An Essay by Fredo Corvo
According to a critical commentary in this review, an article by ‘Nuevo Curso’ apropos of the self-chosen death of Noa Pothoven (a severely traumatized Dutch youngster) suggests that “‘(state) assisted suicide and euthanasia’ would be routinely practiced in the Netherlands by way of a cynical reply of the bourgeoisie and its state to a degradation of the country’s health service, to the extent of constituting ‘a real mass crime’ committed against the ‘damaged and unproductive’ and the elderly in particular”. (1)
The following essay takes up the challenge that “a debate among those who adhere to the cause of proletarian emancipation should also take into account that certain moral dilemmas based on the development of medical science and technology, demographic developments like increases in life expectancy, and changing patterns of need for cure and care, will not somehow be automatically resolved after a proletarian revolution, but will have to be taken up by the proletarians collectively under qualitatively different conditions.” (Ibid.)
From a layman’s point of view, this essay examines qualitative developments in medical care in the field of technology, medical ethics and budget cuts. However, in order to analyze the financial results of measures taken by the Dutch state for each medical condition, the expertise of a medical economist would be required.
The rise of medical technology
For centuries, the medical professionals, general practitioners, medical specialists and nursing staff had a professional ethic derived from the Hippocratic oath. It contains the promise “Neither will I administer a poison to anybody when asked to do so, nor will I suggest such a course”. (2)
It has recently become clear that medical ethics lag behind medical, social and economic developments in health care. Developments in medical technology provide more possibilities to prolong the life of patients also in a phase in which recovery is no longer possible and at the end of life. These medical techniques differ according to the type of terminal disease, and include for example artificial feeding, oxygenation, blood transfusion, resuscitation and kidney dialysis. Other technological developments have made it possible to prolong life in cases of diseases that previously led to a relatively rapid death. This applies to some cancers, which can now be stopped temporarily or permanently. However, surgical treatment, radiotherapy and chemotherapy can affect the quality of life during treatment, or permanently, by not only damaging the tissue affected by cancer, but healthy tissue as well, or can cause harmful side effects. Nowadays, cardiovascular diseases can be combated with sometimes invasive operations that offer varying chances of survival for each patient. Taking a closer look at kidney dialysis may clarify the problem at hand. Kidney dialysis is a treatment for patients with renal failure. The treatment is unpleasant, sometimes painful, and involves the patient in a half-day treatment three to four times a week. Nowadays, the medical specialist consults with the patient about the desirability of this treatment. It is discussed how long life can be extended with dialysis as opposed to the time that dialysis takes. Non-dialysis means that the patient dies within a range of some days to several months. Some dialysis patients at some point in time, usually in the event of further deterioration, choose to discontinue the treatment and thus to end their lives.
Initially, physicians – in accordance with current medical ethics – generally applied all life-enhancing techniques available to them. The medical sector was almost exclusively focused on prolonging life, on healing, even in cases where this was not possible. The sector, incidentally, is still largely organized accordingly; it is only in recent years that end-of-life hospices have been established on a larger scale. Under pressure from health-care professionals themselves, from terminally ill patients and their relatives more attention is now being paid to the suffering, the pain and anxiety often associated with the final phase of life, and to prolonging this suffering by means of medical proceedings whose usefulness is not clear. In addition, more attention has been paid to the quality of life following surgery or treatment in a broader sense. This can vary from the brain-dead patient whose body can be kept alive with the heart-lung machine to the question what the quality of life is of a patient with hereditary breast cancer who has her breasts amputated in order to increase her chances of life. Also, more resources have become available today to combat pain and to provide calm to patients. The use of opiates as a pain treatment traditionally has already raised the ethical question where the boundary lies between pain control – a conscious intervention by a physician – and a shortening of life, thus euthanasia.
The independent patient wants a free choice in the treatment
The current practice of consultation between patient and physician about the desirability of certain interventions, about continuing or discontinuing treatment (see the graph below) (3), is also the result of the empowerment of the patient and his environment. Medical practitioners no longer have the authority of the past, and are partly proletarianized. (4) In addition to a loss of authority on the part of the health-care professionals, the fact that patients and their relatives regard themselves as consumers, who themselves seek information on the Internet, consider themselves as citizens with rights and who can adopt an individualistic, even an egotistical, attitude is a factor in this. Health-care workers are confronted with requests for information about possible treatment and, for their part, provide more information than in the past. Some patients demand participation and the right to decide.
In addition to pain control, tranquilizers and sleeping pills, more space has been created for saying goodbye to loved ones or, on the contrary, for the desire of personal privacy. Some people prefer to die alone, others prefer to die in the company of the whole family, sometimes at home or in an institution. The wishes of the individual and his or her social environment can be different and can conflict with each other, depending on the influence of tradition or modernity, and of cultural origins. All of this has made it necessary for medical staff, patients and their families to consult each other before decisions are taken. Of course these choices – like all choices that individuals face within capitalism – also depend on the meager possibilities this exploitative society offers. But while in our time of economic crises, imperialist wars and destruction of the natural environment, socialism is a social issue of life or death, this is not the case with the individual end of life in a health-care situation. These are moral choices in a largely given situation.
Visions on suicide and assistance to it
In the traditional Christian view suicide is a form of murder, and therefore any possible assistance to it constitutes one of the most serious sins, because a person practically denies that it is God who gives and takes life. This view is a projection in the superstructure of the ideology of the gruesome practice of production relations between slave owners and slaves. The ideology of slave owners is still alive with the resistance of the Church of Rome against every death of someone’s own choice. For example, the current Pope joined in with the selective indignation on Twitter about the self-chosen death of Noa Pothoven. (5)
The Christian ban on suicide has been outmoded by capitalism’s class need for an ideology of abstract freedom and equality that hides the exploitative relationship of capital with wage slaves. The bourgeois state, however, also demands a monopoly on the use of force, which arose from the period of Terror in the French bourgeois Revolution, and which guarantees its continued existence by all means, including the death penalty. In countries where the death penalty is no longer provided for in criminal law, it continues to exist at least in military criminal law. The firing squad was and is the ultimate means for capital to get uniformed workers to massacre each other in imperialist wars.
It is therefore not surprising that in circles of the conservative-liberal VVD, which has been in government since 2002, it is being argued that citizens or associations of citizens providing the means for a voluntary end to life should no longer be in violation of the criminal law prohibition of suicide assistance, as is now the case (art. 294 of the Criminal Code). From these quarters comes the proposal that the state respects the “fundamental right” to suicide and at the same time oversees the carefulness of the balancing process in which the interests of the patient’s close environment are also taken into account. (6)
Neo-liberal budget cuts and freedom of choice
So far, we have focused on euthanasia. But when it comes to budget cuts in healthcare, it is important to see that the liberal ideology of freedom of choice is applied in much broader areas of health care. This makes it possible to pass on savings and costs to wage earners on a large scale and in a way that is not possible with the current euthanasia practice. In this more general sense, the VVD (7) takes pretext of the freedom from patronizing and oppression sought by workers, the desire to control one’s own live, to limit the latter to the choices that remain after austerity measures. The same applies to the pursuit of equality. From its position in capitalism, the working class tends towards the abolition of class society, at moments in which its struggle based on solidarity is shaking the power relations. By contrast, the VVD offers the workers the equality of commodity exchange: what do I give and what do I get in return? Let us look at what a right-wing liberal pamphlet (8) notes about the mandatory basic health insurance and a voluntary supplement of choice (9), which was introduced in the Netherlands under the pressure of the 2008/2009 crisis: “the costs of health care continue to rise” and because “paid premiums are less and less in proportion to the actual health care received, social justice, on the basis of which our collective health-care system was built, is under pressure. According to the Netherlands’ Central Planning Bureau (CPB), the lower educated use an average of 3,000 euros of health care per year over their entire life cycle in 2011, while they pay 2,000 euros in premiums. People with a [higher or university] education use an average of 2,000 euros in health care, but pay 4,000 euros premium.” The latter group, largely wage-dependent like the lower educated, belongs to the electorate of the “people’s party” VVD, while the complaint about rising costs of health care originates from the demands to reduce labor costs by the small and especially the large bourgeoisie that the VVD responds to. With regards to health care proper, the pamphlet states that the state’s task should be to “supervise a minimal quality on behalf of the patient’s safety. For other choices in health care, the individual patients decide in the first place what they regard as quality themselves”. This abstract liberal principle of individual freedom of choice in health care ignores the reality of the limitations of a society divided into classes, which mainly affect less paid and often less skilled workers. And which are increasingly imposed upon them, as the so-called welfare state is further eroded in order to cut social wages, without the working class being able to defend itself against it with strikes limited to a sector or a profession. (10)
What is the communists’ attitude towards individual freedom of choice, and more specifically towards suicide? Trotsky’s personal will is telling in this respect: “I reserve the right to determine for myself the time of my death. The “suicide” (if such a term is appropriate in this connection) will not in any respect be an expression of an outburst of despair or hopelessness. Natasha and I said more than once that one may arrive at such physical condition that it would be better to cut short one’s own life or, more correctly, the too slow process of dying …” (11) This quotation shows that Trotsky, in his desperate own individual situation of impending brain hemorrhage and possibly prolonged vegetation, wished a voluntary end to life. His last wish also shows the possibility of combining individual freedom of choice over the end of one’s life with the confidence that collective workers’ struggles and solidarity will lead to the victory of socialism.
What happens to health care in the proletarian revolution? For the communists this revolution consists of breaking the bourgeois state. This same bourgeois state, when demolishing the so-called ‘welfare state’, has strengthened its grip on health care, precisely in its efforts to reduce social wages. In contrast to the state socialist views of social democrats, Stalinists and Trotskyists, council communism argues that just as the working class has nothing to expect from the bourgeois state before the revolution, it cannot rely on a “proletarian” state after the revolution either. As Marx emphasized after the 1871 Commune, followed by Lenin in 1917, the destruction of the bourgeois state in the revolution relates to its repressive functions. To the extent that the state fulfills socially useful functions, these are separated from the state proper, stripped of their bourgeois character, and are placed with the enterprises and industries that, according to Marx (but not to the state socialist Lenin), is governed by the “association of free and equal producers”, meaning the workers’ councils.
At the beginning of this article we have seen a foretaste of the social upheavals that will then be possible, namely the pressure exerted by health-care professionals, together with patients and their families, on the consequences of a medical ethic that was outdated by developments in medical technology. The importance of the patient’s or the client’s freedom of choice is not called into question by the abuse of this freedom by the state, for example in order to shift health care from hospitals and homes for the elderly to home and informal carers. After the revolution, in considerably more favorable social conditions, the victorious proletariat will develop a morale of health care on a larger scale and at a much higher level, with the freedom to decide about one’s own life and death, which meets the development of each person’s individual qualities. (12)
This view of the importance of freedom, individualism and the development of each person’s unique qualities also corresponds to the proletarian morality within today’s class society. As far as the struggle of the working class is concerned, which can only be a collective one of mutual discussion, of enterprise and unemployed nuclei, of general assemblies in the streets and in enterprises, revolutionary morality is nothing but the constantly changing relationship between goals and means in the class struggle. That is to say that the means of the struggle are chosen in accordance with its goal, the development towards the revolution. (13)
In addition to the moments of collective class struggle, in which solidarity and individuality reinforce each other, (14) there remain situations of severe illness, such as those discussed here, including for example the depression suffered by Noa Pothoven. (15) Situations in which the individual workers and revolutionaries concerned, taken alone and outside the struggle, are not able to link their fate directly to the collective struggle of their class. It seems to me that in these cases the communists respect and cherish the individual’s freedom of choice to decide about his or her own life and death. This also means that they do so with an understanding of the social limitations with which capitalism presents these choices. Eventually, the working class will discover possibilities to include such apparently individual issues in its collective struggle.
From this point of view, euthanasia and its authorization under strict conditions in the Netherlands since 2001 (16) is not just a matter of austerity. The right to suicide and assistance has been claimed by health-care workers, patients and their families. It is true that the struggle for self-determination over one’s own death, as part of the right to self-determination over one’s own life, cannot immediately be included in the solidarity of the collective labor struggle. But it would be opportunistic to leave this issue to the bourgeoisie. It is also true that the liberalist bourgeoisie in particular can incorporate any claimed right into its ideology of abstract human rights, aimed at concealing the exploitation and oppression by capital, in this case to facilitate the implementation of budget cuts in health care. It is to this demystification of liberalist ideology that this essay seeks to contribute.
Fredo Corvo, August 28, 2019.
Translation and proofreading: H.C., September 12, 2019
1 ‘Nuevo Curso’ apropos of a failure of ‘youth care’ in the Netherlands, with a commentary by the editor (also in AFRD Vol.3 #3, July 17, 2019).
2 Wikipedia, Hippocratic Oath.
3 Source: Kroneman M., Boerma W., van den Berg M., Groenewegen P., de Jong J., van Ginneken E. (2016). https://ec.europa.eu/health/sites/health/files/state/docs/chp_nl_english.pdf. p. 192 Table 7.2.
4 Like other practitioners of liberal professions, the physician has lost his authority as well as his financial independence as an entrepreneur. Doctors are more often wage earners, like other health-care professionals. Formal independence is often just an appearance. Health-care workers are increasingly bound to state regulations, sometimes concealed by privatization and deregulation. It is not surprising that they often take the lead during high points of workers’ struggles, like in the strikes and demonstrations in Egypt 2011, and recently in Sudan.
6 De Bontridder en Kok “De overheid verzuimt wat Coöperatie Laatste Wil nastreeft: waarom artikel 294 Sr in strijd is met het recht op sterven” in ‘Liberale Reflecties’, July 2018, pp. 38-47.
7 Neo-liberalist ideology is not only advanced by the VVD, but in slight variances by the left-wing liberal party D’66, the Christian “centrists” CDA, PvdA (‘Labor’/social-democrats) and Groen Links (the “Green Party”) as well. We limit ourselves to the right-wing liberalist VVD because of its long participation in diverse governments.
8 Plooij-Van Gorsel, “Kunnen kiezen. Vrijheid, keuzes en rechtvaardigheid in de curatieve gezondheidszorg”, Teldersstichting 2015. The Telders’ foundation is the scientific institute of the VVD.
9 Both the old system, a national health insurance for the low waged and voluntary private insurances for the higher paid, and the new system have different effects for different income categories. Both systems consist of a state imposed “solidarity” that has nothing in common with the combative solidarity of the proletariat.
10 An analysis of these “neoliberal” policies in the Netherlands can be read on the Libcom blog (July 14, 2017): In the Country of Dijsselbloem – Labor Relations in the Netherlands.
11 The Testaments of Trotsky. This version should not not be confused with a very critical text that passes for Trotsky’s political testament, and that has been regarded by the ‘Fourth International’ as a falsification. The question whether Trotsky can still be regarded as a communist at the end of his life, because he had relinquished his past, correct conception of the mass character of the workers’ struggle, and because of his role in the counter-revolution in Russia (as for instance in the Kronstadt uprising), is not dealt with here.
12 See also Marx/Engels in ‘The German Ideology’: “In a real community the individuals obtain their freedom in and through their association. … the proletarians, if they are to assert themselves as individuals, will have to abolish the very condition of their existence hitherto (which has, moreover, been that of all society up to the present), namely, labor. Thus they find themselves directly opposed to the form in which, hitherto, the individuals, of which society consists, have given themselves collective expression, that is, the State. In order, therefore, to assert themselves as individuals, they must overthrow the State. … With the community of revolutionary proletarians, on the other hand, who take their conditions of existence and those of all members of society under their control, it is just the reverse; it is as individuals that the individuals participate in it.” Part I: Feuerbach. Opposition of the Materialist and Idealist Outlook. D. Proletarians and Communism.
13 This also means NOT as in the Jesuits’ morals or in that of the Bolsheviks, who did not refrain from any means after the revolution, as long as they considered it serving the “workers’ state” (their own position of power) and “socialism” (state capitalism).
14 A point that Pannekoek has made in several articles.
15 Not to be confused with the temporary feelings of depression which are part of life, and have come to be diagnosed as depression under influence of the pharmaceutical industry.
16 In 2011 the Dutch minister of health care Els Borst (D’66) implemented a law legalizing Euthanasia in the Netherlands. Borst has been murdered in 2014 by a “mentally unstable man” who declared “having killed Borst because divine inspiration told him to do so, holding her responsible for the Dutch policy on euthanasia” (Wikipedia, Els Borst).
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