The WMA and the Foundations of Medical Practice, Declaration of Geneva (1948), International Code of Medical Ethics (1949).
The physicians practise in Canada, where euthanasia and assisted suicide (EAS) are legal, [3,4] recognized as therapeutic medical services by the national medical association [5,6] and provided through a public health care system controlled by the state, which also regulates medical practice and medical ethics. The national government is now poised to make EAS available for any serious and incurable medical condition, vastly increasing the number of patients legally eligible for the service [7].
In these circumstances, it is urgent to reassert that the duty to practise medicine “with conscience and dignity” includes unyielding refusal to do what one believes to be wrong even in the face of overwhelming pressure exerted by the state, the medico-legal establishment and even by medical leaders and colleagues. That the founders of the WMA not only supported but expected such principled obstinacy is evident in the WMA’s early history and the development of the Declaration, all of which remain surprisingly relevant.
Early Developments: 1945–46
A meeting of physicians from 30 countries in London in June 1945 discussed the formation of an international medical association [8, 9]. Some continental physicians spoke of crimes by physicians in their countries during the war [10], and over the next 18 months the world medical community became increasingly aware of physician participation in crimes against humanity [8, 11, 12].
National medical association delegates returning London in September 1946 were uneasy and ambivalent about plans to nationalize health care systems in Britain and the Continent. On the one hand, they welcomed the growing interest in medicine by governments around the world. On the other, they worried about the consequences of (as later expressed) transforming all physicians into “Civil Servants controlled by the State” [13, 14]. They conceived an international medical association as support for national associations defending practitioners and patients from government demands. They reminded the British health minister that physicians treat human beings, not collections of tissue, and must practise with “a discipline of the heart that makes it difficult to integrate [them] into the State machine”[15].
While delegates were motivated to organize the WMA by concerns about the profession-state relationship, they were also deeply disturbed by physician participation in war crimes [8].
In the month following the London gathering, twenty German physicians were arraigned in Nuremberg [13]. And the organizing committee drafted the WMA constitution and prepared for the first General Assembly while the Nuremberg “Doctors Trial” was in session. Reports from the trial resonated deeply with physicians anxious about being integrated into a “State machine” [16,17,18,19].
First General Assembly: War Crimes and Medicine (September 1947)
Physician war crimes dominated the agenda of the first WMA General Assembly, displacing discussion of the profession-state relationship. Delegates heard impassioned testimony from physician victims of the Third Reich and received the BMA report, War Crimes and Medicine [20, 21, 22].
The report denounced physicians responsible for crimes against humanity as lacking “moral and professional conscience,” condemning them for having allowed the state to use medical knowledge and science as “instruments of wanton destruction in the pursuit of war.” It asked the WMA to endorse the prosecution of physicians for war crimes and adopt a World Charter of Medicine, explicitly reaffirming medical ethics “in the spirit of the Hippocratic Oath,” suggesting that medical graduation should include a promise to adhere to the Charter [10].
The Assembly accepted the recommendations and approved a public apology and undertaking to be required of the German Medical Association as a condition for admission to the WMA. It also approved an oath affirming that a physician’s first duty is to care for a patient, “to resist any ill treatment that may be inflicted on him” and “to refuse my consent to any authority that requires me to ill-treat him.” Finally, it appointed a committee to produce a report about war crimes [23, 24].
Over the following year, the war crimes committee solicited forms of medical engagement from national associations with a view to formulating an international medical oath. The WMA Council also agreed to develop an international code of medical ethics, concerned that jurists reacting to physician war crimes might do so if the WMA did not [24,25].
Second & Third General Assemblies
Declaration of Geneva (September 1948), International Code of Medical Ethics (September 1949)
At the second WMA General Assembly, delegates were presented with War Crimes and Medicine: The German Betrayal and a Re-statement of Medical Ethics. It urged the Assembly to prevent physician crimes against humanity by reaffirming basic Hippocratic principles, which, it argued, would be universally acceptable. Requiring medical graduates to abide by a modern version of the Hippocratic Oath would help to impress them with the fundamentals of medical ethics. The suggested modern version, containing ten promises, was approved by the Assembly and published as the Declaration of Geneva [26].
The Second General Assembly also approved the development of an international code of medical ethics. The final version, which included the Declaration of Geneva, was approved at the Third General Assembly in 1949 [27].
Refusing the fatal surrender of conscience
The documents make clear that what the authors of the Declaration and the ICME meant by practising medicine “with conscience and dignity” was not only doing what one believes to be right, or only doing what one believes to be best for patients, but refusing “to make the easy and fatal surrender of one’s conscience to the mass mind of the totalitarian state” (18). A British physician responding to the BMA report on war crimes commented:
During the terrible years of occupation by a brutal enemy the large majority of doctors of most of the occupied countries maintained their moral integrity, their unswerving loyalty to their patients, and their spiritual and professional freedom, even at the risk of torture and death. They thereby set a great example and vindicated the honour of their profession [19].
According to Leo Alexander, writing a year later, just before the ICME was adopted, Dutch physicians collectively demonstrated such heroism [28]. Steadfast refusal to do what one believes to be wrong was understood to be central to practising medicine “with conscience and dignity,” an essential safeguard for personal and professional integrity and patients.
That was then; this is now
It is easy to understand this duty in relation to refusing to comply with the murderous dictates of a totalitarian regime that have been universally derided for decades. It is more difficult to see why it should apply to refusing to provide legal services requested by patients in a democracy. The difficulty disappears once one admits that both totalitarian and democratic regimes can make grave moral errors in law and public policy.
Events in Germany from 1920 to 1945 demonstrate that physicians willingly enlisted and collaborated in the implementation of a biopolitical ideology thought to be on the cutting edge of science and progressive ideas. Exactly the same thing has happened elsewhere and is likely to happen again. When it does, the medical profession is likely to be most accommodating and even anxious to participate to ensure that the state “gets it right.”
At issue here is the freedom, integrity, dignity and obligations of individual physicians who are convinced that the profession and the state have got it wrong, yet face demands that they participate in activities that they reasonably believe to be immoral or contrary to good medical practice.
Then...
When the Nazi regime was installed, officials of the largest German medical associations “gladly” welcomed it and placed themselves at its service, celebrating the intimate links of the medical profession with “the wisdom and aims of the State”. Those intimate links were reflected in the law directing compulsory sterilisation of those with “genetic illnesses” (including alcoholism and mental deficiency) enacted in response to a petition from the associations [29]. Physicians sterilized about 300,000 persons before the war, and began killing the handicapped when the war began, a project supported directly and indirectly by colleagues and scientists [30].
Physicians were predisposed to cooperate because they were convinced of the value of eugenics. Eugenics was a widely accepted scientific discipline, “on the cutting edge of science”, supported by respected scholars, various scientific disciplines, major universities and scholarly journals [30, 31]. The eugenics movement propagated the belief that people inherited not only eye and hair colour, but were criminals, or rich, poor, lazy, industrious, promiscuous or faithful because they were “born that way” [32]. Leading scientists and activists campaigned to prevent the reproduction of such “defectives” by contraception and sterilization of “inferior types,” including the mentally ill, physically handicapped, criminals, and certain “degenerate” races [33,34].
Eugenics was popular among the socially elite, including Winston Churchill, Herbert Hoover and Alexander Graham Bell (35). Eugenic societies and scientists successfully lobbied for laws authorizing voluntary or compulsory sterilization of “defectives”, including criminals, the mentally handicapped and mentally ill; 27 US states had such laws in 1931. By 1935 sterilization laws had been adopted in Canada, Denmark, Switzerland, Germany, Norway and Sweden [36].
Eugenics was especially influential in Germany after the First World War [37] and was absorbed into Nazi party policy. Since physicians were among eugenics’ foremost exponents, to hear Nazi policy described as “nothing but applied biology” was especially attractive to them. Hence, many willingly joined the vanguard of what became “the most ambitious and murderous eugenics program in human history”. Their characteristic response was not just acquiescence, but “eager and active cooperation” [31,38,39].
Such eagerness was not limited to German physicians. In 1936, the Canadian Medical Association Journal featured a lengthy essay on the superiority of the Aryan/Nordic Race by an author who, the year before, had held up Germany as a model for other nations and toasted Adolph Hitler as “a great leader” [40,41]. Two years earlier it had published a glowing report about eugenic sterilizations authorized by the Alberta Eugenics Board [42].
Over 44 years Alberta physicians sterilized 2,822 people at the Board’s direction [43]. A court reviewing its operations found that it had routinely flouted the law, and, as late as the early 1960’s, physicians had performed illegal sterilizations and medically unnecessary castrations, hysterectomies, oophorectomies and biopsies of testicular tissue, behaviour the judge described as “unlawful, offensive and outrageous”. He excoriated one Board geneticist for, among other things, encouraging the use of persons with Down Syndrome as “medical guinea pigs” [44]. However, she had “no regrets,” defending her activities as “a very reasonable approach to a very difficult problem” [45]. Awarded the Order of Canada and other honours [46, 47, 48], she was eulogized in 2014 as one of Canada’s most respected geneticists (49).
Even as the Alberta court was ruling on the Alberta Eugenics Board, Alberto Fujimori was mobilizing physicians in Peru for the National Program for Reproductive Health and Family Planning. By the time it ended four years later, 200,000 to 300,000 people had been sterilised, most without valid consent: some forcibly, others bribed or threatenedby government officials or health care personnel. Most victims were poor and often illiterate women from indigenous ethnic groups. The technical standard of medical care was often appalling, and numbers of women died [50, 51, 52, 53].
The WMA’s denunciation of coercive sterilization came 12 years too late for Fujimori’s victims [54]. In the United States, Oregon abolished its eugenic sterilization law only in 1983, and another 20 years passed before the state acknowledged the injustice suffered by victims sterilized according to the ethical standards of the day [55]. The Tuskegee Syphilis Study continued until it was exposed in 1972, the same year the Alberta Eugenics Board was abolished. It took almost 25 years for victims to receive a public apology for unethical human experimentation [56, 57].
In 2012, a generation of German physicians unconnected with the Nazi era admitted the enthusiastic participation of German physicians at all levels of the profession in crimes against humanity, apologized, begged forgiveness, and described what their predecessors had done “as a warning for the present and the future” [58].
The warning points, in the first place, to the risk of sea changes with incalculable consequences. It appears that the German medical profession’s eugenic outlook and interests converged with other social and political dynamics and Hitler’s rise to power. The convergence triggered a sudden, seismic socio-political shift that supercharged Nazi biopolitical ideology. The medical profession rapidly transformed itself and was transformed to fulfil its new biopolitical responsibilities [29], and new possibilities suddenly materialized [59]. Carl Jung experienced this as an “earthquake” and an “avalanche” that was sweeping all before it [60].
Second, the warning reminds us that modern biopolitical ideologies are advocated worldwide by lobbyists as prominent, powerful and influential as the eugenic enthusiasts of yesteryear.
Finally, we are warned that state collaboration with the medical profession in support of faulty biopolitical ideologies is far more dangerous than the exercise of freedom of conscience by individual physicians. Literally millions have suffered and died as victims of what seemed like a good idea at the time, at least in the eyes of those in positions of power and influence.
Now...
The euthanasia/assisted suicide (EAS) movement backs a biopolitical ideology that is enormously popular in the developed world, now entrenched in Canadian law and collectively supported by the medical profession. This has serious implications for the nature of medical practice.
Leading Canadian EAS advocates told the Supreme Court of Canada that physicians are ideal EAS practitioners because they will agree to it only “as a last resort” [61]. Indeed, they argued that “physician-assisted dying” is not only “medical treatment,” but “at the core of health care” [62]. This must place killing patients at the core of the practice of medicine and require transformation of the medical profession to fulfil its role in the new order. How far this will go remains to be seen.
Physicians cannot currently be compelled to personally administer or prescribe lethaldrugs, though some prominent academics argue that should change [63,64]. However, the national government allows state medical regulators to compel unwilling practitioners to facilitate EAS by effective referral [65] or effective transfer of care [66], which even some strong supporters of the procedures acknowledge to be morally equivalent to personally killing patients [64,67,68]. Courts in the province of Ontario support this coercive policy, ruling that physicians unwilling to comply can move into fields like sleep medicine, hair restoration and dermatology [69].
Unsurprisingly, some academics recommend that medical schools deny admittance to anyone with conscientious objections to providing whatever the state considers medical treatment or health care, including EAS [70]. Anecdotal reports indicate that some dissenting medical students face intense pressure to conform to the EAS biopolitical agenda, experiencing isolation, disregard and disdain among their peers (71).
No wonder Canadian physicians who refuse to support or collaborate in killing their patients feel themselves to be in the midst of a socio-political and ethical avalanche.
Summing up
The historical record suggests that support for physicians who refuse to kill or facilitate the killing of their patients is justifiable on prudential and pragmatic grounds. Tolerating refusal to participate in killing seems to be a safer course than imposing an obligation to kill and is certainly consistent with the high value EAS advocates have placed on physician reluctance to kill as a primary safeguard for patients.
As a matter of principle, one must distinguish what is demonstrably necessary to preserve a free and democratic society from what may be necessary to enforce a biopolitical ideology. The difference is significant but can be difficult to discern in an avalanche. EAS ideology is grounded upon metaphysical, philosophical and moral premises that can be rationally contested but cannot be empirically validated. Among these is the dogmatic claim that a human being can be better off dead. In a free and democratic society, it ought to be unacceptable to force physicians to profess this article of faith, or to demonstrate practical adherence to it by killing or facilitating the killing of a patient.
Finally, there is an issue that goes to the heart of what concerned the authors of the Declaration of Geneva.
Competent patients may refuse even lifesaving/sustaining interventions based entirely on their subjective views of what is beneficial, harmful, or in their best interests. Physicians ensure that patients have information relevant to such decisions and may make recommendations, but they are legally and ethically obliged to respect patients’ inviolability and abide by their decision. The foundations of medical ethics and the personal integrity of physicians who disagree are untouched by the patient’s decision.
While competent patients can absolutely refuse interventions, they cannot demand interventions because medical decisions to intervene are not based solely upon patients’ demands [72]. Among other things, they engage physicians as moral agents.
Patients request an intervention, including euthanasia, because they believe it is not harmful, is beneficial, or is in their best interests. Physicians may reasonably disagree. If, despite this, physicians are compelled to further a patient’s request, the concepts of benefit, harm and best interest become irrelevant. All that remains is the demand of the patient, backed by the power of the state to ensure compliance.
This treats physicians as mere technicians or state functionaries, as cogs in a state machine delivering services upon demand, not as responsible moral agents who, like their patients, must form and act upon judgements about benefits and harms. It imposes a form of servitude that is incompatible with human equality, dignity and personal and professional integrity.
The authors of the Declaration and ICME denounced such instrumentalization of physicians and the medical profession in the strongest terms. The precept to practise medicine with conscience and dignity imposes an obligation to resist and refuse such demands, notwithstanding overwhelming pressures exerted even in democratic societies.
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Sean Murphy,
Administrator Protection of Conscience Project
British Columbia Canada
Dr. Ramona Coelho,
MDCM, CCFP
Dr. Philippe D. Violette, MSc.
MDCM, FRCSC
Assistant Professor Depts. of Surgery and Health Research Methods, Evidence and Impact,
McMaster University, Hamilton, Ontario, Canada.
Ewan C Goligher MD PhD
Assistant Professor
Interdepartmental Division of Critical Care Medicine
University of Toronto
Timothy Lau, MD, FRCPC
Distinguished Teacher, Associate Professor, Faculty of Medicine,
Department of Psychiatry, Geriatrics, Royal Ottawa Hospital.
Sheila Rutledge Harding,
MD, MA, FRCPC
Hematology
Saskatchewan Health Authority
Professor, University of Saskatchewan Saskatoon, Saskatchewan, Canada
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