Principles of the German Medical Association regarding the accompaniment of the dying process by physicians

In 2004, the German Medical Association drew up principles regarding the accompaniment of the dying process by physicians („Grundsätze der Bundesärztekammer zur ärztlichen Sterbebegleitung"). In these principles, they state that the „deliberate curtailment of life by measures which bring about death or accelerate the dying process" as assisted suicide (active euthanasia) is „impermissible and subject to punishment” and therefore to be rejected. However, it also states that „the relief of suffering can be of such importance that a possible shortening of life may be inevitable and hence tolerated". According to these principles, life-prolonging measures can only be terminated or omitted if „they only delay the moment of death and the illness cannot be prevented from worsening". In cases of patients who are unable to give their informed consent, the physician must obtain a relevant declaration from the legal guardians who may have to be appointed by a guardianship court. 

In 2011 the German Medical Association published its revised principles. According to the German Medical Association's own statement, this revision became necessary for two reasons: first, because of a revised version of the law relating to care and control and second, because of a change in the fundamental attitude of the physicians, according to a poll of 2009. Besides many other passages of the original document, the new version also includes the programmatic set phrase of the preamble of 2004: „It is the duty of the physician to protect and restore the patient's health as well as to alleviate the patient's suffering and assist dying patients until death, while preserving life according to the patient's right of self-determination.” Both preambles indicate that life cannot be preserved under any circumstance and that the physician's duty to do so is limited. Furthermore, the rejection of „active euthanasia” (2004) as well as „killing of the patient” (2011) remains intact.

Yet, the wording regarding assisted suicide has remarkably changed. While the 2004 version states that „[t]he physician's involvement in suicide contradicts medical ethics and can be punishable”, the 2011 version states that „[t]he physician's involvement in suicide is not a medical task.” It becomes thus clear that assisted suicide should not belong in the medical field of activity (of the physician). Nevertheless, the new wording of the 2011 version has changed the tenor of the debate on which the president of the German Medical Association, Jörg-Dietrich Hoppe, reacts in his foreword: „This explicit statement underlines the fundamental principles regarding accompaniment of the dying process by physicians. It substitutes the former statement which pointed out that the physicians' involvement in the suicide of the patient contradicts medical ethics. Thus it recognizes the many different and individual concepts of morality of the physicians in a pluralistic society, without questioning the fundamental principles and statements regarding the accompaniment of the dying process by physicians.”

Suggestions of the German Medical Association on medical dealing with suicidal tendencies and death wishes in accordance with the decision of the Federal Constitutional Court on §217 of the Criminal Code

In reaction to the decision of the Federal Constitutional Court of February 26, 2020, declaring Act 217 as unlawful and the thus resulting uncertainty regarding the current legal situation, the German Medical Association published an announcement with suggestions on medical dealing with suicidal tendencies and death wishes. These suggestions were formulated following consultations in the Committee on ethical and medico-legal principles, in the board of the German Medical Association and the fundamental debate at the 124th German Doctors’ Congress. In the preamble, it is stated that the suggestions „should give physicians an orientation, to find their own position, when being confronted with wishes for medical assistance in suicide. The individual decision in the concrete situation remains in the responsibility of the physician.” In the publication, it is primarily clarified wherein the tasks and functions of physicians are laying while dealing with critically ill or dying patients, according to the German Medical Association, as well as the current legal framework regarding the dealing with suicidal tendencies and death wishes. An understanding and empathetic handling of the patients is highlighted as well as the joint and informed search for possible ways to lessen or to release the sufferings or symptoms that are being experienced as unbearable.

This also applies if the patient expresses a death wish or thoughts of suicide, as the „conversation about suicidal tendencies and death wishes is a medical task.” Whereas, as it is already stated in the German Medical Association’s principles, it is also here repeated, that “the physician's involvement in suicide is not a medical task.” With regard to the right of self-determination, which played a fundamental role in the repeal of § 217, it is stated in the suggestions, that “no physician can be obliged to an involvement in suicide.” The right of self-determination can be invoked for the rejection of certain interventions, but not for the demand for certain interventions. In the current legal situation, it remains, however, that it involves an individual decision of the physician, “whether he complies to the wishes for assisted suicide expressed to him and whether he can reconcile such action with his conscience and his medical self-conception.”