cowardice, and as such it must of course, be condemned, especially so where the step is taken regardless of the pain and suffering which the act may cause to others. But there are cases where suicide is resorted to because a man believes, rightly or wrongly, that it will really be better ,for his loved ones if he is " out of the way." Such
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cases are to be deprecated because it is not for a m a n to decide for himself, a b o u t such an irrevocable step, and he m a y so easily be mistaken. Pity, however, rather t h a n censure should be the p r e d o m i n a n t s e n t i m e n t in such cases. Legalised voluntary euthanasia would come into quite a different category as an act which was rational, courageous, and often highly altruistic.
A Practical ProposaL--Some sixty years ago (in 1873) the H o n . Lionel T o l l e m a c h e published an article in the " F o r t n i g h t l y R e v i e w , " entitled " A Cure for I n c u r a b l e s , " in which he endorsed and s u p p o r t e d an essay, pleading for the legalisation of euthanasia, p u b l i s h e d in the previous year b y S. D. Williams, Junr. I n this article, Mr. T o l l e m a c h e said that he was in no wise ambitious of introducing a practical scheme of euthanasia a m o n g the subjects of Q u e e n Victoria. H e merely wished to discuss the subject philosophically as a preliminary to r e f o r m in some later age. Is it too m u c h to hope that t o - d a y that later age has arrived, or is at least a p p r o a c h ing, and that the present generation m a y see this r e f o r m an accomplished fact ? I n order to bring the p r o p o s e d r e f o r m more within the range of practical politics I have drafted a Bill to make voluntary euthanasia legal. T h e essential provisions of this Bill are as follows : The Act to be called " The Voluntary Euthanasia (Legalisation) Act." 1. An application must be made by the dying person who desires to receive euthanasia, hereafter referred to as the applicant, stating that he has been informed by two medicat practitioners that he is suffering from a fatal and incurable disease (as defined in the Act), and that the process of death is likely to be protracted and painful; that he desires to take advantage of the provisions of the Act; that his affairs are in order; that his near relatives (as defined in the Act) have been informed ; and that he knows of no valid reason why he should not be granted the necessary licence or permit. This application must be duly attested by a magistrate or commissioner of oaths. 2. The application must be accompanied by two medical certificates, one from the ordinary medical attendant, and one, the confirmatory certificate, from an independent medical practitioner, of a specified status, who must not be related to the applicant, nor be financially interested in his death. 3. The application, with the certificates, must then be sent to an official appointed for the purpose and referred to hereafter as the euthanasia referee. It would be the duty of the latter to examine the papers and see that they were all in order ; to interview the applicant and the near relatives, and, if thought desirable, the medical practitioners who gave the certificates. The referee being satisfied will then
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give his certificate to the effect that the ease appears to him to be a proper one to be granted a permit under the Act. 4. The application and certificates will then come before a court of summary jurisdiction, usually sitting in special session. The referee would be present to answer any questions, and representatives of the applicant and of the near relatives would also have the right of being present, if they so desired. The Court, having considered the application and heard objections, if any, would, if satisfied, issue the necessary permits--one to the applicant to receive euthanasia, and one to a medical practitioner, who would usually be named in the application, to administer the euthanasia. Only practitioners who had been licensed for the purpose would be eligible to act as euthanisors. Where the euthanasia referee held a medical qualification (which personally I regard as very necessary) he might well also act as the official euthanisor; but provided he held the necessary licence, the applicant's own medical attendant might often be preferred. 5. A euthanasia permit would remain valid for a certain specified time, say, three months, after which it would lapse, but could be renewed. This would mean that the applicant would be under no obligation to act upon the permit immediately. Often he would prefer to wait, holding the permit in reserve in case the pain should become intolerable. Sometimes, no doubt, a permit would never be used, the applicant's courage failing him, or death supervening sooner or more easily than he expected.
Procedure for Administering Euthanasia.A s s u m i n g that the t i m e has come w h e n the applicant, having discussed the m a t t e r with those near a n d dear to him, and with his spiritual advisor, decides to act u p o n his permit, he will send word to the practitioner concerned and arrange date and other details. T h e p r o c e d u r e for administering euthanasia would be governed b y regulations to be m a d e b y the H o m e Secretary or Minister of Health. N o d o u b t alternative m e t h o d s would be a p p r o v e d and these could be varied f r o m t i m e to time as experience m a d e desirable. I n the present state of o u r knowledge the usual m e t h o d of choice, where the patient was able to swallow, would p r o b a b l y be a lethal (narcotic) draught, which m i g h t be given in a special utensil, the " lethal c u p . " A prescribed p r o c e d u r e w o u l d have to be followed, which would include an express statement b y the euthanisor as to the object of the draught, and a direct question to the applicant as to whether he was quite sure that he wished to anticipate death ? I f his answer was in the affirmative the lethal cup would be handed to h i m or placed within his reach. I n cases where the patient was unable to swallow, the lethal dose could be a d m i n i s t e r e d hypodermically. A n i n d e p e n d e n t and official witness would need to be present, and only persons of a certain
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status, e.g., magistrates, clergymen, solicitors, or doctors, would be eligible for this duty. Euthanasia having b e e n accomplished, the euthanisor would fill up and sign the necessary certificate on a prescribed form, and this would t h e n be counter-signed b y the official witness. T h i s certificate, which would state the fatal disease f r o m which the deceased had suffered, and would specifiy euthanasia as the m o d e of death, would take the place of the ordinary medical certificate for purposes of registration of death. T h e p r o c e d u r e detailed above m a y sound a little complicated, t h o u g h in real{ty it is not m u c h m o r e so t h a n the procedure which has to be gone t h r o u g h in the case of cremation, on which, indeed, i t i s largely modelled. I n practice, w h e n we had b e c o m e familiarised with it, it would not, I think, be really very formidable. At first, no doubt, the n u m b e r of persons who would take advantage of the Act would not be large, possibly very small. By degrees, however, as people became accustomed to the idea and prejudice broke down, and as public opinion came to regard euthanasia as a courageous, rational, and often very altruistic course, the n u m b e r s would increase. Doubtless, as in the case of cremation, the m o v e m e n t would be helped forward b y the example set b y a few outstanding m e n and w o m e n , distinguished in the spheres of science, philosophy, art, and religion.
Objections to Euthanasia.--As regards possible
objections to the legalising of voluntary euthanasia, these m a y be classified as (1) Ethical and Religious ; (2) Legal ; (3) Practical.
1.--Ethical Objections.--To m e e t the objections which will no d o u b t be raised on the g r o u n d of religion and ethics I cannot do better t h a n shelter myself b e h i n d a distinguished m e m b e r of the Anglican Church, C a n o n Peter Green,* who, in a b o o k on ethics, The Problem of Right Conduct, published this year, refers expressly to this subject, u n d e r the heading " T h e C h u r c h ' s Attitude towards Suicide." H e writes : - " A man suffers, let us suppose, from cancer of the larynx. Operation is impossible and there is at present no known cure. What medical science may achieve in the future we cannot say. As things are, the man's fate, the moment his ailment is diagnosed as malignant, is certain. It means for him, months of agony, terminating in a hideous race between strangulation and starvation. It means,
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for those who love him, the misery of watching him die in slow agony without being able to do anything to ease his pain. Under such circumstances, might not both Church and State allow a man, under due safeguards and conditions, to end his life painlessly ? Many men every year do ,commit suicide to escape lingering agony. But they do it in a spirit of angry revolt against God ; they die without the consolation of religion ; they may lose the whole of any insurance they have made for wife and children; they shock their loved ones, and outrage public opinion. In such a case, I should myself like my doctor, in conjunction with a specialist, to be allowed to state that the disease was fatal and likely to be slow and painful ; and then I might be permitted to make a sworn declaration that I desired to end my life at once in some painless manner. This would enable a man to settle his affairs; to say goodbye to his friends, and to receive the last rites of the Church. What are the arguments against the granting of such liberty by Church and State to' those who desire it ? " One might, of course, argue that as God alone confers life, God alone may decree its end. That argument, however, is impossible while we permit war and capital punishment. " It is often argued that for a man to end a painful illness, by his own act, is to avoid a divinely-appointed discipline of trial and suffering. But it may be noted that precisely that argument was used by many religious people to prove the unlawful nature of anaesthetics... " I have found it impossible to discover any really conclusive argument against suicide under due restrictions." O n one point I think that C a n o n Peter G r e e n is not, perhaps, quite correct, viz., where he says that we can do n o t h i n g to ease the pain in the cases we are considering. T h a n k s to m o r p h i a and the h y p o d e r m i c syringe we can do a good deal, especially if the medical attendant is not afraid of incurring the risk of going too far and so relieving the pain entirely. But the position is m o s t unsatisfactory. T h e dose has to be increased again and again as tolerance is established. A merciful doctor Canon Green is the author of a number of other religious books, including the following : Our Lord and Saviour. A Study of the Person and Doctrine of Jesus Christ. Our Heavenly Father. A Study of the Nature and Doctrine of God. Personal Religion and Public Righteousness. With an Introduction by the Bishop of London. The Problem of Evil. Being an attempt to show that the existence of Sin and Pain in the World is not inconsistent with the Goodness and Power of God. The Town Parson : His Life and Work. With Preface by the Right Rev. E. S. Talbot, D.D., formerly Bishop of Winchester. Parochial Missions To-day. A Handbook of Evangelical Missions for Missioners and Parochial Clergy-
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literally hovers on the brink of manslaughter,'* and in cases where m o r p h i a is resorted to liberally and is long continued the effect, in m a n y cases, is u n d o u b t e d l y to shorten life.
2.--Legal Objections,v-As regards any legal objections, there is the question of possible abuse, e.g., b y friends anxious for selfish reasons to be rid of a t r o u b l e s o m e patient. Subject, however, to the conditions and precautions we have indicated, it is difficult to see how the p r o p o s e d a r r a n g e m e n t could really be abused. Certain contingencies would need to be provided for, e.g., the matter of life insurance policies. A clause in the Act would deal with existing policies, allowing insurance societies to deduct a discount of say, 5 per cent. for, say, three months, f r o m the s u m assured ; b u t in policies taken out after the passing of the Act m o s t societies would doubtless insert a clause agreeing to make no difference in the s u m assured in case death was b r o u g h t about b y legatised euthanasia. F o r after all, a p e r m i t could only be obtained where a m a n was suffering f r o m a fatal disease. M o r e o v e r , even at present, suicide " whilst t e m p o r a r i l y insane," the usual verdict, does not affect life assurance. 3.--Practical Objections.--It m a y be argued that the procedure, as detailed above, to he gone t h r o u g h in order to obtain a p e r m i t would * Dr. Axel Munthe, in his remarkable book, The Story of San Michele, has an eloquent passage, on page 25, under the title " T h e Eternal Sleeping Draught," which bears on this aspect of the subject. " But was it really so that my mission was at an end when His (Death's) was to begin ? Was I to be an impassive spectator of the last unequal battle, to stand by helpless and insensible while He was doing His work of destruction ? Was I to turn my face away from those eyes who implored my help, long after the power of speech had gone ? Was I to loosen my hand from those quivering fingers who clung to mine like a drowning man to a straw ? I was defeated, but I was not disarmed; I had still in my hands a powerful weapon, tie had His eternal sleeping draught, but I l~ad also mine entrusted to me by benevolent Mother Nature. When he was slow in dealing out His remedy, why should I not deal out mine with its merciful power to change anguish into peace, agony into sleep ? Was it not my mission to help those to die I could not help to live ? " The old nun had told me I was committing a terrible sin, that Almighty God in His inscrutable wisdom had willed it so, that the more suffering He inflicted at the hour of death, the more forgiving would He be On the Day of Judgment. Even sweet Sister Philomene had looked at me disapprovingly when, alone among my comrades, I had come with my morphia syringe after the old padre had left the bed with his Last Sacrament."
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seem so complicated that no one would trouble to take advantage of the Act. I do not think that a m a n faced with the grim alternatives depicted so eloquently b y C a n o n Green, assuming that he felt there was no moral or legal objection, would be so d e t e r r e d ; but even admitting that some obstacle would exist, that very fact would itself be some security against euthanasia being resorted to too readily. Another practical difficulty m i g h t be the opposition of friends. At first this would sometimes be a real obstacle, b u t by degrees, as prejudice was overcome, and as euthanasia came to be regarded as a reasonable and p r o p e r course u n d e r certain circumstances, pity for the sufferings of a loved one would cause euthanasia to be welcomed. I n this connection we may observe that doubtless in m a n y cases the motive actuating an applicant for euthanasia would not be merely to escape physical suffering for himself, b u t even m o r e to shorten and relieve the v e r y serious physical and mental strain which a long d r a w n - o u t painful illness ~so often entails u p o n those who are nearest and dearest. Viewed f r o m this standpoint, euthanasia would come to be regarded as s o m e t h i n g heroic,, an act of true altruism, to be applauded, not deprecated. Possibly, some, whilst agreeing in theory with the proposals we have here put forward, will regard t h e m as " U t o p i a n " (in a double sense !), and will think that any chance of their ever being sanctioned b y public opinion is too remote to be w o r t h considering. M o s t i m p o r tant reforms, w h e n first b r o u g h t forward, have b e e n similarly regarded. W h a t m o r e drastic and revolutionary change, involving at first sight o v e r w h e l m i n g practical difficulties, can possibly be imagined than the innovation of " S u m m e r T i m e " ? H o w little it was t h o u g h t - w h e n the late Mr. Willett first b r o u g h t forward the i d e a - - e v e n b y those who a p p r o v e d of it i r / t h e o r y , that we should ever see it b e c o m e an accomplished fact ! Or think of the very strong opposition which the proposal to legalise cremation m e t with, b o t h on religious grounds, as b e i n g directly opposed to the whole tradition of Christianity, and on legal grounds as being likely to cover up evidence of foul play. Still m o r e recently there is the case of b i r t h control. Less t h a n a generation ago this was generally c o n d e m n e d . It was said to be " u n - n a t u r a l , " r e p u g n a n t to decent feeling, dangerous to health, and altogether contrary to the highest interests of the nation. I t was
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difficult for its early advocates even to get a hearing, and the subject was strictly tabooed in respectable society. It is hardly necessary to say how completely public opinion has changed. Although strong opposition still persists, the taboo has been entirely removed; it is a popular subject for discussion on platform and in the Press, the opposition of organised religion (apart from Roman Catholicism) is disappearing, and it is hardly an exaggeration to say that very many of the present generation of young people accept birth control almost as a matter of course.
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This is an age of toleration. We are living in the twentieth, not in the nineteenth century. Public opinion has more claim to-day to be considered " enlightened " than ever before. New ideas are more readily accepted than ever before. Is it then so very improbable that the legalisation of voluntary euthanasia may become an accomplished fact within the life-time of some of us ! " To stretch the octave 'twixt the dream and deed, Ah, that's the thrill ! "
THE JOINT TUBERCULOSIS COUNCIL.
A meeting of the Joint Tuberculosis Council was held at the house of the Society of Medical Officers of Health on October t7th, 1931. Twenty-three members were present, with Dr. Lissant Cox occupying the chair. Dr. Lissant Cox was nominated Chairman of Council for 1932; Drs. L. S. T. Burrell and S. Vere Pearson, Vice-Chairmen; Dr. Ernest Ward, Hon. Secretary; Dr. G. Jessel, Hon. Treasurer, and Dr. D. P. Sutherland, Hon. Auditor. Concerning post-graduate study, Dr. Brand narrated that Dr. Peter Edwards had held eight useful,intensive three-day courses at the Cheshire Joint Counties Sanatorium with especial reference to artificial pneumothorax. A course had been held "in Holland from June 29th to July 4th this year, and there were eleven participants. The visitors were kept busy from breakfast until 6 p.m., and much appreciated the organisation and the kindness t h e y received. The desire was expressed for a similar course in Germany next year. At Victoria Park Hospital, from February 16th to 21st, a course had been held in which forty-four participated, and sixteen names had been received for the Lancashire post-graduate course to be held from October 19th to 24th. Dr. Gloyne, who was unable to be present at the meeting, wrote that he was hoping to make a collection of cases of acute tuberculosis in children under five from the East End of London, but hitherto no one had offered to undertake another district. Considerable discussion on collective research followed. The essentially individualistic nature of most research was emphasised and the difficulty of persuading those able and ready to carry
out research to follow lines suggested by any Committee. It had proved helpful in some districts to allot certain subjects to certain workers and publish the results of their investigations in the local annual report. It was also suggested that a simple but useful form of research would be the publication of reports of interesting clinical cases, which could be done every three months without any great effort, by clinical workers to whom case notes are readily accessible. The Secretary mentioned that some members of the Canadian Tuberculosis Service might be visiting this country for the Centenary meeting of the British Medical Association next July. He was asked to ascertain the number and names of these in order that some hospitality might be arranged by the Joint Tuberculosis Council and the participants in the Transatlantic Tour. It was resolved that this Council welcomes the suggested formation of a tuberculosis library and information bureau, and wishes every success to the Tuberculosis Association in its efforts to that end. Saturday, January 16th, at 10 a.m.,was the date and time fixed for the next meeting of Council. After the meeting~ Dr. Lissant Cox entertained to lunch members of Council, together with Sir George Newman, Dr. A. S. McNalty, Dr. Charles Porter, Dr. Morland, and Mr. Lewis Elliston. A successful and happy luncheon party was followed by a thoughtful speech by Sir George Newman, speaking on behalf of the guests. Dr. Charles Porter then proposed health and thanks to Dr. Lissant Cox, and was ably seconded by Dr. Morland. Dr. Cox replied suitably.
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T h e Legalisation of V o l u n t a r y Euthanasia. Being the Presidential Address of DR. C. KILLICK M~ILLARD, Medical Officer of Health, City of Leicester, President of the Session, at his Installation on October 16th, 1931. " 0 death, where is day sting ? "--St. Paul. " No one knows but that death is the greatest of all goods to man ; but men fear it as if they knew that it is the greatest of evils."--Plato. " Death sets us free, even from the greatest evils."-Plutarch. " T h e best of rest is sleep, and that thou oft provok'st ; yet greatly fear'st thy death, which is no more."~Shakespeare. " I have often thought upon death and find it the least of all evils."--Bacon. " 0 Death! the poor man's dearest friend, the kindest and the best."--Burns. " 0 what a wonder seems the fear of death, seeing how gladly we all sink to sleep."~CoIeridge. " Sleep that no pain shall wake, Night that no morn shall break, Till joy shall overtake Her perfect peace." Christina Rossetti. The great task of Medicine is to prevent disease ; and failing that, to cure disease. If it fails in both, Science, at least, enables us to shorten the sufferings caused by disease. ] I N spite of all the advances which preventive I r a nd curative medicine have made, and of all that m o d e r n science has achieved in the alleviation of h u m a n suffering, the fact remains that vast numbers of h u m a n beings are doomed to end their earthly existence by a lingering, painful and often agonising form of death. U n d o u b t e d l y , m u c h of the " sting of death " ties in the prolonged physical suffering which so often precedes it. T h e actual death itself is often regarded by both patient and friends as a " h a p p y release." T h e very serious increase during recent years in the mortality from e a n c e r - - a notoriously painNl disea~:e---has ;iJefinitely increased the proportion of painful deaths. T h e time seems opportune, therefore, for the consideration of a subject which hitherto has been b u t little discussed. I refer to voluntary euthanasia and the question of making it legal u n d e r certain circumstances, and subject, of course, to p r o p e r restrictions and safeguards. Euthanasia ~ (tit. " easy death " ) i s defined in the Encyclopaedia of Religion and Ethics as : ~
" The doctrine or theory that in certain circumstances when owing to disease, senility or the like, a person's life has permanently ceased to be either agreeable or useful, the sufferer should be painlessly killed either by himself or another." Voluntary euthanasia, the subject of this address, clearly excludes anything but euthanasia which is desired by the person concerned. Nevertheless, to prevent misapprehension, let me make it quite clear that w h a t ~ I am proposing is not :-(a) T h a t imbeciles and mentally defectives should be painlessly deprived of l i f e ; (b) T h a t old people who have become a b u r d e n to their relatives should be quietly consigned to the lethal c h a m b e r ; (c) Or that any one who wishes to do so should be allowed, still less encouraged, to c o m m i t suicide. T h e proposition merely is that individuals, who have attained to years of discretion, and w h o are suffering from an incurabIe and fatal disease which usually entails a slow and painful death, should be allowed b y l a w - - i f they so desire, and if they have complied with the requisite c o n d i t i o n s - - t o substitute for the slow and painful death a quick and painless one. This, I submit, should be regarded not merely as an act of mercy, but as a matter of elementary human right. It is difficult to see, if properly safeguarded, that it would be in any way contrary to the highest interests of the c o m m u n i t y as a whole. I am aware, of course, that this proposition is likely to meet with opposition, in certain quarters, on so-called moral and religious grounds. T h a t is no proof, however, that it is * Tt~e word " euthanasia " is used by Bacon in his essay " De Augmentis Scientiarum " in the following passage :-" But in our times the physicians make a kind of scruple and religion to stay with the patient after he is given up, whereas in my judgment, if they would be wanting in their office, and indeed to humanity, they ought both to acquire the skill and to bestow the attention whereby the dying may pass more easily out of life. This part I call the inquiry concerning outward euthanasia, or the easy dying of the body (to distinguish it from that euthanasia which regards the preparation of the soul) ; and set it down among the desiderata,"
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in any way contrary to true morality, or that it will not ultimately be a p p r o v e d and sanctioned b y the enlightened conscience of mankind. In the case of an animal suffering f r o m some incurable and painful disease, or which has been hopelessly mutilated b y s o m e accident, c o m m o n h u m a n i t y d e m a n d s that we should " put the poor creature out of its p a i n . " T h i s is not only regarded as an act of mercy, but as a positive duty, neglect of which a m o u n t s to actual cruelty. I n India, however, where animal life is regarded as sacred, H i n d u i s m forbids the killing of sick or w o u n d e d animals, no matter what their sufferings m a y be. " G o d alone ordains," t h e y say, " w h e n death shall occur."* Such an attitude seems clearly w r o n g to W e s t e r n ideas. M a y not our o w n attitude in denying h u m a n beings the privilege of a painless death, p r o v i d e d they so desire it, be also w r o n g ? T h e proposal I a m p u t t i n g f o r w a r d is b y no means new. Sir T h o m a s M o r e , in his U t o p i a , published in 1516, over 400 years ago, represented the inhabitants of his imaginary K i n g d o m of U t o p i a as not only allowing euthanasia to those who were suffering f r o m incurable disease, b u t of actually encouraging it. T h e following is the passage (mediaeval spelling has been m o d e r n i s e d ) : - " The sick they see to with great affection, and let nothing at all pass concerning physic or good diet whereby they may be restored again to health. Such as be sick of incurable diseases they comfort by sitting by them, by talking with them, and to be short, with all manner of helps that may be. But if the disease be not only incurable, but also full of continual pain and anguish: then the priests and the magistrates exhort the man, seeing he is not able to do any duty of life, and by over-living his own death is noisome and irksome to others, and grievous to himself: that he will determine *My friend, Dr. A. S. H u m , tells me that Indian cities abound with stray dogs, often diseased or badly injured. An attempt was made by the Government of Bombay to bring in a measure for the destruction of stray dogs by the police. This was opposed on the ground that it would wound the religious susceptibilities of the Hindus. The Government representative said : " Is it a decent sight to see some poor animal disembowelled, legs broken and bleeding, in the streets of Bombay. The only humane thing is to put the beast out of misery." The reply to this was : " The framers of the Bill think that shooting an animal which is diseased and which could not be cured is much better. We, on the other hand, think that God Himself has ordained what is to come about." To overcome Hindu objection, it was proposed to exempt cows and bulls which are especially sacred, but the opposition prevailed and killed the Bill.
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with himself no longer to cherish that pestilent and painful disease. And seeing that his life is to him but a torment, that he will not be unwilling to die, but rather take a good hope to him, and either dispatch himself out of that painful life as out of a prison, or a rack of torment, or else suffer himself to be rid out of it by other. And in so doing they tell him he shall do wisely, seeing by his death he shall lose no commodity, but end his pain. And because in that act he shall follow the counsel of the priests, that is to say, of the interpreters of God's will and pleasure, they show him that he shall do like a Godly and virtuous man . . . . But they cause none such to die against his will, nor they use no less diligence and attendance about him, believing this to be an honourable death. On the contrary, he that killeth himself before that the priests and counsel have allowed the cause of his death, him as unworthy to be buried, or with fire to be consumed, they cast unburied into some stinking marsh." Sir T h o m a s M o r e was a very able man. H e succeeded Cardinal Wolsey in the office of L o r d Chancellor, and he was noted for his integrity and m o r a l courage, which qualities, indeed, cost h i m his life on T o w e r Hill. M a n y of his ideas for the good g o v e r n m e n t of m a n kind, as p u t forward in his Utopia, reveal rare prescience, good j u d g m e n t , and sound c o m m o n sense. Sir George N e w m a n , in his recently published H a l l e y - S t e w a r t L e c t u r e for 1930, after referring in detail to s o m e of M o r e ' s anticipations of m o d e r n public health (though he does not include M o r e ' s suggestions as to euthanasia) writes : - " It would be difficult to find a more succinct programme of the essentials of personal and public health than this j e u d'esprlt of a Tudor scholar and statesman . . . . During the four hundred years which have elapsed since More's U t o p i a was published, we have travelled a long way towards his ideals, but it cannot be truly said that we have yet arrived." T h e w o r d " U t o p i a n " has come to signify s o m e t h i n g which, although desirable, is impracticable or visionary. Evidently, however, m a n y of M o r e ' s ideals are far f r o m b e i n g U t o p i a n in the ordinary sense of the word. W e h o p e to show that the ideal of euthanasia is not only desirable b u t would also be quite practicable, once public opinion were converted to it. But the idea of euthanasia as s o m e t h i n g desirable dates back long before the 16th century and the t i m e of More. M a n y of the ancient philosophers were definitely in favour of it. Pliny declared that it was one of the greatest proofs of the b o u n t y of Providence that it has filled the world with herbs b y which the weary m a y find a rapid and painless death. Seneca, the Philosopher, said : - -
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" If I can choose between a death of torture and one that is simple and easy, why should I not select the latter ? As I choose the ship in which I will sail, and the house I will inhabit, so I will choose the death by which I will leave life . . . . Man should seek the approbation of others in his life ; his death concerns himself alone . . . . Why should I endure the agonies of disease . . . when I can emancipate myself from all my torment . . . . I will not depart by death from disease as long as it may be healed and leaves my mind unimpaired . . . . But if I know that I will suffer for ever I will depart, not through fear of the pain itself but because it prevents all for which I would live." Lecky, in his " History of European Morals," from which the above quotations have been taken, tells us that the younger Pliny described in terms of the most glowing admiration the conduct of one of his friends, who, struck down by disease, resolved calmly and deliberately upon the path he should pursue. H e determined, if the disease was only dangerous and long, to yield to the wishes of his friends and await the struggle ; but if the issue was hopeless, to die by his own hand. Having reasoned on the propriety of this course with all the tranquil courage of a Roman, he s u m m o n e d a council of physicians, and with a mind indifferent to either fate, he calmly awaited their sentence. T h e same writer (the younger Pliny) also mentions the case of a man who was afflicted with a horrible disease, which reduced the body to a mass of sores. His wife, being convinced that it was incurable, exhorted her husband to shorten his sufferings ; she nerved and encouraged him to the effort, and she claimed it as her privilege to accompany him to the grave. H u s b a n d and wife, b o u n d together, plunged into a lake. Epictetus, although opposed to indiscriminate suicide, considered it justifiable u n d e r certain circumstances such as incurable disease, intolerable pain, or misery of any kind. Before proceeding further, I wish to stress the point that there is a fundamental distinction between legalised voluntary euthanasia and what is ordinarily understood by the t e r m " suicide." T h e difference is just as real as the difference, say, between laying down one's life for one's friends and suicide; or between the killing of one's fellow men in war and m u r d e r ; the difference consisting in the fact that the one is legalised and approved, whilst the other is illegal and condemned. I contend that it is erroneous and unfair to describe legalised voluntary euthanasia as suicide, the latter being a t e r m which carries with it, after centuries of condemnation, the stigma of a
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revolt against religion, law, and public opinion. History of Suicide.--Having pointed out the distinction, however, it may be of interest, as certainly having a bearing upon our subject, to consider briefly the attitude towards suicide of different ages, races and religions. F o r the data which follow we are indebted principally to Westermark's great work, The Origin and
Development of Moral Ideas. Amongst some primitive peoples suicide appears to be practically u n k n o w n ; amongst others it is common. Amongst most it would seem to be deprecated, but this may possibly be attributed to the widespread belief t h r o u g h o u t the world that the spirit of a man who has died by his own hand does not rest in peace. Probably this belief accounts for the c o m m o n practice amongst so many tribes of not burying the body of a suicide in proximity to the usual burying place, but in some place apart. At the same time some forms of suicide are regarded not only as meritorious but as a positive duty. T h u s , where men are supposed to require wives in a future life it is the " correct " thing for wives to die with their husband, and women who refuse to do so are disgraced. We are told that the Kamchadales inflict death on themselves with the utmost coolness because they believe that the future life is a continuation of the present, but m u c h more complete and perfect. T h e suicides of old people, again, are in some eases due to the belief that a man enters into the next world in the same state as that in which he leaves this, and, consequently that it is better for him to die before he grows too old and feeble. Amongst many tribes the ghosts of any one who has died a violent death, and not merely those dying by their own hand, are believed to be " uneasy." Westermark says that, speaking generally, savages are seldom reported as attaching a stigma to suicide. Passing from primitive peoples to civilised races, we find that suicide has always been very c o m m o n in China. U n d e r certain circumstances it is regarded as highly meritorious, e.g., in the case of soldiers and officers of state who choose suicide rather than survive disgrace or defeat in battle. In this connection, we may observe that even amongst Christians, it is considered praiseworthy for soldiers or sailors to die fighting rather than surrender, although in a sense this is a form of suicide. It is also honourable in China for women to kilI themselves on the death of their husbands, or even of those to whom they are betrothea, and,
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in spite of imperial prohibitions sutteeism flourished until quite recent times. In Japan, admiration for suicide is carried even further, and the Japanese calendar of saints is said to be filled with canonised suicides and committers of harakiri. Harakiri, or " belly-cutting," was of two kinds, the one obligatory by command of the Emperor, as an alternative to being handed over to the execut i o n e r - t h i s was a boon granted to the Samurai or ancient military caste ; the other, voluntary, was performed from loyalty to a superior, to avoid disgrace, to restore injured honour, or as a protest when other protests were unavailing. Such cases were assured of honourable interment and a respected memory. Coming now to India, Hinduism not only sanctions but actually encourages many forms of suicide. Sutteeism, or suicide of widows, was only suppressed by the British with great difficulty. Buddhists, on the other hand, look upon suicide with much less favour, whilst Mohammedans not only condemn it but teach that it is a greater sin for a man to kill himself than to kill another. The Jews condemn suicide, and Josephus wrote strongly against it, but the Talmud sanctions the suicide of generals defeated in battle. It is noteworthy that suicide as such is nowhere forbidden either in the Old or New Testament. The attitude of the Ancients towards suicide is a little difficult to assess. A number of the ancient philosophers wrote in favour of it. Some of these we have already quoted from. Others, such as Pythagoras, condemned it on the ground that men ought not to depart from their station or guard without the order of the Commander, i.e., God. Plato held similar views, although he permitted suicide when the law required it, or when men were stricken down by intolerable calamity. Aristotle condemned it on civic grounds, as being an injury to the State. Cicero held the doctrine of Pythagoras, although he praised the suicide of Cato. Seneca, as we have already seen, strongly advocated suicide. Marcus Aurelius seems to have wavered. Speaking generally we may say that public opinion in the time of the Ancients, though opposed to suicide was much less severe than has been the case during the Christian era. Even where it was condemned little or no stigma attached to the act, and consequently the relatives did not suffer to any extent. The Romans had no law against suicide, and it was not a penal offence to attempt suicide, except
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in the case of soldiers. If an accused man, however, committed suicide it was regarded as a confession of guilt, and the same penalty followed, e.g., as regards confiscation of property, as if he had been found guilty. The Attitude of Christianity towards Suicide.Christianity has always been strongly opposed to suicide. It is true that the Earlier Fathers sanctioned it in certain cases, e,g., to avoid apostacy, to preserve the crown of virginity, or to procure martyrdom. But St. Augustine* went further and forbade it under any circumstances. He held that the Biblical injunction " Thou shalt not kill " (Ex. 20. 13) was to be interpreted as meaning neither thyself nor any other person. This doctrine was definitely accepted by the Church, and suicide was regarded as a form of murder, indeed, as the worst form of m u r d e r - - " The most grievous thing of all." Probably another reason why Christianity came to regard suicide as such a heinous sin was that it was bound up with another doctrine, that of the vital importance of absolution before death. Suicide obviously deprived a man of any chance of repentance and therefore doomed him, so it was taught, to eternal damnation. St. Thomas Aquinas definitely took this view. Hence the reason for d e n y i n g " Christian burial" to those who had died by their own hand and thus deliberately placed themselves " outside the pale." For centuries it was the custom to bury suicides at cross roads with a stake driven through the body, a practice only discontinued fifty years ago. Presumably the reason for this barbarous mutilation was the primitive superstition of the restlessness of a suicide's ghost, and the idea that this would help to keep it from wandering. The object of selecting cross roads is not so clear, unless it was to serve as a deterrent to others, as in the case of the gibbet. Certainly, such procedure must have deeply impressed on the public mind the exceptional wickedness and disgrace of suicide, which idea, as we know, still persists. Here we may pause to consider whether the Church's doctrine that suicide is self-murder is really justified ? Was St. Augustine right in teaching that the Biblical injunction " Thou shalt not kill " was intended to include suicide ? After all, there is this fundamental difference between suicide and murder, viz., that in murder we commit a serious wrong against another, in that we rob him of his most precious
The City of God. Bk. I, Chaps. XVI and XIX.
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possession, his life ; whereas, in suicide we are only destroying that which, humanly speaking, is our own, and we are not necessarily injuring another in any way. In this connection it is relevant to observe that when St. Paul says " T h o u shalt not kill " (Romans 13. 9) he couples with it other prohibitions, against adultery, stealing, bearing false witness, &c., all calculated to injure others, and he sums up with the famous sentence " and if there is any other c o m m a n d m e n t it is briefly c o m p r e h e n d e d in this saying, namely, T h o u shalt love thy neighbour as thyself." It is noteworthy, also, that in the Revised Version of Ex. 20. 13, " T h o u shalt not kill " is translated " T h o u shalt do no m u r d e r . " No doubt Christianity also disapproved of suicide on the same ground as that taken up by Pythagoras, v i z . , that it was desertion of a sacred trust without permission of God, but this would hardly have been a sufficient ground for ranking the sin of suicide with that of murder. T h e attitude of the Christian C h u r c h was reflected in that of the secular law, and suicide was, and still is regarded as a felony. In this country the confiscation of the p r o p e r t y of those who were guilty of felo de se was only discontinued as recently as 1870. Even attempted suicide is a felony in the eyes of the law, and although public opinion is coming to take a much more lenient view of this offence, we still occasionally witness the old spirit of prejudice and intolerance. In a recent case at Middles° brough, the u n h a p p y mother of fourteen children, who had attempted to put an end to herself, was sentenced to three months imprisonment ! Happily, in this case the t t o m e Secretary intervened, and the poor woman was liberated and restored to her family. T o avoid the stigma attaching to suicide modern coroner's juries usually bring in a verdict, regardless of the evidence, of " suicide whilst temporarily insane." In many cases such a verdict is doubtless quite justified, but in others it is entirely against the weight of evidence. Perjury, as Bentham said, being the penance which prevents an outrage on humanity ! F r o m time to time, however, there have been those who took a more enlightened attitude towards this question. We have already quoted from More's " U t o p i a . " Donne, a well-known Dean of St. Paul's, wrote in his younger days a book in defence of suicide. Montaigne was certainly sympathetic. Montesquieu advocated its legitimacy. Paulsen said that to refrain from suicide in great bodily or mental anguish
43
might be heroic but was no definite duty. Voltaire strongly condemned the cruel laws which subjected a suicide's body to outrage and deprived his children of their heritage. Beccarla said that the State is more wronged by the emigrant than b y the suicide, in that the f o r m e r took all his property with him, whilst the suicide left it behind. Holbach said that the suicide was guilty of no outrage on nature or its Author ; on the contrary, he follows an indication given by nature when he pa~ts from his sufferings through the only door which has been left open. H u m e wrote a famous essay on suicide, in which he said : - " Suppose that it is no longer in my power to promote the interests of society ; suppose that I am a burden to it; suppose that my life hinders some person from being much more useful to society. In such cases, my resignation of life must not only be innocent but laudable." He also suggested that it is no more a sin to shorten life than to try to lengthen it beyond the natural span. Dr. Inge, the present Dean of St. Paul's, is distinctly sympathetic. In his last book, Christian Ethics and Modern Problems, in a chapter on Suicide, he sums up as follows : - " Some of the arguments against suicide are losing their force . . . . It seems anomalous that a man may be punished for cruelty if he does not put a horse or a dog ' out of its misery,' but is liable to be hanged for murder if he helps a cancer patient to an overdose of morphia . . . . I confess that in this instance I cannot resist the arguments for a modification of the traditional Christian law which absolutely prohibits suicide in all circumstances. I do not think we can assume that God willed the prolongation of torture for the benefit of the soul of the sufferer. Nor do I judge other suicides so severely as is the custom of Christian moralists." Dean Inge adds, however: " At the same time I hope, inconsistently, perhaps, that if I were attacked by a painful illness, I should have patience to wait for the end, and I do not think I should wish anyone near and dear to me to act otherwise... " M y own feeling about the ethics of suicide is that it depends almost entirely upon the motive prompting the act. Excluding that large group of cases where the mind is unhinged and which should only call for pity, suicide is usually resorted to as an easy way out of difficulties, financial or otherwise. It then too often represents an act of moral cowardice, and as such it must of course, be condemned, especially so where the step is taken regardless of the pain and suffering which the act may cause to others. But there are cases where suicide is resorted to because a man believes, rightly or wrongly, that it will really be better ,for his loved ones if he is " out of the way." Such
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cases are to be deprecated because it is not for a m a n to decide for himself, a b o u t such an irrevocable step, and he m a y so easily be mistaken. Pity, however, rather t h a n censure should be the p r e d o m i n a n t s e n t i m e n t in such cases. Legalised voluntary euthanasia would come into quite a different category as an act which was rational, courageous, and often highly altruistic.
A Practical ProposaL--Some sixty years ago (in 1873) the H o n . Lionel T o l l e m a c h e published an article in the " F o r t n i g h t l y R e v i e w , " entitled " A Cure for I n c u r a b l e s , " in which he endorsed and s u p p o r t e d an essay, pleading for the legalisation of euthanasia, p u b l i s h e d in the previous year b y S. D. Williams, Junr. I n this article, Mr. T o l l e m a c h e said that he was in no wise ambitious of introducing a practical scheme of euthanasia a m o n g the subjects of Q u e e n Victoria. H e merely wished to discuss the subject philosophically as a preliminary to r e f o r m in some later age. Is it too m u c h to hope that t o - d a y that later age has arrived, or is at least a p p r o a c h ing, and that the present generation m a y see this r e f o r m an accomplished fact ? I n order to bring the p r o p o s e d r e f o r m more within the range of practical politics I have drafted a Bill to make voluntary euthanasia legal. T h e essential provisions of this Bill are as follows : The Act to be called " The Voluntary Euthanasia (Legalisation) Act." 1. An application must be made by the dying person who desires to receive euthanasia, hereafter referred to as the applicant, stating that he has been informed by two medicat practitioners that he is suffering from a fatal and incurable disease (as defined in the Act), and that the process of death is likely to be protracted and painful; that he desires to take advantage of the provisions of the Act; that his affairs are in order; that his near relatives (as defined in the Act) have been informed ; and that he knows of no valid reason why he should not be granted the necessary licence or permit. This application must be duly attested by a magistrate or commissioner of oaths. 2. The application must be accompanied by two medical certificates, one from the ordinary medical attendant, and one, the confirmatory certificate, from an independent medical practitioner, of a specified status, who must not be related to the applicant, nor be financially interested in his death. 3. The application, with the certificates, must then be sent to an official appointed for the purpose and referred to hereafter as the euthanasia referee. It would be the duty of the latter to examine the papers and see that they were all in order ; to interview the applicant and the near relatives, and, if thought desirable, the medical practitioners who gave the certificates. The referee being satisfied will then
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give his certificate to the effect that the ease appears to him to be a proper one to be granted a permit under the Act. 4. The application and certificates will then come before a court of summary jurisdiction, usually sitting in special session. The referee would be present to answer any questions, and representatives of the applicant and of the near relatives would also have the right of being present, if they so desired. The Court, having considered the application and heard objections, if any, would, if satisfied, issue the necessary permits--one to the applicant to receive euthanasia, and one to a medical practitioner, who would usually be named in the application, to administer the euthanasia. Only practitioners who had been licensed for the purpose would be eligible to act as euthanisors. Where the euthanasia referee held a medical qualification (which personally I regard as very necessary) he might well also act as the official euthanisor; but provided he held the necessary licence, the applicant's own medical attendant might often be preferred. 5. A euthanasia permit would remain valid for a certain specified time, say, three months, after which it would lapse, but could be renewed. This would mean that the applicant would be under no obligation to act upon the permit immediately. Often he would prefer to wait, holding the permit in reserve in case the pain should become intolerable. Sometimes, no doubt, a permit would never be used, the applicant's courage failing him, or death supervening sooner or more easily than he expected.
Procedure for Administering Euthanasia.A s s u m i n g that the t i m e has come w h e n the applicant, having discussed the m a t t e r with those near a n d dear to him, and with his spiritual advisor, decides to act u p o n his permit, he will send word to the practitioner concerned and arrange date and other details. T h e p r o c e d u r e for administering euthanasia would be governed b y regulations to be m a d e b y the H o m e Secretary or Minister of Health. N o d o u b t alternative m e t h o d s would be a p p r o v e d and these could be varied f r o m t i m e to time as experience m a d e desirable. I n the present state of o u r knowledge the usual m e t h o d of choice, where the patient was able to swallow, would p r o b a b l y be a lethal (narcotic) draught, which m i g h t be given in a special utensil, the " lethal c u p . " A prescribed p r o c e d u r e w o u l d have to be followed, which would include an express statement b y the euthanisor as to the object of the draught, and a direct question to the applicant as to whether he was quite sure that he wished to anticipate death ? I f his answer was in the affirmative the lethal cup would be handed to h i m or placed within his reach. I n cases where the patient was unable to swallow, the lethal dose could be a d m i n i s t e r e d hypodermically. A n i n d e p e n d e n t and official witness would need to be present, and only persons of a certain
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status, e.g., magistrates, clergymen, solicitors, or doctors, would be eligible for this duty. Euthanasia having b e e n accomplished, the euthanisor would fill up and sign the necessary certificate on a prescribed form, and this would t h e n be counter-signed b y the official witness. T h i s certificate, which would state the fatal disease f r o m which the deceased had suffered, and would specifiy euthanasia as the m o d e of death, would take the place of the ordinary medical certificate for purposes of registration of death. T h e p r o c e d u r e detailed above m a y sound a little complicated, t h o u g h in real{ty it is not m u c h m o r e so t h a n the procedure which has to be gone t h r o u g h in the case of cremation, on which, indeed, i t i s largely modelled. I n practice, w h e n we had b e c o m e familiarised with it, it would not, I think, be really very formidable. At first, no doubt, the n u m b e r of persons who would take advantage of the Act would not be large, possibly very small. By degrees, however, as people became accustomed to the idea and prejudice broke down, and as public opinion came to regard euthanasia as a courageous, rational, and often very altruistic course, the n u m b e r s would increase. Doubtless, as in the case of cremation, the m o v e m e n t would be helped forward b y the example set b y a few outstanding m e n and w o m e n , distinguished in the spheres of science, philosophy, art, and religion.
Objections to Euthanasia.--As regards possible
objections to the legalising of voluntary euthanasia, these m a y be classified as (1) Ethical and Religious ; (2) Legal ; (3) Practical.
1.--Ethical Objections.--To m e e t the objections which will no d o u b t be raised on the g r o u n d of religion and ethics I cannot do better t h a n shelter myself b e h i n d a distinguished m e m b e r of the Anglican Church, C a n o n Peter Green,* who, in a b o o k on ethics, The Problem of Right Conduct, published this year, refers expressly to this subject, u n d e r the heading " T h e C h u r c h ' s Attitude towards Suicide." H e writes : - " A man suffers, let us suppose, from cancer of the larynx. Operation is impossible and there is at present no known cure. What medical science may achieve in the future we cannot say. As things are, the man's fate, the moment his ailment is diagnosed as malignant, is certain. It means for him, months of agony, terminating in a hideous race between strangulation and starvation. It means,
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for those who love him, the misery of watching him die in slow agony without being able to do anything to ease his pain. Under such circumstances, might not both Church and State allow a man, under due safeguards and conditions, to end his life painlessly ? Many men every year do ,commit suicide to escape lingering agony. But they do it in a spirit of angry revolt against God ; they die without the consolation of religion ; they may lose the whole of any insurance they have made for wife and children; they shock their loved ones, and outrage public opinion. In such a case, I should myself like my doctor, in conjunction with a specialist, to be allowed to state that the disease was fatal and likely to be slow and painful ; and then I might be permitted to make a sworn declaration that I desired to end my life at once in some painless manner. This would enable a man to settle his affairs; to say goodbye to his friends, and to receive the last rites of the Church. What are the arguments against the granting of such liberty by Church and State to' those who desire it ? " One might, of course, argue that as God alone confers life, God alone may decree its end. That argument, however, is impossible while we permit war and capital punishment. " It is often argued that for a man to end a painful illness, by his own act, is to avoid a divinely-appointed discipline of trial and suffering. But it may be noted that precisely that argument was used by many religious people to prove the unlawful nature of anaesthetics... " I have found it impossible to discover any really conclusive argument against suicide under due restrictions." O n one point I think that C a n o n Peter G r e e n is not, perhaps, quite correct, viz., where he says that we can do n o t h i n g to ease the pain in the cases we are considering. T h a n k s to m o r p h i a and the h y p o d e r m i c syringe we can do a good deal, especially if the medical attendant is not afraid of incurring the risk of going too far and so relieving the pain entirely. But the position is m o s t unsatisfactory. T h e dose has to be increased again and again as tolerance is established. A merciful doctor Canon Green is the author of a number of other religious books, including the following : Our Lord and Saviour. A Study of the Person and Doctrine of Jesus Christ. Our Heavenly Father. A Study of the Nature and Doctrine of God. Personal Religion and Public Righteousness. With an Introduction by the Bishop of London. The Problem of Evil. Being an attempt to show that the existence of Sin and Pain in the World is not inconsistent with the Goodness and Power of God. The Town Parson : His Life and Work. With Preface by the Right Rev. E. S. Talbot, D.D., formerly Bishop of Winchester. Parochial Missions To-day. A Handbook of Evangelical Missions for Missioners and Parochial Clergy-
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literally hovers on the brink of manslaughter,'* and in cases where m o r p h i a is resorted to liberally and is long continued the effect, in m a n y cases, is u n d o u b t e d l y to shorten life.
2.--Legal Objections,v-As regards any legal objections, there is the question of possible abuse, e.g., b y friends anxious for selfish reasons to be rid of a t r o u b l e s o m e patient. Subject, however, to the conditions and precautions we have indicated, it is difficult to see how the p r o p o s e d a r r a n g e m e n t could really be abused. Certain contingencies would need to be provided for, e.g., the matter of life insurance policies. A clause in the Act would deal with existing policies, allowing insurance societies to deduct a discount of say, 5 per cent. for, say, three months, f r o m the s u m assured ; b u t in policies taken out after the passing of the Act m o s t societies would doubtless insert a clause agreeing to make no difference in the s u m assured in case death was b r o u g h t about b y legatised euthanasia. F o r after all, a p e r m i t could only be obtained where a m a n was suffering f r o m a fatal disease. M o r e o v e r , even at present, suicide " whilst t e m p o r a r i l y insane," the usual verdict, does not affect life assurance. 3.--Practical Objections.--It m a y be argued that the procedure, as detailed above, to he gone t h r o u g h in order to obtain a p e r m i t would * Dr. Axel Munthe, in his remarkable book, The Story of San Michele, has an eloquent passage, on page 25, under the title " T h e Eternal Sleeping Draught," which bears on this aspect of the subject. " But was it really so that my mission was at an end when His (Death's) was to begin ? Was I to be an impassive spectator of the last unequal battle, to stand by helpless and insensible while He was doing His work of destruction ? Was I to turn my face away from those eyes who implored my help, long after the power of speech had gone ? Was I to loosen my hand from those quivering fingers who clung to mine like a drowning man to a straw ? I was defeated, but I was not disarmed; I had still in my hands a powerful weapon, tie had His eternal sleeping draught, but I l~ad also mine entrusted to me by benevolent Mother Nature. When he was slow in dealing out His remedy, why should I not deal out mine with its merciful power to change anguish into peace, agony into sleep ? Was it not my mission to help those to die I could not help to live ? " The old nun had told me I was committing a terrible sin, that Almighty God in His inscrutable wisdom had willed it so, that the more suffering He inflicted at the hour of death, the more forgiving would He be On the Day of Judgment. Even sweet Sister Philomene had looked at me disapprovingly when, alone among my comrades, I had come with my morphia syringe after the old padre had left the bed with his Last Sacrament."
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seem so complicated that no one would trouble to take advantage of the Act. I do not think that a m a n faced with the grim alternatives depicted so eloquently b y C a n o n Green, assuming that he felt there was no moral or legal objection, would be so d e t e r r e d ; but even admitting that some obstacle would exist, that very fact would itself be some security against euthanasia being resorted to too readily. Another practical difficulty m i g h t be the opposition of friends. At first this would sometimes be a real obstacle, b u t by degrees, as prejudice was overcome, and as euthanasia came to be regarded as a reasonable and p r o p e r course u n d e r certain circumstances, pity for the sufferings of a loved one would cause euthanasia to be welcomed. I n this connection we may observe that doubtless in m a n y cases the motive actuating an applicant for euthanasia would not be merely to escape physical suffering for himself, b u t even m o r e to shorten and relieve the v e r y serious physical and mental strain which a long d r a w n - o u t painful illness ~so often entails u p o n those who are nearest and dearest. Viewed f r o m this standpoint, euthanasia would come to be regarded as s o m e t h i n g heroic,, an act of true altruism, to be applauded, not deprecated. Possibly, some, whilst agreeing in theory with the proposals we have here put forward, will regard t h e m as " U t o p i a n " (in a double sense !), and will think that any chance of their ever being sanctioned b y public opinion is too remote to be w o r t h considering. M o s t i m p o r tant reforms, w h e n first b r o u g h t forward, have b e e n similarly regarded. W h a t m o r e drastic and revolutionary change, involving at first sight o v e r w h e l m i n g practical difficulties, can possibly be imagined than the innovation of " S u m m e r T i m e " ? H o w little it was t h o u g h t - w h e n the late Mr. Willett first b r o u g h t forward the i d e a - - e v e n b y those who a p p r o v e d of it i r / t h e o r y , that we should ever see it b e c o m e an accomplished fact ! Or think of the very strong opposition which the proposal to legalise cremation m e t with, b o t h on religious grounds, as b e i n g directly opposed to the whole tradition of Christianity, and on legal grounds as being likely to cover up evidence of foul play. Still m o r e recently there is the case of b i r t h control. Less t h a n a generation ago this was generally c o n d e m n e d . It was said to be " u n - n a t u r a l , " r e p u g n a n t to decent feeling, dangerous to health, and altogether contrary to the highest interests of the nation. I t was
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difficult for its early advocates even to get a hearing, and the subject was strictly tabooed in respectable society. It is hardly necessary to say how completely public opinion has changed. Although strong opposition still persists, the taboo has been entirely removed; it is a popular subject for discussion on platform and in the Press, the opposition of organised religion (apart from Roman Catholicism) is disappearing, and it is hardly an exaggeration to say that very many of the present generation of young people accept birth control almost as a matter of course.
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This is an age of toleration. We are living in the twentieth, not in the nineteenth century. Public opinion has more claim to-day to be considered " enlightened " than ever before. New ideas are more readily accepted than ever before. Is it then so very improbable that the legalisation of voluntary euthanasia may become an accomplished fact within the life-time of some of us ! " To stretch the octave 'twixt the dream and deed, Ah, that's the thrill ! "
THE JOINT TUBERCULOSIS COUNCIL.
A meeting of the Joint Tuberculosis Council was held at the house of the Society of Medical Officers of Health on October t7th, 1931. Twenty-three members were present, with Dr. Lissant Cox occupying the chair. Dr. Lissant Cox was nominated Chairman of Council for 1932; Drs. L. S. T. Burrell and S. Vere Pearson, Vice-Chairmen; Dr. Ernest Ward, Hon. Secretary; Dr. G. Jessel, Hon. Treasurer, and Dr. D. P. Sutherland, Hon. Auditor. Concerning post-graduate study, Dr. Brand narrated that Dr. Peter Edwards had held eight useful,intensive three-day courses at the Cheshire Joint Counties Sanatorium with especial reference to artificial pneumothorax. A course had been held "in Holland from June 29th to July 4th this year, and there were eleven participants. The visitors were kept busy from breakfast until 6 p.m., and much appreciated the organisation and the kindness t h e y received. The desire was expressed for a similar course in Germany next year. At Victoria Park Hospital, from February 16th to 21st, a course had been held in which forty-four participated, and sixteen names had been received for the Lancashire post-graduate course to be held from October 19th to 24th. Dr. Gloyne, who was unable to be present at the meeting, wrote that he was hoping to make a collection of cases of acute tuberculosis in children under five from the East End of London, but hitherto no one had offered to undertake another district. Considerable discussion on collective research followed. The essentially individualistic nature of most research was emphasised and the difficulty of persuading those able and ready to carry
out research to follow lines suggested by any Committee. It had proved helpful in some districts to allot certain subjects to certain workers and publish the results of their investigations in the local annual report. It was also suggested that a simple but useful form of research would be the publication of reports of interesting clinical cases, which could be done every three months without any great effort, by clinical workers to whom case notes are readily accessible. The Secretary mentioned that some members of the Canadian Tuberculosis Service might be visiting this country for the Centenary meeting of the British Medical Association next July. He was asked to ascertain the number and names of these in order that some hospitality might be arranged by the Joint Tuberculosis Council and the participants in the Transatlantic Tour. It was resolved that this Council welcomes the suggested formation of a tuberculosis library and information bureau, and wishes every success to the Tuberculosis Association in its efforts to that end. Saturday, January 16th, at 10 a.m.,was the date and time fixed for the next meeting of Council. After the meeting~ Dr. Lissant Cox entertained to lunch members of Council, together with Sir George Newman, Dr. A. S. McNalty, Dr. Charles Porter, Dr. Morland, and Mr. Lewis Elliston. A successful and happy luncheon party was followed by a thoughtful speech by Sir George Newman, speaking on behalf of the guests. Dr. Charles Porter then proposed health and thanks to Dr. Lissant Cox, and was ably seconded by Dr. Morland. Dr. Cox replied suitably.