A Doctor's Respect for the Suffering Patient
Gonzalo Herranz. department on Bioethics, University of Navarra
lecture in the course “Four Current Issues in Fundamental Bioethics”
association de la Rábida
Segovia, May 11–13, 1990
Medical respect is a respect for the weak human being.
Rebuilding respect for the weak
Acknowledgement and words of thanks for the occasion.
Professor Polaino has order asked me to address a topic topic that is particularly close to my heart: the physician’s attitude toward weakness and pain. topic is a highly topical issue, because for some years now there has been a growing belief among the general public—and naturally among doctors, since we doctors are ordinary people—that there are human beings so debilitated by illness and pain that they no longer deserve the respect with which doctors have traditionally treated their patients. We see this in many ways: the systematic destruction of the disabled through eugenic abortion, neonatal euthanasia, or forced sterilization; the elimination of terminally ill patients and the senile demented through euthanasia or the withholding of food and drink; the trivialization of abortion for socio-economic reasons, the alienation of the young embryo as belonging to a race other than the human race, and many other things besides. What all of these have in common is the doctor’s loss of respect for certain groups of human beings weakened by pain or disability: those who should be the objects of his utmost care are instead the objects of the utmost contempt.
My talk today is intended to be a wake-up call regarding the growing danger facing the vulnerable in our contemporary society. I hope that in the discussion that follows, I can learn from your questions and comments.
It has been said that the most fruitful and positive element—both in the progress of society and in the Education of each human being—lies in understanding that the weak are very important. The most brilliant moments in history are those in which people strove to put into internship the generous conviction that we are all wonderfully equal, unique, and endowed with a singular dignity. This is a beautiful thing to say, and we speak of it with great enthusiasm. It is by no means easy, however, to live by this doctrine. Despite two millennia of Christianity, it continues to encounter resistance to its practice within each of us and within society itself. And today—as I said before—we are witnessing a rapid deterioration of what has taken so many centuries to achieve and uphold. Today, in many places, the weak are at a disadvantage. In the medical deontological tradition degree scroll , being weak was sufficient to warrant the utmost respect and privileged protection; now, in the strained atmosphere of the new libertarian and individualistic ethics, it can be the stigma that marks one for programmed destruction. Many doctors, betraying their calling as protectors of human life, attempt to rationalize the elimination of the weak. They seek to change the very purpose of medicine. Medicine would no longer exist to cure disease and alleviate pain and disability, but rather to maximize pleasure, physical performance, psychoneurological power, and physical aesthetics.
This new culture replaces the notion of the sanctity of human life with that of quality of life. It demands that every individual’s life have a certain quality—a minimum standard—below which life lacks dignity and must be eliminated. It therefore excludes the weak, who are unable to benefit significantly from modern medicine. But it does not merely marginalize and abandon them; it makes them the object of a cold, destructive passion.
We must counter this mindset—which blends the hedonist’s refined aversion to pain with the utilitarian mindset of the neo-aristocracy (the maximization of well-being, not for the greatest issue, but for those who already possess it)—with the message of respect for life and, more specifically, for the frail, as a fundamental ethical value in medicine. That is the focus of my talk.
I will first attempt to argue that, in medicine, respect for life is inextricably linked to the acceptance of human beings’ essential vulnerability, their fragility, and the limited, incomplete nature of medical treatment. I will then go on to present some examples of how respect for the vulnerable is being undermined in contemporary medicine. And I will conclude with some thoughts on how to rebuild medical respect for the vulnerable.
Today, there is much discussion of respect as a core element of biomedical ethics. All the documents in which medical deontology has taken shape since World War II—that is, following the Geneva Declaration—assign respect a central role in the moral conduct of physicians. Codes and declarations refer to it time and again: respecting the secrets entrusted to the physician during his or her meeting with patients; showing the utmost respect for human life from the moment of conception; and respecting the staff integrity of the patient.
What does the ethical respect required by a physician’s professional code of conduct entail? Much has been said—and in quite varied ways—about respect in philosophical ethics since Kant. In medical ethics, we have excellent programs of study on the elements of medical respect and the different ways in which the concept is used by the medical profession. To simplify matters and as a starting point, we can accept that the respect most consistent with the ethos of medicine is a basic moral attitude on the part of the physician that enables him or her to discover and respond to the moral values inherent in individuals and in the critical circumstances of their illness. Both the richness and the quality of the physician’s professional moral life depend on his or her ability to perceive these values. The physician who cultivates respect has his sensitivity and judgment honed to discern, in the presence of each of his patients, the full scope of his service. Conversely, a lack of respect renders the physician insensitive to the ethical problems of medicine and insensitive or blind to the needs that each patient presents. Respect prevents the physician from glossing over parts of reality, capriciously weighing conflicting values, or manipulating the ethical demands of patients. Finally, respect allows the physician to provide care to the patient with complete dignity—not because the patient can force such responses upon the physician, but because the respectful physician bows with dignity before the value he recognizes in others, in a gesture plenary session of the Executive Council of intelligence and professionalism. In the Hippocratic tradition, respect is purely ethical in nature and has little or nothing to do with the legalistic submission to patient autonomy about which so much is written today.
Medical respect is a respect for the weak human being.
Genuine respect for human life impels the physician, in the first place, to be an expert in perceiving it under the pleomorphic appearances in which it presents itself, to discover it in the healthy and in the sick; in the elderly and the terminal patient as well as in the child; in the embryo no less than in the adult at the height of its fullness. In all cases, it has before it human lives, enjoyed by human beings, all of whom are, irrespective of their legal rights, supremely and equally valuable. Whatever these human beings may lack in size, in intellectual wealth, in beauty, in physical fullness, all these, including all their deficiencies and handicaps, are made up for by the physician with his respect.
This is a constant feature of the physician’s “ work .” The physician does not have to deal with healthy people. It is the sick, the disabled, and those experiencing the terrifying crisis of losing their vigor, their “ Schools ,” or their very lives who come to him. The physician is always surrounded by pain, deficiency, and incapacity. The lives he encounters are lives marked by pain or decline. His respect for life is respect for life in pain. His true calling is to be a healer and protector of the weak.
This idea is very clear to the physician who follows the Hippocratic tradition. Respect for all patients without distinction was included in the Declaration of Geneva precisely in a clause of inexhaustible ethical content: the one that enshrines the principle of non-discrimination, by virtue of which the physician cannot allow his service to the patient to be interfered with by considerations of creed, race, social status, sex, age or political convictions of his patients, or by the feelings that patients may inspire in him, and he undertakes to provide all of them equally with a competent attendance .
But reality seems to deny that physicians are willing to comply with such a lofty commandment, since there are many who cynically violate it or consider it to be of an unattainable moral stature. For this reason, it should be emphasized that the prohibition of discrimination is an absolute precept, which includes all human beings without exception. In other words, the right to life and health is the same for everyone, it is possessed by the simple fact of being human. The physician does not discriminate. He does not submit to the strong man because he has the power to demand his right to be respected, or disregard the weak man because he lacks strength and rights. He treats and serves everyone equally, not because he is an activist of political or social egalitarianism, but because Withdrawal, in the face of the fragility that disease creates in everyone without distinction, to take advantage of his position of power in front of them.
For those of us who fight for respect for life, the letter and spirit of the Declarations of Human Rights and of the Charters of the Rights of the Sick are clear and do not admit any attenuation. We consider unethical the conduct of those physicians who select their patients, who discriminate among them, who accept some and reject others, who care for some and abandon others. The ethical tradition admits, however, not exceptions, but priorities within the rule of non-discrimination. One, for example, is created by the status emergency. The physician must first attend to the urgent case, the one most in need of financial aid. But this is a technical reason, since all patients are equally worthy in terms of their dignity. Another is the one that orders the patients according to a scale of weakness, in order to give more attentive and solicitous care to the one who appears more seriously damaged by the disease.
Today, the appreciation of weakness is at a low ebb. The medical profession, born precisely as a human response to the vulnerability of mankind, seems to be disinterested in the pain and handicap of the weak and allows itself to be dragged into an alliance with the powerful. For this reason, it is worth reconsidering in some depth the ethical value of weakness and suffering.
In each encounter with patients, the doctor is faced with a challenge: to recognize, in that suffering humanity, the full dignity of the human person. Illness tends to overshadow dignity: it hides it and, at times, even destroys it. If being healthy confers, in a certain sense, the capacity for full humanity, being ill, on the other hand, implies—in a thousand different ways—a limitation on that capacity to become fully human.
A serious, debilitating, painful illness that diminishes our humanity consists not only of molecular or cellular disorders: it also constitutes, and primarily, a threat to our staff integrity or a permanent limitation of it. It subjects us to test as human beings. We should not forget this when we are ill or when caring for the sick. The Hippocratic tradition, enriched by the Christian ethos, saw in the impairment of humanity that comes with illness the root of the fundamental mandate to use all available means to restore the patient’s human wholeness and health—or, at the very least, to alleviate, to the extent possible, the consequences of that threat. The physician acts on behalf of and by the mandate of humanity to save and relieve the suffering patient. Often, medical “ attendance ” cannot be reduced to a mere technical-scientific operation; rather, it must encompass a projimal dimension—it must be a “ staff ” response to the “ staff ” threat facing the patient.
Res sacra miser. With this denomination of Christian-Stoic origin, the special status of the sick person in the field of tensions of human dignity has been magnificently expressed. It beautifully translates into medical language the general notion of the sacredness of human life. When the human condition of the sick person is considered in this light, we recognize the inviolability and, at the same time, the neediness of the sick person and the linked responsibility of the healthy person to the sick. Respect for the sacredness of the sick person does not render him intangible, but impels us to pity, to compassion, to make him the object of active love.
Certain mentalities, then as now, are blind to the ethical value of weakness. The philosophies of power and vitality, ancient-pagan or modern, have always shown their contempt for the sick and the weak, sometimes disguised as compassion. Nietzsche, who has more disciples than it seems, by elevating the will to health and life to the category of a general principle, established that the sufferer is not a res sacra, but a res detestabilis. The instinctive and vital will to live of the healthy man expresses itself, before the sick, not in respect and consideration, but in contempt and rejection. Conversely, attention, care, compassion, and love for the weak and the small belong for Nietzsche to the slave morality of a decadent and instinctually impoverished humanity.
I believe there is a specific dignity of the patient that entitles him or her to a special subject of respect. We can speak of a specific dignity of the patient because the human being who is ill faces a threat to his or her human dignity. The specific dignity of the patient—that is, of the sick person who enters into a relationship with a doctor—stems from their legitimate demand for protection of their precarious humanity, from their human right to recover as much of their integrity as possible staff. The doctor’s respect must be commensurate with that need: the patient has a right to the doctor’s care, to the doctor’s time, to the doctor’s capacity, and to the doctor’s skills. And, throughout the entire course of the doctor-patient relationship, while the doctor fulfills, in the name of humanity, his healing “ official document ,” he must maintain what I like to call a binocular view of his patient. He must remain constantly aware that he is facing a human being, that the doctor-patient relationship is a person-to-person relationship, a subject-to-subject relationship, an “I-You” relationship. But while the patient desires to be taken seriously by the doctor as a person, he also needs to be examined and considered as a biologically disturbed entity. The patient can never be reduced to a collection of disordered molecules or dysfunctional organs, nor to an enigmatic diagnostic problem or a mere opportunity for therapeutic “ essay .” Yet he is all of these things and, at the same time, a person.
Therein lies the greatness and the risk of medical respect. There is an inevitable and necessary objectification of the patient demanded by the scientific structure of medicine. It is necessary that, in the course of the doctor-patient relationship, there be a greater or lesser shift from the primary “I-You” relationship—that is, from the human, interpersonal level—toward an “I-It” relationship, in which the patient is conventionally transformed into an object of scientific-natural observation and manipulation, through which the doctor seeks to obtain an exact, goal, purely scientific-natural “ knowledge ” of the pathological process and the corresponding treatment. The naked body, the object of physical examination and instrumental invasion, symbolizes this “ goal ” element in the doctor-patient relationship, which, by its very nature, demands the most complete possible disconnection from all subjective considerations. The doctor could not be a good doctor if he did not do things this way.
The dazzling progress of modern medicine, with its incredibly effective diagnostic and therapeutic methods, has only served to make this aspect even more evident. That is why we must guard against the temptation of anti-intellectual pessimism and the jeremianic prophecies of those who loudly decry the dehumanization of modern medicine or the factory-like structure of today’s hospitals. For many who have lost their balanced perspective, this inevitable objectification of the patient constitutes a temptation to become dehumanized. But, at its core, it is a prodigious manifestation of humanity, a lofty ethical act, full of application. Unfortunately, one sometimes hears well-intentioned criticisms of the cold technology of modern hospitals and the apparent detachment of the physician when he is separated from his patient by machines and staff. And it is said that all of this has caused medicine to lose its humanity. Yet, today as in the past, effective medical attendance is only possible when the patient trusts the doctor. But today that trust is not based primarily on subject certain displays of sympathy from the doctor—on his humanity in the popular sense—but rather on his scientific objectivity, on the reliability of his knowledge, his skill, and his familiarity with accepted treatment methods. Thus we have the seemingly paradoxical fact that the highest degree of subjectivity—trust—is grounded in the highest degree of objectivity, that is, in the doctor’s scientific reliability, skill , and skill . It is essential to dispel the false dichotomy between skill the physician’s technical skills, experience, and scientific knowledge—which must necessarily be objective—and their human qualities, character, and ethics. Indeed, the physician’s true competence and authority lie in the meeting integration of both fields of skill, which must be inseparable in a good physician. Ethical insensitivity and therapeutic malpractice are equally egregious as breaches of medical respect.
But having clarified the previous point, we must acknowledge that there are quite a few doctors today who have decided to ally themselves with the powerful and have stopped respecting everyone equally. To justify their disrespectful behavior, they need to disguise it with a false, artificial respectability. More than eighty years ago, Chesterton wrote with his characteristic sagacity that, in the modern world, science serves many purposes, and that one of them is to provide long words to disguise the errors and misdeeds of the rich. These long words—Chesterton gave the example that if a rich person steals, they are not a thief but a poor victim of kleptomania—have a respectable appearance. They are words we all know—such as “quality of life,” “health for all,” or “technological imperative”—all of them melodious, modern, and of noble academic lineage, until one discovers that they are serving as a cover for inhumane business practices.
The radical application of the concept of quality of life leads, for example, to the desperate conclusion that there are lives lacking in quality and so overburdened with weakness that they are not worth living and, consequently, must be eliminated.
The notion of health as a state of perfect physical, psychological and social well-being to which everyone should aspire leads us to consider living with limitations as a failure, which is the only true and real health attainable in this world. Consequently, irreversible deficiencies, irreparable disorders turn the weak into human scrap, whose repair is a useless waste and whose appearance must be prevented at all costs. Thus the way is paved for the euthanasia of the deficient.
The technological imperative is becoming an end in itself, even if the applications of new techniques sometimes serve only to humiliate or destroy human beings.
Many physicians have placed themselves at the service of the powerful to the detriment of the weak. They have allied themselves with fertile parents to eliminate by means of abortion or neonatal infanticide the deficient children or those with the modern and incurable weakness of being unwanted. They have allied with infertile parents to create for them an ardently desired child through assisted reproductive techniques. It does not matter that the price is a hecatomb of embryonic siblings, sacrificed as if they had no destiny staff in the Cosmos. They sterilize deficient girls in order to forcibly expropriate them of the possibility of becoming mothers, the noblest human capacity they still retain, and thus reduce them to the condition of sexual objects at the disposal of the first aggressor. In conclusion: some physicians have become agents at the service of the strong to expropriate the weak of their remaining human dignity.
Let's take a look at three significant examples of how these physicians act.
The first one alerts us to the risk that, under the appearance of a cutting-edge biomedical project , the transplantation of embryofetal cells and organs, a regression to a new form of cannibalism is hidden. It started with the effects produced by certain fetal neurons implanted in the brains of senile rats: the old animals seemed to remember better and learn faster. That opens the way to treat millions of elderly people with senile dementia! Other fetal neurons are able to reconnect the ends of the severed optic nerve: exaggerating the matter a lot, it was said that this will allow refund to restore sight to some blind people. To treat certain blood diseases, it is more immunologically advantageous to transplant hematopoietic tissue from fetal liver than to transplant adult bone marrow. We are assured that embryofetal tissues will remedy many diseases and will be more important in medicine than antibiotics or psychotropic drugs.
In the face of so much promise, human embryos and fetuses are seen by some as promising banks of tissues and organs for transplantation, but very few have asked themselves about the ethical consequences of the utilitarian exploitation of these human beings. New applications demand high quality for the materials they employ. It is not simply a matter of rummaging through the bucket of aborted fetuses and picking out the best-looking ones to make use of their cells or extracts. Living, intact material from unusable or rejected neonates is needed. At the moment, it is the turn of the anencephalons. Those that until recently were considered the most qualified candidates for third trimester abortion are now carefully delivered and transferred directly from conference room to operating room - as they have no brain, there is no need to anesthetize them - for live scrapping and removal of the liver, heart and kidneys. There is no other choice but to proceed in this way, because, although it may seem cruel, it is not advisable to wait for them to die, as their more or less long agony would reduce the quality of the organs.
But, in any case, there are very few anencephalics. For this reason, there are now plans to conceive fetuses in order to abort them. This will make it possible to produce tailor-made fetuses, which have undeniable advantages over the bulk fetuses offered by fetuses aborted in any clinic. A news item, published last August in the Wall Street Journal, stated: "A woman, whose father suffers from kidney failure, has order to be artificially inseminated with the father's sperm to abort the fetus in the third trimester and donate the fetus' kidneys to her father. Doctors believe that the tissue compatibility would be almost perfect."
We see how the technological imperative transforms some scientists into lesser gods. It amplifies their power and, with it, their capacity for moral error. It exalts them to the point of placing them among the inhabitants of the pagan Olympus, but assigns them a place of Saturn, who obtained his strength by devouring his own children.
My second example aims to show how the obsession with applying scientific advances leads some doctors to develop an acquired intolerance toward weakness. Prenatal diagnosis is becoming—thanks to the screening out of the weak—a moving-target shooting contest, where the rule of “aim and shoot” prevails. This is clearly demonstrated in the case of prenatal diagnosis of albinism. Thanks to ingenious procedures at Genetics Biochemistry , we are gaining a better understanding of the different varieties of this disorder every day. At the same time, the procedures—no less ingenious—that allow people with albinism to adapt to their condition are constantly improving, enabling them to lead normal lives and hold regular jobs. It is true that they will never be able to excel in certain activities, but it seems that, thanks in part to their superior use of report, they can achieve higher social and economic status than their normally pigmented siblings. Now, a method for the prenatal diagnosis of albinism has been developed. Some clinical geneticists are unwilling to accept that this new technique will be excluded from the range of eugenic abortion options. And since it is unlikely that the selective elimination of albinos will ever be accepted in Western countries with temperate climates, they are offering the new “ procedure ” to tropical countries, where the sociocultural, ocular, and skin problems of albinos are deemed incompatible with the dignity due to human life.
The elimination of the weak seems to have become the dominant passion of some scientists. I believe that with the same tenacity we must spread our message of respect for weakness.
Rebuilding respect for the weak
It is clear that the weak have few true friends, and this may be because so little thought is given to—and so little is written about—the dignity of the weak today. Perhaps there are very few medical schools in the world that devote at least one class hour in some corner of the curriculum to teaching the ethical significance of weakness. We are all interested in developing the theory and internship of respect for weakness, gathering ideas and experiences on this topic so we can start talking about it more widely.
We must explain and expand upon, for example, the doctrine I have summarized at outline . Not long ago, France’s National committee t for Ethics in the Life and Health Sciences issued a statement condemning the conduct of experiments on patients in a chronic vegetative state. In it, the committee made a strong defense of sick human beings and attributed high ethical value to their vulnerability. The report of the committee stated, among other things: “Patients in a chronic vegetative coma are human beings who have all the more right to the respect due to the human person precisely because they are in a state of great vulnerability. They may not be used as a means for scientific progress, regardless of the interest or importance of an experiment that does not aim to improve their condition.” This precisely expresses the concept of the direct proportional relationship between weakness and respect: the greater the patient’s weakness, the more the physician must respond with greater dedication, more careful attendance , and the most scrupulous rejection of any manipulation or abuse.
Another field worth exploring—to try everything and keep what works—is the literature on disability. In addition to highly critical works such as * programs of study * on the social marginalization of people with disabilities, a substantial number of testimonial stories— issue —have recently been published, featuring physically disabled individuals, the terminally ill, or those who care for them. Some of these biographies or autobiographies read like epics of willpower or odes to physical strength, which have enabled heroes and heroines afflicted by illness to triumph over their own weakness despite it and in defiance of it—by denying it and refusing to let it become part of their identity. This literature of supermen is not always comforting or a source of hope. But there is no shortage of truly human narratives that describe how ordinary men and women—of different ages and educational backgrounds—live and cope with their limitations; they have learned to overcome the daily difficulties of a life marked by disability through ingenuity, good humor, and a zest for life, revealing the kind and familiar face of weakness. After reading these writings, one is left even more firmly convinced that the world would be impoverished in humanity and compassion if our weakest brothers and sisters were to disappear from it.
Finally, we must offer a serious philosophical justification for the phenomenon of human frailty and biological disability—that inevitable companion of human life, the acceptance of which is the most human of all adventures. No matter how much rehabilitation techniques advance, no matter how generous the budgets for health and preventive care may be, weakness can never be eliminated from the earth, nor can suffering, illness, and death be abolished. It is illusory to think that the slogan “Health for All” can change the essentially weak and vulnerable condition of humankind, for to be human is to receive an inescapable lot that includes pain and disability. Every person’s life—their human destiny—includes the capacity to suffer and the acceptance of limitation. Faced with the inexorable reality of human frailty in the world, the physician strives to reduce the pain, distress, and disabilities of their patients, knowing full well that they will never know enough to completely overcome these adversities. Herein lies the human core of medicine. Applying the most modern therapies—almost miraculous in their effectiveness—is just as demanding in terms of science and skill as administering palliative care, both of which require extensive knowledge and mastery of what I believe is the most difficult aspect of the medical art: knowing how to tell patients that human beings are made to endure the wounds that illness and the passage of time inflict on their bodies and spirits, and that accepting these limitations is part of the process of becoming fully human. One is not truly human unless one accepts a certain Degree of frailty in oneself and in others. This is required of us as part of fulfilling our duty as human beings.
I will end now. Someday the accounts of what our time has meant for the development of Science, of truly human Science, will be drawn up. Lewis Thomas, that most brilliant and paradoxical figure of American biological thought, has given us a revealing part of that judgment. "A society may be judged by the way it treats its most unfortunate members, the least liked, the insane. As things stand, we are going to be regarded as a very sad lot. It is time to make amends for our mistakes.
Thank you very much.