Abstract
The editorial by Radbruch and Jaspers entitled “Is This the Society in Which We Want to Live?” 1 discusses the current international trend toward legalization of assisted dying, focusing on the situation in Germany. The authors raise questions about the implications of a legally regulated practice of assisted suicide for society at large and for palliative care in particular. Stating his personal opinion in the end, Radbruch writes: “As a member of society, if people are desperate, lonely and sad, or do not want to be a burden unto others, I can certainly understand their wish to end their life. I just do not want to live in a society that readily accepts this as a rationale for assisted suicide, and not as an imperative to improve end-of-life care, providing adequate medical and social care in an adequate economic setting.”
With this statement, Radbruch creates mutually exclusive alternatives that do not exist as such in our opinion. Although surely nobody wants a society that withholds “adequate medical and social care” from its members, we believe that a desirable society should—for good reasons—respect well-considered and stable individual decisions concerning one's own end of life.
The authors of the present editorial have been actively involved in the German and European debate on autonomy at the end of life for many years. Some of us have published comparative quantitative data on assisted dying over time in the main jurisdictions allowing these practices. 2 We see substantive ethical and empirical arguments for differentiating between euthanasia and assisted suicide. Even in states with strict regulations, euthanasia practice poses the risk of a slippery slope, as shown by documented cases of life-terminating acts without explicit request, and its harmful effects on the administering physicians are significant.2–4 In contrast, data from Oregon strongly suggest that a legally well-regulated practice of physician-assisted suicide avoids most of the negative implications of euthanasia and offers a sustainable option for people who wish to hasten their death.5,6 In our opinion, this could also be a model for German law. 7
Unfortunately, after an intense debate, the German Parliament inserted in 2015 a new clause into the penal code that prohibited any kind of suicide assistance if performed as a recurring pursuit, such as a professional service. Alongside the Catholic and the Protestant churches, the German Association for Palliative Medicine was among the leading supporters of this new regulation. As we and others had warned from the beginning, the law was eventually found to be unconstitutional and repealed by the German Constitutional Court on February 26, 2020. As a central argument, the court emphasized the respect for human dignity. A legal regulation now to be created, which is already being discussed, should secure individual autonomy as specified by the Court and at the same time protect vulnerable persons through appropriate procedural and professional safeguards. 7
In accordance with the Constitutional Court, we are convinced that it is one of the main hallmarks of an open democratic society to allow for the peaceful coexistence of divergent points of view, particularly concerning ethical issues. In this regard, the role of legislation is not that of prioritizing one ethical viewpoint over all others (as is the case e.g., in theocratic states). Rather, it falls to the parliaments to create the legislative framework in which space is given for divergent ethical attitudes and their implementation in real life, while ensuring that the necessary safety measures are in place to secure the basic rights of others and prevent dangers, especially for the weakest members of society. The creation of such a framework presupposes a common ground of basic and widely shared societal norms, which can be found in the states' constitutions, the concept of human dignity, and the catalog of human rights.
In line with this reasoning, we acknowledge Radbruch's personal opinion when he writes that “the provision of a lethal medication” does not align “with the ethical and moral values that I feel [all italics by the authors] are inherent in the medical profession.” From our point of view, we would argue that the physician's duty of care is toward a particular patient, not toward life as an abstract and absolute value. Correspondingly, we do not see a contradiction between respecting a patient's autonomy and offering high-quality palliative care, but this is a fruitful controversy that needs to be openly debated. In contrast, we consider it highly problematic when Radbruch makes a normative claim that extends to all professionals in the field: “As palliative care specialists, we certainly should not include the provision of assisted suicide as a part of palliative care.” This appears to imply an a priori superiority of the stated opinion above all others, although it is well known that there is a significant diversity of opinions within the palliative care community with regard to suicide assistance that needs to be respected.
The aforementioned quote is in keeping with the actions of Radbruch as president of the German Association for Palliative Medicine, where, as he states, the Board “refrained” from taking a neutral stance on the issue of assisted suicide, to avoid “ending the opposition.” With all due respect, we consider a categorical “opposition” to assisted suicide by palliative care societies not to be in the best interests of patients, families, and professionals—in the same way, as we would consider a promotion of assisted suicide by palliative care societies to be deleterious. The history of medical paternalism should warn us not to believe we know what is best for the patients more than they do.
As the German Constitutional Court has stated, all citizens are entitled to their own beliefs and attitudes, but no one should be allowed to impose them on others who do not want to share them. This is a non-renounceable tenet of free societies and stems from the respect for human dignity. We, therefore, welcome a society that accepts ethical plurality, and in which people with diverse views on assisted suicide, and its relationship to palliative care practice, are able to coexist peacefully and are not forced to take actions that they would perceive as incompatible with their personal ethical stance. We welcome a society that puts in place measures to protect vulnerable patients, with the aim of helping them realize their autonomy while giving them all the care and empathy they need and wish for. And we welcome a society that allows its members to act according to their own moral convictions in matters of life and death, including suicide assistance.