By Dr. Coe


Well, the members already know this, but I might say to the guests that my presentations to this particular society never turn out very well.  Last time I talked, I recall, it was on Sherlock Holmes, and I was enthused about the subject because I had been in Edinburgh for a short time during World War II, really a very short time.  But I thought that this really gave me a bit of upmanship, you know, on the membership having been where Arthur                lived and went to medical school.  And I remember that night that I came through this door out here, and Al Lansing, had a foot just inside the door, and Al Lansing said, "I want you to meet Dr. James Hargis.  He is from Edinburgh.  He went to medical school."  And I thought, "Well, hellfire that.”

When I began to think about tonight's presentation, I always give careful consideration to the make up of the audience, and thought well, Miss Joan Titley is going to be there, and she is certainly by far the smartest person that will be there.  So if there is something I can do to intimidate her, it would be helpful.  And I thought the only way you can intimidate a librarian is by asking them for a reference which they have never heard of before.  So, I called Joan about three or four weeks ago, I guess it was, and I said, “I would like to speak to Miss Joan Titley.”  And they put her on the phone.  And I said, "Miss Titley I would like to have the Pontifical Papers of the fall of 1958 in which Pope Pius XII addresses the Psychopharmacists Society in Rome.”  And I leaned back in my chair waiting for the stunned silence.  And she said, "Oh, yes, I know all about those."  And she went ahead and told me a lot more about them than I cared to know at the time.  So, I got off to a bad start on both occasions.

Just this past Wednesday morning, you will think I am making this up actually, but I was making rounds out at the Baptist, and I came to the room of a patient that I had known for a number of years.  We will call her Mrs. Smith.  I have treated her for arteriosclerotic heart disease, severe angina pectoris, and on occasions, congestive heart failure.  She is the kind of person that you would enjoy meeting and taking care of.  She's well educated, lively person, witty, wonderful sense of humor.  And I was about to leave the room on Wednesday when she said, "Dr. Coe, I want to talk to you about something which I can't discuss with my family and which I can't discuss with my friends because it upsets them too much, or would upset them too much.”  She said, "But this is about the fourth time this year that I have been brought into this hospital by ambulance.”  Each time she has been admitted to coronary care, and each time the nurses in coronary care thought that she wouldn't be there the next morning.  She was critically ill with pulmonary edema, synotic distended neck veins.  This had been the picture as she said on about four different occasions.  And she said, looking at me straight in the eye, and didn't seem to be depressed about it at all, but very matter of fact, "Next time this happens, I don't want you to make the big effort that you have done in the past.”  She said, "It's foolish, in fact, it is stupid, and I just don't want you to do it again."  Well, what is the situation here?  Does she have a moral or ethical right to ask me to do what she did?  And what should my response have been?

It was interesting in view of the fact that I was already in the process of developing this paper.  Sometime ago, I am not a regular reader of the Wall Street Journal, being neither a bear nor a bull, but something more of a wolf.  But I did notice a headline in the Wall Street Journal a couple of months ago, and it was in the lead column, and it was entitled, “A Good Death - Increasing Support for Euthanasia Spurs Heated Medical Debate.  Doctors Ponder Their Duty as Dying Patients Plead to Have Treatment Ended."  First column of the Wall Street Journal.  It goes on to say that Margaret Hoffman, the 42 year old secretary at a large metropolitan medical center in New York learned about a year ago that she had cancer.  The slender grained Mrs. Hoffman, not her real name obviously, says she is not afraid of death, but she does dread, however, the prospect of a long painful illness.  Hoffman says. "My mother lingered dying of cancer for 15 months,” Mrs. Hoffman says.  “She was in agonizing pain.  I don’t want the people I love to witness that kind of suffering.  I am not going to fight with death.  It is a losing battle that is futile, stupid, and useless.”  In an attempt to avoid that battle, Mrs. Hoffman took a step that has been taken recently by a growing number of Americans.  She signed a living will in which her doctors are requested that she be allowed to die if it becomes apparent that there is no reasonable hope for her recovery, rather than being kept alive by machines or heroic measures.

Mrs. Hoffman's will was provided by the Euthanasia Educational Fund, a non-profit organization headquartered in New York.  Since last March the fund has distributed almost 50,000 living wills which state in part “I do not fear death as much as I fear the indignity of deterioration, dependence, and hopeless pain."  The signers further request the right “to die in dignity”.  Advocates of euthanasia, and the definition here in this article is “the act of inducing death for merciful reasons”, realize that such wills aren't legally binding.  However, signers like Mrs. Hoffman are hopeful their documented wishes will help remove the burden of guilt doctors and relatives who otherwise might feel compelled to demand prolonged treatment even in cases that are considered hopeless.  Actually the thought for this particular paper comes from the third chapter of the Book of Ecclesiastes,

For everything there is a season, and for every activity under heaven its time.  A time to be born and a time to die.  A time to plant and a time to uproot.  A time to kill and a time to heal.  A time to pull down and a time to build up.  A time to weep and a time to laugh.  A time for mourning and a time for dancing.  A time to scatter stones and a time to gather them.  A time to embrace and a time to refrain from embracing.  A time to seek and a time to lose. A time to keep and a time to throwaway.  A time to tear and a time to mend.  A time for silence and a time for speech. A time to love and a time to hate.  A time for war and a time for peace.


Now, if you look up the new word euthanasia in the new Webster's International Dictionary, you find that it comes from the Greek prefix of “eu” which means good or easily, and the Greek word “thanatos” which means death.  And the definition given in that dictionary is "an easy death or a means of inducing one."

In the first century B.C., a geographer, Strabo, wrote that elderly people on the Greek island of Cos having outlived their usefulness to society would gather at an annual banquet to drink a lethal poison.  0ne of the oldest Greek colonies is now the modern   , France.  In the days that it was part of the Greek colonies it was called          .  In ancient             , a death potion was kept in public for use by those who could justify to public officials their wish for death.

Margaret Mead, the anthropologist that all of you are familiar with, has pointed out that until recently the grandmothers in the Eskimo society, often, when they became a burden on the family, often would stay behind as the family migrated.  This would be with the cooperation of the family of course, and would lead to the fairly early death.  Now, this has been true in a number of societies in the past, particularly in the nomadic societies.  It is regarded as part of the social pattern, or it was, at one time, with the Laps, the Bushmen, the Australian Aborigines, and even the Hopi Indians.  The Hopi Indians apparently have always had a regard for the aged.  But there was a point in their development when they were nomadic, and it was a custom that once the individual became an age that it was difficult for them to keep up as the tribe moved, that they would be abandoned.  In the pre-Christian era, various forms of euthanasia were practiced.  In primitive societies abandonment of the aged was a common feature, but apparently was never practiced in Greece or Rome.  In India at one time it was the custom to take the old to the banks of the Ganges, fill their mouths and nose with sacred mud and throw them into the river.  Child exposure, however, was known to Greece.  “The question arises,” writes Aristotle in Politics, “whether children should always be reared, or sometimes be exposed to dying.  There should certainly be a law to prevent the rearing of deformed children,” Aristotle says, “is to limit the size of each family, and if children are then conceived in excess of the limit so fixed, to have miscarriage induced before sense and light began in the embryo.”

                   was a well known philosopher who lived in Rome about 4 B.C. to 65 A.D.  He was a tutor of Nero, and wrote on one occasion, incidentally, he was an advocate of euthanasia, he wrote on one occasion, “If one death is accompanied by torture and the other is simple and easy, why not snatch the latter?  Just as I shall select my ship when I am about to go on a voyage or my house when I propose to take a residence, so shall I choose my death when I am about to depart from life.  Moreover, just as a long drawn out life does not necessarily mean a better one, so a long drawn out death necessarily means a worse one.”

With the beginnings and spread of Christianity, euthanasia generally ceased to be advocated.  In Sir Thomas More's Utopia, he states that those suffering from torturing and lingering pain as he describes it, would with the consent of priests and magistrates, be allowed to take their own lives.  Now this position from Utopia has been used by advocates of Euthanasia, to support their argument on more than one occasion.  However, More actually was not advocating euthanasia, but his intention was to show the institutions which would likely develop in a community which had no Christian guidance as he described it.

An example of what has been called compulsory euthanasia came into being on September 1, 1939.  It was on that day by the secret order of Hitler that the Nazi policy of compulsory euthanasia was introduced.  At first, it was confined to the Germans, but later, it extended to foreigners.  However, it was back in 1936, that Hitler had demanded of the German medical profession that they adopt a euthanasia plan, and I read in just this last week, the writings of a prominent English physician on this subject who said that in 1936 when Hitler first advocated this, to the German medical profession that there were at least twenty prominent German professors associated with teaching institutions that agreed with this concept and indicated their willingness to participate.  In 1943, aroused by the reports of what was taking place in Germany, Pius WII reiterated the Catholic condemnation of euthanasia.  He stated, “Conscious of the obligation of our high office, we deem it necessary to reiterate this grave statement today, when to our profound grief we see the bodily deformed the insane, and those suffering from hereditary disease at times deprived of their lives as though they were useless burden to society.  And this procedure is hailed by some as a new discovery of human progress, and is something that is altogether justified by the common good.  Yet what sane man does not recognize that this not only violates the natural and divine law written in the heart of every man, but flies in the face of every sensibility of civilized humanity.”  The pope here, was referring to compulsory euthanasia.  But later he made it clear that he condemned voluntary euthanasia, as well.  He said, "It is never lawful to terminate human life."  He said this in an address to a group of Italian doctors in 1948.  "And only the hope of safeguarding some higher good or preserving or prolonging the same human life will justify exposing it to danger," he said.

The Church of England through her leading spokesman, has condemned euthanasia.  In a House of Lords debate 1936, the Archbishop of Canterbury denied that any man was entitled to take his own life.  In 1950, the Church of England’s Hospital Chaplain's Fellowship expressed its corporate condemnation of euthanasia.  The Protestant Episcopal Church of America passed a resolution in 1952 opposing euthanasia, “under any circumstances whatsoever.”  Pope Pius XII's view on physical suffering was given in an address to Italian anesthesiologists in 1957.  And to quote him directly, “Now the growth and the love of God in abandonment to His will does not come from the sufferings themselves which are accepted, but from the intention in the will supported by grace.  This intention in many of the dying can be strengthened and become more active if their sufferings are eased, for these sufferings increase the state of weakness and physical exhaustion, check the order of the soul and sap the moral piers instead of sustaining them.  On the other hand, the suppression of pain removes any tension in body and mind, renders prayer easy and makes possible a more generous gift of self.”  He said that if some dying persons accept their suffering as a means of expiation and a source of merit in order to go forward in the love of God, and in abandonment to His will, do not force anesthetics on them.  Rather they should be aided to follow their own way.  Where the situation is entirely different it would be inadvisable to suggest to dying persons the anesthetical considerations set out above, and it is to be remembered that instead of assisting towards expiation and merit, suffering can also furnish occasions for new thoughts.

It is recorded that Pope Pius XII told a group of Catholic physicians they could use drugs on terminal patients to ease pain, even if the use of such drugs served to shorten life.  In fact, this was part of his address to a medical group in September of l958, and this address occurred just some two or three weeks before his own death.  The phrases “ordinary means of preserving life” and “extraordinary means of preserving life” seem to turn up commonly in the Catholic literature and frequently in relation to the care of the terminally ill.  In this respect, a Father Gerald Kelly who has written rather extensively on this subject, and in writing for the Catholic Hospital Association gives the following definitions.  “As regards various hospital procedures, the theologian would say that ordinary means of preserving life are all medicines, treatments, and operations which offer a reasonable hope of benefit for the patient, and which can be obtained and used without excessive expense, pain, or other inconvenience.  In contradiction to ordinary or extraordinary means of preserving life, by these we mean all medicines, treatments, and operations which cannot be obtained or used without excessive expense, pain, or other inconvenience, or which, if used, would not offer a reasonable hope of benefit."  Now Father Kelly admits the limitations of these two definitions.  Despite the many objections to euthanasia, particularly by religious groups, various societies have been formed in England and America since World War I to secure the legalization of euthanasia.  The Voluntary Euthanasia Legislation Society was formed in England in 1936 under the presidency of Lord Monyhan who was a past president of the Royal College of Surgeons.  Supporters of the Society include a number of prominent English citizens including Dr. Julian Huxley.  The same year it was founded, the Society introduced a bill into the House of Lords to legalize euthanasia.  It was defeated.  The subject was debated again in the House of Lords in 1950.  In the United States a Society similar to that established in England was formed in 1938 by the Reverend Charles Potter.  And when the Reverend Charles Potter first suggested this, he included some aspects of involuntary euthanasia, that is the grossly mentally retarded and deformed.  However, with the advents of developments in Germany, the American society quickly dropped the involuntary aspect of euthanasia, and ever since concentrated on legalizing voluntary euthanasia.

Again, just three years ago, 1969, euthanasia was a subject of intense debate in the House of Lords.  On March 25, 1969, Lord Raglin moved the second reading of his voluntary euthanasia bill in the House of Lords. The debate lasted six hours and was vigorous.  The bill failed to get its second reading by a vote of 61 to 40.  But many of those who opposed the bill said they were not doing so on the grounds of principle but they thought the bill in its present form was not a good one.  In the fall of 1969, intense debates in the Royal Society of Medicine on the subject of euthanasia.  These debates are recorded in the proceedings of the Royal Society of Medicine.  The debates were participated in by leading members of the English medical profession, such as the Right, Honorable Lord Brock, for instance, prominent lawyers, professors and laymen. 

It would seem from all of this that the English have given the subject much more attention and thought than we Americans.  Perhaps this will change, however, as beginning the first of this past August, a special Senate committee on Aging opened hearings on this very same question.  The leading editorial in the Louisville Times which I have here, this was August 10, is entitled “A Time to Live and A Time to Die,” and I will read you the last few paragraphs.  They are short.

The fact of the matter is that some doctors, we have no idea what percentage, do withhold after consultation with relatives of the patient himself, the heroic measures which serve only to prolong life.  Yet conventional medical tradition, as we understand it, is that a doctor's highest duty is to preserve life.  To us, this sets up a conflict between ethics and tradition on one hand, and compassion on the other.  We wonder if the conflict could be eased if in fact, the Senate hearings could be given more immediacy, if the definition of live were to be expanded to something more positive and meaningful, than the mere murmur of a heart or a twitch of an eyelid.  Something better than the absence of a clinical...

In one of the October Journals the following is currently reported: “A Dr. Walter            , of Florida testified at the hearings held at the special Senate committee on aging, that in his state alone it would cost five billion dollars to allow l,5OO individuals retarded to the point that they are bedridden, diapered, tube fed and completely unaware, to live out an artificial life.  The doctor said the money could better be used on persons with illnesses that could be cured.”

Dr. Lawrence, Boye, Jr., of the Veterans Administration testified saying, “Neither I nor anyone else knows how to side when being alive becomes useless.  Only when death beats a patient should we give up.”

I haven't said anything up to this point about the legal aspects of this subject, and in my reading I did come across some material of this sort.  Dr. Robert Williams, Professor of Medicine out at the University of Washington and Chief of Endocrinology out there, has been very much interested in this subject, particularly in the past four or five years, and in his President's Address to the American Association of Physicians in Atlantic City of May, 1969, he stated that it is estimated that mercy killings now occur in this country at the rate of one per week.  The killers are almost never convicted.

In July of 1971 there was a case in Florida of Mrs. Carmen Martinez, a 72 year old Cuban refugee.  Mrs. Martinez, who had been hospitalized for almost two months with what was called in intractable hemolytic anemia, begged her doctors to let her die.  The treatment for her disease involved continual blood transfusions, it is stated.  Mrs. Martinez pleaded with her daughters to “please don’t let them torture me anymore.”  Her doctor however, felt that agreeing to her wishes might lead to his being charge with aiding a suicide, and conversely a denial of her request might lead to his being charged with violating Mrs. Martinez's civil rights.  The doctor took the case to court.  The decision was as follows: “This woman has a right not to be hurt,” ruled the Judge of                County Circuit Court.  “She has a right to live and to die indicative.”

Henry H Foster, is a professor of law at New York University, and he has made a particular study of the legal aspects of euthanasia.  He says, “If a patient and his doctor come to the mutual decision to, discontinue heroic measures which are prolonging life, the chances the doctor will be held liable are minimal, if not non-existent.

Active euthanasia according to Professor Foster is another matter.  If the doctor hastens the moment of death by any affirmative action, he could incur civil or criminal liabilities.

Aside from any legal matters, nowadays, dying is often a painful and lonely experience.  When death comes to grandfather nowadays he is apt to find himself in a strange institution, perhaps in a CCU unit, an ICU unit, or perhaps a           bed.  He is apt to have tubes and several body openings.  Loved ones are not permitted in the room or perhaps sometimes they have gone home for the night.  Grandfather's physician is not apt to be there in the vast majority of cases.  In fact if he is not in an ICU unit or a CCU unit, there is a fair chance that he is going to die all by himself in a room.  In contrast to this, I have very vivid childhood memory of the very first time that I saw a person die.  It was my grandmother.  It was on a night in May of 1925, and I obviously was very, very young.  I remember, perhaps with some degree of nostalgia that she was in her own home, in her own bed, surrounded by her children, a few of her grandchildren.  I recall, even, that one of my aunts was holding her hand.  Now the family physician and family friend, Dr. Charles Slater was there that evening.  Now perhaps this is all a little           and over sensitive at this point, but I really can’t recall when I last saw a dying patient in one of our hospitals whose hand was being held by one of the loved ones.

In this week's issue of Medical World News, October 6, 1972, I looked at it last night.  Just happened to come across it.  There is a book review in there called the psycho-social aspects of terminal care.  It is based on a meeting which was held by Columbia University in 1970, a two day discussion of this subject.  And I will read you a couple of paragraphs from the book review.

There is one predominant theme that despite the fact that we all must die sometime, and that increasingly death does occur in the hospital, there is relatively little or no attention paid to the training period to help physicians develop skills in caring for the terminally ill patient, and their families.  Seminar topics on ward rounds rarely include more than a passing comment on the terminally ill patient.  Many students, house officers, and more appalling senior           , are inaccessible to these patients and their families.  This state of affairs is as Dr. Henry Associate Professor of Medicine at New York Hospital says, "It's a direct reflection of the scientific age.  The young physician thinking of himself as a scientist, often considers that the scientific approach to medicine has no purpose other than to inquire into the nature of disease.  The individual and his emotional response is considered as irrelevant in his pursuit.

I was particularly interested in that because just the night before on Sunday night, I read a little book which was published in England in 1887.  It was written by an English physician by the name of William Dr. Monk.  Dr. Monk said that the medical schools and the medical profession weren't giving enough thought to the care of the dying.  Dr. Monk quoted quite freely from the writings of another English physician by the name of Lord             in fact who practiced in England in the 1500’s, in the 1580’s in fact.  And he had a direct quote from Dr.              .  Dr.               held it as much of the physician to “smooth the bed and render the departure from this life easy and gentle as it is to cure disease and restore health." 

Well, how should I terminate these rambling ruminations?  I have no illuminating conclusions to offer and no set in summary, and all I can say is, I am with you, Lord.