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Ethical Challenges

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A History of Palliative Care, 1500-1970

Part of the book series: Philosophy and Medicine ((PHME,volume 123))

Abstract

This chapter studies the early modern debates on major ethical challenges that arose in palliative care and which are still at the heart of medical ethics today: The permissibility of intentionally shortening of a dying person’s life, of giving medicines to alleviate a patient’s suffering that might accelerate the approach of death and of forgoing the attempt to cure dying patients, at the risk that the occasional, only seemingly desperate patient could have been saved by more radical means. The chapter highlights the very lively – and so far virtually unknown – debate on popular practices like “pulling the pillow” which were explicitly designed to speed up the dying process. In conclusion, it examines attitudes towards truth-telling and shows that physicians, fearing negative effects on the body, were unanimous that patients should be kept ignorant of their fatal prognosis as long as possible.

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Notes

  1. 1.

    Hippocratis iusurandum, in: Alessandro Benedetti, Anatomice, sive de hystoria corporis humani libri quinque, Strasbourg: apud Iohannem Hervagium 1527, fols 111v–112r: “Rogatum mortale venenum nemini daturum, neque id cuiquam consulturum”.

  2. 2.

    Petrus Memmius, Hippocratis Coi iusiurandum commentario recenter illustratum, cui accessit altera pars, qua ratione medicorum vita et ars sancte conservetur declarans, Rostock: typis Augustini Ferberi 1577.

  3. 3.

    François Ranchin, Opuscula medica. Ed. by Henricus Gras, Lyon: apud Petrum Ravaud 1627, pp. 28–31.

  4. 4.

    Boudewijns, Ventilabrum (1666), pp. 219–23, chapter on “An medico liceat mortem accelerare, ut desperatus aeger a doloribus liberetur?”; cf. Michael Ernst, Ärztliches Handeln und ethische Fragen am Lebensende im Ventilabrum medico-theologicum von Michael Boudewijns (1666), Cologne: WiKu-Verlag 2012.

  5. 5.

    Questel, De pulvinari (1678).

  6. 6.

    Krünitz, Oeconomische Encyclopädie, vol. 73 (1798), p. 175.

  7. 7.

    For later overviews see Bächtold-Stäubli, Handwörterbuch (1937), pp. 438–450; Falk, Geschichte (1983), pp. 27–9; Cavina, Andarsene (2015).

  8. 8.

    Giulio Raviglio Rosso, I successi d’Inghilterra dopo la morte di Odoardo sesto fino alla giunta in quel regno del sereniss. Don Filippo d’Austria Principe di Spagna. Scritti volgarmente da Giulio Raviglio Rosso da Ferrara, Ferrara: Francesco di Rossi 1560, fol. 103r; cf. Rodolfo Graziani, Non-utopian euthanasia. An Italian report, c. 1554, in: Renaissance quarterly 22 (1969), pp. 329–333.

  9. 9.

    Frank, System (1788), pp. 666–7.

  10. 10.

    Dieffenbach, Anleitung (1832), p. 176.

  11. 11.

    Georg Andreas Ioachimus, Dissertatio iuridica de vivi sepultura delicto et poena. Submittit Hieron. Wilhelmus Arnold, Leipzig: Langenhemius 1732, pp. 27–8, December 1727.

  12. 12.

    Krünitz, Oeconomische Encyclopädie, vol. 73 (1798), p. 176.

  13. 13.

    Ferriar, Treatment (1798), p. 199.

  14. 14.

    Heinrich Hoops, Sassenart. Niedersächsische Volkssitten und Bräuche, Bremen: Angelsachsen-Verlag 1922, pp. 115–6; further references in Georg Schoppe, Sterbende werden auf die Erde gelegt, in: Archiv für Religionswissenschaft 17 (1914), pp. 341–2.

  15. 15.

    Albrecht Dieterich, Mutter Erde. Ein Versuch über Volksreligion, Leipzig−Berlin: Teubner 1905, pp. 26–7; Ernst Samter, Antike und moderne Totengebräuche, in: Neue Jahrbücher für das klassische Altertum, Geschichte und deutsche Literatur (1905), pp. 34–45, hier p. 36; Bächtold-Stäubli, Handwörterbuch (1937), cols 438–50.

  16. 16.

    Rudolf Cruel, Geschichte der deutschen Predigt im Mittelalter, Detmold: Meyer 1879, p. 239; Bächtold-Stäubli, Handwörterbuch (1937), col. 446, on St. Benno. Financial considerations may also have been at play. Beds were expensive and the dying might easily soil them with their excretions.

  17. 17.

    Alfonso de Liguori, Theologia moralis. Ed. by P. Leonardi Gaudé, vol. 1, Rome: Typogr. Vaticana 1905, p. 627. My thanks to Isacco Turina for pointing out this passage to me.

  18. 18.

    See also Arnold van Gennep, Manuel de folklore français contemporain, vol. 1: Introduction générale et première partie: du berceau à la tombe, Paris 1946, pp. 664–7.

  19. 19.

    Georg Andreas Ioachimus, Dissertatio iuridica de vivi sepultura delicto et poena. Submittit Hieron. Wilhelmus Arnold, Leipzig: Langenhemius 1732, pp. 27–8, December 1727.

  20. 20.

    Questel, De pulvinari (1678), p. 13.

  21. 21.

    Hauptstaatsarchiv Stuttgart A 209, Bü. 558, expertise by the Faculty of Law in Tübingen, 1699.

  22. 22.

    Questel, De pulvinari (1678), p. 8.

  23. 23.

    Hennig, De dysthanasia medica (1735), p. 40; deliberately shortening a patient’s life was alien to the physician’s identity (“character medici”) we read in another dissertation with the same praeses, Michael Alberti (Alberti, De religione (1722b), p. 36).

  24. 24.

    Krünitz, Oeconomische Encyclopädie, vol. 73 (1798), p. 175.

  25. 25.

    Stahl, Mortis theoria (1702), p. 39.

  26. 26.

    Hennig, De dysthanasia medica (1735), pp. 38–9.

  27. 27.

    Overview in Bonifacio Honings, L’eutanasia attiva e passiva secondo i manuali classici. Dal XVI al XX secolo, in: Lateranum N. S. 44 (1978), pp. 515–34.

  28. 28.

    Ibid., especially pp. 521–526; cf. Alfonso de Liguori, Theologia moralis. Ed. by P. Leonardi Gaudé, vol. 1, Rome: Typogr. Vaticana 1905, p. 627.

  29. 29.

    Wedel, De cura palliativa (1703), pp. 24–31.

  30. 30.

    Georg Wolffgang Wedel, Opiologia, Jena: Sumptibus Johannis Bielkii 1682, pp. 153–4.

  31. 31.

    Cf. Philippe Hecquet, Reflexions sur l’usage de l’opium, des calmants, et des narcotiques pour la guerison des maladies, Paris: Guillaume Cavelier 1726.

  32. 32.

    Wedel, Opiologia (1682), p. 155.

  33. 33.

    Severinus Hee, De methodis medendi in medicina et chirurgia suspectis. Praes. Georg Detharding, Copenhagen: Höpffner 1734, p. 17.

  34. 34.

    George Young, A treatise on opium founded upon practical observation, London: Millar 1753, pp. 124–9.

  35. 35.

    Oberlin, De opio (1752), preface.

  36. 36.

    Fearon, Abhandlung (1790), pp. 83–5.

  37. 37.

    Ibid., pp. 80–3.

  38. 38.

    Ibid., pp. 88–91. The patient survived the operation but he died 5 months later, after his pain and the resulting insomnia had become refractory to opium; Siena, Suicide (2009), p. 59, mentions similar cases of patients who declared that they would rather suffer the torments of medical treatment.

  39. 39.

    On the history of informed consent Martin S. Pernick, The patient’s role in medical decision-making. A social history of informed consent in medical therapy, in: The ethical and legal implications of informed consent in the patient-practitioner relationship, vol. 3, Washington: U.S. Government Publishing Office 1982, pp. 1–35; Ruth R. Faden and Tom L. Beauchamp, A history and theory of informed consent, New York: Oxford University Press 1986; Elkeles, Schweigsame Welt (1989).

  40. 40.

    For a detailed account of the surgical treatment of cancerous breasts see Lorenz Heister, Chirurgie, Nürnberg: Johann Hoffmanns sel. Erben 1724, pp. 612–8; on the negotiation of surgical interventions between Heister and his patients see Marion Maria Ruisinger, Patientenwege. Die Konsiliarkorrespondenz Lorenz Heisters (1683−1758) in der Trew-Sammlung Erlangen, Stuttgart: Steiner 2008.

  41. 41.

    Margarethe E. Milow, Ich will aber nicht murren. Ed. by Rita Bake and Birgit Kiupel, Hamburg: Dölling und Galitz 1993, pp. 298–9.

  42. 42.

    Johann Friderich Schwalb, Andächtiges Gebet vor und nach der schmertzhaften Operation weiland Marx Albrecht Sturm, wohlverdienten Handelsbedienten, welcher Dienstags den 28. Januarii 1772. in dem 43. Jahr seines christrühmlich geführten Alters Vormitag an einem Stein glücklich geschnitten worden, verrichtet von M. Johann Friderich Schwalb, Diac. II. Minorit., Augsburg: [N.N.] 1772, fols 4r–v.

  43. 43.

    Cabrol, Alphabeton (1604), pp. 108–9.

  44. 44.

    Fearon, Abhandlung (1790), pp. 95–7; in the end, when it was already too late according to Fearon, she did ask for an operation. On her urgent request, he sent her to a surgeon who performed an operation, which initially yielded good results.

  45. 45.

    Ibid., pp. 85–7.

  46. 46.

    Ibid., pp. 77–80.

  47. 47.

    For a detailed analysis of the differences between a “symptomatic indication” and therapeutic approaches that targeted the very essence of the disease see Gmelin, Allgemeine Therapie (1830), pp. 64–71.

  48. 48.

    Cf. e.g. the case histories in Augenius, Epistolarum (1602), fol. 86v, and in Henricus Casparus Abelius, Dissertatio inauguralis medica in casu practico complicatissimo, exponens aegram phthisicam, diu quidem pro desperata habitam, ast per Dei gratiam feliciter curatam. Praes. Heinrich Christoph Alberti, Erfurt: Groschius 1692.

  49. 49.

    Hanß Heinrich Helcher, Cur incurabler Kranckheiten beweiset durch Gottes Seegen und mit Goldes Hülffe, Leipzig: Tietzen [around 1723], pp. 240–1 and p. 259.

  50. 50.

    Ibid., p. 259.

  51. 51.

    Johannes Bohn, De officio medici duplici clinici nimirum ac forensis, Leipzig: Gleditsch 1704, pp. 67–8.

  52. 52.

    Friedrich Hildebrandt, Ueber die Arzneikunde, Erlangen: bei Johann Jacob Palm 1795, pp. 99–100.

  53. 53.

    Cardano, De malo medendi usu (1536), pp. 8–9.

  54. 54.

    Alberti, De religione, p. 37.

  55. 55.

    Fabry, Wund-Artzney (1652), pp. 1269f, letter to the physicians and surgeons in Geneva, September 15, 1596.

  56. 56.

    Heurne, Praxis (1590), pp. 343f; Guy de Chauliac, Chirurgia magna, 1585 (repr. Darmstadt: Olms 1976), pp. 398–400; Guido Guidi, De curatione generatim, in idem: Opera omnia sive ars medicinalis (separate pagination), Frankfurt: typis et sumptibus Wechelianorum 1626, p. 121; Wedel, De cura palliativa (1703), p. 33; similarly idem, Opiologia, Jena: Sumptibus Johannis Bielkii 1682, p. 157.

  57. 57.

    Sylvius, Praxeos medicae idea (1695), p. 701 (“Incurabilis ergo phthiseos palliatio consistet in symptomatum molestorum alleviatione vel alteratione, viriumque collabentium convenienti reparatione ac sustentatione”).

  58. 58.

    Wedel, Opiologia, Jena: Sumptibus Johannis Bielkii 1682, p. 157.

  59. 59.

    Stahl, Mortis theoria (1702), p. 39; Alberti, De abstinentia (1722a), p. 31.

  60. 60.

    Michael Alberti, Nobilissimo et clarissimo Dn. Candidato, in: Schulz, De euthanasia medica (1735), appendix (no page numbers).

  61. 61.

    Cf. Johannes Upmarck, De euthanasia (1760), pp. 60–4.

  62. 62.

    Zach, De cura (1792), p. 28.

  63. 63.

    Peter Kennedy, An account of a contagious fever, which prevailed lately at Aylesbury, and in some of the adjacent parts of Buckinghamshire, Aylesbury: printed by W. Nicholls 1785, pp. 33–4, footnote; my thanks to Kevin Siena for pointing out this passage to me.

  64. 64.

    Ariès, Western attitudes (1974), pp. 85–6.

  65. 65.

    Leonardo Botallo, I doveri del medico e del malato. Ed. by Leonardo Careri and Anita Bogetti Fassone, Turin: Unione tipografico-editrice torinese 1981 (orig.: Commentarioli duo, alter de medici, alter de aegroti munere, Lyon: Gryphius 1565).

  66. 66.

    Codronchi, De christiana ratione (1591), pp. 57–9.

  67. 67.

    On the controversial contemporary debates about telling patients the truth see Schleiner, Medical ethics (1995), pp. 5–48; on communicating a fatal prognosis, in particular, ibid., pp. 27–9; see also Bergdolt, Gewissen (2004), pp. 145–7. By contrast, Roy Porter, Death (1998), p. 82, possibly relying on Ariès’s work, has claimed erroneously that traditional medical etiquette demanded that patients be informed about their poor prognosis without any reservations.

  68. 68.

    Castro, Medicus politicus (1662), p. 145.

  69. 69.

    Ibid.; see also Zacchia, Quaestiones (1651), pp. 392–3; Seidel, Liber morborum incurabilium (1662), p. 133.

  70. 70.

    Michael Stolberg, “Zorn, Wein und Weiber verderben unsere Leiber.” Krankheit und Affekt in der frühneuzeitlichen Medizin, in: Johann Anselm Steiger (ed.), Passion, Affekt und Leidenschaft in der Frühen Neuzeit, Wiesbaden: Harrassowitz 2005, pp. 1033–59.

  71. 71.

    Stephanus Guazzus, Euthanasia, Das ist: Ein lehrreich, nütz- und sehr tröstliches Gespräche, wie man nemlich christlich leben und seliglich sterben soll. Transl. by Melchior Wisaeus, Leipzig: Bey Abraham Lamberg 1625, p. 6.

  72. 72.

    Döbeln, De erroribus (1700), p. 65; similarly Rosa, De curatione palliativa (1742), p. 5.

  73. 73.

    Michael Stolberg, La négociation de la thérapie dans la pratique médicale du XVIIIe siècle, in: Olivier Faure (ed.), Les thérapeutiques: savoirs et usages, Lyon: Fondation Marciel Mérieux 1999, pp. 357–68.

  74. 74.

    Zach, De cura (1792), p. 18.

  75. 75.

    Gregory, Lectures (1772), p. 34.

  76. 76.

    Beinecke Library, Yale University, New Haven, Gen. Mss. 353 60, letters from Mme de Graffigny, here letter, December 8, 1758, the handwriting is probably that of Mme de Graffigny’s daughter.

  77. 77.

    Haller, Briefe (1923), pp. 545–6, December 3, 1777.

  78. 78.

    Gregory, Lectures (1772), pp. 34–5; a similar approach can be found with Lorenz Heister; see Rüdiger Korff, Das Berufsethos in der Chirurgie Lorenz Heisters 1683−1758, Zürich: typescript med. diss. 1975, p. 37.

  79. 79.

    Jean-François Marmontel, Mémoires. Ed. by John Renwick, Clermont-Ferrand: G. de Bussac 1972, pp. 56–7.

  80. 80.

    Döbeln, De erroribus (1700), p. 65.

  81. 81.

    Stadt- und Universitätsbibliothek Frankfurt, Senckenbergarchiv, letter from Belzer to Senckenberg, January 13, 1738.

  82. 82.

    Thomas Gisborne, An enquiry into the duties of men in the higher and middle classes of society in Great Britain, resulting from their respective stations, professions, and employments, London: printed by J. Davis for B. and J. White 1794, pp. 383–426 (chapter “On the duties of physicians”), cit. pp. 401–2; Gisborne explicitly drew on Gregory’s “Lectures” and on parts of Percival’s “Medical ethics” that Percival had already composed and communicated to Gisborne (ibid., note on p. 383).

  83. 83.

    Gregory, Lectures (1772), p. 34.

  84. 84.

    Percival, Medical ethics (1803), p. 31.

  85. 85.

    Seidel, Liber morborum incurabilium (1662), pp. 131–3.

  86. 86.

    Freiburg, Stadtarchiv, C1 Medizinalwesen 1, N. 44, ordinance of the government of Vorderösterreich, October 9, 1779; similar ordinances can still be found in the nineteenth century; see Joseph Müller, Systematische Darstellung der Krankenpflege nach den im österreichischen Kaiserstaate geltenden Normen bearbeitet, Vienna 1844, note on p. 70, referring amongst others to a Hofdekret (Imperial ordinance) of 1812.

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Stolberg, M. (2017). Ethical Challenges. In: A History of Palliative Care, 1500-1970. Philosophy and Medicine, vol 123. Springer, Cham. https://doi.org/10.1007/978-3-319-54178-5_3

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