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12-1965 UWOMJ Volume 36, Number 2, December 1965 Western University

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Morality and ethics as they apply to medicine are bewildering and vital in about equal measure. In these areas grey is the predominant colour; there are no pat solutions. The complexity of these issues is heightened by lheii' intimate involve-­ ment with religion and law - fields especially conducive to disagreement.

For all their vagueness, moral issues such as abortion or euthanasia, and ques­ tions of ethics such as the therapeutic use of placebos or the physician's responsi­ bilities at the scene of an accident, must inevitably be faced in the course of medical practice.

In the standard medical curriculum such problems are dealt with pragmatically, if at all. The physician's legal position is stressed, while questions of ethics and morality are largely ignored. In this number of the Journal an attempt is made to illuminate the underlying issues and to offer possible solutions to several of these problems. A physician's actions must be governed not merely by a knowledge of what is permissible, but also by an accurate understanding of the basic issues. He cannot abdicate his responsibility to formulate for himself, moral and ethical stand­ ards which will guide his behaviour as a medical practitioner.

In this issue an article entitled "a new deal for homosexuals" appears under the heading, DISSENT. This feature is designed to serve as a medium· for the presentation of views which are opposed to traditional or prevailing thought. Any subject relevant to medicine is fair game for DISSENT. Medical education, the "image" of the profession, the "foreign doctors" question, and medicare, are but a few of the many issues which might conceivably be discussed.

A number of technical innovations have been made in this number of the Journal. These changes are strictly tentative; their future will be determined by reader reaction. B.G.H.

DECEMBER, 1965 33 £etters to t~e ~Jitor In the past, letters to the editor have not been a prominent feature of the Medical Journal - not because we are unreceptive to them but merely because few have been received. Irate or otherwise inspired readers may address their comments to the Editor-in-Chief, UWO Medical Journal.

INTERN: by Doctor X; Harper and Row His comments on hospital procedures, Publishers, New York, 404 pages ( 7.95). nursing staff, and medical staff are candid, illuminating, and sometimes shocking - Intern by Doctor X is the diary of a always lucid, sometimes lurid. His person­ young doctor recorded on tape day by day ality is projected throughout the diary. He throughout his year of internship at a pri­ has remarkable candor and a wry humour, vate metropolitan hospital. He describes and like many junior physicians has the his experiences as he rotates through the refreshing faculty of talking and thinking four services - Medicine, Obstetrics and in laymen's terms. Gynecology, Surgery, and Paediatrics. Dr. X is presently a practicing physician Technically the diary is not a "book" in a large American city. He explains the as it consists of a series of sometimes un­ publication of this remarkable diary in the related experiences which ·seem to have no introduction. "There is an ancient un­ spoken code of secrecy surrounding the beginning and no end. The ~riter ' s mood and style vary according to the events practice of medicine and the men who of the day and the number of hours of practice it .... I am convinced that this sleep he obtained the previous night. As attitude is wrong and unworthy of the a result the diary accomplishes what no great profession that perpetuates it . . . . elaborately contrived "medical" novel People need to understand how a doctor could do. It elucidates the awesome work becomes a doctor, what the practice of load of the junior intern and his resulting medicine is all about . . . and, above all, mental and physical exhaustion, his mood they need some insight into the human swings as he is confronted with the reality limitations upon a doctor's powers .. .. of death and new life, his wrath at nurs­ My intention in publishing this journal ing incompetence, his shame at medical has been to contribute to such an under­ incompetence, and his admiration of medi­ standing between doctors and the general cal genius. It is a graphic portrayal of the public." drudgery of menial medical tasks, the Intern by Doctor X is an intimate living disappointments, disillusionments, and diary and of interest to medical personnel disasters that are part of the intern's life, as well as laymen. as well as the intellectual and emotional rewards of a tiring and often thankless job. Reviewed by Wayne Howell '66

34 U.W.O. MEDICAL JouRNAL DISSENT

a new deal ·for homosexuals*

by brian hutchison '67

In our mid-twentieth century concern with the rights of minorities, one such group, representing in excess of four per cent of the male population, seems to have escaped notice homosexuals. Having fallen victim to the doctrine equating orthodoxy with virtue and nonconformity with evil, homosexuals are persecuted by society" · gen­ erally, and in particular by society's agent, the law .This vilification is .: founded firmly upon ignorance.

Simply defined, homosexuality is a pro­ exclusively homosexual for at least th~~ pensity for persons of one's own sex. years between the ages of 16 and 65, and Homosexuality is not an "all or none" that 3 7 per cent have at least some overt proposition. W ith respect to sexual pro­ homosexual experience, to the. point of pensity a continum exists between absolute orgasm, between adolescence and old age. heterosexuality and absolute homosexuality The labels with which homosexuals have along which all individuals may be placed. been tagged include: criminal, immoral, Sexual preference need not always be mentally ill, a scourge upon society, and reflected in behaviour. others not worthy of repetition. By objec­ tive standards all are misnomers. This article introduces "DISSENT", a feature of The Journal designed to accom­ criminal? modate expressions of opinion on subjects Under current Canadian law a male en­ relevant to medicine, which dissent from gaging in homosexual activity, under any the prevailing view. Contributions to circumstances whatever, is subject to im­ "DISSENT" may be submitted to the prisonment. The law is sporadically en­ Editor-in-Chief, UWO Medical Journal. forced. Crackdowns are generally the result of periodic waves of self-rigliteous The four per cent figure cited above public indignation. represents the proportion of males whose The function of law is the preservation sexual activity is exclusively homosexual. of public safety and the protection of Kinsey in the United States found that individual rights. In what conceivable 10 per cent of males were more or less manner do homosexual acts performed ·in

•This article will deal exclusively with the question of homosexuality in males. Female homosexuality is omitted due to 1) the Jack of information concerning homo­ sexuality in females and 2) the fact that female homosexua.Js are largely ignored rather. than persecuted. The conclusions, however, are in most instances equally applicable to female homosexuals.

DECEMBER, 1965 35 --Dissent------private between consenting parties con­ scourge? stitute a threat to public welfare or the Homosexuality is widely regarded as a rights of others? Obviously there is no malevolent force which, unless checked, threat. will bring about the degeneration and de­ Many persons find the mere thought of cay of our civilization. homosexuality repulsive. But moral con­ viction or instinctive feeling, however In order to determine the validity of strong, is not sufficient justification for this claim we must examine the nature of violating an individual's privacy and for the homosexual. Some experts contend that bringing private sexual behaviour within homosexuality is not peculiar to members the realm of criminal law. The fact re­ of particular professions or social classes. mains that homosexuality per se is in no Others argue that the practice is seen pre­ way contrary to the public good. dominantly in artistic individuals or among the intelligentsia. The clash of There are those who contend that a opinion is of no consequence to this dis­ relaxation of the law will produce mass cussion. However, the agreement that conversion to homosexuality. Surely the homosexuals are productice members of majority of the population remains hetero­ society, is very much to the point. Homo­ sexual not because of existing prohibitions sexuals, far from being a drain on society, against homosexuality but because of a take their place as useful members of the positive attraction to the opposite sex. community. Indeed, for a switch to homosexuality to exert a detrimental effect on society, it In view of these facts it is difficult to would have to be of sufficient magnitude envision the manner in which the expected to prevent society from perpetuating itself. decay and degeneration will come about. Such a result is hardly within the realm of possibility. " illness? In contradiction to popular belief, Without reason, homosexuality has come seduction of children, assault, or violations to be considered a mental illness. of public decency (acts which the public In order to merit recognition as an ill­ see and are offended by) enter the picture ness or disease, a condition must at some in only a small proportion of homosex­ stage produce either discomfort or a de­ uals. gree of incapacitation in the afflicted Many advocate strong penalties for individual. Homosexuality fails to qualify homosexual seduction of youths on the on both counts. The practice is compatible theory that such seductions are the decisive with full mental health and normal func­ factor in the production 9f homosexuality tioning. as a condition. There is no convincing Popular opinion notwithstanding, homo­ evidence to support this contention. sexuals are for the most part indistinguish­ There can be no justification for differ­ able from heterosexuals on the basis of entiating between a heterosexual and a speech, appearance or manner. Tranvesti­ homosexual offence as regards the law. tism or blatant effeminacy are seen in only Neither is inherently more dangerous than a small proportion of homosexuals. When the other. General provisions covering they occur, these bizarre accompaniments sexual offences are sufficient for protec­ of homosexuality are in all probability the tion of the public. Such an approach has result of conflicts and stresses engendered been adopted in a number of countries by social condemnation. Indeed, it has including Belgium, Italy, Norway and been suggested that in those countries Spain. characterized by tolerant attitudes toward

36 u.w.o. MEDI~ JOURNAL homosexuality, associated psychiatric ab­ This position is valid only insofar as one normalities are rare or even absent. accepts the premise that procreation is the sole valid function of sexual activity · a The concept of homosexuality as a principle which has been rejected in our disease originates not from scientific evi· society. We acknowledge that the pro· dence but from a misguided attempt to vision of pleasure is a legitimate function equate mental illness and "immorality". of the sexual act. Indeed we do not stop We do not consider fornication a psychi· there but go so far as to recognize mutual atric problem. Nor do we regard adultery enjoyment ALONE to be sufficient justi· as a disease of the mind. How then can fication for sexual intercourse - as evi· we justify the equation in respect to denced by the acceptance of birth control homosexuality ? We cannot. (be it rhythm or "the pill"). Having rejected the concept that a possi­ If then, homosexuality is not a mental bility of conception must be present to illness, what are the responsibilities of the validate sexual activity, the argument that medical profession in this matter? Ob­ homosexuality is unnatural loses much of viously the profession is obligated to con· its force. When we consider that accepted vince the public that homosexuality as heterosexual love-making is by no means such is not a psychiatric problem but one confined to the act of coitus alone, the of morality. argument becomes altogether meaningless. Medicine will of course have a role to Our concepts of sexual morality have play in the treatment of homosexuals with changed dramatically in recent years. Un· associated psychiatric problems. Such fortunately we have failed to update our treatment should in most instances be attitudes toward homosexuality in accord­ directed toward relieving mental stress by ance with these changes. producing a better adjustment, rather than Any sexual act which is pleasurable to attempting to alter the individual's sexual the participants and is performed in good propensity. Homosexuals are for the most faith, is a valid act. The sex of the par­ part neither interested in nor amenable to ticipants has no relevance. "cure" in the sense of conversion to heterosexuality. solution? By encouraging increased toleration of Question: What are we to do about the homosexuality by the public, medical problem of homosexuality? practitioners can do much to prevent the Answer: There is no problem. development of secondary mental illness Homosexuality poses no threat to so· in homosexuals. ciety, yet the public is possessed by a fanatical fear of the practice. Homosexuals im moral? are productive citizens, yet they are re· Homosexuality is universally condemned garded as a destructive menace. By our as immoral on the grounds that sexual abuse and persecution of homosexuals we relations between members of the same are not coping with a problem, we are sex are "unnatural". manufacturing one.

O ECE 1BER, 1965 37 PLACEBO THERAPY

CAROL HINDMARSH '67

"A lie is useful only as a medicine to men. The use of such medicines should be confined to physicians." Plato, The Republic

The history of medicine up until fairly be reassured. This reassurance alone will recent times may well be said to be the do much to relieve the subjective sense of history of the placebo effect.1 .Almost all suffering, and, if emotional changes were drugs and procedures used before the responsible for the originial physiological eighteenth century are known today to be changes, a cure may be achieved. useless. Many have been demonstrated to be potentially harmful. For example, Let us now examine a modern defin­ bleeding was one of the commonest forms ition of a placebo. .A placebo refers to of treatment. In 1827 alone thir ty-three "any therapeutic procedure or component million leeches were imported into France of that procedure which is given delib­ because domestic supplies were exhausted. erately to have an effect, or unknowingly Items in the seventeenth century London has an effect on the patient, syndrome, Pharmacopoeia included lozenges of dried symptom, or disease, but which objectively vipers, powders of precious stones, saliva is without specific activity for the con­ of a fasting man, spider webs, moss from dition being treated. The placebo effect is the skull of a victim of a violent death, defined as the changes (if any) favourable and human urine. Medical reasoning was or unfavourable, produced by placebos."2 primitive. The lungs of a fox, a long­ Placebo preparations are often classified winded animal, were given to consump­ as 'pure' and 'impure', the former being an tives. The fat of a bear, a hairy animal, inert preparation such as lactose, and the was prescribed for baldness. Mistletoe was latter an active agent used in a non-specific prescribed for the falling sickness because fashion such as vitamin B in neuras­ it grew on the oak and could not fall. 12 thenia. The pure placebo is described as The question which now arises is how relieving only the patient, while the im­ physicians maintained their positions of pure placebo relieves the doctor as well. honour and respect throughout thousands The lack of literature on this unique of years of prescribing these medications. medication was first commented on by This was possible because, despite the use­ Pepper in 1945. "The giving of a placebo - lessness of the drugs and procedures em­ when, how and what - seems to be a func­ ployed, physicians did in fact help their tion of the physician which, like certain patients, through a potent placebo effect. of the functions of the body, is not to be One factor underlying this effect is the mentioned in polite society." 3 natural tendency of the human organism to recover, often in spite of treatment. The The placebo acquired new dignity in patient assumes that the physician has been 1946 when it became the subject of the responsible, especially where treatment has Cornell Conferences on Therapy. Various been especially dramatic, exotic, or mys­ physiological alterations attributable to terious. This process generates faith in the placebos were discussed. For example, sig­ physician's ability . .Another factor is that nificant alterations in pain perception, man in distress wants action. He thus goes and dramatic improvement in Raynaud's to the physician, in whom he has faith, to Disease following a program of saline

38 U.W.O. MEDICAL JOURNAL iontophoresis were reported. There was ETHICAL CONSIDERATIONS also considerable discussion (and dis­ There seems to be a defensive attitude agreement) as to the ethics and applica­ among physicians toward the use of this tion of placebo therapy.4 medication. For example, Hofling reported on a questionnaire in which the average The topic has been increasingly well physician preferred to think of himself as documented in recent years, and is of in­ needing to resort to the use of placebos terest to several disciplines. less often than his colleagues. 5 Let us thus Pharmacologists are mainly concerned examine the arguments against the use of with the nature of the placebo because of placebos which might lead to this feeling its role in the double-blind clinical trial. of guilt. This is a well-established application, and 1. Placebo therapy involves deception it is not my intention to discuss it. of the patient, for he believes he is getting Psychiatrists have attempted to charac­ specific medication for his illness. How­ terize the so-called 'placebo reactor', and ever, the clinician encounters cases where to identify the various non-specific factors the truth must be evaded or softened, as in treatment. Early papers tried to estab­ in incurable cancer. The physician w 10 lish that the placebo-reactor was more says, "I cannot help you because there is suggestible, but psychological tests for no cure for your disease," is cruel and suggestibility correlated poorly with re­ surely not to be praised for his morality. 6 action to placebos. 2 Anxiety has been I would agree with Leslie that deception shown to be an important factor - the is completely moral as long as it is used greater the need for help, the more likely for the welfare of the patient. a positive placebo response. Other factors related to the patient are faith, or antici­ 2. Placebo therapy might lead to a lax­ ity in diagnosis. If placebo therapy seemed pation of relief, hidden dependency needs to work, diagnostic efforts would be cur­ or a need to be cared for, and catharsis or tailed and a serious illness could be missed. expiation of guilt. The relationship with It is evident, therefore, that placebo ther­ the doctor is of considerable importance. Also related are various environmental apy should not be ordered unless the physician has examined the indications factors, such as the details of the treat­ even more carefully than if he were about ment procedure (shape size and colour of pill, private or clinic situation). In sum­ to order specific therapy. mary, the reaction to placebos will vary 3. Placebo therapy might lead to a less­ from person to person and in the same ened effort to understand the patient as a person depending on the expectations of person. However, in the case where diag­ both therapist and subject. The typical nosis is unclear, placebos should be used placebo reactor does not exist. only to placate the patient while continu­ ing diagnostic efforts. If a diagnosis of Psychotherapists are studying the place­ psychoneurosis has been reached, non­ bo effect because it is always present when directive or expressive psychotherapy is psychotherapy is given. They hope by understanding it to be able to dissect it considered by many to be the therapy of free from psychotherapy, so that the actual choice. However, this is often impossible benefit of the latter can be appreciated. because the average general practitioner bas neither time nor training to carry it Internists and General Practitioners are out, and the patient may have neither concerned with the ethics of, and indica­ funds nor inclination to see a psychia­ tions for, placebo medications. This will trist. The alternative is directive or sup­ be considered in the following section. pressive psychotherapy with placebos,

DECEMBER, 1965 39 --Placebo Therapy------which may not produce a cure, but will Reluctance to use a placebo may be relieve the very real suffering of these related to the physician's personality. The patients. Although most psychiatrists are prescription of a specific powerful medi­ optimistic about the benefits of expressive cation followed by dramatic improvement psychothrapy, the opposite view has re­ may be a source of great ego gratification cently been taken by Eysenck, as reported and provide a satisfying sense of power in by Ford.7 His research indicates that any the prescriber. The prescription of a benefits observed cannot be distinguished placebo on the other hand may be consid­ from the non-specific effects of routine ered an admission of failure or lack of medical treatment. That is, they are insep­ knowledge. Dichter states that the phy­ arable from the placebo response, and sician is almost narcissistic in his self­ probably identical with it. regard, citing the example of the doctor who said, "When I get a good drug I feel 4. Some physicians argue against the almost like God." Davidson writes, "Per­ of inert agents and prefer to use potent haps herein lies an explanation of the drugs or impure placebos when prescrib­ average physician's weakness for unproved ing non-specific therapy. They argue that drugs, and prompt rejection of drugs that there is always the possibility of 'hitting fail him. Therapeutic failures threaten his on' an effective remedy and that the pa­ self image; therapeutic catastrophes shat­ tient is less likely to discover the decep­ ter it. Perhaps more than compassion moti­ tion. There is little justification for this vates the humble physician, and perhaps practice. Placebos can be effectively dis­ with each prescription he treats himself as guised so that not even the pharmacist well as his charge."8 knows he is preparing a placebo. The possibility of chance beneficial therapy is In any case, the physician should pre­ slight. There is a much greater likelihood scribe this therapy only if he feels com­ that the physician will be deceived, by the fortable about it. Otherwise the effect is placebo effect, into thinking that the impaired at the outset. medicine prescribed was, in fact, specific. It appears that the impure placebo is a Many of today's medicines are found to salve to conscience which should be be less specific than we like to think, when avoided. subjected to rigorous pharmacological testing.5 Thus no physician can correctly 5. It should be borne in mind that make a blanket statement that he never placebos are potent drugs which can pro­ employs a placebo. He merely uses it in­ duce marked toxic effects. Numerous ex­ voluntarily without knowledge or under­ amples are recorded in the literature. In standing. The real question is probably one double-blind study a patient developed not whether the physician should or severe epigastric pain within ten minutes should not use the placebo, but rather how of taking the pill. Watery diarrhea, he may best use the ever present effect. urticaria, and angioneurotic edema of the lips followed on each occasion. When the It will be apparent by now that many results of the study were analyzed it was authors are convinced that placebos have found that these reactions occured first on a valid place in therapy. In Hofling's sur­ the placebo, then on the drug.5 Addiction vey, physicians were asked to report on a to placebos has been documented. One good example of placebo therapy. The amputee developed severe phantom limb most frequently mentioned were reduction pain without his twice daily injection of of pain, increased appetite, increased sex­ saline. Thus these drugs, though inert ual desire, sleep induction, relief of vari­ pharmacologically, should not be regarded ous allergic conditions, and removal of as completely harmless. skin blemishes.

40 U.W.O. MEDICAL JOURNAL ------

INDICATIONS 3. In psychogenic disturbances related The following are some clear indications to organic disease (for example, to stimu­ for placebo therapy. late appetite after an infection). 1. In research. CONCLUSION 2. As a substitute for narcotics in the Present knowledge of the placebo effect addicted or dependent patient to smooth is such that placebo administration can be the transference to no medicine. considered a scientific form of treatment. 3. In the incurable cancer patient to There is little reason to feel defensive raise the pain threshold and reduce the about the use of a properly applied place­ amount of narcotics required. bo. There are still many patients to whom the physician has nothing to offer except 4. For the patient who demands medi­ it and himself. cation while the diagnosis is as yet un­ clear. 5. To provide a background for effec­ SELECTED REFERE CES tive psychotherapy. For example, a in­ 1. Shapiro, A. K.: History of the Placebo Effect­ Implications for Psychiatry, Amer. ]. Psycbiat. jection may lure the patient in for regular 116:298, 1959. psychotherapy. 2. Shapiro, A. K.: Factors Contributing to the 6. To clarify the picture and aid diag­ Placebo Effect, Amer. ]. Psychotherapy 18 Suppl. 1, 1964. nosis when a patient is taking a conglom­ eration of drugs and is dependent on 3. Pepper, 0 . H. P. : A ole on Placebo, Amer. ]. Phacm. 11 7:409, 1945. them. 4. Wolff et a!: Cornell Conferences on Therapy, The following indications are less clear. Use of Placebos in Therapy, N. Y. State J. Med. 46: 1718, 1946. 1. In chronic disease where it is desira­ 5. Wolf, Stewart: The Pharmacology of Placebos, ble to avoid dependence on drugs. The Phacm. Rev. 11 :689, 1959. possibility of addiction to the placebo should be remembered. However, other 6. Leslie, Alan : Ethics and Practice of Placebo Therapy, Amer. ]. Med. 16:854, 1954. undesirable phenomena, such as necessity to increase the dose, sedation, and consti­ 7. Ford, K. ]. R.: Realism in Psychiatry, College General Practice of Cda., Vol. 12, o. 2, pation are avoided. ept. 1965. 2. In psychiatry. The placebo can be 8. D avidson, Alan: Placebos, Pills atrd Physicians, diagnostic in psychoneurosis. The ques­ Can. Med. Assoc. ]. 88:1310, 1960. tion of therapy in psychoneurosis has al­ 9. Findley, Thomas: The Placebo and the Phy­ ready been considered. sician, Med. Clin. . A., p. 1821, Nov. 1953.

D ECE MBER, 1965 41 The Practice of

Euthanasia*

HAROLD WATIS, '68

Until very recent times, the chances of an agomzrng and prolonged period of dying at the hands of a chronic disease were slim. Acute, highly fatal, infectious conditions, such as pneumonia (often referred to as the "friend" of the incurably ill), almost invariably intervened. However with the discovery of first the sulfonamides and then penicillin and now the wide range of antibiotics, t e process of dying has been prolonged, often into a long battle. It is for this reason that mercy killing as we know it was not practised in previous history to the extent to which it is advocated by some now. This is not to say however that our ancestors did not practise euthanasia.

In the ancient world, life expectancy person who was mortally sick and in great was short, an estimated 23 years. The pain, because disease could be expected to chronic illnesses, typical of old age, were reap its toll within a short time. Thus therefore uncommon. Since acute illnesses euthanasia in the ancient world was con­ were the usual cause of death, there was fined mainly to the congenitally deformed. little need for the practice of killing a The practice of infanticide was very com-

*The term "euthanasia·· has two distin.ct meanings: an easy and painless death, or alternatively, the a.ct of causing death painlessly in order to end suffering. It is in the latter sense that the term will be employed in the following three articles.

42 U.W.O. MEDICAL JOURNAL mon among most of our ancestors except before the practice was suppressed. The the Jewish people. Quite probably the rea­ Romans also practiced euthanasia on mor­ son for the Jewish aversion to this practice tally wounded soldiers. Rather than let was that they were a small group and were them die slowly and painfully, the Romans determined to grow into a large and pow­ would, at the soldier's request, speed the erful nation and also because they wanted process mercifully. as many children as possible so that the With the advent of the Christian out­ coming Messiah might be among their look on life, all forms of mercy killing descendants. were abandoned. During the Middle Ages, In the Grecian states, infanticide was not the concept of pain and disease was that merely permitted but was enforced by these were punishment meted out for past law. In Sparta, every child was examined sins and were tests of the convictions of by the elders of the city to be checked for the sick person. The alleviation of pain deformities. If the child was deformed, it was considered to be contrary to God's was killed by throwing it into a deep way. Thus not only did the practice of cavern at the foot of Mount Taygetus. euthanasia die out but also much of the However cruel this may appear to us, it practice of medicine was suppressed. must be remembered that life in those days As the concept of disease changed, the was extremely difficult and a physicial de­ Church again began to allow the practice formity could seriously limit the life of a of medicine and became one of the leaders person and result in much suffering. Also it should be remembered that the deform­ in the medical field. Mercy killing how­ ever was not permitted. The closest thing ed would be a real burden upon the rest to mercy killing was the burning at the of the community. The practice of infanti­ stake of a mentally deranged person. The cide was condoned by the great philoso­ theory behind this practice was that the phers Plato and Aristotle as a means of mental illness was caused by devils within controlling the population increase. the person. While the devils were within, The Romans also practised infanticide it would be impossible for the person to of those who were congenitally deformed. go to Heaven. "Treatment" to remove the The children were left on the steps of a devils was burning which would cause temple to die from exposure but a com­ them to flee. This practice reached its passionate person might come and take greatest height during the Spanish inqui­ them and assume responsibility for their sition. care. Originally the deformed child had to During the 18th and 19th centuries, have his deformity certified by at least mercy killing was not practised. Medical five persons other than the parents before efforts centred around the provision of it could be left to die, but later the decis­ euthanasia in its literal sense of "an easy ion was left completely to the father and death." The chief aim was to secure the many normal children perished because maximum comfort of the patient by drug the parents just did not want them. therapy and by proper nursing care. To help make the patient more comfortable Until Constantine became the first when it was apparent that his condition Christian ruler of the Roman empire, the was hopeless, the physician was advised to practice continued unabated and became acquiesce to the patient's wishes and sug­ progressively more cruel. In A.D. 315, gestions, even though these might be con­ Constantine enacted a law which prohib­ trary to the best medical treatment. ited the killing of children and provided for maintenance and education of the In the 20th century, euthanasia has child. However, it was nearly a century come to mean mercy killing. Several cases

DECEMBER, 1965 43 --The Practice of Euthanasia------

have been brought to trial with charges of against the acquittal were held showing murder against those involved. These cases that public opinion was still very much may be regarded as an expression of 20th divided. century attitudes toward the practice of At the same time, two members of par­ mercy killing. liament in London, England announced One of the first cases of euthanasia that they would introduce a bill to the brought to court occurred in Manchester, Commons whereby "in future cases of ex­ New Hampshire, where Dr. Hermann N . treme deformity, medical practitioners may Sander was accused of murdering a patient be authorized to apply euthanasia." Also of his, who was suffering from incurable there was a move to legalize abortion in cancer, by injecting four 10 c.c. doses of cases where the mother had taken thalido­ air intravenously. However the case was mide. These actions were discussed but not not argued in the realm of the moral right­ voted upon. ness or wrongness of euthanasia, but rather A third case of euthanasia was heard in on a legal point over confusion about Shrewsbury, England in October, 1965. In whether the patient had died previous to this case, a father pleaded guilty to a re­ the injections. Due to this confusion, the duced charge of manslaughter in the death doctor was given an acquittal. An affir­ of his son who had had cancer of the mation of the public's belief in the doctor spine causing severe pain and paralysis of was given when a fund of 40,000 was arms and legs. His father gave him sleep­ collected to pay for the doctor's legal fees ing pills and then gassed him while he and to make up for his lost income. The was sleeping. In concluding, the judge said New Hampshire Medical Society while not that no one would consider the father a taking any disciplinary action against the criminal for his action and gave him a doctor came out with a statement saying sentence of two years on probation. that "it disproves and condemns any pro­ cess for relieving suffering by the delib­ These three cases show that public feel­ erate termination of life, including that ing on the subject of euthanasia has which is termed euthanasia or mercy kill­ changed considerably from that of prev­ ing . ..". Dr. Sander did not escape with­ ious periods. Nevertheless the legal posi­ out punishment however, as he lost the tion remains unchanged: to wilfully ad­ privilege of practising at two Roman minister death to a patient is murder; to Catholic hospitals in the area and had his withold treatment that would prolong life license to practice suspended for a period is a criminal act. of one month. Perhaps the only safe prediction that In late 1962, the trial of Mrs. Vandeput can be made concerning the future of in Liege, Belgium was the focus of public euthanasia is that it will continue to be the attention as once again the legal position subject of vigorous controversy. Its fate is of euthanasia was brought to trial. Mrs. by no means settled. Vandeput was charged along with her husband, her mother, her sister and her SELECTED BIBLIOGRAPHY family physician, Dr. Jacques Casters with ElementJ of Medical JuriJprudence: T. R. Beck killing her eight day old "thalidomide and ]. B. Beck, 1836, pp. 201-213. baby" born with no arms. The doctor pre­ A Dictio1rary of Medicine: R. Quain, 1895, pp. 635-637. scribed barbiturates and gave instructions EugenicJ, Sterilization, Birth Control, Euthana.Jia. to the mother on how to mix them in the Collected Clippings, U.W .O. Med ica l Library. baby's milk. All five of the defendants London Free Preu, Oct. 8, 1965. were acquitted of the charges against Collected ClippingJ, 1961-1962-1963, U.W .O. them. Public demonstrations for and Medical Library.

44 U.W.O. MEDICAL JOURNAL I AM SOilRY J)OCTOR, BUT THE" CA81N£T Ff:E:LS TI-41S PATIENT IS If N OP£RATI Vt C liND 11J/lTE F'"O~ l>lt'Tifl PANCREATECTOMY, SPL.ENECTOMY , ANl> £1/D,-TO-S/D£ PANCR.£ATI CoJ"FJ"UNOSToMY. l IN VI£W Of=" Tll 1:" S£RUM ~MYLAS£•···--, ~~

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D ECEMBER, 1965 45 EUTHANASIA

the Pros • • •

"Whether tis nobler in the mind to suffer the slings and arrows of outrageous fortune or by dying end them". Hamlet's words elucidate a complex moral problem of our day which must be met by physician and layman alike. Too many of us however have been caught up in the much too fanciful notion of preserving life at all costs, thereby neglecting the happiness and mental well-being of the popula­ tion at large. Do we call ourselves a democracy? Do we believe in the greatest good for the greatest number? Surely then we must as rational beings institute these basic ideas toward a solution for the moral issue of euthanasia. "The time has come when we keep people alive who should not be kept alive" (Dr. Charles Mayo). Physicians must decide when to arrest all efforts and allow the incurable patient to die in peace. Nevertheless as doctors we must insure our every effort when a patient may have years or even months of useful comfortable existence remaining. We have all followed newscasts where violence has not daunted man in his search for freedom of word and action. We all know the meaning and purpose of our Bill of Rights. Then are we not hypocrits when we deny man the right to die with dignity? Could a man who has been a source of strength to his loved ones ever wish to be a source of pity and a nuisance to them at the end? Is it just that such a man be humiliated, degraded to the level of a puppet, kept alive only by tubes, wires and innumerable dials. I say no. Accord him the self respect he deserves and let the cloak of immortality fall gently. Financial worries are yet another problem that plague a dying man. Regardless of the amount of savings accumulated while alive, a lingering death greatly dimin­ ishes hopes of continuing prosperity for his family. The time has come, I feel, when we must allow man his choice to leave this world without undue stress and burden to those he loves. Another fact which escapes the so-called "moralists" is that of a painful, intolerable demise eased only by an addiction to morphine or other "neural depressives". You who preach "life at all costs" no matter what the consequences, you with your holier than thou attitude, take time. Live with pain. Experience the pleas of a friend in agony. Then reply "Thou shalt not kill". As with the advent of any new idea, its initiation as an acceptable part of everyday life will necessitate a certain flexibility in many of our preformed ideas. Who will make the choice between life and death? Above all the patient's decision must be respected, but where the doctors must make the choice such situations will merit the consideration of a board. Inhuman? Perhaps according to past standards, but what of the future? Even today such decisions are made as to whether patient X or patient Y receives a kidney transplant in cases of limited supply. How? Impersonally! Rationally! In terms of years of useful comfortable existence. We have arrived, there is no turning back. The choice is ours. Let us be brave in our decisions. "Look at everything that exists and observe that it is already in dissolution and in change and that everything is so constituted by nature as to die" (Marcus Aurelius). IAN YEATS '68

46 U.W.O. MEDICAL JOURNAL

------and Cons •

Nowadays few men seem to fear or respect God's commandment: "Thou shalt not kill". Advocates of euthanasia would have us disobey it on compassionate grounds. Most men dread death; some fear suffering and pain even more. Death and prolonged suffering are the doctor's paramount adversaries. He has sworn to oppose both and this he is obliged to do with wisdom. Without enlisting the aid of death, he must overcome suffering. Since death is the inevitable victor, elaborate techniques which offer little hope of success need not be employed. Appropriately it has been stated: "Thout shalt not kill, but thou needst not strive officiously to keep alive". Euthanasia is upheld to varying degrees by its pseudo-humanitarian advocates. Some favour voluntary euthanasia( that is, the patient, upon request, is granted an "easy death") . Others believe this "blessing" should be bestowed on all persons afflicted with terminal illnesses accompanied by pain and suffering. Still others would extend the indications for "mercy killing" to defective individuals (mentally or physically), the senile, and other supposedly useless and burdensome people. Any doctor who condones, advocates or practises the above forms of killing is commit­ ting a criminal act (murder, suicide or both) and is neglecting his duty to his patients and to society. Man as a social being forbids murder and suicide even when these wear the mantle of mercy. The entire Judeo-Christian tradition stands solidly opposed to the usurping of guiltless human life. Laws governing the interaction of man emanate from ideas of individuals, just as do inventions and discoveries. Therefore, the individual and the community are mutually reciprocal agents, each sustaining the life of the other. The few doctors who condone euthanasia mean well, being often motivated by true compassion, but they fail to comprehend the dangerous conse­ quences which might follow a general acceptance of euthanasia. For example, under German totalitarianism the Nazi euthanasia of the senile and infirm was extended to attempted genocide. The error lies in the euthanasian's philosophy of life which equates a suffering person to an injured animal, and bases the worth of human life on its usefulness to others and to the state. Recently a minor neurosurgical procedure has been devised for the relief of all forms of intractable pain (the most common excuse for euthanasia). Such advances do not occur by surrendering patients to death. Even in the past, mercy killing to relieve pain has been medically unnecessary. The new and ingenious prosthetic devices for crippled persons could not have been developed so quickly had all thalidomide babies been killed or aborted. These thalidomide babies are being helped to live useful and intellectually active lives through rehabilitation procedures. Were euthanasia legalized, people might forego responsibility and seek suicide. Indications for mercy-killing could burst "moderate" limitations as they did in Germany. And who would make the decision? The family doctor? A group of

(Continued on page ~1)

DECEMBER, 1965 47 Good Samaritan Laws

by RON ROBINS. '68

Doctor Thrope, an internist and county medical examiner of Hyannis Massachusetts, was spending the last day of his pre-Christmas vacation in St. Thomas, a United States territory in the Virgin Islands, when he was summoned from his hotel room to attend the captain of a charter boat, who had apparently been electrocuted. After arriving at the scene of the accident, Doctor Thrope immediately proceeded to apply mouth to mouth resuscitation and external cardiac massage to the stricken skipper. After about ten minutes of this treatment with no apparent success, Doctor Thrope opened the chest cavity and began internal massage of the heart, his only thought being "to get that heart to beat again."

Although Doctor Thrope continued the chusetts and t.he only crime he committed massage in the ambulance en route to the is that he did not apply for a license and hospital, his efforts failed to revive the have it issued while the man apparently skipper. The Massachusetts physician was lay dying. What he did was to go for­ then promptly charged by the Attorney ward and do his best to save a man's life General of the Virgin Islands with prac­ and this harsh treatment is poor payment ticing medicine without a license, and for his prompt and thoughtful action." since the severing of an artery with result· ant loss of blood was cited as the possible Good Samaritan Laws are statutes de­ cause of death, a homicide charge also signed to free the physician from liability wavered over the physician's head, depend­ when he renders first aid in an emergency ing upon the results of autopsy. After an situation. A secondary but nevertheless unprecedented lapse of two months, in which important purpose of this legislation is to Doctor Thrope had a difficult time keep­ ensure that accident victims receive the ing his mind on his work, the autopsy best available emergency assistance. report finally declared that the cause of At one time it was customary for the death could not be determined. The cor­ physicia_n, wherever he might be, to stop oner ruled that the victim died due to a his car and help the accident victim, but combination of circumstances following an to-day, in an age when people are ex­ accident for which no one could be held tremely lawsuit conscious, some doctors criminally responsible. think twice before stopping, if, indeed, When asked whether he would respond they stop at all. In Canada and the United in the same manner to another emergency States, where more than 43,000 people die call, Doctor Thrope said, "I wish I had each year as a result of motor vehicle courage to act again in the same way if a accidents alone (many through the lack of similar circumstance should arise. But I first aid), the serious implications of this don't know, I've had a lot of trouble." situation are not difficult to appreciate. An important phase in the treatment of the The Daily News of St. Thomas said, injured is immediate care at the scene of "Must we be licensed to relieve human the accident. Very often the end result of suffering? Doctor Thrope is a qualified treatment will depend upon the initial medital doctor in his home state of Massa- handling.

48 U.W.O. MEDICAL JOURNAL Why do physicians fail to respond to Although the physician is under no the emergency ? The answer appears to be legal obligation to assist an accident vic" fear-fear of the possible legal conse­ tim, many regard such assistance as a quences of their assistance. moral and ethical duty. The resulting con­ In 1961, the Medical Research Institute flict between self-interest and profess­ of Boston University conducted a 10% ional responsibility is no doubt a source sample survey of the practicing physicians of anxiety to many physicians. in Massachusetts. In one of the situations The question as to whether physicians' physicians were asked to assume that they fears are well-founded would seem to be were enjoying an evening at the theatre. answered by the fact that the American They were then queried if they would Medical Association Law Department has answer the call, "Is there a doctor in the no record of court cases involving physi­ house?" 27 % replied that they would; cians and roadside emergencies. A similar 41% replied that they would if they saw situation exists in Canada. The vast major­ no other doctor respond; 14% replied that ity of physicians however, are either they would if they could first determine unaware of, or unconvinced by this fact. what the trouble was ; 16% said no; 2% The fears remains, and with it, the danger failed to answer the question. Of those that accident victims will be denied medi­ who said they would not respond, 76% cal assistance that would otherwise be indicated that the fear of a malpractice available to them. suit was their principal reason for not doing so. Of those who said they would UN ITED STATES respond only after they had found out In the United States the state of Cali­ what was wrong, 51% expressed concern fornia was the first to enact the Good regarding a malpractice suit. Of those who Samaritan Laws in 1959. Subsequently 30 said they would respond if no other doc­ other states have followed suit. The exist­ tor would, 35 % indicated that a fear of ing laws are not particularily uniform. malpractice suit was the thing which held Some cover only physicians, who are them back. licensed in that state, as in Arkansas and What has caused this fear? Three gen­ California; others cover all doctors licensed eral factors may be listed: in any state, as in Alaska and Colorado; 1. A continuing increase in malpractice lia­ still others cover anyone who renders bility claims. Since the end of World emergency first aid, as in Florida and War II, malpractice claims have surged Georgia. Some cover all negligent acts; from 6,000 to 9,000 per year in others exempt gross negligene. Some re­ United States and Canada. quire that the service be rendered gratui­ 2. Careless rumors and unsubstantiated tously; others fail to indicate any objec­ remarks spread throughout the halls tions to a fee being charged. of medical schools and hospitals, often The Executive Council of the state of based upon scare stories in magazines New York, which vetoed it's proposed and fictional medical television pro­ Good Samaritan legislation stated, "There grams which are more entertaining is no need to undesirably lower the stand­ than factual. ard of accepted conduct for physicians 3. Physicians' concern that the circum­ which has prevailed for many years. To stances of road side first aid can easily require a reasonable degree of care in all lead to charges of negligence arising instances is a proper standard since what is from a hasty and incomplete exam­ reasonable depends in any situation on all ination, improper attention, or failure surrounding circumstances." Hence, the to follow standard procedure. Council claims that a physician has no

DECEMBER, 1965 49 --Good Samaritan Laws------

need of protection as long as he exercises ticc. It was felt that Canadian Courts are a reasonable degree of care. They are con­ not going to expect that a doctor, can vinced the courts of the State of New render as skilled and as competent services York will uphold him. in a 'half-water-filled ditch' as he could under optimum circumstances. The Medical The Medical Journal of the State of Protective Association advised the various Pennsylvania had this to say about it's new Colleges of Physicians and Surgeons, that in Good Samaritan Laws. "The Good Sam­ their opinion, they hould not press for the aritan Act represents a significant and enactment of this kind of legislation. Not necessary modification to tlie laws of medi­ only was there no need for it, but the fact cal malpractice. It demonstrates a recog­ that doctors were pressing for it's enact­ nition by the General Assembly of the ment might easily do more harm than good importance of assuring physicians, who for its general public image. In the opin­ arc called to give emergency treatment to ion of the Association, they could ignore people they have never seen before; that talk about Good Samaritan Legislation they will not be subjected to unwarranted and could do so in the comforting know­ liability as a result of their disinterested ledge that Canadian Courts are not going and charitable service." to impose unjust penalties. CANADA The College of Physicians and Surgeons of Ontario, which was chosen as repre­ Canada is at the present time without sentative, advises that if a physician renders Good Samaritan Legislation. Within the medical aid under emergency circum­ past year the Canadian Medical Protect­ stances such as at the scene of an auto­ tivc Association was asked by a number of mobile accident, he is not viewed as giv­ the Provincial Colleges of Physicians and ing medical services in the usual sense, Surgeons to investigation the wisdom of unless he attempts to acquire some advan­ working toward the enactment of so-called tage, thereby, be it financial or otherwise. Good Samaritan Laws. The Association Therefore, under these circumstances, he reported that up to that time there had is not liable to any action for malpractice. been no actions against doctors and no Physicians from other provinces and threats of actions against doctors, who American states, who, while in Ontario, had given assistances to persons involved come upon such a situation, are free to in accidental injuries that constituted render medical aid without risk, even emergencies. They maintain that doctors though they do not possess a license to should continue to fulfill their ethical and practice in Ontario. They are so informed moral duties by giving such help as they by the College when they inquire about could under emergency circum.stances. such a situation. They should not, ever, v.:ithold their help when that help has any value. The Asso­ CONCLUSIONS ciation expressed the view that as long as That physicians do not require the legal the physician renders the best services of protection offered by Good Samaritan which he is capable at the time of the emerg­ Laws is readily apparent. However, in the ency, he would be upheld by any Canadian interests of public welfare it is essential Court to which a patient brought a claim that steps be taken to alleviate doctors' of poor services. Naturally, they pointed fears of litigation arising as a result of out, the physician who had not fulfilled treatment provided in an emergency situa­ his reasonable duty and had not exercised tion. This can be accomplished by one of reasonable care, would be liable for his two methods. The first possibility is the failure as he would be if his failure had enactment of Good Samaritan Legislation, occurred in the course of his routine prac- not in order to protect physicians but

~0 U.W.O. MEDICAL JOURNAL merely to reassure them. The alternative REFERENCES approach is a massive program of educa­ 1. The Canadian Medical Protective Association; tion designed to convince physicians that ASsistant Secretary. the danger of malpractice suits resulting 2. Ontario Medical Association; from assistance rendered at the scene of Secretary-Treasurer. an accident is nonexistant. Failure to insti­ 3. Law Departmeit of the American Medical tute one of the above measu.res will pose Association. a threat to the physician's peace of mind 4. California Medical Association; and the accident victim's life. Executive Secretary.

Euthana.ria (Continued from page 47) doctors? The church? The state? Patients might rightly fear death at the ha_nds of the doctor rather than seek a cure. Doctors who mete out death, rather than struggling against it are neglecting the high office of which Medicine would make them ministers. They are assuming rather the part of some superior being deciding who will die and who will live. MARIO F. CASTELU '68

The author wishes to thank Dr. L. L. deVeber and others for their willing assistance in preparing this article.

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DECEMBER, 1965 51 Maintenance Dose Therapy in Drug Addiction

By JON W AISBERG '67

"Addicted patients are asocial, inadequate, immature and unstable ... Their major problem is the maintenance of the supply of drugs, or the immediate satisfaction of their desire for drugs."1

On these premises Lady Frankau his dependence to medical prescriptions or M.D. of England has founded her other more easily accessible drugs. There­ regime of treating drug addicts through fore, following the stabilization period the use of maintenance doses of drugs. Lady Frankau employs a two stage process Lady Frankau feels that most persons ad­ of withdrawal, using progressively reduced dicted to narcotics suffer from psycho­ doses first, followed by complete with­ neurotic or psychopathic personalities. drawal of the drugs. Consequently she advocates psychothera­ peutic treatment before withdrawal is From August 1958 until March 1960 Lady attempted. Dr. Frankau maintains, "The Frankau treated, in England, a group of goal of the psychiatric treatment is to 51 Canadian narcotic addicts. The results correct as far as possible these personality of this experiment were published in The difficulties, to give the patient a sense of Lancet in December, 1960. Lady Frankau security, self reliance and self confidence; differentiated three classes of addict: to establish good personal relationships "medical", "professional" and "criminal". and a sense of responsibility towards him­ Those whose addiction resulted from long self, his family and friends, and towards term medical use of narcotics for pain the community . . . ." were termed "medical addicts". Six patients fell into this category. "Profess­ It is during this period of "stabiliza. ional addicts" were those whose profession tion", when the apparent basic problem allowed them access to narcotics. Nine is being attacked, that Lady Frankau patients were classified as "professional uses maintenance doses of narcotics. addicts". The remaining 36 addicts were This permits all efforts to be directed engaged in criminal activities to support at achieving an understanding of the their addiction and were classed as "crim­ patient and the factors which lead him inal addicts". In the medical group, all to seek relief in drug addiction. The were cured. Of the professional addicts, patient is enabled to look into his own three were cured, two remained on small personality difficulties and put forth a doses, and the sixth was apparently resist­ positive attempt to control and correct his ant to treatment. Finally, in the criminal basic shortcomings. During this stabiliza­ group twenty were cured, ten were still tion period arrangements are made for the under treatment and six were apparently patient to be gainfully employed. With the resistant. assured constant supply of drugs the patient is encouraged not to contact illegal From Lady Frankau's published results sources outside the therapeutic program. it would at first glance seem that she had hit upon the long sought after panacea The ultimate aim in the medical treat­ in the treatment of narcotic drug addic­ ment of an addict is to release him tion. Why then has such a program not from physical and psychological depend­ been widely instituted in Canada? A par­ ence on narcotics, not simply to transfer tial explanation is provided by the marked

52 U.W .O. MEDICAL JOURNAL contrast in the public view of the narcotic Inherent in the Narcotic Control Act of addict encountered in Canada as compared 1961 is the concept that such treatment to that found in England. In England the must be founded on strict control such addict is considered a medical problem, that narcotic drugs are not diverted into whereas in Canada (where addiction is a illicit traffic or used as a supplement to much greater problem) there is a tendency illegally acquired drugs. This would mean to view the addict as a criminal worthy that the physician must not only exercise only of punitive measures. The Opium and the strictest control in the giving of drugs Narcotic Drug Act, which was in force to the patient, but also must attempt to till 1961, divorced the addict from the control the patient's outside contacts. This realm of medical treatment. Consequently, could be approached by attempting to im­ "organized" treatment in Canada has tra­ press on the patient that he must not have ditionally centred around immediate with­ contact with outside illicit drug interests drawal and isolation of the addict from or by placing him in an institution. society. If the physician chooses to treat the The question now is whether the Can a­ addict outside an institution, that is as an dian physician can legally treat the addict ambulatory patient, he must be prepared to with maintenance doses, and if so, should devote a great deal of time and effort to he? the patient. The full extent of such an The legality of maintenance dose treat­ undertaking is clearly pointed out in the ment of the narcotic addict is considered American Medical Association's 1963 in the current Narcotic Control Act which statement on "The Use of Narcotic Drugs was passed in the House of Commons in in Medical Practice and the Medical Man­ 1961. This act allows the doctor "to ad­ agement of Narcotic Addicts," in which minister a narcotic to an addict or to it suggests that "withdrawal on an ambu­ prescibe such for him, if the addict is a latory basis is generally unsound and not patient under the doctor's care." Under recommended on the basis of present Canadian law the doctor must provide knowledge. Only under exceptional cir­ sufficient and plausible reason that the cumstances is it proper to attempt with­ drug is "required for the condition for drawal on an ambulatory basis and then which the patient is receiving treatment." it must be done only by a physician of A further clarifying discussion was spon­ special skill and experience in the manage­ sored by the Addiction Research Founda­ ment of addicted patients. In such cases tion of Ontario in 1963 to elucidate the there should always be consultation with meaning of the expression "required for a psychiatrist if one is available or with the condition for which the patient is another physician who will substantiate receiving treatment", and to determine the fact that ambulatory withdrawal is, in whether the arrived at interpretation could fact, indicated." encompass the prescribing of maintenance doses of narcotics on a long term basis A Special Committee appointed by the outside an institution but with the ulti­ Executive Committee of the Canadian mate aim of withdrawal of the narcotic. Medical Association Journal made the fol­ The reply given by the legal advisor to lowing suggestions concerning treatment the Department of National Health and of drug addicts by individual physicians Welfare was that "if such a procedure is and the prescription of maintenance doses recognized as good medical practice it on a long term basis: could hardly be regarded as illegal ... it "For the individual practitioner who was the responsibility of the medical proposes to treat addicts, consultatioq with authorities to define good medical practice a respected colleague is essential . . . If in this context." there is a suitable clinic or social agency

DECEMBER, 1965 53 --Maintenance Dose Therapy in Drug Addictio'n------

in the neighbourhood, its resources should A number of arguments have been ad­ be enlisted . . . vanced in support of the Frankau approach "It is always good medical practice for to therapy. All rest on the basic assump­ a doctor to refrain from undertaking ther­ tion that large numbers of addicts who apy in fields in which he has little exper­ now consider the "disease" to be prefer­ ience and no special training, if more able to the "cure" would volunteer for competent professional help is available treatment. It is argued that the promise of . . . it may in certain circumstances be maintenance dose administration followed good medical practice to prescribe main­ by gradual withdrawal in a non-institu­ tenance doses of narcotics for long periods tional setting, will attract addicts who to an addict at liberty, if other components would not otherwise seek treatment. Such of good medical care are provided. If they a result would strike a telling blow agai nst are not, the doctor may be guilty of traf­ illicit drug traffickers and reduce the num­ ficking. Our advice to the general prac­ ber of addicts engaged in criminal activity titioner is that they should, if possible, to support their habit. Considerable sav­ avoid prescribing narcotics for long per­ ings on law enforcement expenditures iods for addicts under their care." could be expected to follow. In view of On the other hand, the physician can the high construction and maintenance make use of an institution in controlling costs of institutions, treatment on an his patient during the stabilization period. ambulatory basis bas obvious economic ad­ The creation of such institutions was vantages. planned for in the 1961 Narcotic Control One can only conclude from the above Act. ln Part II of the Act, narcotic addic­ tion is seen as a medical disease and pro­ discussion that "maintenance dose ther­ vision is made for "preventive detention apy" is by no means established as the treatment of choice in drug addiction. and custody for treatment". It also pro­ vides for continuing "supervision under While preliminary results are encouraging, the Parole Act after the release of the extensive controlled studies must be under­ addict, during which treatment can be taken in order to adequately assess the continued . . . which means in essence merits of this form of treatment. The persuading street addicts to become rela­ failure of traditional methods to produce tively useful citizens". However such ar­ lasting cures in a significant proportion of rangements must await the establishment cases demonstrates the pressing need for of suitable federal institutions. such investigations. For the most part the use of institutions would negate the chief advantage claimed BIBUOGRAPHY for maintenance dose therapy, that of 1. Frankau, Lady; Canadian Narcotic AddictJ in England - The Experience of 0 11e PhyJician, allowing the patient to be treated in and Addictions, Vol. II No. 1, 47, Summer 1964. adjust to ·a normal environment. lnstituta­ 2. Macdonald, R. S. & ] .; Narcotics, AddicJJ and lization of the patient carries with it the the Law, Addictions, Vol. II, No. 1 18, suggestion of coercian and punishment Summer 1964. for a crime, and views the addict as a 3. Ferguson, ]. K. W .; Ehinger G. H ., Jaron criminal rather than a patient. The use of G. E., Lederman ]. ]., MacKenzie D. ].; Good Medical Practice in the Care of the institutions and their necessarily artificial Narcotic Addia, The Canadian Medical Asso­ social environment as a setting for the ciation Journal 92, 1040-43, May 8, 1965. critical stabilization period which was de­ 4. Holmes, S. ].; arcotic Addiction: Some signed to help the patient establish himself · Tho11gh11 on Preunt ProgramJ and F11t11re in everyday life is self-defeating and con­ eed1. Addictions - Papers on Drugs. 5. World Health Organization: St11dy Gro11p on trary to the principles of this treatment the Treatment and Care of Dr11g AddiciJ, method. W . H. 0 . Techn. Rep. Sec., No. 131:3, 195 7.

54 U.W.O. MEDICAL JOURNAL Abortion:* Historical Background

HEATHER PENNEY, '68

The practice of artificial abortion is as old as history. The same may be said of the controversy in which the subject is now steeped. The history of abortion is a record of disagreement and fluctuating attitudes - some­ times in the direction of permissiveness; othertimes toward restraint.

In the Old Testament, the foetus was The .Aristotelian school held that a veget­ regarded as a tumour or fruit growing able soul came into being first, followed upon a woman, and not as a human being. by an animal soul at forty days and finally .As a result of this concept, the pregnant a human soul at eighty days. Stoic philoso­ woman was free to rid herself of the phers believed the soul was not united to foetus, just as she would any other neo­ the body until the act of respiration. plastic mass. This idea prevailed through­ These theories were later sup- out the early Greek and Roman eras. planted by the Christian view that the Plato ( 429-347 B.C.) and Aristotle soul existed from conception until death. (384-322 B.C.) approved of abortion and In accordance with this belief, the Christ­ infanticide to limit the size of one's fam­ ians maintained that the foetus was holy ily . .Although the Hiippocratic oath states: or sacred and could not be destroyed at "I will not give to a woman a pessary to any time. produce abortion," Hippocrates ( 460-370 In a move to repress abortion, the prac­ B.C.) performed an abortion himself on tice was classed as a crime under third a young woman who was less than one century Roman law. Abortion was re­ month pregnant. garded as an offence against the husband, Both infanticide and abortion were gen­ depriving him of children. This attitude erally condoned by the Greeks of this soon disappeared and the law was largely period. .Abortion was practised not only ignored. to limit family size but also out of fear The Justinian Code in the sixth century that childbirth would detract from the incorporated the idea of animate and in­ mother's appearance and to avoid the animate foetuses. Due to the uncertainty shame of illegitimate births. concerning the time when the foetus be­ The question of foetal "animation" has came animate, the events of quickening always been a central issue in the abortion and animation were regarded as taking controversy. Among Greek philosophers place concurrently. (Quickening refers to there was considerable disagreement on the first signs of life felt by the mother this matter. Hippocrates felt that the male as a result of foetal movements, usually became animate at thirty-two days and the occurring in the fourth or fifth month of female at forty-two days after conception. pregnancy.) .Abortions procured after

•For purposes of this article and the two which follow, the term ''abortion" will be used to refer to artificially induced abortion as opposed to so-called " natural abortion." Abortion is defined as expulsion of the foetus from the uterus before it is viable ( capable of surviving outside of the uterus). The foetus is generally considered viable at 28 weeks gestation.

DECEMBER, 1965 55 --Abortion: Historical Background------

quickening were regarded as a serious ments was not covered by this act. How­ crime, whereas those induced before that ever, this omission was rectified by Lord time passed unnoticed. Lansdowne's Act of 1828, which made any attempt to destroy an animate foetus a This attitude was incorporated during criminal offence. the Middle Ages into the canon of the Roman Catholic Church and was subse­ In the late 1830's a statute which re­ quently reflected in the laws of those moved both the death penalty and the countries which came under the influence distinction between the "quick" and "non­ of that church. The Roman Catholic view quick" woman, was passed by Parliament: has since undergone revision. The foetus is now considered animate from concep­ "Whosoever with the intent to procure tion and abortion under all but the most the miscarriage of any woman, shall un­ exceptional circumstances is condemned. lawfully administer to her, or cause to be taken by her, any poison or other BRITAIN noxious thing, or shall unlawfully use any instrument or other means what­ In Anglo-Saxon England abortion was soever with the like intent, shall be an ecclesiastical offence. It was not until guilty of felony, and being convicted the middle of the thirteenth century that thereof, shall be liable, at the discretion it became an offence under English com­ of the court, to be transported beyond mon law: the seas for the term of his or her nat­ "Moreover, who shall have overlain a ural life, or to be imprisoned for any pregnant woman, or shall have given term not exceeding three (3) years." her drugs of blows, in such a sort to procure abortion or non-conception after In 1861 Parliament approved an Act the foetus shall have been already form­ which, in addition to prohibiting abortion ed and endowed with life, is by law a as described above, made it an offence for homicide. Also the woman commits a woman to attempt to abort herself. A homicide, who by potions and drugs of 1929 statute provided for destruction of a that sort shall have destroyed her ani­ viable foetus in order to preserve the mate child in the womb." (Stephen's mother's life, but corresponding changes History of Common Law, Vol. 1) were not made with respect to abortion which is, by definition, performed before Here again we see a distinction between viability. However, since 1939 the 1861 the animate and inanimate foetus. Act governing abortion has been judicially interpreted in such a manner as to allow In 1768, the English jurist and legal abortion in cases where the pregnancy historian Blackstone expressed the opinion seriously threatens the mental or physical that abortion should be considered a fel­ health of the mother. ony (a class of crime including arson, rape, murder, etc.) rather than homicide. The distinction was purely academic however, CANADIAN LAW since the penalty was death in either case. Canadian abortion law is somewhat more stringent than that in Britain. The An Act of Parliament passed in 1803 question of abortion is dealt with in Sec­ prescribed the death penalty for anyone tions 209, 237 and 238 of the Criminal who attempted, by the administration of Code. These sections read as follows: drugs, to procure an abortion in a woman who was "quick with child." Such attempts 209. ( 1) Killing unborn child. Every made prior to quickening were less severe­ one who causes the death of a ly punished. Abortion by means of instru- child that has not become a

56 U.W.O. MEDICAL JOURNAL human being, in such a man­ produces a drug or other noxious ner that, if the child were a thing or an instrument or thing, human being, he would be knowing that it is intended to be guilty of murder, is guilty of used or employed to procure the an indictable offence and and miscarriage of a female person, is liable to imprisonment for whether or not she is pregnant, is life. guilty of an indictable offence and (2) Saving. This section does not is liable to imprisonment for two apply to a person who, by years. means that, it considers neces­ In Canada in recent years there has been sary to preserve the life of the mounting demand for increased permis­ mother of a child that has not siveness toward the practice of abortion. become a human being, causes In the vast majority of non-Catholic hos­ the death of the child. pitals illegal abortions are now openly 237. (1) Procuring miscarriage. Every performed. Many individuals and organ­ one who, with intent to pro­ izations, including medical association, ad­ cure the miscarriage of a fe­ vocate a broadening of abortion laws to male person, whether or not allow the procedure in all cases where the she is pregnant, uses any mental or physical health of the mother means for the purpose of is jeopardized by the pregnancy. Legalized carrying out h is intention is abortion in pregnancies carrying a high guilty of an indictable offence risk of congenital anomalies is being sug­ and is liable to imprisonment gested . An increasingly vocal minority for life. proposes that abortion be made available (2) Woman procuring her own to any woman who desires it, as is pres­ miscarriage. Every female per­ ently the case in Sweden and Japan. The son who, being pregnant, with Roman Catholic Church stands virtually intent to procure her own alone in its opposition to the relaxation miscarriage, uses any means or of laws governing abortion. permits any means to be used for the purpose of carrying BIBLIOGRAPHY out her intention is guilty of an indictable offence and is Burns, John; Obstetrical Works. Collins and liable to imprisonment for two Perkins, ew York, 1809. years. Ellison, John; Sex Ethics. Balliere, Tindall and Cox, London, 1934. (3) "Means" defined. In this sec­ tion, "means" includes Hale, Edwin ; Syuematic Treatise on Abortion. Halsey Chicago, 1866. (a) the administration of a drug or other noxious Taussig, Frederick; Prevention and Treatment of thing Abortion. Mosby Company, St. Louis, 1910. (b) the use of an instrument, The Criminal Code of Canada, Sections 209, 237, and HB; 1965. (c) manipulation of any kind. Thomas, Gai llard; Abortion. Appleton and Com· pany, New York, 1894 . 238. Supplying noxious things. Every W illiams, Glanville; T he Sanctity of life and The one who unlawfully supplies or Criminal Law. Alfred A. Knopf, ew York, 19:57.

D ECEMBER, 1965 57 ABORTION? Yes!

The practice of medically induced abortion may be legally employed in Canada only when the procedure is necessary to preserve the mother's life. In view of growing doubt among the medical profession and the general public as to the wisdom of our present abortion laws, a critical appraisal of the subject is in order. Modifications in the law must be considered. Prior to 500 grams or 20 weeks, a foetus is not considered to be viable even by the most cautious of medical experts. The non-viable foetus is a tumour which, if removed from its maternal environment, could not survive even with the best of medical assistance. Up to 10 per cent of all pregnancies spontaneously abort. When this occurs, laws do not require registration of the conceptus and thus do not recognize its existence as a human being. Since the non-viable foetus has no recog­ nition by law and no possibility either of life or of appreciating its situation, one concludes that abortion cannot be an act of murder, as opponents of abortion would lead us to believe. Therapeutic abortion is permitted by law if a pregnancy endangers the life of the mother. The procedure, one of low mortality rate, is recognized as being pref­ erable to a potentially disastrous full term pregnancy. This legislation demonstrates society's belief that the life of a productive citizen takes precedence over a foetus which has yet to achieve human life. Although the mother's life is protected, her future health is not. Surely she should not be condemned to a life of ill health as a result of a full term pregnancy. Unfortunately, the mental health of the mother is also largely disregarded; yet, increasingly, medicine is recognizing the psychology of man as being of equal import to his physiology. Abortion laws should be extended to include all pregnancies which will be detrimental to the total future health of the mother. Conception resulting from rape is clearly a case where abortion should be permitted. While the father is punished in a physical sense by our criminal code, the guiltless mother suffers both mentally and physically. The mother, regardless of her age, must carry the foetus to delivery and suffer without reason the brunt of a full term pregnancy. The pregnancy is a constant reminder of an unpleasant and emotionally upsetting experience. Conception arising from rape typifies the cases where abortion is necessary to alleviate a situation in which the birth of a child cannot be regarded as a desirable event. The unwed mother is another case in point. She gains nothing more than lasting guilt as a result of a full term pregnancy and the birth of a child. Provided a woman's religious beliefs permit her to consider abortion, this solution should be available to her. There is a relatively high possibility that a malformed foetus will be produced in certain pregnancies. German measles and mutagenic drugs are two examples in which the risk of deformity is known well before viability of the conceptus. These malformations are tragic and irreversible. The economic and psychological burden facing parents of prospective malformed babies could be effectively reduced if (Continued on page 11)

58 U.W.O. M EDICAL JOURNAL ABORTION? No!

From before Hippocrates time to the present day man has been obsessed by moral problems. One such problem has been the question of abortion. The Hippo­ cratic oath states: "I will give no deadly medicine to any one if asked, nor suggest any such counsel; and in like manner I will not give to a woman a pessary to produce abortion." However, this sentence alone has not been enough to satisfy the analytical mind. As with all moral problems there is a divergence in opinions concerning the moral justification or acceptability of the act in question. Thus the case for abortion rests on the question of when life begins. There are those who hold the theory of Immediate Animation which states that the soul is infused at the time of con­ ception. According to this theory the ovum possess an intrinsic property (the capability of becoming an adult human being) which is actualized at the moment of fertilization. From then on the fertilized egg progresses through a series of predetermined stages the end result of which is an adult human being. Since only fertilization is required to release this capability, human life must begin at the moment of fertilization and with it human rights. Another theory is that of Mediate Animation which states that the soul is infused when the embryo takes the shape of a human ( 6 to 8 weeks). Most philosophers believe that the embryo becomes a human being at the stage when it is no longer possible for identical twins to be formed. And finally there are those who believe that the fetus is not a living human being until it is capable of survival independent of its mother (approximately 28 weeks). We are confronted, then, with four divergent theories, none of which is subject to objective proof. Since we cannot determine the exact time at which the soul is infused, we must face the possibility that human life comes into being at the time of conception, Therefore, an abortion at any time from the moment of conception may result in the destruction of a human being and consequently must be con­ demned. A physician is responsible for two patients in pregnancy, mother and child. Keeping this in mind we will now deal with four sets of circumstances where the question of abortion would arise. First, let us consider the case of where the mother's physical health may be threatened by the pregnancy. The physician is morally responsible for the lives of his patients. He must not prescribe treatment which is detrimental to their health and life. Thus, faced with the possibility that the pregnancy may be injurious to the mother's health he cannot act in any way so as to directly endanger the life of either patient. If he is placed in a position where he must ultimately make a choice as to which patient he will save, his choice must be based on which one has the better chance of survival. However, having made this choice he still cannot take any steps which will directly endanger or terminate the other life. Thus, he cannot trade one life for the other. He is still treating two patients, two lives. The second circumstance arises where the mother's psychological well-being is threatened by the pregnancy. Prediction of the effect of an event on psychological (Continued on page 71)

D ECEMBER, 1965 59 Medicare: The Facts

by BRIAN HUTCHISON, '67

Among medical students, and no doubt among physicians as well, the subject of medicare is discussed often-but not well. Frequently, discussion is based on misconception rather than know ledge. Emotion and reason commonly become so hopelessly intertwined that the conclusions are inconsistent with the facts. This article is an attempt to present the facts concerning medicare as a basis for rational discussion. In it will be presented the positions and proposals of the federal government, opposition parties, the Canadian Health Insurance Association and the Canadian Medical Association. The salient features of proposed o r existing provincial health insurance sc :~ emes will be outlined.

Federal Governm ent 4) that the benefits be portable from pro­ vince to province. The Liberal government's medicare pro­ posals were presented by Prime Minister "Comprehensive physicians' services Pearson at the Federal-Provincial Con­ refers to all services provided by general ference held in Ottawa on July 19 and 20, practitioners and specialists, with the 1965. exception of services provided under other legislation and such items as medically While recognizing that health services unnecessary cosmetic surgery. Provinces are constitutionally a provincial responsi­ could provide other benefits but initially bility, the Prime Minister indicated that the federal contribution would be based on his government is prepared to accept physicians' services only. financial responsibility for approximately one-half the per capita cost of medicare. A publicly administered, universal plan This one-half was estimated to be 14 per would necessitate "a replacement of exist­ capita. ing plans of other types". The Prime To be eligible for the federal contri­ Minister stated that "there will of course bution, provincial programs would be be scope for the continuation of private required to meet four basic criteria: insurance for services above those provided in the public plan". 1) that comprehensive physicians' services be the basic minimum benefits pro­ Judy LaMarsh, Minister of Health vided. and Welfare, indicated at the Health Ministers Conference on September 23 and 2) that coverage be universal. 24 that acceptance of the government's 3) that the plan be publicly administered, proposal would not necessarily mean the either directly by the provincial gov­ demise of doctor-operated plans. She ernment or by a provincial government stated that a province could conceivably agency. adopt a system in which a doctor-operated

60 U.W.O. MEDICAL JOURNAL plan acted in certain respects as the agent "I must say, however, that the federal of a provincial department or commission. government is conscious that practice out­ side the program might introduce features There remains considerable doubt in such as extra billing (charging of fees many people's minds as to the precise greater than those found in the plan's meaning of the term "universal coverage". schedule), which could seriously interfere When introducing the government pro­ with the principles of universality and posals, the Prime Minister said the plan free access. If such a procedure led to a "should cover all residents of the Province situation where either the number of doc­ on uniform terms and conditions". He tors operating outside the plan or the continued, "If a Province chooses to amount of extra billing violated the prin­ finance its plan without premiums, uni­ ciple of universality, then obviously there versal coverage means that the services could be no federal contribution." must be available to all residents without exclusion because of age, economic cir­ At the Federal-Provincial Conference cumstances or pre-existing conditions." the Prime Minister declared that, in order Commenting on this statement Miss to insure the availability of adequate num­ LaMarsh has said, "This should mean, in bers of health services personnel to meet practice, 100% coverage." Mr. Pearson future needs, the federal government was further stated, "If a Province elects to use prepared to establish a Health Resources a premium, universality means that the Fund which would provide grants to help premium should be compulsory for the meet the capital costs of such facilities as same people as are covered by the Prov­ research establishments, teaching hospitals ince's hospital insurance plan . . . the and medical schools. He subsequently premium would be compulsory in the announced on September 23 that 500 sense that taxes are compulsory. Obviously million would be made available from this there is no compulsion on people to use fund over the next 15 years. the services . . . " These federal proposals, scheduled for Referring to the physician's right of implementation in July, 1967, are of course non-participation, the Prime Minister subject to both provincial and parliament­ commented that there is no compulsion on ary approval. the individual doctor to join the plan " if the demand for his services is such that he Reaction of the Provincial Premiers to can practice successfully outside it". the federal medicare proposals has been mixed. E. C. Manning, Social Credit Prem­ Miss LaMarsh in her October 1 reply ier of Alberta, has stated that his govern­ to a submission by the Canadian Medical ment does not wish to participate in the Association, made the following statement "compulsory program" outlined by the concerning the patient's free choice of Prime Minister. Other Premiers, includ­ doctors and the physician's right to non­ ing W . A. C. Bennett (S.C.), British participation: "There has never been any Columbia; John Robarts ( P.C. ) , Ontario question that we agree that a patient and Duff Roblin (P.C.), Manitoba, should retain complete freedom to choose expressed some dissatisfaction with the his own physician. compulsory features of the plan but did not indicate an unwillingness to partici­ "As for the right of a physician to re­ pate. frain from joining the plan and for a patient to receive reimbursement for his services we have made it clear that this is Opposition Parties not in itself to be ruled out, as far as a The Progressive Conservative party has federal contribution is concerned. been notably silent on the subject of medi-

DECEMBER, 1965 61 --Medicare: The Facts------

cal care. P.C. leader, John G. Diefenbaker, They propose a voluntary, prepaid medi­ stated in a nationally televised campaign cal insurance plan, subsidized by the fed­ address that his party would implement eral government but supervised by the the recommendations of the Hall Com­ provinces. Under the Social Credit plan, mission report while preserving the indi­ the government would provide full or vidual's right to freedom of choice. (The partial premium subsidies to those indi­ Hall Royal Commission on Health Ser­ viduals unable to afford premium pay­ vices concluded that a universal plan was ments. Medical insurance policies for necessary to adequately meet the health subsidized individuals could be issued needs of Canadians.) The promise of either through the provincial government "universal Medicare" appeared in a num­ or by existing insurance carriers. Unsub­ ber of newspaper advertisements spon­ sidized individuals would be permitted sored by the Progressive Conservative free choice of carrier. No individual would Party of Canada. be compelled to subscribe to a medical insurance program. No reply was received to inquiries directed by this author to Dalton Camp, Provincial Plans National President of the Progressive Conservative Association. Medical insurance schemes are presently in operation in three provinces and in the The New Democratic Party has long planning stages in two others. The Sas­ been an advocate of universal, compulsory, katchewan plan is compulsory, while government administered medicare. As Alberta and British Columbia have volun­ proposed, the New Democratic "National tary medical insurance programs. The Health Plan" would be based on the pres­ Ontario government has introduced leg­ ent hospital insurance program and like it, islation which will provide a voluntary would be administered in cooperation with scheme. Premier Lesage of Quebec has the provincial governments. promised legislation in 1966 to furnish medical care for low income groups until While arrangements with respect to the a full-scale plan can be instituted. non-participation of physicians and the patients' choice of doctor have not been The "Saskatchewan Medical Care In­ spelled out, John G. O'Sullivan, Imme­ surance Plan" was inaugurated on July 1, diate Past President, London and Middle­ 1962. sex Ridings Association of the New Demo­ Participation in the plan is compulsory cratic Party, states that they would for all provincial residents. The plan is undoubtedly closely resemble the provis­ administered by a Commission with a ions currently in effect in Saskatchewan. membership of eleven responsible to the These arrangements are outlined elsewhere Minister of Public Health. The Deputy in this report. Minister of Public Health serves as an ex officio, non-voting member. Of the re­ The New Democratic Party proposes maining, ten, five are physicians, three of federal financial assistance for scholar­ whom are nominated by the College of ships, research facilities, and development Physicians and Surgeons of Saskatchewan. and expansion of teaching centres in order to provide adequate numbers of health The plan is financed partly through a personnel. personal tax or premium and partly ( ap­ proximately 75 % ) through appropriations The Social Credit Party has declared it­ from general revenue. The medical insur­ self unalterably opposed any element of ance premium is paid jointly with the compulsion in a medical care scheme. provincial hospitalization tax and consti-

62 U.W.O. MEDICAL JouRNAL tutes one-third of the joint tax. Current Significantly, the ratio of physicians to joint tax levels are $36 for single persons population has increased since the plan's and $72 for families. The provincial gov­ inception - from 1:1028 in 1961 to 1:962 ernment pays the premiums of those in 1964. receiving "Old Age Assistance". Recipients Alberta's subsidized, prepaid medical of municipal social aid have their prem­ insurance plan is entirely voluntary. Stand­ iums paid by the municipality. ard medical insurance policies are offered Payment under the plan is made at 85 % by carriers who have registered under the of the Schedule of Minimum Fees of the plan. The government stipulates the mini­ College of Physicians and Surgeons of mum coverage which must be provided Saskatchewan. Three methods of fee-fo r­ and maximum premiums which may be service payment are offered: charged. 1) A physician may submit a bill directly The government provides subsidies to the Commission for payment. In which pay 50% of the premium for indi­ doing so he agrees to accept the Com­ viduals with no taxable income and 25 % mission payment as payment in full. for those whose taxable income is not in This method accounted for 25 % of excess of $500.00. the claims in 1964. Under this plan 80% of Alberta resi­ 2) A physician may become a member of dents are now covered by some form of an approved health agency. He submits medical insurance after one year of opera­ the bills of that agency's subscribers to tion. the agency for payment. The agency in Early in 1965 the British Columbia leg­ turn submits the bills to, and receives islation passed "The Medical Grant Act" payment from, the Commission, then under which the government, through forwards payment to the physician. agreements with certified, non-profit medi­ The physician agrees to accept payment cal insurance carriers, would pay one-half as payment in full. In 1964, 67% of the premium cost for persons with no claims were handled in this manner. taxable income, and one-quarter the prem­ ium cost for those whose taxable income 3) A physician may submit his bill to the does not exceed $1000. patient. The fee charged is a private matter between the physician and his The government subsequently initiated patient. The patient may, however, sub­ the formation of a government agency, the mit the itemized bill to the Commis­ British Columbia Medical Plan, which be­ sion and receive payment to a came the first and, to date, only certified maximum of 85 % of the schedule of carrier. This voluntary prepaid medical fees. This method accounted for 8.5% care plan is available to all residents of of claims in 1964. the province. The alternative to fee-for-service pay­ Non-subsidized residents are free to sub­ ment is a fixed sum contract. A physician scribe to the British Columbia Medical who chooses to practice under this arrange­ Plan, any other prepaid plan, or no plan. ment is paid a fixed sum by the Commis­ Physicians practicing within the British sion on a periodic basis. The physician Columbia Medical Plan submit the ac­ reports the services provided, so that his counts of Plan subscribers directly to the volume of work may be periodically re­ Plan for payment. The physician currently viewed. No record of payment on this receives payment at the rate of 90% of basis is contained in the 1964 Annual the schedule of fees of the British Colum­ Report. bia Medical Association.

DECEMBER, 1965 63 --Medicare: The Facts------

A subscriber may elect to utilize the The CHIA advocates a voluntary pro­ services of a non-participating physician, gram with the following features: in which case the subscriber pays the 1) A standard health insurance contract attending physician and is reimbursed by available to all residents. the Plan to the value of "90% of the 2) Free choice of doctor. amount paid ... (provided the bill) is not in excess of the rate agreed upon between 3) A statutory maximum premium. the (British Columbia Medical) Associa­ 4) Government subsidies for low-income tion and the Plan for such services".1 groups and those on welfare. Ontario's "Medical Services Insurance 5) Free choice of carrier from which to Act" is scheduled to go into effect on purchase medical care insurance. June 1, 1966. 6) Freedom to decide whether or not to purchase protection. Under the Act, standard medical insur­ ance contracts will be provided by the 7) A variety of additional plans from government through a division of the which the individual may choose. Department of Health to residents who are unable to afford such insurance. Dr. Canadian Medical Association Mathew Dymond, provincial health min­ "We believe in medical services insur­ ister, has stated that the government will ance and feel that it should be available to fully subsidize premiums of persons with all who desire to purchase it but that the no taxable income. Single individuals with proper role of the state is to identify and incomes not in excess of 500, couples assist those persons who cannot finance with taxable incomes not exceeding 1000 such coverage from their own resources." and families with taxable income not ex­ This comment by Dr. A. D. Kelly, Gen­ ceeding 1200, will be partially subsidized. eral Secretary of the Canadian Medical The Act also provides that standard Association expresses the essence of CMA medical insurance contracts be made avail­ policy with regard to medical services· in­ able by private carriers to non-subsidized surance and the role of government in the individuals. Maximum premium levels provision of medical care. would be stipulated by the government. In June of 1965 the CMA issued a Benefits under a standard contract, policy statement on medical services insur­ whether provided by the government to ance advocating that such insurance be subsidized persons or by a licensed carrier made available and accessible to all Cana­ to non-subsidized individuals, will be dians on a voluntary basis. It was stated 100% of the Ontario Medical Association's that medical services insurance is a pro­ schedule of fees. For a period of two years vincial responsibility and that financial the benefits will remain at the level of the contributions by the federal government fee schedule in force on the day the Act should not interfere with self-determina­ comes into effect. tion of the provinces. The provinces should "provide . . . enough financial Health Insurance Companies assistance to persons in need to enable The Canadian Health Insurance Associ­ them to purchase insurance - using the ation, which represents the major insur­ annual income tax declaration as the basic ance companies providing accident and criterion". sickness insurance policies, has expressed strenuous opposition to the federal gov­ On the subject of freedom of choice and the physician's right of non-participation ernment's medicare proposals. the following view was presented: "The 1 British Columbia Medical Plan Contract. Canadian Medical Association believes that

64 U.W .O. MEDICAL JOURNAL every resident of Canada should have as amounts of public funds were being used, free a choice as possible among different overall policy would be formulated by a carriers and different plans, as well as body representative of the medical profes­ free choice of physicians; and that every sion, government and recipients of health physician should have free choice of services. patient except where humane considera­ The CMA has consistently emphasized tions dictate the contrary, and be free to the necessity for effective measures on the participate, or not to participate, in any part of government to increase the output plan or with any carrier. of physicians and other health personnel "There must be no discrimination by in order to maintain and enhance the any insurance plan against the non-par­ quality of medical care. In the policy state­ ticipating physician, or against the sub­ ment the CMA warned that the extension scriber who consults him. The subscriber of coverage to the whole population "will who consults a non-participating physician place a considerable strain on available must not be obliged to relinquish any personnel and may endanger the quality benefits for which he has directly or in­ of the care which the public receives". directly paid, and clear provision for his T he author wishes to thank the following indemnification (reimbursement) must be organizations and ind ividuals fo r their coopera­ assured." tio n in the preparation of this report: the Uni versity of Western Ontario Liberal Club; The CMA favours non-governmental ad­ John G . O "Sullivan, Immediate Past President, London and Middlesex Ridings Association of ministration of medical insurance pro­ the ew Democratic Party; Province of as­ grams and has suggested that doctor-spon­ katchewan Medical Care Insurance Commission; sored agencies could act as administrators W. D . Black, Provincial Secretary, Provi nce of British Co lumbia; the Canadian Medical Asso­ of provincial plans. Where substantial ciation.

D ECEMBER, 196) 65 Alumni News Class of 19 55 Dr. Kenneth Adams, 3615 Ridgewood Teaching Hospitals, he was appointed Ave., Apt. 305, Montreal 26, Quebec, in­ Pathologist at Princess Margaret and terned at Hamilton General Hospital. Wellesley Hospitals in Toronto. He is Since then he has been with the R.C.A.F. married with two boys and a girl. and at Montreal General Hospital. He is now an ophthalmologist on the staff of Dr. Donald Cotton., interned at Victoria Montreal Children's Hospital. Hospital, London. From 1955-60 he was associated with the R.C.A.F. In 1960 he Dr. Donald Bebensee, 8998 Eldora, was a demonstrator for the Department of Cincinatti, Ohio 45236, interned at Wayne Pharmacology at the University of Wes­ County General Hospital, Eloise, Michi­ tern Ontario Medical School. He is mar­ gan. Following this, he did post-graduate ried and has three sons. work in obstetrics and gynecology in South Bend Indiana. Dr. Velta J. Cernavski, 6 Ballantyne Dr. William Bota, 41 Braemar Place, Court, Islington, Ontario, interned at St. Hamilton, Ontario, interned at Hamilton Joseph's Hospital in Toronto, Ontario. She General Hospital. After doing post-gradu­ did post-graduate training in pathological ate residencies in Buffalo in anaesthesia, chemistry at the University of Toronto, he accepted a position as an anaesthesio­ and is now engaged in general practice in logist at St. Joseph's Hospital, Hamilton. Islington, Ontario. He is married and has three children. Dr. Edward C. Chagnon., 17 King St. W ., Stoney Creek, Ontario, interned at This year, the Alumni Staff, in an Hamilton General Hospital, Hamilton, On effort to bring Alumni News up to date, tario, and is presently in general practice has sent out questionnaires to certain in Stoney Creek, Ontario. He is married graduating classes. As many of these forms and has four children, including one set have not been returned, we have been of twins. forced to consult the limited information contained in the University alumni files. Dr. Richard Webster Charteris, 63 6th Any letters concerning recent activities St., Chatham, Ontario. and achievements of our alumni would Dr. Robert Talbot Collyer, 7 Chalmers be appreciated for future use. Ave., London, Ontario, interned in Lon­ don, Ontario, after which he did post­ Dr. Eldon James Brown is now living at graduate studies in ophthalmology in Tor­ 142 Sherwood Rise, Hamilton, Ontario. onto, Ontario and London, England. He is He interned at Toronto Western Hospital presently an ophthalmologist in London, and did post-graduate training in obstet­ Ontario and is married with three child­ rics and gynecology. He is married and ren. has three children. Dr. Edward Crispin., 17 Wolfond Cresc., Dr. John S. Carruthers, 92 Otter Cres­ Guelph, Ontario, interned at Montreal cent, Toronto 12, Ontario, interned at General and Hamilton General Hospitals. Toronto General Hospital. After doing his He and his wife, Maxine, B.Sc. '51, have post-graduate training in the Toronto three children.

66 U.W.O. MEDICAL JOURNAL Dr. Jeanne Deinum, 234 Sunset Drive, Dr. Gavin Hamilton, 531 Canterbury St. Thomas, interned at Victoria Hospital. Rd., London, married the former Sheila She did her post-graduate training in McDonald. psychiatry at the University of Toronto Dr. Murray C. Henderson, 397 North and is presently Clinical Director, Male Shore Drive West, Burlington, Ontario. Division, Ontario Hospital, London. He has been awarded an F.R.C.S.(C) and is an orthopaedic surgeon in Burlington. Dr. Robert G. Eddy, 171 Brant Ave., He is married and has one boy and two Brantford, interned at Toronto East Gen­ girls. eral. He is in general practice at Brant­ ford and a member of the medical staff Dr. Kenneth Hobbs, 112 Centre N ., of Brantford General Hospital. He married Whitby, Ontario, interned at Ottawa Civic the former Helen Hart, Honours Arts '53, Hospital and is now practising in Whitby. and has three children. He is married to the former Eva Stumpf (Arts '53) and has one boy and two girls. Dr. John M. Edwards, 92 Mary St., Dr. Richard Hutson, 2897 Raddison Orillia, interned at Toronto Western Hos­ Ave., Windsor, Ontario, is presently in pital. private practice in Windsor. He is married Dr. Alfred Eistetter resides at 89 and has a son born in 1963. Motherwell Cres., Regina, Saskatchewan. Dr. John W. Irvine, 53 East Drive, He obtained his F.R.C.S.(C) in obstetrics Columbia, Missouri. and gynecology. Dr. Stanley R. lwan, 265 Glasgow Dr. David Bruce Forbes, 39 Winston Street, Kitchener, Ontario is presently Circle, Pointe Claire, Quebec, interned in practising neurosurgery in Kitchener. He Montreal and continued his studies at Ox­ is married to the former Carol J. Ander· ford. He is presently Orthopaedic Surgeon son (Nursing '59). They have two boys at Montreal Children's Hospital. He is and a girl. married and has three children. Dr. Harold Jackson, 198 Millard Ave., Newmarket, Ontario is married and has Dr. Leonard Goldman interned at Tem­ three children. ple University Hospital. He served on active duty with the U.S. Navy (Medical Dr. Harold Johnson, 253 Watson Ave., Corps) 1956-1958. He married the former Oakville, Ontario, interned at Hamilton Betty Jean Silverstein. General Hospital, and is married to the former Isobel Cebrowski. Dr. Douglas G. Grant, 751 St. W ., Kit­ Dr. Thomas Jory, 398 Riverside Drive, chener, interned at Victoria Hospital, Lon­ London, Ontario. He has obtained his don. He did post-graduate training in fellowship in surgery and practises general dermatology and is married with three surgery in London. He is also an instructor children. in the Anatomy Department of UWO. He is married to the former Pat Boug (B.Sc. Dr. Ronald Eric Groshaw, 1826Y2 Wes­ ton Road, Weston, Ontario, interned at '53). Victoria Hospital, London. He did post­ Dr. Erving L. Kirsh, 24 Kilburn Place, graduate training at the Sussex Eye Hos­ Weston, Ontario, interned at Toronto pital, Brighton, England and the Univers­ General Hospital, and did post-graduate ity of Toronto. He is consultant in ophthal­ training at Wellesley Hospital and the mology, Sunnybrook Hospital. He is mar­ Hospital for Sick Children, Toronto. He ried and has one child. is married and has two children.

DECEMBER, 1965 67 --Alumni News:------

De. Charles R. W. Knight, 1207 Cairno American College of Physicians & Surg­ Ave., Saskatoon, Saskatchewan, interned at eons and was recently appointed Assistant Victoria Hospital, London, and did Clinical Professor of Medicine at the post-graduate training not only in Medical College of Virginia. He has a Canada but also in the U.S., U.K. and private practice in gastro-enterology and Scandinavia. He is now a plastic surgeon internal medicine. and an instructor in surgery at the Uni­ versity of Saskatchewan. He and his wife, Dr. J. S. Morrison, 375 Maio St. East, the former Elizabeth McWhirter (Nursing Hamilton, Ontario, completed his intern­ administration '56) have one child. ship at St. Joseph's Hospital, Hamilton. Following this he set up general practice Mrs. John D. Leitch (Dr. Sheila Kings­ in that city. He is married and has seven mill), 494 Dunedin Drive, London, On­ children. tario, interned at Victoria Hospital, Lon­ don and did post-graduate work in psy­ Dr. William Mund is practising in Lis­ chiatry. She is presently associated with the towel, Ontario. He was married in Eng­ London Mental Health Clinic. land in 1958. De. A. Craig MacDonald, 466 Mohog­ Dr. Donald C. Munro of St. Mary's On­ any Road, London, Ontario, interned at tario is in practice there. He married Victoria Hospital, London and later spent Suzanne Powers, also a graduate of West­ some time at the R.C.A.F. Station in ern. He is Chief of Staff at St. Mary's Claresholf, Alberta. He is presently work­ Hospital. ing in the field of diagnostic radiology and is married with four children. De. Max Nathan, 452 Maio St. East, Hamilton, was awarded his B.A. in 1951, Dr. J. Alan Maloney, 76 Craobrooke entered Medicine and is now a paedia­ Crescent, Sudbury, Ontario, interned at trician in the Carr-Nathan Clinic of Ham­ St. Michael's Hospital, Toronto, and is ilton. He is married and has three children. now an obstetrician-gynecologist in Sud­ bury. He is married to the former Mary Dr. George Pearce, 278 Charles St., Lenore MacLean (Arts '55). Belleville, interned at Toronto General Dr. William S. McLean, Main Street, Hospital. He spent several years with the Stayner, Ontario, interned at Hamilton R.C.A.F. as Medical Officer. General Hospital and is in general prac­ Dr. Alexander Polak, deceased April tice in Stayner. He is married and has 1965, in Vancouver. three boys. Dr. Helmut Mathies, resides at 215 De. Robert Porter, 393 University Ave., Lincoln Road, Waterloo. He earned his Toronto 1, earned his B.A. in 1951, enter­ Bachelor of Science degree, then studied ed medicine, and interned at Hamilton medicine, and interned at Victoria Hos­ General Hospital. At present he is with pital in London. He is married and has the Bell Telephone Company as Medical one daughter. Officer for the Toronto area. He is mar­ ried, with four sons. Dr. Dennis J. Morey, 8 Westmorland Ave., Richmond 26, Virginia, interned at De. John Rhodes, 244 Greeobrook Dr., Orange Memorial Hospital, Orlando, Kitchener, was awarded his B.A. in 1951, Florida and then studied three years of then entered medicine. After his intern­ internal medicine and one of gastro-en­ ship he entered general practice in Osh­ terology. He is married with three child­ awa for a time. He is married and has ren. Last year he was admitted to the two sons.

68 U.W .O. MEDICAL JOURNAL Dr. Richard W. Roberts, 2126 Norway a Fellow of the American College of Rd., Montreal, P.Q., interned at Montreal Obstetricians and Gynecologists, a member General Hospital, and studied anaesthesia of the Michigan Society of Obstetricians at McGill University. At present he is and Gynecologists and a member of the practising his specialty in Montreal. He is Detroit Surgical Society. He is married married with three children. and has two sons. Dr. Shirley Richardson, (nee Shir· Dr. Kenneth Threo.dyle, Corunna, On­ ley Mossing), 113 Broadmeadows Blvd., tario, interned at Victoria Hospital in Columbus, Ohio, interned in Alberta, and London, Ontario. He did a residency in married S. R. Richardson that year. He general practice at the Euclid Glenville graduated from UWO Medical School in Hospital in Euclid, Ohio and is now en­ 1956. gaged in general practice. He is married Dr. Jack L Sales, 356 McKeon Ave., and has four children. London, Ontario, interned at Victoria Dr. Kenneth E. Tumbull, 200 Scott Hospital, London, and spent an additional Block, Moose Jaw, Saskatchewan, interned three years at Victoria studying surgery, at the General Hospital in Regina, Sas­ then to Toronto become a resident in katchewan and is now practicing obstetrics urology. In 1961 he was awarded the and gynecology. McLachlin Travelling Fellowship. His wife graduated from UWO in 1956 with a Dr. Robert Ross Turner, 300 Hampshire B.Sc.N. They have two sons. Court, Dearborn, Michigan, interned at Viictoria Hospital, London, Ontario. He Dr. Jack Shaver is currently in general then did post-graduate studies in obstet­ practice in Scotland, Ontario and a mem­ rics and gynecology at the Detroit Re­ ber of the medical staff at Brantford ceiving Hospital, Detroit, Michigan, and General Hospital. He is married and has is now in private practice in Dearborn, three children. Michigan. He is married and has two Dr. James Stanton, 225 South Gratiat children. Ave., Mt. St. Clements, Michigan, interned at St. Francis Hospital, Evanston, lllinois. Dr. I. Henry Upmalis, 133 Ripplewood Cresc., K.itchener, Ontario, interned at Dr. Graham K. Stratford, 154 Ontario Victoria Hospital, London, Ontario and St., Cobourg, Ontario, interned at the did post-graduate training in general sur­ Royal Victoria Hospital in Montreal, Que­ gery. He is presently a surgeon on staff bec and did post-graduate studies in Eng­ at the K.itchener-Waterloo and St. Mary's land. He is now engaged in group prac­ Hospitals in K.itchener. In addition he is tice as a general practitioner in Cobourg, surgical consultant for Freeport Sanitor­ Ontario. He is married and has three child­ ium, Kitchener. He is married and has ren. five children. Dr. Donald C. Swan, 9876 W. Outer Db. John Urschel is a resident at Uni­ Drive, Detroit 23, Michigan, interned at versity Hospital, Edmonton, Alberta. Sinai Hospital in Detroit. He then took on a residency in obstetrics and gyne­ Dr. Pavils Vasarinsh, 140 Marguerite cology at Sinai Hospital and Crettenton Lane, Burlington, Ontario, interned at the General Hospital in Detroit from 1956 to Hamilton General Hospital, Hamilton, 1959. He is presently an active member of Ontario and did post-graduate training at the A.M.A., Wayne County Medical So­ Westminster Hospital from 1956-1957. He ciety; an associate member of the Oakland then went into general practice until 1965 County Medical Society. In addition he is and is now a resident in dermatology at

DECEMBER, 1965 69 ----Alumni ~~5------

the Detroit General Hospital. He is mar­ the Toronto East General Hospital and is ried and has two children. now engaged in general practice in Tor­ onto. He is married and has two children. Dr. John Wallace, 16916 33rd Ave. N.E., Seattle, Washington, interned at the Calgary General Hospital and did post­ graduate studies in adult and child psy­ Class of 1954 (correction) chiatry at the University of Michigan. He is presently an instructor of child psy­ Dr. John Erhardt, cjo Arabian Ameri­ chiatry in the Department of Psychiatry, can Oil Co., Box 561, Abqaiq, Saudi University of Washington School of Medi­ Arabia interned at Orange Memorial Hos­ cine, Seattle, Washington. He is married pital, Orlando, Florida. After taking a year and has three children. of general practice residency at St. Joseph's Hospital, Flint, Michigan, he was Dr. James Louis Weber, 30 Lormar Dr., in private practice in Mississippi for about Islington, Ontario, interned at the Toronto five years, prior to spending three years in Western Hospital and did post-graduate post-graduate training (Internal Medicine) training in paediatrics at the Children's at Baylor University Medical Centre in Medical Center in Boston, Mass. He is Houston, Texas. Since 1963 he has been married and has two sons. supervisor of clinical medicine for the Dr. Olris Yankou, 179 Bayview Heights Arabian American Oil Company in Ab­ Drive, Toronto 17, Ontario, interned at qaiq, Saudi Arabia.

70 U.W.O. MEDICAL JOURNAL Abortion? Yes! (Continued from page 58) abortion laws were extended. While it is true that the foetus might develop normally, there can be no injustice in abortion since the non-viable foetus, whether normal or malformed, does not constitute a human life. Abortion should be considered in pregnancies tending to have a destructive influence on the family. For example, the thirteenth child of a labourer is not likely to be welcomed as a "bundle from Heaven". The additional psychological and economic stress can aggravate existing emotional problems resulting in dissolution of the family unit. Provided that both parents consent, abortion should be available in these circumstances. In the situations considered above, medical abortion offers a simple and adequate solution. Unfortunately this solution is, in most instances, not legally available. The result is unnecessary suffering. Revision of the Criminal Code is urgently needed to permit abortion in all cases where one or more of the following conditions prevails: 1) The mental and/or physical health of the mother is threatened by the pregnancy. 2) The child will not contribute gainfully to the life of the mother. 3) The birth of the child would impose an undue economic and/ or psychological burden on the parents or family. JOHN PATRICK '67

Abortion? N of (Continued from page 59) well-being is both difficult and extremely subjective. The percentage error in such a decision is extremely high. Where human life is concerned, the decision to term­ inate a life based on conjecture is hardly justified. The third question arises when the likelihood of the baby being born with congenital malformations is high. Again, there is no justification for abortion. The child has the right to live. No type of rationale such as "the child would rather have died than lived the life of the hopelessly deformed" can change this fact. No one has the right to sit in judgement on the life or death of an innocent party. The last situation arises when an abortion is sought simply as a means of birth control. There is no simpler way of answering this question than with an emphatic, no! The purpose of this essay has been to impress upon the reader the fact that when treating a pregnant mother a physician is dealing with more than just one patient and is thus responsible for more than just one life. No amount of ration­ alization can obscure the fact that an abortion, even in the early months of gestation, may involve the destruction of a human being. It is for this reason, therefore, that abortion must stand condemned.

D ECEMBER, 1965 71 UNIVERSITY OF WESTERN ONTAIUO MEDICAL JOURNAL

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