Advance Directives under Germany’s Civil Code in a Comparative Context

Inhaltsverzeichnis

A. Introduction

B. The Need for Advance Directives as Protective Legal Tools

C. Advance Directives under German Law

D. Concluding remarks

Literature:

Abstract: Aging societies and advances in medicine make it likely that biomedical issues will pose legal challenges. While biolaw can provide some regulation, important life and death decisions have to be taken by patients and physicians. Often, though, patients are no longer capable of making such decisions. In 2009, Germany formalized the private law rules on advance directives. While advance directives, also referred to as living wills, are still widely associated with wishes for euthanasia, they function today goes far beyond that. In terms of criminal law, Germany still outlaws active euthanasia. In so far it differs from the Netherlands, Belgium, Luxembourg and Switzerland. Given that there has been a noticeable shift of emphasis from human dignity and the right to life to personal autonomy as a function of human dignity and in light of the legalization of euthanasia in several neighboring countries and resulting euthanasia tourism from Germany to Switzerland, there is a risk that the legal situation or at least the general attitude and the perception of the law will also change in Germany. This can lead to a risk of unwanted active or passive euthanasia, a problem which is highlighted by a case which is currently pending before the European Court of Human Rights against France. Taking into account human rights and human dignity as well as the continued underlying role of cultural-religious values it will be shown that there is now an emerging role for advance directives as tool to enable patients to protect their lives if the law fails to do so.

Keywords: advance directive, living will, Germany, European Convention on Human Rights, Netherlands, Belgium, France, physician, euthanasia.

A. Introduction

The decision what is to happen in case a medical issue renders a person unable to make decisions with regard to medical treatments has to be made in advance1F^[1] - at a time when that person has little or no information about the medical issue in question.2F^[2] Such advance directives or living wills aim at protecting the will of the patient as it has been formulated at a time when the patient was still capable of making such important decisions. The motivation of such a decision, if made in a state of legal competence, is not questioned. Often advance directives are aimed at preventing prolonged exposure to ‘machine medicine’, i.e. technological measures which continue human life but which are seen as unnatural by some patients. It is often the fear of the unknown and of things which might happen to oneself and which would be outside one’s control. What is desired by many patients is essentially passive euthanasia, i.e. ending the use of lifesaving measures.3F^[3] Others might seek more drastic measures and resort to active euthanasia or suicide. Under Germany’s Criminal Code, the Strafgesetzbuch 4F^[4] (StGB), assisting in a suicide is not a crime5F^[5] because inciting or supporting an act of an other person requires that act to be criminal in nature,6F^[6] which is not the case with regard to suicide.7F^[7] In Germany, parliament is set to decide on legal rules concerning the participation in suicides in autumn of 2015.8F^[8] While maintaining the lex lata is one option,9F^[9] it is also possible that helping in a suicide will become a crime under German law.10F^[10] Active euthanasia, killing somebody due to that person’s demand to be killed,11F^[11] on the other hand, is indeed a crime under German law.12F^[12] This can happen through a positive action as well as through an omission: While German law considers omissions to lead to criminal culpability if they are equivalent to an action,13F^[13] which makes the question whether turning off a life-saving machine more of a theoretical question,14F^[14] Common Law has a more dramatic importance of the distinction between action and omission.15F^[15]

In addition, there is some suicide tourism to Switzerland16F^[16] (where active euthanasia in legal, as it is in the Netherlands, Belgium and Luxembourg17F^[17] ) and there have also been attempts to force German authorities to make pharmaceuticals available for the purpose of committing suicide.18F^[18] A lot of these fears could be dealt with in other ways which would not lead to the death of the patient. In particular better information about modern medicine but also an increase in the offers of palliative care could go a long way to reduce the number of people who want to end their life in this way.

This text will look at advance directives under German law19F^[19] and by analyzing recent trends in the development of the laws of neighboring countries show that there is a need for advance directives in order to effect a truly effective protection of the right to life. Along the way some attention will be paid to the impact of Christian values while particular attention will be given to the concept of human dignity.20F^[20]

B. The Need for Advance Directives as Protective Legal Tools

In general,“[t]here are two basic forms for advance directives.[21F^[21] ] Commonly used names for these two forms are ‘instruction’ directives and ‘proxy’ directives. The first category contains directives that give physicians instructions about the patient’s choices or wishes; the second name a proxy to make choices on the patient’s behalf and to convey them to the treating physicians.”22F^[22] Advance directives are not only about euthanasia23F^[23] but the fact that some European states have embraced euthanasia and cases such as that of Lambert and others v. France 24F^[24] before the European Court of Human Rights (ECtHR) now apparently make it necessary to take measures to protect oneself against unwanted euthanasia. Such fears can grow as euthanasia becomes more widely - legally - available. Especially in cases such as Lambert and others v. France, in which there is no written statement by the patient, it is dangerous for the right to life to place great emphasis on the prevention of suffering.

In the Netherlands, euthanasia of severely ill newborns is not prosecuted if it is undertaken in accordance with specific guidelines.25F^[25] These guidelines, the Groningen Protocol,26F^[26] are not legally binding but are taken into account by the authorities.27F^[27] In 2002, the Netherlands legalized euthanasia.28F^[28] Prior to this practice,29F^[29] “necessity, which [at that time was] the legal basis of all decisions on euthanasia and assistance to suicide in the Netherlands, was accepted”30F^[30] as a valid defense in Dutch criminal law, although a distinction was made between somatic and psychiatric cases, the latter including stricter procedural standards than in cases of somatic health issues,31F^[31] on which the courts appear to have been fairly lenient, allowing a claim of “necessity [also in cases in which the physician] did not follow precisely the consultation rules.”32F^[32] A similar law was introduced in Belgium in 2002 as well.33F^[33] But the reality in the Netherlands is hardly covered by the law as Dutch physicians only report 54 % of all euthanasia cases.34F^[34] The key difference between the Dutch norms and the Belgian law is that Belgium does not even bother with statistics anymore in so far as euthanasia deaths which comply with the law are now considered to be natural deaths for statistical purposes.35F^[35] This will make it possible to delete euthanasia from the public awareness - and with it the awareness of risks of abuses. Such abuses are very real as an other statistic from the Netherlands shows: there, 25 % of all euthanasia cases involve patients who never asked for euthanasia.36F^[36] These cases then are no longer about the patient's wishes and autonomy but about a decision made about the value of the life of the patient. In Belgium, children of all ages can request euthanasia without the consent of the parents.37F^[37] In both the Netherlands38F^[38] and Belgium,39F^[39] legislative measures have been taken to facilitate euthanasia and make it as accessible as possible. In France, a 2005 law also makes it possible to end life-saving measures.40F^[40]

In Germany, the law is not yet as far as e.g. in the Netherlands but there is a risk that relatives and physicians might feel that a patient’s life no longer is worth living - a way of thinking familiar from the National-Socialist ideology of the same name41F^[41] - and agree on terminating necessary lifesaving measures. This part of German history remains relevant for the understanding of the law.42F^[42] Under German law, euthanasia is a crime.43F^[43] This includes especially cases in which suffering plays an important role.44F^[44] There is no life which is not worth living and every life is protected by law (although the protection of life before birth under German law is less than complete). This protection includes in particular severely ill or handicapped newborns.45F^[45] In so far the importance of human dignity in the German legal order46F^[46] — and the particular role of the concept of human dignity for biolegal questions47F^[47] — is to be kept in mind.

[...]

^[1] Hans-Georg Koch / Erwin Bernat / Alan Meisel, Self-Determination, Privacy, and the Right to Die. A Comparative Law Analysis (Germany, United States of America, Japan), in: 4 European Journal of Health Law (1997), pp. 127-143, at p. 127.

^[2] Hans-Georg Koch / Erwin Bernat / Alan Meisel, Self-Determination, Privacy, and the Right to Die. A Comparative Law Analysis (Germany, United States of America, Japan), in: 4 European Journal of Health Law (1997), pp. 127-143, at p. 127.

^[3] Helmut Hildebrandt et al., Pschyrembel Klinisches Wörterbuch, 257th ed., Walter de Gruyter, Berlin, New York (1994), p. 1460.

^[4] Strafgesetzbuch [Criminal Code], 15 May 1871, reissued on 13 November 1998, Bundesgesetzblatt [Federal Gazette] 1998 I 3322, last amended on 23 April 2014, Bundesgesetzblatt [Federal Gazette] 2014 I 410; an official English translation (up to date as of 2 October 2009), is available online at <http://www.gesetze-im-internet.de/englisch_stgb/german_criminal_code.pdf> (all websites last accessed 29 / 30 January 2015).

^[5] Wolfgang Joecks, Studienkommentar StGB, 5th ed., Verlag C. H. Beck, Munich (2004), p. 396.

^[6] Walter Gropp, Strafrecht - Allgemeiner Teil, 1st ed., Springer, Berlin / Heidelberg / New York (1998), p. 326.

^[7] Wolfgang Joecks, Studienkommentar StGB, 5th ed., Verlag C. H. Beck, Munich (2004), p. 393.

^[8] Rainer Beckmann, Suizidbeteiligung auf der parlamentarischen Agenda, in: 23 Zeitschrift für Lebensrecht (2014), p. 1.

^[9] Rainer Beckmann, Suizidbeteiligung auf der parlamentarischen Agenda, in: 23 Zeitschrift für Lebensrecht (2014), p. 1.

^[10] Rainer Beckmann, Suizidbeteiligung auf der parlamentarischen Agenda, in: 23 Zeitschrift für Lebensrecht (2014), p. 1.

^[11] § 216 paragraph 1 StGB.

^[12] § 216 paragraph 1 StGB foresees as punishment imprisonment between six months and five years.

^[13] § 13 paragraph 1 StGB on omissions reads as follows: “(1) Whosoever fails to avert a result which is an element of a criminal provision shall only be liable under this law if he is responsible under law to ensure that the result does not occur, and if the omission is equivalent to the realisation of the statutory elements of the offence through a positive act.”, official translation supra, note 5.

^[14] On this issue see Stefan Kirchner, Ending Lifesaving Measures — Action or Omission ?, available online at <http://www.ssrn.com/abstract=1283584>.

^[15] See Andrew Grubb, The Persistent Vegetative State: A Duty (Not) To Treat and Conscientious Objection, in: 4 European Journal of Health Law (1997), pp. 157-178, at pp. 160 et seq.

^[16] Marie Ellis, Study reveals 'suicide tourism' has doubled in Switzerland, in: Medical News Today, 21 August 2014, available online at <http://www.medicalnewstoday.com/articles/281339.php>.

^[17] Bernadette Rainey / Elizabeth Wicks / Clare Ovey, Jacobs, White & Ovey - The European Convention on Human Rights, 6th ed., Oxford University Press, Oxford (2014), p. 168; European Court of Human Rights, Koch v. Germany, Application No. 497/09, Judgment of 19 July 2012, para. 26.

^[18] European Court of Human Rights, Koch v. Germany, Application No. 497/09, Judgment of 19 July 2012, para. 9.

^[19] On advance directives in an international context, specifically in the context of the Council of Europe, see Roberto Andorno, Regulating Advance Directives at the Council of Europe, in: Roberto Andorno, Principles of international biolaw - Seeking common ground at the intersection of bioethics and human rights, 1st ed., Bruylant, Brussels (2013), pp. 194-207.

^[20] On different viewpoints as to what is covered by this concept see Christoph Menke / Arnd Pollmann, Philosophie der Menschenrechte - zur Einführung, 1st ed., Junius, Hamburg (2007), p. 130 and p. 132.

^[21] See also Roberto Andorno, Regulating Advance Directives at the Council of Europe, in: Roberto Andorno, Principles of international biolaw - Seeking common ground at the intersection of bioethics and human rights, 1st ed., Bruylant, Brussels (2013), pp. 194-207, at p. 194.

^[22] Herman Nys, Emerging legislation in Europe on the legal status of advance directives and medical decision-making with respect to an incompetent patient (‘living-wills’), in: 4 European Journal of Health Law (1997), pp. 179-188, at pp. 179 et seq.

^[23] Herman Nys, Emerging legislation in Europe on the legal status of advance directives and medical decision-making with respect to an incompetent patient (‘living-wills’), in: 4 European Journal of Health Law (1997), pp. 179-188, at p. 180.

^[24] European Court of Human Rights, Lambert and others v. France, Application No. 46043/14, Communiqué of 24 June 2014; see also European Court of Human Rights, Forthcoming hearings in January 2015, Press Release ECHR 282 (2014), 23 December 2014, pp. 1-2.

^[25] Robert J. M. Dillmann / John Legemaate, Euthanasia in the Netherlands: The state of the legal debate, in: 1 European Journal of Health Law (1994), pp. 81-87, at p. 81.

^[26] See in more detail Eduard Verhagen / Pieter J. J. Sauer, The Groningen Protocol - Euthanasia in Severely Ill Newborns, in: 352 New England Journal of Medicine (2005), pp. 959-962.

^[27] Stefan Kirchner, Euthanasie in der Rechtsprechung des Europäischen Gerichtshofs für Menschenrechte,: in: 23 Zeitschrift für Lebensrecht (2014), pp. 9-12, at p. 9.

^[28] Stefan Rehder, Das Problem der “schiefen Ebene” - Warum der Gesetzgeber auf dem Feld der Biopolitik nur eine Richtung zu kennen scheint: die nach unten -, in: 23 Zeitschrift für Lebensrecht (2014), pp. 12-16, at p. 13.

^[29] See also H. J. J. Leenen, Handboek gezondheitsrecht - Deel I - Rechten van de mensen in de gezondheidszorg, 4th ed., Bohn Stafleu Van Loghum, Houten / Diegem (2000), pp. 304 et seq.

^[30] H. J. J. Leenen, Dutch Supreme Court about Assistance to Suicide in the Case of Severe Mental Suffering, in: 1 European Journal of Health Law (1994), pp. 377-379, at p. 377.

^[31] H. J. J. Leenen, Dutch Supreme Court about Assistance to Suicide in the Case of Severe Mental Suffering, in: 1 European Journal of Health Law (1994), pp. 377-379, at p. 378.

^[32] H. J. J. Leenen, Dutch Supreme Court about Assistance to Suicide in the Case of Severe Mental Suffering, in: 1 European Journal of Health Law (1994), pp. 377-379, at p. 378.

^[33] Stefan Rehder, Das Problem der “schiefen Ebene” - Warum der Gesetzgeber auf dem Feld der Biopolitik nur eine Richtung zu kennen scheint: die nach unten -, in: 23 Zeitschrift für Lebensrecht (2014), pp. 12-16, at p. 14.

^[34] Stefan Rehder, Das Problem der “schiefen Ebene” - Warum der Gesetzgeber auf dem Feld der Biopolitik nur eine Richtung zu kennen scheint: die nach unten -, in: 23 Zeitschrift für Lebensrecht (2014), pp. 12-16, at p. 13.

^[35] Stefan Rehder, Das Problem der “schiefen Ebene” - Warum der Gesetzgeber auf dem Feld der Biopolitik nur eine Richtung zu kennen scheint: die nach unten -, in: 23 Zeitschrift für Lebensrecht (2014), pp. 12-16, at p. 14.

^[36] Stefan Rehder, Das Problem der “schiefen Ebene” - Warum der Gesetzgeber auf dem Feld der Biopolitik nur eine Richtung zu kennen scheint: die nach unten -, in: 23 Zeitschrift für Lebensrecht (2014), pp. 12-16, at p. 13.

^[37] Stefan Rehder, Das Problem der “schiefen Ebene” - Warum der Gesetzgeber auf dem Feld der Biopolitik nur eine Richtung zu kennen scheint: die nach unten -, in: 23 Zeitschrift für Lebensrecht (2014), pp. 12-16, at p. 14.

^[38] Stefan Rehder, Das Problem der “schiefen Ebene” - Warum der Gesetzgeber auf dem Feld der Biopolitik nur eine Richtung zu kennen scheint: die nach unten -, in: 23 Zeitschrift für Lebensrecht (2014), pp. 12-16, at p. 13.

^[39] Stefan Rehder, Das Problem der “schiefen Ebene” - Warum der Gesetzgeber auf dem Feld der Biopolitik nur eine Richtung zu kennen scheint: die nach unten -, in: 23 Zeitschrift für Lebensrecht (2014), pp. 12-16, at p. 14.

^[40] Cf. European Court of Human Rights, Forthcoming hearings in January 2015, Press Release ECHR 282 (2014), 23 December 2014, pp. 1-2, at p. 1.

^[41] See Robert N. Proctor, Nazi Ärzte, Rassenmedizin und "lebensunwertes Leben" -- von der Ideologie zur “Euthanasie”, in: Andreas Frewer / Clemens Eickhoff (eds.), "Euthanasie" und die aktuelle Sterbehilfe-Debate: Die historischen Hintergründe medizinischer Ethik, 1st ed., Campus, Frankfurt / New York (2000), pp. 65-89 and Erich H. Loewy / Roberta Springer Loewy, Lebensunwertes Leben and the Obligation to Die - Does the Obligation to Die Rest on a Misunderstanding of Community?, in: 7 Health Care Analytics (1999), pp. 23-36.

^[42] See Gerd Geilen, Materielles Arztstrafrecht, in: Frank Wenzel (ed.), Handbuch des Fachanwalts Medizinrecht, 1st ed., Luchterhand, Cologne (2007), pp. 326-444, at p. 373, but see also ibid. p. 374 where Geilen assumes a more historic role for this issue. It has to be hoped that he is right in this assessment but some developments since his text was published, such as the introduction of pre-implantation diagnostics, indicates a movement back towards a more quality-based than dignity-based understanding of the right to life.

^[43] Gerd Geilen, Materielles Arztstrafrecht, in: Frank Wenzel (ed.), Handbuch des Fachanwalts Medizinrecht, 1st ed., Luchterhand, Cologne (2007), pp. 326-44, at p. 374.

^[44] Gerd Geilen, Materielles Arztstrafrecht, in: Frank Wenzel (ed.), Handbuch des Fachanwalts Medizinrecht, 1st ed., Luchterhand, Cologne (2007), pp. 326-444, at p. 374.

^[45] Gerd Geilen, Materielles Arztstrafrecht, in: Frank Wenzel (ed.), Handbuch des Fachanwalts Medizinrecht, 1st ed., Luchterhand, Cologne (2007), pp. 326-444, at p. 375.

^[46] For a critical view of human dignity as a mere “promise” (Jan C. Joerden, The promise of human dignity and some of its juridical consequences, especially for medical criminal law, in: Britta van Beers / Luigi Corrias / Wouter Werner (eds.), Humanity across International Law and Biolaw, 1st ed., Cambridge University Press, Cambridge (2014), pp. 197-219, at p. 197) see ibid., pp. 197 et seq. From a German human rights lawyer’s perspective, this view appears to underestimate the legal importance of human dignity. Rather than having to be given content (cf. ibid. p. 199), human dignity provides a fundament on which other constitutional norms as well as other laws are based.

^[47] Josef Römelt, Menschenwürde und Freiheit - Rechtsethik und Theologie des Rechts jenseits von Naturrecht und Positivismus, 1st ed., Herder, Freiburg (2006), p. 150.