11. V. Lerch, “Why the Price Isn’t Right at the Hospital,” Raleigh News and Observer, October 3, 2006; J. O’Shea, “More Medicaid Means Less Quality Health Care,” Heritage Foundation WebMemo 1402, 2007, at http://www.heritage.org/Research/HealthCare/wm1402.cfm. 12. J. Barton, “Save Medicaid from Itself: Health Care Plan is Growing, Collapsing,” Washington Times, October 31, 2005. 13. For example, a 2006 study found that 60 percent of respondents believed that smokers should pay more for their health insurance premiums, and 29 percent believed that obese people should pay more; M.L. Berk et al., “Exploring the Public’s Views on the Health Care System: A National Survey on the Issues and Options,” Web exclusive, Health Affairs, 2006, at http://content.healthaffairs.org/cgi/reprint/25/6/w596. Views such as Kluge’s, asserting that society should not be responsible for providing certain types of health care for problems directly related to an individual’s poor lifestyle choices, are also relevant in this context; E.H. Kluge, “Drawing the Ethical Line Between Organ Transplantation and Lifestyle Abuse,” Canadian Medical Association Journal 150, no. 5 (1994): 745-46. 14. 42 U.S.C. Sec. 1396. 15. P. Cunningham and J. May, “Medicaid Patients Increasingly Concentrated among Physicians,” Center for Studying Health Systems Change Tracking Report No. 16, 2006, at http://www.hschange.org/ CONTENT/866/866.pdf. 16. M. Johnson, “Meeting Health Care Needs of a Vulnerable Population: Perceived Barriers,” Journal of Community Health Nursing 18, no. 1 (2001): 35-52; R. Tidwell, “The ‘No-Show’ Phenomenon and the Issue of Resistance Among African American Female Patients at an Urban Health Care Center,” Journal of Mental Health Counseling 26, no. 1 (2004): 1-12. 17. S. Zenk et al., “Neighborhood Racial Composition, Neighborhood Poverty, and the Spatial Accessibility of Supermarkets in Metropolitan Detroit,” American Journal of Public Health 95, no. 4 (2005): 660-67; S. Amesty, “Barriers to Physical Activity in the Hispanic Community,” Journal of Public Health Policy 24, no. 1 (2003): 41-58. 18. G. Bishop and A. Brodkey, “Personal Responsibility and Physician Responsibility—West Virginia’s Medicaid Plan,” New England Journal of Medicine 355, no. 8 (2006): 756-58. Two Pioneers of Euthanasia around 1800 BY MICHAEL STOLBERG I n his autobiographical “Apologie,” the famous French surgeon Ambroise Paré recalled how in 1536, he witnessed a remarkable case of mercy killing. On entering a conquered city, he encountered three fatally wounded soldiers. They were leaning with their backs against the wall of a horse stable, next to four others who were already dead. An old soldier approached Paré and asked him whether there was any hope for the three who were still alive. When Paré indicated there was none, the old soldier, to the surgeon’s great dismay, calmly proceeded to cut their throats with a knife.1 Paré’s story is just an anecdote, but it has important implications. It shows that active euthanasia was clearly not beyond imagination in the early modern period. This conclusion is confirmed not only by the famous fictional account of active euthanasia in Thomas More’s Utopia, published in 1516, but also by reports of “popular” customs like pulling the legs of hanged but still living criminals or suffocating dying patients with cushions to end their suffering.2 Western, Christian physicians, however, are generally thought to have unanimously rejected active euthanasia until the late nineteenth century. It was only then, historians of medical ethics have found, that individual physicians joined the ranks of those who, from the 1870s onwards, publicly advocated active euthanasia.3 As W.B. Fye has argued, various developments in late nineteenth-century medicine and society Michael Stolberg, “Two Pioneers of Euthanasia around 1800,” Hastings Center Report 38, no. 1 (2008): 19-22. May- June 2008 HASTINGS CENTER REPORT 19 made it feasible to propose “a concept as radical as ‘active euthanasia.’” These developments were a “spectacular growth of sophistication” in medical diagnosis and prognosis that made it possible to judge a patient’s condition as incurable “with reasonable accuracy”; the development of anesthesia and other new, powerful means for the relief of pain and suffering; and the decline of religiously motivated resistance.4 This standard account of the rise of the modern medical debate on active euthanasia needs to be revised in one important respect, however. It is undoubtedly true that active euthanasia moved into the center of a lively controversial debate only in the late nineteenth and early twentieth centuries. But at least two well-known German physicians already publicly endorsed active euthanasia around 1800. Their stance must be understood within the rather special context of German medicine and society at that time. succeeded in cleaning the cancerous ulcer and relieving the pain it caused. But each time, eight to twelve days later, the ulcer returned in an even more aggressive form. After the cure had been tried three times, the patient—once a strong and healthy man—had become frail and discouraged, and death appeared only a question of time. At this point, he refused further treatment. He asked Mursinna for his “dissolution” instead. As Mursinna explained, the patient wanted him to “accelerate his death.” Mursinna fulfilled his wish, although probably not in the way the patient had hoped. He died many months later, after the cancer had eaten away half of his tongue and penetrated far into the throat. “He would have died even later,” Mursinna wrote, “and in an undescribably painful, horrendous manner, if I had not given him opiates so often and thus alleviated his indescribable suffering and promoted his end.”6 A Radical Break The German Context I U n the year 1800, Carl Georg Theodor Kortum (1765–1824), a physician in the town of Stolberg near Aachen, published a series of short essays in the leading German medical periodical, Hufelands Journal der practischen Arzneykunde. In one of these essays, Kortum reported various cases of advanced consumption. The patients, he explained, sometimes went through the most horrendous agony, the mere sight of which was difficult for witnesses to bear. As they approached the end, for a period of some days they could hardly expectorate or even swallow, until they gradually lost their senses. Yet a patient would sometimes live on for another forty-eight hours beyond that, with an incessant death-rattle emanating from his or her chest. In such cases, according to Kortum, the only thing one could desire was that a gentle death end the patient’s suffering. His counsel was clear and explicit: “a moderate dose of poppy juice, e.g., 20 drops of Laudanum liq., infallibly shortens such agony, by extinguishing the weak vital flame entirely, and it is, in my opinion, morally permitted in such cases.”5 For all we know, Kortum may well have been the first physician in the Christian West who publicly justified and indeed advised active euthanasia on terminally ill patients. And although Kortum did not explicitly state that he himself had acted in this manner, his comment about what dose of laudanum was “infallibly” successful implies concrete practical if not personal experience. A year later, Christian Ludwig Mursinna (1744–1823), professor of surgery and head surgeon at the Charité hospital in Berlin, was even more explicit in this respect. In the first volume of his new Journal für die Chirurgie, Arzneykunde und Geburtshülfe, he publicly admitted that he had hastened the death of a patient and thus shortened his suffering. The patient, a military officer, had a lip cancer. A few weeks before Mursinna saw him in the Charité, a military surgeon had cut the cancerous parts away, but the cancer had grown back since and spread worse than ever. Applying the “cosmical” remedy, of which his article praised the virtues, Mursinna repeatedly 20 H A S T I N G S C E N T E R R E P O R T ndoubtedly, Kortum and Mursinna were exceptional. In my survey of pre-1850 medical case reports and contemporary works dealing with cancer, consumption, and other deadly chronic diseases, I have not found any other physicians who publicly endorsed active euthanasia on terminally ill patients. Nevertheless, the statements of these two figures have far-reaching consequences for our understanding of the history of euthanasia. They show that the gradual change and transformation of ethical thinking among the medical profession, at least in Germany, had by 1800 reached the point that fairly well-known physicians could publicly advocate active euthanasia. Of course, we do not know whether individual physicians, in Germany or elsewhere, had practiced active euthanasia in secrecy even before 1800. Some may at least have occasionally resorted to potent drugs like hemlock or opium, to massive bloodletting, or to risky operations on terminally ill patients, knowing or even expecting that this might bring life to an end. In published medical writing, however, active euthanasia had hardly been mentioned even as a theoretical possibility until this time. And those few authors who did address the issue routinely condemned it as a blatant violation not just of the Hippocratic Oath, but also of the laws of God and nature. This absence of any real debate on active euthanasia was certainly not due to a lack of cases in which the thought of shortening the suffering of dying patients might at least have crossed a physician’s mind. On the contrary, as numerous medical observations and case reports from the late sixteenth century onward show, many patients—especially those suffering from cancer, consumption, dropsy, and gout—died after months of horrible agony. In the case of cancer, already then considered the most terrible disease of all, the often excruciating physical suffering was aggravated by putrid secretions oozing from ulcerating organs or skin, filling the room with their stench. In the light of this kind of often highly visible decay, which left no doubt about the fatal prognosis, Fye’s assumption that only the marked improvement of medical diagnosis May- June 2008 and prognosis in the nineteenth century made active euthanasia acceptable makes little sense. And, in contrast to Fye’s position, it seems that the very lack of efficient anesthesia and analgesia before 1850 should have made it all the more pressing to consider other, more radical means to end the dying patient’s agony. Why did Kortum and Mursinna make this radical break with the tradition? The answer is bound to be speculative. After all, we are dealing with only two individuals, each of whom lived and worked in different circumstances, far removed from the other. But certain features of the professional lives of Kortum and Mursinna and of contemporary German medicine may help us understand what drove them. First, on an individual level, both were highly experienced physicians who had seen many of their patients die. Their training and professional background were quite different, but both had long years of medical practice behind them—fifteen years for Kortum and fortythree for Mursinna. Kortum had built himself a very sizable practice in and around Stolberg, then one of the most heavily industrialized areas in Germany. Consumption was rampant there, especially among the lower classes, and he must have frequently witnessed the slow and agonizing death he described in his paper.7 Mursinna’s experience with death and dying was even more extensive. Originally trained as a barber and only much later honored with a medical doctorate, he made a career as a military surgeon.8 In this position, he must have seen many soldiers die from battlefield injuries or disease. In a later speech to his students, he made no secret of the enormous emotional challenges of the military surgeon’s work.9 At the time he administered opium to the officer with lip cancer, he was responsible for the care of large numbers of patients at the Charité hospital, among them many whose diseases inevitably took a lethal turn. In other words, both Kortum and Mursinna were, by all appearances, reacting to the concrete challenges that they faced in their ordinary, everyday work life; it is noteworthy that they endorsed active euthanasia not in general deontological treatises, but in very concrete, practice-oriented texts. Second, Kortum and Mursinna in important respects represent a significant humanitarian movement among eighteenth-century physicians in Germany and elsewhere. Many eighteenth-century physicians combined enlightened rationalism and empiricism with the ideal of the emotional, com- passionate physician. Their detailed and emphatic descriptions of individual suffering and of the collective plight of the lower classes illustrate what Thomas W. Laqueur has aptly called the “humanitarian narrative.”10 They were designed to evoke the reader’s sympathy and compassion by focusing on the common human experience of bodily suffering, and to drive the reader to action. Kortum and Mursinna’s writings are excellent examples of a humanitarian narrative. The language they used to convey patients’ pain was highly emotional. Both had also written medical topographies, on Stolberg and Poland respectively. Kortum described the miserable living conditions and the degraded environment to which the working classes around Stolberg were exposed.11 Mursinna denounced the poor nutrition and the virtual slavery in which many Polish farmers lived.12 They presented themselves as endowed with an extraordinarily exquisite sensibility for the sufferings of their fellow human beings.13 Third, although Fye places the decline of religiously motivated resistance to active euthanasia in the late nineteenth century, it was well under way long before that in Germany. By 1800, the church had already lost a great deal of its former pervasive power among the learned elites there (although not only in Germany). Many eighteenth-century physicians and patients found it increasingly difficult to attribute a transcendental meaning to disease and suffering—to see them as a divinely ordained punishment for sins or as a test of pious patience.14 Early nineteenthcentury physicians were even frequently suspected of atheism. There was no sharp break; religion remained important, and some German physicians continued to offer religious arguments against active euthanasia. But Germany never had the massive evangelical revival that occurred in nineteenth-century Britain. Finally, medical writing in eighteenth- and early nineteenth-century Germany was characterized by a fairly unique interest in the care of dying patients. Following Francis Bacon’s oft-quoted admonition, physicians all over Europe had come to accept, at least in theory, that the physician’s task was not only to prevent and cure diseases, but also to provide “euthanasia”—that is, a good, mild death—by alleviating pain and suffering when a cure was no longer possible.15 But in Germany in particular, a very sizable body of literature on the care of the terminally ill developed. Works on “palliative therapy” began appearing in the 1680s,16 and dissertations and Euthanasia moved to the center of a lively, controversial debate only in the late nineteenth and early twentieth centuries. But two well-known German physicians publicly endorsed it around 1800. May- June 2008 HASTINGS CENTER REPORT 21 treatises discussed the issues of “dysthanasia” and “euthanasia.”17 This special German interest in palliative medicine and medical assistance for the dying continued unabated after 1800. About two dozen dissertations were devoted to socalled medical euthanasia—palliative medicine in the modern sense.18 In contrast, physicians outside Germany hardly published on this topic at all before 1850. The declining force of religious resistance and a longstanding German interest in the medical care of dying patients did not automatically lead physicians to demand active euthanasia. But combined with extensive personal exposure to the terminal suffering of dying patients and a secularized ideal of the humanitarian, compassionate physician, these developments created the conditions in which practically minded, hands-on physicians like Kortum and Mursinna could put the relief of individual suffering above any general theological or philosophical considerations. 1. A. Paré, “Apologie, et Traité Contenant les Voyages Faits en Divers Lieux,” Oeuvres Complètes, vol. 3, ed. J.-F. Malgaigne (Geneva, Switzerland: Slatkine, 1970), 676-734. 2. G.R. 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 (Ferrara, Italy: F. di Rossi da Valenza, 1560); R. Graziani, “Non-Utopian Euthanasia: An Italian Report, c. 1554,” Renaissance Quarterly 22 (1969): 329-33; M. Stolberg, “Active Euthanasia in Early Modern Society: Learned Debates and Popular Practices,” Social History of Medicine 20 (2007): 205-221. 3. G.J. Gruman, “An Historical Introduction to Ideas about Voluntary Euthanasia,” Omega 4 (1973): 87-138; R. Gillon, “Suicide and Voluntary Euthanasia: Historical Perspective,” in Euthanasia and the Right to Die, ed. A.B. Downing (London, U.K.: P. Owen, 1969), 171-92; E.J. Larson and D.W. Amundsen, A Different Death: Euthanasia and the Christian Tradition (Downers Grove, Ill.: InterVarsity Press, 1998); U. Benzenhöfer, Der Gute Tod? Euthanasie und Sterbehilfe in Geschichte und Gegenwart (Munich, Germany: Beck, 1999); D.W. Amundsen, “Medical Ethics, History of Europe,” in Encyclopedia of Bioethics, third edition, ed. W.T. Reich (New York: Macmillan Reference/Thomson Gale, 22 HASTINGS CENTER REPORT 2004), 1555-1658; W.B. Fye, “Active Euthanasia: A Historical Survey,” Bulletin of the History of Medicine 52 (1978): 492-502. 4. Fye, “Active Euthanasia.” 5. C.G.T. Kortum, “Kleine Aufsätze,” Hufelands Journal der praktischen Arzneykunde 10 (1800): 21-64. 6. C.L. Mursinna, “Etwas über den Gebrauch des Cosmischen Mittels und dessen Wirkung,” Journal für die Chirurgie, Arzneykunde und Geburtshülfe 1 (1801): 440-79. 7. C.G.T. Kortum, Beiträge zur praktischen Arzneiwissenschaft (Göttingen, Germany: Vandenhoek und Ruprechtischer Verlag, 1796). 8. A. Hartung, “Christian Ludwig Mursinna, ein Grosser Sohn der Stadt Stolp,” reprinted from Ostpommersche Heimat (Stolp, Germany, 1936). 9. C.L. Mursinna, Rede über die Geschichte der Preussischen Chirurgie im Achtzehnten Jahrhundert gehalten am Stiftungstage der MedizinischChirurgischen Pepiniere (Berlin, Germany: Unger, 1804). 10. T.W. Laqueur, “Bodies, Details, and the Humanitarian Narrative,” in The New Cultural History, ed. L. Hunt (Berkeley: University of California Press, 1989), 176-204. 11. Kortum, Beiträge zur praktischen Arzneiwissenschaft. 12. C.L. Mursinna, Neue Medicinisch-Chirurgische Beobachtungen (Berlin, Germany: Himburg, 1796). 13. Ibid.; Kortum, “Kleine Aufsätze”; C.L. Mursinna, MedicinischChirurgische Beobachtungen, nebst einigen Anmerkungen Darüber (Berlin, Germany: Himburg, 1782). 14. R. Porter, “Death and the Doctors in Georgian England,” in Death, Ritual and Bereavement, ed. R. Houlbrooke (New York: Routledge, 1998), 77-94 and 216-20 (notes). 15. F. Bacon, De Dignitate et Augmentis Scientiarum Libri IX (Paris, France: Mettayer, 1624). 16. E. Küchler, De Cura Palliativa. Praes. H.C. Alberti (Erfurt, Germany: Groshius, 1692); G.L. Rosa, De Curatione Palliativa. Praes. A.E. Büchner (Erfurt, Germany: Hering, 1742). 17. C.C. Hennig, De Dysthanasia Medica. Vom Schwehren Todt. Praes. M.l Alberti (Halle-Magdeburg, Germany: Hendel, 1735); M.F.V. Alberti, De Euthanasia Medica, Vom Leichten Todt. Resp. Z.P. Schulz (HalleMagdeburg, Germany: Hendel, 1735). 18. C. Hoffmann, Der Inhalt des Begriffs “Euthanasie” im 19. Jahrhundert und seine Wandlung in der Zeit bis 1920, typescript (Berlin, Germany, 1969). May- June 2008