SPIEGEL Interview with Dr. Michael de Ridder: 'What Is So Bad About Dying?'

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SPIEGEL: Why is that?

De Ridder: In the past, doctors were acting under much stricter conditions. They would only treat patients who, for example, had a heart attack with atrial fibrillation but who were otherwise healthy. I happen to be one of those patients. Without highly advanced medical procedures, I would not be sitting here today. Nevertheless, I still support the conditions that doctors worked under then. Because since then, the use of medical technology has been expanded to include even the chronically ill and those who have already reached the limits of their lives. In an extreme case, a patient with an end-stage tumor is shocked back into life.

SPIEGEL: What criteria should a doctor use to decide which lives are worth preserving?

De Ridder: It isn't about morals. It's about empiricism. You could say, for example: If a treatment was not successful the first 100 times, it should not be used for the 101st time. With the example of resuscitation: No brain can survive without oxygen for more than eight to 10 minutes. If I know that this time limit has been exceeded -- the patient has enlarged pupils and is almost clinically dead -- then my efforts are pointless. Unless of course, I think it's a good thing to produce patients in a vegetative state, at a 99-percent success rate. But doctors are fighting such concepts with all their might. They say: But you never know! There are 100 extraordinary circumstances that may mean that it is possible to help one out of 100 patients to continue to live a meaningful life, they say.

SPIEGEL: So should that person, that one out of 100, simply be abandoned?

De Ridder: Let me answer that with a question: Should I be allowed to put 99 people into a terrible situation, just because what I do benefits one person? How ethical is behavior where 99 decisions cause suffering: Are these (decisions) not as important? The guiding principle for any physician is not to harm the patient. Additionally resuscitating someone who has metastasizing cancer and failing kidneys, after cardiac arrest, is completely pointless. This isn't any requirement for dialysis any longer either. Doing this, I am just prolonging the patient's suffering. And in fact, our ICUs are filled with people who are being treated without good medical reason, people who don't belong there.

SPIEGEL: Does this also affect other areas of intensive care?

De Ridder: Yes, for example, artificial feeding through a percutaneous endoscopic gastrostomy (PEG) tube inserted into the abdominal wall. The PEG tube was invented to feed accident victims or people with a temporarily impaired ability to swallow. It was never intended as a long-term measure. But today about 100,000 people in Germany are living off these tubes. That is even though many studies have shown that a PEG tube neither prolongs life nor improves its quality during the end phase. On the contrary, in fact. And this is particularly applicable to patients with advanced dementia. These are expensive human rights violations that are happening at the end of life -- and doctors are responsible for them.

SPIEGEL:Some patients want their doctors to help them end their life with dignity because they can no longer tolerate their suffering.

De Ridder: I am convinced that there are situations in which it isn't just ethically justified, but in which I, as a doctor, have a duty to do this. Situations in which I am called upon to relieve the suffering of someone who is severely ill, and in a hopeless situation -- and to conduct this in the manner in which the patient wants. In this sense, I see assisted suicide as a kind of palliative measure, albeit a very extreme one.

SPIEGEL: What kinds of situations are you thinking of?

De Ridder: I experienced one case, up close. A patient had a tumor in his neck, and it began to bleed. He was in his last few weeks. He said: I don't want to burden my family, or myself, in this condition. A completely plausible concern. And his doctor helped him. That is ethical behavior, as far as I'm concerned.

SPIEGEL: Would you help?

De Ridder: Yes, if their decision were permanent and it was reached without external pressure, and if there is no evidence of psychiatric illness. You have to know the patient very well for this. Over the past year and a half, I have come to know a young woman, a brilliant scientist, who, since an accident two years ago, has been paralyzed from the head down and is completely without feeling. She wanted the artificial respiration shut off but she was refused, as that is clearly illegal. She was literally reproached for being the only patient in the ward who didn't want to live.

SPIEGEL: How is the young woman doing now?

De Ridder: She is breathing on her own again. But she says that she can't touch anyone anymore, she can't do her work anymore, she can't even lift a pebble. She doesn't want to live like this. Mind you, it's a life that wouldn't even exist without advanced medical procedures and it's also one that she can no longer end on her own. In that situation, I can't exactly order that the woman should be turned so-and-so-many times a day, that she should be fed and that she should lie there for another 40 years, just because we have the technological know-how and we want to satisfy our ethical standards.

SPIEGEL: So what do you intend to do?

De Ridder: If she stands by her decision, then I will help her. And I will face the consequential controversy.

SPIEGEL: You could run up against medical rules of conduct.

De Ridder: Yes, official medical ethics forbid something that is permissible under criminal law and constitutional law. But should they? We have to clarify this. A large number of my colleagues support what I say -- this is confirmed regularly by opinion polls. For years, the German Medical Association (Editor's note: the national umbrella organization for German regional medical associations which helps in establishing health policy) has had a de-facto ban on thinking or speaking about this issue. But as doctors we need an open debate on physician-assisted suicide and the problems that arise around the administration of palliative care.

SPIEGEL: Mr. de Ridder, we thank you for this interview.

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• Part 1: 'What Is So Bad About Dying?'
• Part 2: 'Expensive Human Rights Violations'