History and Philosophy of Medicine

The Doctor’s Dilemma: The Utilitarian Medical Ethics of Nazi Physician

Joshua J. Schultz, MA, BHSc candidate, Brock University

medicine, which had spawned advances in public health, Abstract pharmaceuticals, and vaccines. He recognized the precipi- Before World War II German physicians and scien- tous decline that had occurred when German medicine be- tists were responsible for major advances in medi- came Nazi medicine. Lead prosecutor General Telford Taylor identified a similar decline. In his view, Nazi medicine was cine. The actions of doctors in the Nazi system were thanatology – the science of death. He argued that Nazi medi- an aberration of this legacy; however, not all Nazi cine’s contribution was techniques for ending life.2 It had not doctors operated in an ethical vacuum. This paper added relevant medical advances through its inhumane ex- examines the doctors’ trial at Nuremberg in 1946. perimentation. Contrary to Telford’s view, not all Nazi doc- This paper draws attention to the utilitarian medi- tors operated in an ethical vacuum. The medical ethics of cal ethics of the Nazi doctor Karl Brandt and dis- some Nazi doctors represented an extreme form of utilitari- cusses how utilitarianism still informs medical prac- anism that instrumentalized human life and disregarded in- tice today. The Hippocratic Oath was cited by the dividual autonomy. The defense of Brandt at the Nuremberg prosecution at the Nuremberg doctors’ trial as part Trials provides a glimpse into the logic behind this peculiar of the common law of medicine. Brandt and his de- medical ethics. This paper draws attention to the utilitarian fense lawyer Dr. Robert Servatius countered by argu- medical ethics of the Nazi physician Brandt and discusses how ing that Brandt was acting in the best interests of the utilitarianism still informs medical practice today. state. He and Servatius argued that the morality of German doctors in the Nazi system represented an Background alternate medical ethics to that practiced in western The trial of Nazi doctors at Nuremberg in 1946 reveals democracies. In the end Brandt was found guilty much about the ethical backdrop in which said doctors prac- of negligence due to the presence of non-German ticed medicine and carried out their research. The Nurem- citizens in the T-4 “euthanasia” program of which berg doctors’ trials were a means for the allied powers to ar- Brandt had been in charge. “Brandt’s trial high- gue for the universality of ideas central to modern medical lights utilitarianism in medical ethics whereby phy- ethics – values such as informed consent, the non-maleficence sicians are responsible for determining the cost that principle, and the beneficence principle. From the perspec- treatment of the individual represents to the com- tive of the prosecution, such values were integral to medical experimentation and medical practice. Under this paradigm munity. The community sets limits and physicians Nazi physicians were duty bound to practice according to must work within those limits, but in order to act these principles. Conversely, the defense argued that the ac- as a bulwark to malevolent state power as existed in tions of German doctors were utilitarian – they were for the Nazi , physicians have a duty to advocate benefit of the German people and the German state. Thus, for life and treatment whenever possible. Nazi physicians like Brandt felt that duty was secondary to consequences. As long as the majority of Germans benefitted, the actions of Nazi physicians were justified. The notion of common law drove the prosecution of Ger- Introduction man war criminals. The Hague Convention of 1907 served as et me remind you only of names like Robert Koch, precedent for deciding what constituted crimes against hu- Emil von Behring, Paul Ehrlich, Theodor Billroth, manity.3 Defense lawyers for German war criminals protested “Land August Bier, or medicines such as Germanim, that the Axis powers were not signatories of this convention.4 Atabrine, Salvarsan, diphtheria serum, tetanus serum, and The prosecution countered that since the bulk of nations had many others.”1 Hans Pribillia’s closing statement for the been signatories, Germany was still bound by its laws. Crimes defense of Nazi physician Dr. Paul Rostock at the Nurem- committed against humanity were recognized as part of the berg trials in 1946 recounted the former glory of German common law of all nations. The prosecution of Nazi doctors similarly found its basis in common law. Expert medical witnesses Dr. Andrew Ivy and Corresponding Author: Dr. Leo Alexander cited the Hippocratic Oath as the prima- Joshua J. Schultz ry code of ethics for any doctor educated in the traditions E-mail: [email protected] of Western medicine. For Ivy, the Hippocratic Oath was a

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The Doctor’s Dilemma: The Utilitarian Medical Ethics of Nazi Physician Karl Brandt universally binding oath that applied to all doctors, and it su- The crux of Taylor’s argument is that violation of the in- perseded laws and directives of the state that demanded ac- dividual’s right to choose is a violation of universal common tion contrary to it. When asked during his testimony whether law. He strongly indicts systems that endorse such a violation. he felt the state could assume the moral responsibility of the His argument has the individual taking precedence over the physician, Ivy replied that the state is incapable of monitor- good of the nation state. The consequences of emphasizing ing the actions of a physician in his or her daily practice.5 individual rights do not factor into his argument. There is Indeed, he argued that physicians have a moral responsibility no recognition of the benefits and downsides such a view has to act according to the Hippocratic Oath.5 Included in Ivy’s for medical practice; instead, consent and autonomy are most testimony was the mention of specific standards for research important because that is what had always been done. In Tay- and experimentation that existed in the United States as part lor’s view consent and autonomy were part of the common of the American Medical Association’s (AMA) guidelines.6 law of medicine. Incidentally, such principles dealing with experimentation Ironically, it was adherence to democratic notions of jus- done on human beings had not existed prior to December tice underlying the Nuremberg trials that made it difficult for 28, 1946. Having become acquainted with the nature of Nazi the prosecution to piece together a case against Nazi doctors. experiments through the reading of the prosecution’s pre- Due to the questionable jurisdiction that the United States trial records, Ivy had reported his findings and given general claimed in prosecuting German citizens, the opening state- recommendations regarding human experimentation to the ment of the prosecution stressed the genocide of Jewish per- AMA, who subsequently codified said recommendations.6 sons.9 This had a two-pronged effect: it downplayed crimes Globally speaking, there were no pre-existing written stan- against other ethnic minorities such as the Roma, and it de- dards for human experimentation before 1946. Ivy claimed emphasized the “euthanasia” program, which had involved that the AMA standards only recently put in to writing had mostly German citizens. The primary defendant among the been common practice.7 In his view, physicians had a duty at 21 doctors at the Nuremberg trial, Dr. Karl Brandt, was head the very least to do no harm. of the Tiergartenstrasse-4 (T-4) “euthanasia” program and only Since written standards to guide doctors in carrying out minimally involved with the genocide of foreign nationals. human experimentation had not existed prior to 1946, the Aktion T-4, which was instituted by the German govern- prosecution had to gather expert testimonies from practic- ment in September, 1939, was a program designed to end the ing physicians and synthesize a code therefrom. Such a code suffering of the so-called “incurably ill”.10 Those judged incur- could be used by the Nuremberg judges in rendering a deci- ably ill tended to suffer from mental illness or mental and sion. The result of this synthesis was the Nuremberg Code, physical disabilities. They had depended on the state for sup- which contained ten principles to which doctors were re- port and resided in state institutions. The scarcity stemming quired to adhere before human experimentation could be from World War I and the 1930s had made Germans much carried out.8 The first principle is most relevant to medical more receptive to ending life that was a drain on the system.10 practice. It states that voluntary consent of the human sub- The Nazi party also portrayed the lives of the “incurably ill” as ject must be attained prior to any research taking place.8 The filled with suffering and devoid of meaning through various ninth principle also addresses the question of consent since propaganda films.10 Throughout the 1930s and World War it requires the researcher to halt his experiment if the hu- II, panels of experts decided on the fate of institutionalized man subject suddenly feels she/he might come to harm.8 The children and adults. As scarcity of resources became a greater Nuremberg Code embodies a core democratic axiom: an in- problem for Germans, the number of institutionalized pa- dividual cannot be controlled or coerced into doing anything tients who were euthanized grew. Brandt was in charge of that may bring her/him harm. According to the code, physi- Aktion T-4. For him the ethical practice of medicine involved cians have a duty not to harm not because it is good for the ending the suffering of the “incurables” in order to free up many, but because human life is valuable in and of itself. resources for the German people. The Nuremberg Code was in line with the general tenure The cornerstone of Brandt’s defense during the Nurem- of the prosecution’s argument against Nazi doctors. They were berg trials centered on painting him as an idealist, who truly being tried for violating what were considered inalienable pa- believed in the objectives of the T-4 “euthanasia” program. In tient/subject rights, for willingly participating in Nazi atroci- his attempt to pass as an idealist adhering to utilitarian ethics, ties, and for cooperating with the Nazi system. General Taylor he selectively discussed his involvement in the “euthanasia” expressed the opinion of the prosecution in this regard: program. He denied that he had ever visited the headquarters of T-4 or that he had inspected any of the killing centres.11 His None of the victims of the atrocities perpetrated by these duty was to be healer and physician to the Fuehrer and the defendants were volunteers, and this is true regardless of what German people. He candidly discussed one of the first docu- these unfortunate people may have said or signed before their mented cases of “euthanasia” performed in Germany. A father tortures began […] It is a fundamental and inescapable had written a request to Hitler to have his deformed son eu- obligation of every physician under any known system of law thanized. As Hitler’s in-flight physician, Brandt was assigned not to perform a dangerous experiment without the subject’s the task of speaking with the doctors who cared for the child consent. In the tyranny that was , no one could to determine if “euthanasia” was viable given the accuracy of give such a consent to the medical agents of the State; and the father’s letter.12 When questioned by the defense counsel, everyone lived in fear and acted under duress.2 he gave the impression of a caring man, concerned with the

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The Doctor’s Dilemma: The Utilitarian Medical Ethics of Nazi Physician Karl Brandt well-being of parents trying to do their best for their suffer- program was a moral or political guilt, and not a criminal one. ing child. Brandt stated: “The important thing was that the He underlined in his final plea for Brandt that the question parents should not feel themselves incriminated at some later of Brandt’s guilt was related only to whether prisoners of war date as a result of this euthanasia – that the parents should or foreign nationals had been “euthanized” with his knowl- not have the impression that they themselves were responsible edge.16 In order to escape the judgment of the court, it had for the death of this child.”11 Brandt’s task as he saw it was to be shown that Brandt acted only against Germans in the to minimize the suffering of the parents and the child they interest of the German nation. In doing so, Brandt tried to had brought into the world. He further justified his actions by evade the charge of immorality directed against him by claim- making it clear that “euthanasia” was already common prac- ing that what seemed like immorality to Americans was in fact tice and an unspoken rule. When questioned about other a different type of morality. His morality was utilitarian in that doctors involved, Brandt replied that “euthanasia” was already it sought the benefit of the many at the expense of the few. It performed in maternity wards on severely deformed infants sought to first and foremost preserve the community. In his without explicitly discussing or documenting it.11 Brandt un- final statement, Brandt expressed his philosophy to the court: derstood certain forms of “euthanasia” to be not only accept- It is immaterial for the experiment whether it is done with or able, but normal for the practice of medicine. against the will of the person concerned. For the individual the The defendants at the Nuremberg doctors’ trial implicitly event seems senseless, just as senseless as my actions as a doctor argued it was Anglo-American medicine that was flawed and seem when isolated. The sense lies much deeper than that. Can not German medicine. Dr. Fritz Sauter, defense counsel for I, as an individual, detach myself from the community? Can defendants Ruff and Romberg, responded to the testimony of I remain outside and do without it? Could I, as part of this Ivy regarding medical ethics in the United States: community, evade it by saying I want to live in this community, The question asked here is always what the opinion of the but I don’t want to make any sacrifices for it, either of body and medical profession in America is. For us in this trial, in the soul?14 evaluation of German defendants, that is not decisive. In my Brandt defended his actions in a system that valued neither opinion the decisive question is for example, in 1942, when individual autonomy nor the sanctity of individual life. What the altitude experiments were undertaken at Dachau, what mattered was that the community thrived. The life and au- the attitude of the medical profession in Germany was […]in tonomy of the community took precedence. Brandt’s defense my opinion a German physician who in Germany performed articulated a new medical ethics born from the twisted system experiments on Germans cannot be judged exclusively according 13 of Nazi Germany. The ends justify the means, community be- to an American medical opinion. fore individual, and system before patient. Defense counsel for Brandt contended that the “eternal Karl Brandt was not hanged for his medical utilitarianism. basic elements of law” constituted nothing more than a guid- While agreeing that German doctors could be not be judged ing principle for the state. Citizens were not excused from civ- according to American law, and without arguing against the il disobedience if they were acting according to the so-called espoused morality of the “euthanasia” program, the judges common law of all nations; ultimately the state decided what convicted Brandt on the weakest points of his defense: negli- was right and wrong and not the citizen. In a statement, which gence and the presence of foreign nationals in the “euthana- goes against the grain of democratic governance, Servatius sia” program. An excerpt from the verdict reads: proposed: We have no doubt but that Karl Brandt – as he himself testified One forgets that eternal law[…] is but a guiding principle for – is a sincere believer in the administration of euthanasia the state and the legislator and not a counter-code of law which to persons hopelessly ill[…] The evidence is conclusive that the subject might use as a support against the state. It is empha- persons were included in the program that were non-German sized that no other state had made such decisions up to now. nationals. The dereliction of the defendant Brandt contributed This is true only to a certain extent. It is no proof, however, that to their extermination. That is enough to require this tribunal such decisions were not necessary and admissible now. There is to find that he is criminally responsible in the program.7 16 no prohibition against daring to progress. In some measure, Brandt’s attempt to pass himself off as Servatius not only argued that the judges of the Nurem- an idealist had succeeded. Unfortunately for him, the judges berg trial had no right to sentence Brandt according to the did not accept that given his title and his proximity to Hitler laws of the United States; he also implicitly stated that the he had been unable to halt the atrocities committed by other “euthanasia” program was evidence of the progressive nature doctors. Brandt was not hanged for his peculiar medical eth- of the German state. Brandt was not a villain with mal-intent; ics; he was hanged for his association with the Nazi party. His he was, according to his defense counsel, a utilitarian physi- trial, however, prompted the Nuremberg Code and a new em- cian healing the ills of his community. phasis on patient autonomy. The prosecution’s contention that the crimes of genocide and the murder of foreign nationals were connected with the Discussion “euthanasia” program necessitated Brandt’s argument that he As far as the German doctors on trial at Nuremberg can be acted only within the German context and that the program said to have a guiding set of ethical principles, Brandt came he was in charge of affected only German citizens. Servatius closest to expressing it. Popular conceptions of Nazi doctors could argue that the guilt ascribed to Brandt for his role in the view them as acting apart from ethics of any kind. The vicious

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The Doctor’s Dilemma: The Utilitarian Medical Ethics of Nazi Physician Karl Brandt experiments performed on inmates of concentration camps medical practice. Due to the Nuremberg Code, the emphasis by men like Josef Mengele support this point.10 The evidence of modern medicine has been on patient autonomy for its suggests, however, that Brandt was never directly involved in own sake.15 Samuel Hellman points out that at least in medi- medical experiments, and in his capacity as co-head of the cal research the deontological position that places a premium “euthanasia” program, he acted according to a set of ideals.7 on individual autonomy has been growing stronger since the This set of ideals emphasized fulfilling one’s duty to the state, formulation of the Nuremberg Code in 1947.18 Brandt was the Volk, and the relief of suffering. “Ulf Schmidt suggests that portrayed as a villain at the Nuremberg trials partly because Brandt was sincere in his belief that the task of the doctor was he disregarded the core deontological values of individual to relieve suffering for the greater good of one’s community autonomy, beneficence, and non-maleficence. His assertion even if the end of suffering meant ending a life.7 There are that he was concerned only with the health of the community serious problems with such a belief. To begin, how is suffering was seen as an excuse for murder. Physicians in Canada do defined and who decides what constitutes suffering? How do not practice murder for the benefit of others; however, they physicians treat patients who are unable to express their suf- may play a role in withholding or rationing treatment. The fering or give their consent? As far as Brandt and other Nazi utilitarian ethic underlying socialized medicine encourages doctors were concerned, the State was the ultimate arbiter of this tendency. such questions. The recent debate about Canadian life support patient The Nuremberg doctors’ trial prompted the creation of Samuel Golobchuk is instructive. Golobchuk was an 84 year the Nuremberg Code in 1947 as well as the Declaration of Ge- old Orthodox Jewish man on life support in a state that was neva in 1948.15 The Nuremberg Code is concerned with prin- not persistently vegetative or brain dead.19 The physicians in ciples for conducting medical research on human subjects. charge of his care had advocated for his removal from life “The Declaration of Geneva is a revision of the Hippocratic support to the protestations of Golobchuk’s family.19 The ac- Oath, and it focuses more specifically on clinical practice. Key tion of these physicians directly contradicts the first principle statements include putting the health and life of the patient of the Nuremberg Code prohibiting decisions regarding a pa- first and maintaining the highest respect for human life.16 tient’s health without patient consent. Yet, said physicians had Since the Nuremberg doctors’ trial, the ideas expressed in the backing of the Royal College of Physicians and Surgeons these documents have exerted a profound influence on the of Manitoba. A 2007 statement from this college regarding practice of medicine.15 These codes are written expressions of life sustaining treatment stated that the decision to withdraw the so-called “common law” of medicine. Notably, the Nurem- life support from a patient unable to provide consent lay with berg code emphasizes the rights of the individual vis-à-vis the the physicians in charge of a patient’s care and not the rela- state, and the Declaration of Geneva emphasizes the need for tives of the patient.19 Golobchuk was unlikely to recover, and physicians to focus on the patient without reference to the from an economic perspective, his advanced age made the needs of society.8,16 Brandt may not have been punished for withdrawal of life support the most efficient course of action. his utilitarian ethics, but the trials of him and other Nazi doc- Golobchuk’s physicians were advocating for a passive form of tors certainly prompted medical authorities throughout the euthanasia in order to better the health of the entire commu- world to define exactly how a physician ought to behave with nity, presumably by freeing up a hospital bed. respect to her/his patient or research subject. In the pursuit of societal benefit it is difficult to discern Brandt’s defense at the Nuremberg doctors’ trial raises an the unintended consequences of one’s actions. Respect for uncomfortable question for doctors practicing modern medi- individual autonomy and doing one’s utmost to treat one’s cine: What are the limits of a physician’s duty to the individual patient without regard for cost are integral to the practice of patient with respect to the needs of the community? The ar- medicine because physicians are not privy to the effects their guments of the prosecution at the Nuremberg doctors’ trial decisions will have 5, 10, or 20 years in the future. In allowing assumed that respect for individual autonomy and life should “incurable” patients to die for the sake of freeing up hospi- be inviolate. The reasoning behind these arguments rested tal beds physicians risk undermining the value placed on life. on the idea of duty: physicians must respect life because that Practicing medicine with utilitarian goals in mind also has the is what physicians do. Just as the so-called “common law” of potential to colour one’s treatment of individual patients as nations forbids “crimes against humanity”, so too does the occurred in the case of Golobchuk. Physicians cannot pre- “common law” of physicians, i.e. the Hippocratic Oath or the dict how a utilitarian mindset may alter the manner in which Geneva Declaration, forbid doing harm to a patient without they treat certain patients “less deserving” of healthcare dol- mention of how carrying out one’s duty may affect others.16,17 lars. The deontological perspective should dominate over the The foundation of modern medical practice rests on the idea utilitarian one precisely because human beings are not able of doing one’s best to treat one’s patient; however, what if the to see all of the variables involved in their decision making. patient is the community and not the individual? Resisting utilitarianism is itself utilitarian. Brandt’s utilitari- The point of this essay is not to draw a direct comparison anism did not leave room for the hopeless cases, the “incur- between modern medicine in nations like Canada and the ables,” or those patients who do not contribute to the social United States and the medicine of Nazi Germany. Rather the good. His approach was an arrogant one because it has physi- purpose of this paper has been to draw attention to the utili- cians playing the role of God in deciding who should live and tarianism of the Nazi doctor Karl Brandt and to point out that who should die; however, it is the humility of medical practice this philosophy still exerts a powerful influence on modern that makes it so beautiful a profession. Admitting that it is

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The Doctor’s Dilemma: The Utilitarian Medical Ethics of Nazi Physician Karl Brandt impossible to know how medical decisions will affect the fu- 5. Extracts from the Testimony of Prosecution Expert Witness Dr. Andrew Ivy. [Internet]. Nuernberg Military Tribunal, Volume II, 86. Mazal Library. [cit- ture compels physicians to follow a code of behaviour that ed 2012 Jun 15]. Available from: http://www.mazal.org/archive/nmt/02/ has been forged and shaped by the history of medical prac- NMT02-T0086.htm. tice. The authors of a 2010 article in the American Journal of 6. Grodin MA. Historical Origins of the Nuremberg Code. The Nazi Doctors and the Nuremberg Code. George J. Annas & Michael Grodin, editors. New Bioethics argue that questions regarding the cost of healthcare York: Oxford University Press, 1992; 121-144. and how to allocate scarce healthcare resources should not 7. Schmidt U. Karl Brandt: The Nazi Doctor. New York: Hambeldon Continu- be dealt with by physicians.19 I propose that this argument um, 2007. 8. The Nuremberg Code. The Nazi Doctors and the Nuremburg Code: Hu- be taken further. Physicians must actively advocate for all of man Rights in Human Experimentation. In Annas GJ & Grodin MA, edi- their patients regardless of how it will affect the community. tors. New York: Oxford University Press, 1992; 2. 9. Schmidt U. Justice at Nuremberg. New York: Palgrave Macmillan, 2004; The community sets limits and physicians must work within 167. those limits, but in order to act as a bulwark to malevolent 10. See Lifton RJ. The Nazi Doctors: Medical Killing and the Psychology of state power, physicians have a duty to advocate for life and Genocide. New York: Pearson Longman, 2006. 11. Extracts from the Testimony of Karl Brandt. Nuernberg Military Tribunal, treatment whenever possible. Karl Brandt’s actions in Nazi Volume I, 894. [Internet]. Mazal Library, [cited 2012 Jun 16]. Available Germany were not excusable from a medical ethics point of from: http://www.mazal.org/archive/nmt/02/NMT02-T0123.htm. view. His first duty should have been to the patient and not 12. Burleigh M. Death and deliverance: Euthanasia in Germany. C. 1900-1945. New York: Cambridge University Press, 1994. the community. 13. Excerpted in Macklin R. The Universality of the Nuremberg Code. The Nazi Doctors and the Nuremburg Code. New York: Oxford University Press, 1992. References 14. Final Plea for Defendant Karl Brandt, Nurenberg Military Tribunal, Vol- 1. Closing Brief for the Defendant Professor Paul Rostock delivered before ume I, 126. [Internet]. Mazal Library. [cited 2012 Jun 16]. Available from: Military Tribunal I, Nuernberg. Page 1 of 53[Internet]. Harvard Law http://www.mazal.org/archive/nmt/02/NMT02-T0123.htm. School Library. Nuremberg Trials Project: A Digital Document Collection. 15. Frewer, A. Human rights from the Nuremberg doctors trial to the Geneva [cited 2012 Jun 15]. Available from: http://nuremberg.law.harvard.edu/ Declaration. Persons and institutions in medical ethics and history. Med php/pflip.php?caseid=HLSL_NMT01&docnum=954&numpages=53&star Health Care and Philos. 2010; 13: 259-268. tpage=1&title=Closing+Brief+for+the+Defendant+Professor+Paul+Rostock 16. World Medical Association Declaration of Geneva [Internet]. [Cited +delivered+before+Military+Tribunal+I,+Nuernberg.&color_setting=C. 2013 Mar 10]. Available from: http://www.wma.net/en/30publications/ 2. Taylor T. Opening Statement of the Prosecution, December 9, 1946. The 10policies/g1/. Nazi Doctors and the Nuremberg Code. George J. Annas & Michael Gor- 17. Hippocrates. The Hippocratic Oath. In Miles SH, editor. The Hippocratic din, editors. New York: Oxford University Press, 1992; 67-93. oath and the ethics of medicine. New York: Oxford University Press, 2005; 3. Hague Convention Section III: Military authority over the territory of a 14. hostile state. [Internet]. Lillian Goldman Law Library. The Avalon Project: 18. Hellman S. On first looking into Kutcher’s “Contested Medicine”: Ethical Documents in Law, History and Diplomacy. [cited 2013 Mar 14]. Available tensions in clinical research. Perspectives in Biology and Medicine. 2010; from: http://avalon.law.yale.edu/20th_century/hague04.asp. 53(2): 304-314. 4. Judgement : The Law Relating to War Crimes and Crimes Against Human- 19. Jotkowitz A, Glick S, Zivotofsky AZ. The case of Samuel Golubchuk and the ity. [Internet]. Lillian Goldman Law Library. The Avalon Project: Docu- Right to Live. The American Journal of Bioethics. 2010; 10(3): 50-53. ments in Law, History and Diplomacy. [cited 2012 Jun 19]. Available from: http://avalon.law.yale.edu/imt/judlawre.asp.

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