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Euthanasia : Towards modification of the code of medical ethics ?

The proposals of the French Minister of Justice

On 27th April, the French Minister of Justice made a declaration to the parliamentary fact-finding mission on the "end of life" with a view to modification of article 37 of the code of medical ethics. The article stipulates that "in all circumstances, doctors must strive to relieve the suffering of their patients, to support them morally, and to avoid any unreasonable obstination in their investigations and their therapies" but the penal code makes no distinction in repressing the fact of taking someone else's life. Thus the actions which, in putting an end to the sustaining of life by technological means, quicken death (disconnecting an apparatus which artificially keeps a patient alive, administration of heavy doses of sedatives to kill pain etc.) may be punished by law. For Dominique Perben, article 37 is not sufficiently clear and liberating for doctors to abstain from disproportionate therapy in a given situation and proposes sufficient analgesics in end of life situations. The new text should authorise doctors, without any ambiguity, to limit or to end treatments which have become useless. The "ethics and deontology" section of the National Council of the Order of Doctors has been tasked with preparing a new version of article 37 which will be submitted to the Council of State before being made into a decree.

The clinical reality in the field

Even if there has been some undeniable progress, the clinical reality in the field is there to confirm the fact : many doctors do not know how to stop when they should or do not dare to prescribe pain killers, for fear of bringing forward the time of death. However, all the ethical and palliative media, are agreed in their thinking that if a pain-killing treatment is administered at a dose which is proportional to the acuteness of the pain, it is legitimate, even if it results in the secondary unwanted side-effect of causing death. It is the double effect rule. In this case there is no euthanasia, since there is no intention to kill, but merely to relieve pain.

That having been said, in certain medical practices contrary to palliative care ethics, pain killers are administered in excess, with the conscious or unconscious intention, to accelerate the dying process : This is a case of euthanasia due to the subjacent intention to cause death. Numerous difficult situations which are hard to bear for the suffering medical teams may lead to such circumstances.
There is therefore a distinction to be made between these two attitudes which are clearly different from an ethical point of view. This is based on the analysis of intentions and on simple rules of good working practices in the use of pain killers.

Training of doctors rather than modification of the code of ethics

Coming back to the medical code of ethics, article 37 is perfectly clear regarding what is expected of doctors; there is therefore no reason to modify it. However, the question to ask concerns the knowledge of the medical code of ethics. In the course of their studies many doctors have not systematically studied this code, which is only handed to them when they register with the Council of the Order, in other words once their training is complete. Few are the doctors who truly know what it contains, and in particular article 37 : it is when being trained in palliative care that this article crops up, and for many, it is a real discovery !

They say : « ignorance of the law is no defence », certainly… But when a framework of good working practices is not applied, the best policy to change habits, is undoubtedly to promote awareness...

Instead of modifying the text, would it not be preferable to include a « medical ethics » module within the course, for example in the 6th year of medical studies? Such training on the eve of exercising their profession, would be far more effective and structuring for doctors than any modification to the code of ethics! Why not also provide post-university courses for doctors in hospitals and in practices? All the training facilities seem on this subject to be preferable to the texts which simply pile up gathering dust in the bottom of a bookcase... The medical code of ethics surely deserves better than that! 

First pregnancy in the world after grafting cryo-preserved ovarian tissue

The team led by Pr. Jacques Donnez at the Saint-Luc Clinical University in, Brussels, has just announced the first pregnancy achieved by grafting frozen ovarian tissue. This result is the culmination of an experiment begun in 1997. A 25 year old patient suffering from an advanced Hodgkin lymphoma requiring chemo and radio therapy. She was then among five patients being offered the freezing of ovarian tissue; she then received the necessary anti-cancer treatment: heavy chemotherapy and radiotherapy. With this type of treatment, the occurrence of premature menopause and sterility is estimated at more than 80 %. In 2003, the young woman, having been cured of her cancer, wished to have a child but blood tests indicated premature menopause; part of the stored ovarian tissue was then defrozen and grafted. The graft showed that the follicles, which are essential to ovulation, were perfectly functional ; in April 2004, the patient was fifteen weeks pregnant and the growth curves and morphology were perfectly normal.

According to predictions, by 2010, one out of 250 women of child-bearing age will have survived cancer; this technique brings them hope of preserving their fertility.

Revision of the laws on bioethics

A utilitarian status for human beings

The draft bioethics law, adopted on second reading at the French National Assembly on 11th December 2003, is due to be presented to the Senate by the summer. In the prevailing climate of general indifference, a utilitarian status is being constructed for human beings.

Authorisation for research on embryos

Stipulated in 1994, the principle under which « research on human embryos is prohibited » suffered a concession: in exceptional circumstances, when the man and woman forming the couple so consent, studies which do not harm the embryo may be authorised (art. L. 2141-8 of the code of public health). The draft revision now states that « research may be authorised on the embryo and on embryonic cells for a limited period of 5 years if they are likely to lead to major therapeutic advances and subject to there not being any alternative method of equivalent efficiency ».

Desire not to limit the number of supernumerary embryos

Considering the high risk of failure of medically assisted reproduction (MAR) in the 1990s, the 1994 law authorised the conception of a larger number of embryos than that actually implanted. Today, despite the progress with MAR techniques which have reduced the rate of failure, Professor Mattei refused, during the first debate at the National Assembly on the draft revision, to reduce the maximum number of embryos. The minister nevertheless estimates at some 200,000 the number of embryos which are no longer part of any parental project, and this number is steadily increasing, since every year, some 35,000 new embryos are frozen. This is more a political issue than a technical one; Germany and Italy have made the opposite decision : the 1990 Embryonenschutz-gesetz and the Italian law dated February 2004 restrict the number of embryos conceived in vitro to the number immediately implanted in utero (See Genethique No. 52).

Diminished penalties for so called therapeutic cloning as opposed to reproductive cloning

The draft law introduces a series of penalties intended to punish « crimes against the human species ». Among these is reproductive cloning, which carries a 30 year prison sentence, and therapeutic cloning which carries a maximum prison sentence of 7 years. How can one understand such a disparity in the punishment when in criminal law, an attempt is punishable in the same way as the act committed and that any attempt at reproductive cloning begins in the same way as so-called therapeutic cloning?

Moreover in French penal law, the motives of an offence are inoperative and are not to be considered during the legal qualification of a prohibited act. However, from a material point of view, the techniques used in reproductive cloning and those used in so-called therapeutic cloning are identical, only the admitted motive is different. How therefore can the law be enforced, unless by applying the benefit of doubt, the most lenient sentence is adopted for offenders having in fact prepared an act of reproductive cloning?

Wish to conceive ‘‘medicine babies"

The National Assembly has come down in favour of extending the pre-implant diagnostic indications, to enable the selection of embryos whose characteristics would enable, after birth, to treat a sick elder brother. At what price? In the United States, in order to treat 9 children requiring a graft of bone marrow, 199 embryos were conceived in vitro of which 28 were compatible, which were selected then transferred in utero to give birth to 5 HLA compatible babies

Source : Quotidien du médecin, 5th May 2004.

See also Gènéthique Nos 48 and 36 on the Revision of the law on bioethics dossier.

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