The Netherlands plans to extend euthanasia to children.

Alex Schadenberg
Executive Director, Euthanasia Prevention Coalition

The NLTimes reported on April 14 that the Dutch government has agreed to extend euthanasia to children, under the age of 12. The article states:

Health Minister Ernst Kuipers announced in a press release on Friday that he expects the regulation to be implemented within the year. The new guidelines will probably only apply to about five to ten children annually for whom “life termination is the only viable option to end the child's hopeless and unbearable suffering,” said Kuipers.

This means that the Netherlands government plans to extend the Groningen Protocol, which applies to newborns, to children between the ages of 1 and 12, rather than amending the euthanasia legislation to include children under the age of 12. 

Extending the Groningen Protocol is very concerning because it permits euthanasia of newborns who are experiencing current or possible future suffering. If you use the same definitions for children under 12, there will be euthanasia deaths of children who may have treatable conditions.

In October 2020, Netherlands Health Minister Hugo de Jonge announced that the government was planning to permit child euthanasia. According to the DutchNews.nl:

De Jonge added that current laws would not need to be amended. Rather, doctors would be exempted from prosecution for carrying out an approved euthanasia on a child.

The NL Times reported today that:

Following life termination, a review committee and the Public Prosecution Service will examine whether the procedure was carried out with due care.

This means that the decision will only be reviewed after the child has died.

Following the annoucement in October 2020, an effective campaign opposing child euthanasia in the Netherlands was launched by a group of Netherlands citizens and the Euthanasia Prevention Coalition. A petition with more than 100,000 people opposing child euthanasia.

I am also concerned that the Canadian govenment will decide to follow the lead of the Netherlands and also extend euthanasia to children.

There was a record number of Netherlands euthanasia deaths in 2022 with 8720 reported deaths representing a 14% increase from 2021 and 5.1% of all deaths in the Netherlands. 288 of the 8720 were based on the person having dementia. 

The World Medical Association declared in 1987  a statement that was referred in 2005 stating:

“Euthanasia, that is the act of deliberately ending the life of a patient, even at the patient’s own request or at the request of close relatives, is unethical. This does not prevent the physician from respecting the desire of a patient to allow the natural process of death to follow its course in the terminal phase of sickness.”

More articles on the topic:

• Euthanasia experts advocate for child euthanasia with or without consent (Link).
• New York Times article promotes infanticide (Link).
• Newsweek promotes infant euthanasia (Link).
• Euthanasia of newborns with disabilities and infanticide.
• Dutch paediatricians want to legalise euthanasia for children under 12.
• Euthanasia of babies with disabilities.
• The Groningen Protocol for euthanasia of disabled babies in the Netherlands.

World Medical Association upholds Conscience Protections.

Alex Schadenberg
Executive Director, Euthanasia Prevention Coalition

Recently the World Medical Association (WMA) upheld, after much debate, a position respecting conscience rights. Physicians from Canada and other jurisdictions proposed that the World Medical Association change their position to require that physicians provide an effective referral, where euthanasia is legal. An effective referral would require physicians to be complicit in the Act.

Several committed physicians spoke out in support of conscience rights and lobbied national medical associations to uphold conscience rights. These physicians took the time to organize a strong response and to travel to the WMA meetings to support conscience rights. Thank you.

Canada's parliament recently defeated Conscience Rights Bill C-230 based on a party line vote with most of the Conservatives, including Pierre Poilievre, supporting the conscience rights and nearly every Liberal, NDP and Bloc Québécois MP voting against it. How your MP voted on C-230 (Link), the battle for conscience rights is far from over.

The WMA victory underlines the importance of continuing the fight to protect the conscience rights of medical professionals. If conscience rights cannot be protected, at this time, federally, then we will renew our commitment at the provincial or state level.

Conscience rights protect medical professionals from being forced to be complicit in acts that they consider wrong, but conscience rights are also important for patients.

All of us need to be assured, in our time of need, that our doctor will respect our opposition to being killed. You need a physician who respects your values. If you are experiencing a difficult medical condition you may become very depressed and ask for something that you would never otherwise request. You need a physician who is free to protect you at the lowest time of your life.

Conscience rights protect medical professionals and conscience rights protect you.

A Medical Perspective on the assisted dying debate.

Alex Schadenberg
Executive Director, Euthanasia Prevention Coalition

The Canberra Times in Australia published an excellent opinion article by Dr Paul Jenkins titled: A Medical Perspective on the voluntary assisted dying debate. Jenkins writes:

For 2000 years physicians have rejected killing their patient as a means of relieving suffering and mental stress.

The most common reasons for people seeking euthanasia are loss of autonomy, loss of dignity and diminished quality of life, not unrelieved pain.

To be clear, consensual voluntary withdrawal of treatment is not euthanasia. Specialist palliative care, at home or in a hospice, provides staff experienced in pain relief and mental health care.

The long-term effects on the maintenance of caring, professional patient relationships of passing this legislation may include:

• Loss of trust in the medical profession. 

• Coercion by relatives to provide physician assisted suicide. 

• The creep to involuntary euthanasia (Belgium legalised euthanasia for children in 2014). 

• The gradual defunding of palliative care. 

• Intimidation of practitioners and facilities who maintain a conscientious objection to euthanasia.
  

The World Medical Association, comprising 114 countries, has reiterated its strong commitment to the principles of medical ethics, and that utmost respect has to be maintained for human life. Therefore the WMA is firmly opposed to euthanasia and physician-assisted suicide.

The AMA's position is largely in line with that of the WMA. I urge the Legislative Assembly to reject any such legislation.

More articles on this topic:

• The World Medical Association re-affirms its opposition to euthanasia and assisted suicide (Link).  
• Australian Medical Association opposes bill to legalize euthanasia (Link).
  

Doctors (world-wide) are being invited to sign this open letter: Doctors Want No Part in Euthanasia and Assisted Suicide.

An open letter from doctors around the world to medical ethicists and lawmakers

Link for doctors to sign the open letter (Link).

Doctors Want No Part in Euthanasia and Assisted Suicide

Euthanasia and Assisted Suicide are not part of Medicine

As medical doctors, we are committed to supporting people to both live and die with dignity and comfort.

We are determined that state-of-the-art care should be available for people who are dying and also for people suffering from chronic disease, disability or mental illness.

We believe that universal and equitable access to effective pain and symptom management, including mental healthcare and palliative care, is a fundamental human right.

We fully support the right of a person with decision-making capacity to decline a treatment offered to them.

We support clinicians and patients agreeing to withdraw or withhold burdensome and ineffective treatment in favour of supportive and palliative care.

We believe that doctors have the training and skill to promote and maintain a caring doctor-patient relationship.

It is our view that skilful and effective pain management neither requires nor uses lethal doses of drugs.

We believe neither assisted suicide nor euthanasia is a medical procedure. Doctors should play no role in the regulation, or practice, of euthanasia and assisted suicide.

We are especially concerned with protecting vulnerable people who can feel they have become a burden to others, and we are committed to supporting those who find their own life situations a heavy burden.

We endorse the views of Medical Associations around the world which hold that physician assisted suicide and euthanasia are unethical, even if they are made legal.

“Leave doctors to focus on advocating for patients – to cure sometimes, to relieve often and to comfort always.”

Join us

If you are a registered doctor and would like to add your name to this Open Letter, complete the form below. These details are required to confirm that you are a medical doctor.

Declaration of good faith and disclaimer

The organisers have sought, and continue to seek, support for this open letter from currently practicing medical doctors within participating countries, and every reasonable effort is made to verify that they hold a valid practicing certificate or licence. The list of supporting doctors is published in good faith with a commitment to correct any errors, but the organisers disclaim any liability for published names found to be ineligible.

Link for doctors to sign the open letter (Link).

Queensland Australia - Dissenting report opposing euthanasia and assisted suicide.

Alex Schadenberg
Executive Director, Euthanasia Prevention Coalition

Dr. Mark Robinson MP in the Queensland Australia parliament and the member for Oodgeroo wrote a dissenting report to the official parliamentary report on the proposed assisted dying bill.

Link to the Dissenting report by Dr Robinson (Link).

Similar to the minority report on assisted dying written for the Western Australian parliament that was by the Hon Nick Goiran, Dr Robinson's report creates a strong basis for opposing assisted dying.

Nick Goiran wrote a 248 page report titled: License to Care not License to Kill opposing the legalization of euthanasia or assisted suicide which was meticulously researched, documenting world-wide concerns with legalizing euthanasia and assisted suicide.

Dr Robinson's dissenting report is 24 pages of strong arguements against euthanasia. Robinson first argues that since the World Medical Association and the Australian Medical Association that physicians should not be involved in interventions that have as their primary intention, the ending of a persons life, therefore acts of euthanasia and assisted suicide are unethical.

Dr Robinson then emphasizes that if proper end-of-life care and palliative care were properly available that there would be no demand for euthanasia. Robinson points out that the administration of poison has become an alternative to the lack of proper end-of-life care.

Dr Robinson then quotes Dr Philip Nitschke, also known as Australia's Dr Death, who now believes that death should be an available option for people who are "Tired of Living," Robinson explains that - Once the euthanasia genie is out of the bottle it doesn’t go back in. He states:

The flow on affect from initial legalisation has proven to be unstoppable and irreversible once introduced. What is initially proposed as a measure to help a very small number of people, said to be in intolerable physical pain, is progressively broadened to apply to thousands of people, including those with no physical medical condition. Initial procedural safeguards are also relaxed. Once you lift the lid on Pandora’s box, there’s no going back.

Many vulnerable people experience subtle pressure to take their own life – some are made to feel almost duty bound to their family or to society to end their life prematurely. When elder abuse is combined with legalised access to the administration of life-ending poisons, it inevitably leaves the most vulnerable at risk of being coerced into ending their lives by assistance to suicide or euthanasia. This results in wrongful deaths, whereby people’s lives are taken from them without their full cognisance or consent. Wrongful deaths have followed these laws everywhere they are introduced.

Queensland Parliament

Dr Robinson challenges the Queensland Voluntary Assisted Dying Bill based on the following eight “Findings”:

• Finding 1: The Bill would make it legal for one person to take the life or help end the life of another person, or to counsel or help another person to take their life. 
• Finding 2: The BiIl would increase the number of suicides in Queensland as opposed to reducing them.
• Finding 3: The Bill fails to ensure that only eligible people will be able to access assisted suicide or euthanasia. 
• Finding 4: The Bill fails to ensure that patients are offered all options to manage their illness prior to the commencement of any life-ending procedure. 
• Finding 5: The Bill fails to adequately define “suffering” to limit it to intolerable physical pain. 
• Finding 6: The Bill provides inadequate protection to those affected by a mental illness. 
• Finding 7: The Bill fails to protect the vulnerable from coercion and undue influence. 
• Finding 8: The Bill fails to safeguard the vulnerable from a prolonged, complicated or painful death as a result of the administration of a poison prescribed under the Bill’s provisions.

I encourage my readers to read Dr Robinson's dissenting report to the Queensland Parliament. There has been much pressure to extend euthanasia to every jurisdiction in Australia and I hope that cooler heads will prevail, preventing the legalization of euthanasia in Queensland.

Link to the Dissenting report by Dr Robinson MP (Link).

World Medical Association debates conscience rights.

This article was published by BioEdge on May 30, 2021.

Michael Cook

By Michael Cook, Editor of BioEdge

The World Medical Association is revising the International Code of Medical Ethics (ICoME) to limit the scope of conscientious objection.

According to a WMA press release, “Workgroup members and observers representing more than 15 countries have reviewed the document carefully to determine what might be missing from the ICoME, what might be superfluous, what could potentially be organised differently”.

The principal change would be to make referral a duty for a doctor who has a conscientious objection. The current code says:

Physicians have an ethical obligation to minimise disruption to patient care. Conscientious objection must only be considered if the individual patient is not discriminated against or disadvantaged, the patient’s health is not endangered, and undelayed continuity of care is ensured.

The proposal is to add a short but significant clause:

[… is ensured] through effective and timely referral to another qualified physician.

Obviously, this would force doctors who object to legal abortion and legal euthanasia to refer patients to a more compliant doctor.

Petition: Tell the World Medical Association to respect conscience rights (Link).

Professor David Albert Jones, of the UK’s Anscombe Bioethics Centre, at Oxford, has commented that this is “deeply problematic”:

In the first place it utterly fails to establish the duty of doctors to object to practices and procedures that are unconscionable because harmful, discriminatory, unjust or unethical. The right to conscientious objection is based on the duty to be conscientious which is fundamental to medical ethics. In the second place, “conscientious objection” is presented as conflicting with “patient care”. This overlooks the fact that there can be no adequate patient care without conscientious healthcare professionals.

He suggests in a press release that “effective referral” simply will not work as an ethical standard:

if a doctor objects in conscience to participation in torture or capital punishment or to force feeding of a prisoner who is on hunger strike, it would be unprincipled for them to find someone with fewer scruples to do the deed for them. To require a conscientious objector to facilitate delivery of the procedure to which they object is a direct attack on person’s conscience and moral integrity, and thus a serious harm to them. It would be much better to say nothing about conscientious objection than to undermine it by imposing a requirement for “effective and timely referral”. 

Article: Conscience duty and good medical practise (Link).

Conscience, Dignity and Good Medical Practice.

Alex Schadenberg
Executive Director, Euthanasia Prevention Coalition

An article by a group of Canadian physicians on conscience rights was published in the December 2020 issue of the World Medical Journal. The article titled: The Declaration of Geneva: Conscience, Dignity and Good Medical Practice starts on page 41 of the World Medical Journal and emphasizes the importance of conscience rights in the practice of medicine. I have limited my article to a few key points:

Conscience rights enable peaceful and productive relationships within a pluralistic society. The article states:

Agreement on foundational principles does not eliminate disagreements, since people hold differing reasonable comprehensive world views leading to different ethical theories, like deontology, consequentialism, principlism and virtue ethics. Recognition of rational moral pluralism enables people to live peacefully and productively with these differences, and this is best ensured by robust protection of freedom of thought, of conscience and of religion, all recognized in Article 18 of the UDHR (Universal Declaration of Human Rights).

Under the section - preservative freedom of conscience - the article recognizes how conscience rights protect physicians and patients. It states:

Refusing to act wrongfully is foundational for the individual and society, contributes substantially to social stability and is the necessary but not sufficient condition for perfective freedom of conscience. It is essential for ethical medical practice because it protects personal and professional integrity and can be the ultimate safeguard for patients.

Forcing a physician to go against their conscience treats them like a government "agent" and causes them to leave their field of medicine. The article states:

For example, a palliative care physician, succumbing to fear of professional discipline, referred a patient for euthanasia. She described the experience as “destructive to my very core.” Haunted for months by the memory, she doubted she could continue in palliative care.  

There is a further point. When the state forces physicians to do what they believe to be wrong it demands the submission of intellect, will, and conscience to serve ends they find morally abhorrent. They are treated as cogs in the state machine,

The article asserts that conscience rights require a moral freedom that enables the goal of treating the other the same as one would treat oneself. The article states:

Thus, to practise “with conscience” is to treat the other as oneself: to impartially care for patients to the best of one’s ability, applying “scientific methods allied with the spirit of charity and service”: to provide for their bodily needs, relieve suffering, prolong human life and prevent disease: to defend fundamental human rights and respect patients’ human dignity and “moral freedom”. Further, recognition of a patient as another self-obliges physicians to prevent and resist harm to patients, and makes deliberately harming them an especially egregious offence.

This group of physicians also had an article published in the September 2020 issue of the World Medical Journal titled: Practising medicine with conscience and dignity (Link).

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

Doctors are Saying No to Assisted Suicide in New Zealand.

Alex Schadenberg
Executive Director, Euthanasia Prevention Coalition

Dr Sinead Donnelly

New Zealand is having a referendum on euthanasia as part of its October 17 federal election.

Doctors say no is an Open Letter to New Zealanders by doctors supporting the World Medical Association and New Zealand Medical Association position statements that euthanasia and assisted suicide are unethical, even if they become legal.

Doctors say no have more than 1750 signatures from New Zealand doctors for a letter to New Zealand citizens opposing euthanasia and assisted suicide. The letter states:

We are committed to the concept of death with dignity and comfort, including the provision of effective pain relief and excellence in palliative care.

We endorse the views of the World Medical Association and the New Zealand Medical Association that physician assisted suicide and euthanasia are unethical, even if they were made legal.

We uphold the right of patients to decline treatment, as set out in the NZ Code of Health and Disability Services Consumers’ Rights.

We know that the proper provision of pain relief, even if it may unintentionally hasten the death of the patient, is ethical and legal. Equally the withdrawal or withholding of futile treatment in favour of palliative care is ethical and legal.

We believe that crossing the line to intentionally assist a person to die would fundamentally weaken the doctor-patient relationship which is based on trust and respect.

We are especially concerned with protecting vulnerable people who can feel they have become a burden to others, and we are committed to supporting those who find their own life situations a heavy burden.

Doctors are not necessary in the regulation or practice of assisted suicide. They are included only to provide a cloak of medical legitimacy. Leave doctors to focus on saving lives and providing real care to the dying.

‘Doctors say no’ is an Open Letter to all New Zealanders by doctors supporting the World Medical Association and New Zealand Medical Association position statements that euthanasia and assisted suicide are unethical, even if they were to become legal.

More articles on the New Zealand euthanasia referendum.

• New Zealand End of Life Choices Act would lead to many, not a few assisted deaths (Link).
• New Zealand End of Life Choices Act is not what it claims to be (Link).
• Claire Freeman was encouraged by the suicide outreach clinic to consider assisted suicide (Link).

Practising Medicine “with conscience and dignity”

The following article was published in the Journal of the World Medical Association (WMA) on August 24, 2020.

The WMA and the Foundations of Medical Practice, Declaration of Geneva (1948), International Code of Medical Ethics (1949).

Beginning with the Declaration of Geneva (the Declaration), for over 70 years the World Medical Association (WMA) has maintained that physicians must practise medicine with conscience and dignity[1]. On the Declaration’s 70th anniversary, seven associate WMA members raised serious concerns about their ability to remain in medical practice if they fulfil this obligation by refusing to support or collaborate in the killing of their patients by euthanasia and assisted suicide (EAS)[2].
 
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