The twilight of life

Gonzalo Herranz, department of Bioethics, University of Navarra
discussion paper at the XXI congress of the National association of Italian Catholic Doctors:
Medicine, Art and Science for Life
Session III: Medical Ethics and the Mystery of Life
Naples, 1997

A good part of this text was only in Italian; we have translated it into Spanish, losing the liveliness of Dr. Herranz's style. The texts of the appendices, which are old and currently inaccessible, are also translated from Italian.

Introduction

1. The deontological texts

In contrast to the discussions of philosophers and bioethicists, the deontological texts still enshrine as the physician's duty the utmost respect for the terminally ill patient and his or her precarious life. As examples, the Declarations of the World Medical Association association (Venice on terminal illness, Madrid on euthanasia, Marbella on financial aid medical suicide), the Italian Code of Medical Ethics of 1995 (Oath, Articles 35 and 36), and some points of Chapter III, Dying, of the Letter to Health Care Workers, which wisely condenses the Christian tradition of service to terminal life, are presented and commented on.

2. The ethical basis of palliative medicine.

Palliative medicine rests, in the author's opinion, on two basic and specific foundations of medical ethics:

a. The medical-ethical respect for the extreme weakness, characteristic of terminal life; and

b. The limited, finite nature of medical interventions; when the intractable nature of the disease excludes any aggressive action and calls for symptomatic treatments as a wise, proportionate and compassionate response to the terminally ill patient.

a. Ethical-medical respect for extreme weakness.

A very fruitful factor for the progress of Medicine, and for that of society, has been the emergence of the concept that the weak are important, a mother-notion that marks the birth of both civilization and Medicine.

In general, medical respect for life is almost naturally linked to the recognition of the vulnerability and fragility inherent in the sick person. Physicians do not ordinarily deal with healthy and strong people, but with sick people who are going through the crisis of wasting their physical strength, their mental Schools , and even their lives. The ethical respect of physicians who administer palliative care is directed towards lives in decline, threatened by the inevitable proximity of death.

The greatest challenge of palliative medicine consists in discovering something hidden: to recognize in the terminally ill, behind the eclipse of human dignity induced by their ruined physiology, the presence of a man who asks us to protect his human dignity and his rights. When the molecular and cellular disturbances are already beyond any possibility of systematization, the task of the physician consists, not in the relentless struggle to do the impossible, but in symptomatic therapy, in the medical reaction to the patient's withdrawal and helplessness, and in the noble medical function of accompanying the dying.

In short, the physician must be able to see in the terminally ill patient a res sacra miser, a man in whom the sacredness and dignity of all human life coexists with the extreme poverty induced by the disease.

b. The limited, finite nature of medical interventions.

It is essential that we physicians learn to recognize the practical and ethical limits of our power. There often comes a point in the patient's clinical course when the benefits of aggressive interventions are disproportionately low in comparison with the suffering they cause or the economic costs they incur. At the moment when the patient's incurability is confirmed, it is necessary to accept that our measures, despite their aggressiveness and presumed efficacy, become inoperative: from then on, neither therapeutic obstinacy nor the patient's withdrawal can be ethical responses to the terminal status . On the contrary, the time has come for palliative medicine. Leaving aside the difficult doubtful cases, in which a prudent bet in favor of life is always advisable, it is necessary to beware of excessive zeal.

3. Specific deontology of the catholic physician towards the patient at the end of life.

Assuming an adequate professional skill , prudence in clinical judgments, due delicacy in relations with the patient, and the utmost respect for the freedom of others, it is worth asking whether the fact that the physician is a Catholic establishes specific duties derived from the faith lived by him in his relationship with the terminally ill patient. Should a physician who believes in the Redemption accomplished by Jesus Christ be concerned about the eternal destiny of his patient? At summary, is there an ethical obligation for the physician to warn his believing patient that the time has come to make peace with God and mankind, and to entrust himself, with the sacred anointing of the sick, to the prayer of the whole Church to the suffering and glorified Lord for relief and salvation?

The answer, always affirmative, can be given at two levels. The first, purely professional, is formulated as follows: both the patients' bills of rights and the norms of medical ethics (the Lisbon Declaration of the World Medical Association association , for example), include the patient's right to "receive or refuse attendance spiritual and moral advice, including that of a minister of his own religion". This right of the patient creates in the physician the correlative moral duty to collaborate diligently in the fulfillment of the decision freely made by the patient.

The second, that of the Catholic physician of living faith, points out that, as a physician and as a disciple of Christ, his financial aid cannot be limited to symptomatic care and human comfort. His presence of faith and hope, as the Letter of Health Care Workers says, is, in addition to a work of theological charity, the highest form of humanization of dying. In these times of postmodern moral relaxation, the doctrine and the internship of the physician's role in the crucial moment of dying must be affirmed. The medical art and the patient's trust create the right circumstances to delicately explore the dispositions of the sick person and negotiate with him/her a agreement on what to do.

Faith in the grace that God grants to all the faithful in every circumstance predisposes them to a serene, even optimistic, attitude regarding the ability of the patient and his or her family to accept the truth and open themselves to the mystery of death. The Catholic physician has a specific responsibility to lead the way in the evangelization of death, which will be completed by the priest.

4. Annexes

End-stage disease statement

(approved by the XXXV World Medical Assembly, Venice, Italy, October 1983)

1. The physician's mission statement is to cure and, as far as possible, to alleviate suffering, always having the patient's best interests at heart.

2. This principle does not admit of exceptions even in the case of incurable diseases or malformations.

3. This principle does not exclude, however, the possibility of applying the following rules:

a) The physician may spare the patient the suffering caused by a terminal illness by abstaining from therapeutic treatments from agreement with the patient, or with the immediate family members if he/she is unable to express his/her own will. However, this abstention from treatment does not exempt the physician from the obligation to attend the dying person and to provide him with the appropriate painkillers and drugs to make the terminal phase of the disease less painful.

b) The physician shall refrain from any therapeutic overtreatment, i.e., from any treatment of an exceptional nature from which no benefit for the patient can be expected.

c) The physician may implement artificial treatments to maintain the organs intended for transplantation, provided that he/she is unable to reverse the terminal process of cessation of vital functions of the patient, and provided that he/she acts in accordance with the laws of the country and by virtue of an explicit or tacit consent of the person concerned and that the determination of death or irreversibility of vital activity is performed by a group of physicians other than the one who assumes the responsibility for transplantation and care of the recipients.

The cost of these artificial treatments should not be borne by the dying patient or his/her relatives at position . The physicians responsible for the dying donor must be completely independent of those responsible for the transplant recipient(s).

 Statement on euthanasia

(Approved by the XXXIX World Medical Assembly, Madrid, Spain, October 1987)

Euthanasia, i.e. ending a patient's life by a deliberate act, either at the patient's request or at the request of the patient's relatives, is unethical. This does not preclude the possibility of the physician respecting the patient's will to let the natural process of death take its course in the terminal stage of the disease.

Physician-assisted suicide declaration

(C by the XLIV World Medical Assembly, Marbella, Spain, September 1992)

Code of Medical Ethics (1995)

A. Oath

Conscious of the importance and solemnity of the act I am performing and of the commitment I am assuming, I swear:

- to pursue as exclusive objectives the defense of life, the protection of the physical and mental health of man and the alleviation of suffering, and that I will inspire all my professional acts with responsibility and constant scientific, cultural and social commitment;

- never take actions capable of deliberately causing the death of a patient;

- I will never use my knowledge against them, but will act with respect for life and the individual.

B. Chapter V. attendance to the dying

Art. 35 (Euthanasia. Prohibition)

The physician, even if requested to do so by the patient, must not perform treatments capable of impairing the patient's psychological and physical integrity and shortening his or her life or causing his or her death.

Art. 36 (Proximity of death)

In the case of illnesses with an unfortunate prognosis, and when the terminal stage is reached, the physician may limit his work, if this is the patient's specific disposition, to the moral attendance and to therapy aimed at avoiding useless suffering, providing appropriate treatments and preserving the quality of life as long as possible.

In case of compromised consciousness, the physician should continue life support therapy for as long as it is reasonably useful.

In case of brain death ...

Health Operators' Charter

committee Pontifical Council for the Pastoral Care of Health Operators, Vatican City, 1994.

III. Dying

Serving life means for the health worker to assist it to its natural end.

Some points of Chapter III, Dying, also condense with great wisdom the Christian tradition of service to terminal life.