Ethical respect for weakness
Gonzalo Herranz, department de Humanities Biomedical, University of Navarra
Session at the VI Master's Degree on Palliative Care
classroom "Ortiz Vázquez", Hospital La Paz, Madrid, Saturday, May 8, 1999
Acknowledgement and words of thanks for the occasion.
What do professional ethics say about palliative care?
The ethical foundations of palliative care
a. Respect for and protection of weakness
b. The finiteness of aggressive interventions and the place of palliative care
Palliative care, a vaccine against euthanasia
I am honoured to support a programme that seeks to implement and consolidate palliative care with scientific seriousness and human encouragement.
Fear of spoiling the course.
The topic that I have to deal with here is particularly relevant. It poses a question: what do the professional ethics of the physician say about the weakness of the patient, and specifically about the weakness of the terminally ill patient? Is weakness a sign for particular protection or a mark for withdrawal and contempt?
This is an essential topic of medicine and, at the same time, an issue of vibrant topicality. This is where palliative medicine presents itself as a protector of humanity.
Because the balancing act between respect and withdrawal is an issue that has been continuously present in the history of medicine and is present in the inner discussion of many doctors and nurses.
Weakness does not seem very respectable in itself. In medicine, it has always been said in front of the terminally ill patient: there is nothing more to be done. And often the reaction to weakness takes one of the many forms of withdrawal.
Plato, in the Republic, summarises the attitude of Greek medicine, including Hippocratic medicine: "Aesculapius taught that medicine was for those of a healthy nature but who were suffering from a specific disease. He delivered them from their malady and commanded them to live normally. For those, however, whose bodies are always in an unhealthy internal state, he did not even prescribe a regimen that would make their life a more prolonged misery. Medicine was not for them and they should not be treated even if they were richer than Midas".
And this is how many rationalists and pragmatists still think today, the followers of any Philosophy, ancient or modern, of power, vitality: in the custom of the ancients to expose the sick or weak, in the instinctive distaste we all feel in the presence of impoverished life. Nietzsche took this rejection to the extreme. Based on the demands of reason, feeling, nature and instinct, he makes the fundamental will to be healthy the fundamental principle of nature. The vital and sure will of instinct does not move the healthy man to respect and pity the sick and the weak, but rather pushes him to contempt, even to annihilation.
The recognition of the human value of the weak enters into humanity with the Judeo-Christian tradition, especially Christian, that we are all, strong and weak, equal before God, that we all possess an identical dignity, intrinsic and inalienable, which is given to us by our very existence. A dignity that comes from being each and every one of us, without distinction and mysteriously, imago Dei.
But it is also the case that the health professions, medicine and nursing above all, are vocationally called to serve and help the sick and weak.
What is proper to true professions, and in particular to those who care for the health of men, is not to possess a complex science that takes many years to master. Rather, it is to use this expert knowledge for the good of others who are in particularly vulnerable situations. True professionals do not deal with things, with partial, fragmentary elements of people's existence, but with their health and their whole life. The sick put themselves in our hands, the whole of them, body and soul, not simply their things.
The sick person, every sick person, is thus forced to trust us. It would be very easy for us to exploit the weakness of the sick person, or to allow ourselves to be driven by other interests than the interests of the sick person. But professional ethics constantly reminds us that we are particularly bound by a commitment of loyalty and respect towards the weakened patient.
The terminally ill patient is a riddle for doctors and nurses. In front of the terminally ill patient we have to solve a riddle: that of discovering and recognising in him or her all the dignity of a human being. Terminal illness tends to eclipse dignity: it hides it and even destroys it. If, in a certain sense, health gives us the capacity to reach a certain human fulfilment, being ill limits, in different ways and at Degrees , the capacity to develop the project of man that each one of us cherishes. A serious, incapacitating, painful illness, which diminishes our humanity, and even more so terminal illness, does not consist only of biological, molecular or cellular disorders. Nor is it an experiential journey of stages that mark the patient's reactions to ineluctable death. Above all, the terminal status constitutes a threat to the integrity staff, which puts the sick person as a human being at test .
Doctors and nurses should not forget this when we are with our patients. Our attendance cannot be reduced to a simple technical-scientific operation. It always includes an interpersonal dimension. It cannot be limited to applying a palliative care protocol : no patient can be served by science and knowledge, tools and systems alone. Protocols are extremely useful, a great financial aid . But they are also fundamentally reductionist. They are like a form in which certain blanks have to be filled in, which always refer to easily measurable things that seemed important to the authors of the protocol. They are forms that, with habit, tend to be filled out in a formulaic way. They take into account some individual variables, but lead to treating patients as interchangeable elements. Protocols and systems are not everything in the service to be given to patients. With their financial aid, they must become more competent in pain and symptom management. But they cannot inhibit the human care that the weakest need: doctors and nurses must communicate peace and human warmth to their patients, suppress the loneliness and helplessness with which illness threatens them.
I have often asked myself: how did medicine begin? Historians and experts tell me about anthropology, archaeology, shamans and magicians. But it seems to me that the answer, rather than historical, must be a sociological, existential one. The threat to the humanity of the sick person, which is illness, awakens in the healthy person the particular responsibility to assist them with all available means, to restore them to their human fullness, or, at least, to alleviate as far as possible the consequences of that threat. The holder of this responsibility and of this service, the one who acts on behalf of and in the name of mankind, is the physician and, with him, the whole of staff health care. This is the special dignity of the health professions. Their purpose is not only to treat illnesses and symptoms, which are alleviated by technical, scientifically based interventions. It is also, and above all, a response staff to the crisis staff through which the sick person is passing. This is the basis of all medical professional ethics.
What do professional ethics say about palliative care?
I recently reviewed what the codes of ethics and deontology of 40 countries on the European and American continents have to say about topic . The conclusion was this: beneath a motley variety of ways of saying, there is a deep unity, a common tradition: alongside the condemnation of euthanasia and physician-assisted suicide, there is a strong recommendation for the use of palliative care.
The terminally ill patient is, for the deontology of doctors and nurses, however weakened he or she may be, just another patient, who is not excluded from the general obligations that, without discrimination, health professionals provide to their patients.
The World Medical Association ( association ) in its Declaration of Venice on Terminal Illness speaks of palliative care as follows: that it is the duty of the physician to cure and relieve suffering as far as possible, always keeping in view the interests of his patients; that he shall admit no exception to this principle, even in cases of incurable disease or malformation; that this principle does not preclude the application of the following rules: The physician may relieve the patient of the sufferings of terminal illness if, with the consent of the patient or, if he is unable to express his own will, with that of his family, he suspends the curative treatment, which is already useless. Such suspension of treatment does not release the physician from his duty to attend the dying person and to give him the necessary medication to mitigate the terminal phase of his illness. And finally, the physician shall refrain from employing any extraordinary means that would be of no benefit to the patient.
In order not to prolong this point, I will read out article of the Spanish Nursing Code of Ethics, which sets out, in a broad and precise manner, the deontology of end-of-life care. It reads as follows: Art. 18: Faced with a terminally ill patient, the nurse, aware of the high professional quality of palliative care, will strive to provide the patient until the end of his/her life, with skill and compassion, the necessary care to alleviate his/her suffering. He/she will also provide the family with the necessary financial aid to enable them to face death when it can no longer be avoided.
The conduct of health professionals towards the terminally ill is defined by the duty to care for them with application, not to discriminate against them. They may not provoke death, but must refrain from aggressive treatment with useless therapies. They will never disregard the life of their patients, but will learn to respect life by accepting the inevitability of dying and death.
There are therefore positive professional duties: to alleviate physical and moral suffering, to maintain as far as possible the quality of declining life, to be guardians of the dignity of every human being and the respect due to him or her, to ensure that palliative care is not marginalised by the scientific advances that come from biomedical experimentation.
And there are also negative professional duties: euthanasia and fierce therapeutic gestures, lacking in reasonableness and good judgement, which seek an already impossible cure, are strictly forbidden. These are the basic ideas of palliative deontology, on which doctors and nurses should often reflect.
From this reflection we can draw a long list of points for consideration.
The one I would put first is the duty to improve, through well-designed and interdisciplinary research projects, the quality of palliative care. It is precisely compassion for patients and openness to the whole person (the whole individual, the family, the community) that creates a broad outlook for research and, consequently, for the professional service. Since palliative care directly or indirectly concerns vulnerable subjects, the ethical analysis of the projects of this very important area of the biomedical research must be given the necessary importance.
But there is also a responsibility to constantly evaluate the quality of care provided; to stratify care for the incurably ill into palliative and terminal measures; to extend the benefit of palliative care to all potential candidates for palliative care, i.e. to the many incurables suffering from long and painful illnesses; to optimise the cost/benefit ratio of palliative care to develop formal and informal methods of teaching the science and general art of palliative care, already in the course of the programs of study of the licentiate degree; to establish palliative medicine and nursing as genuine and recognised specialities.
Few today doubt the usefulness and efficiency of palliative care. But there is no shortage of those who offer euthanasia as the most efficient, quickest, most economical and rational solution, and cynically accuse palliative care of its poor therapeutic performance, when things are measured by the biological metre of fees of cure or years of survival. Such nonsense is not worth refuting.
It is now time to consider the central point of my intervention.
The ethical foundations of palliative care
Palliative care rests, in my view, on two basic pillars of medical ethics. One is the ethical respect for weakness, which must be accepted and protected as part of human existence. The other is the limited, finite nature of aggressive medical interventions, which must give way to palliative care as a wise and compassionate response to terminal illness. These are worth considering in detail.
a. Respect for and protection of weakness
The vocation of doctors and nurses is a vocation of service. They are vocations that serve man, from agreement with a deep understanding of the dignity of the patient and the value of health and human life. Such service is primarily about meeting the genuine needs of the patient. They can never devote themselves to slavishly indulging his or her whims.
It is crucial to dialogue with the patient in order to agree, through the ethical and humanising management of consent, on his or her legitimate control over treatments, always in accordance with the demands of science and professional ethics. If the doctor/patient or doctor/nurse relationship were to be infiltrated by servility, in the form of autonomous tyranny, Medicine and Nursing would become mercenary activities.
Health professionals are not the patient's slaves, nor are they the patient's masters. Their role is to judge the value of the means at their disposal, not the value of the lives entrusted to them. Yet some doctors and nurses consider some lives so lacking in quality and dignity that they consider them unworthy of medical care and human comfort. Such an attitude is not only a total subversion of the ethical tradition of the health professions and of all Western culture, but also an apostasy from the future.
The reason is obvious: one of the most fruitful and positive elements in the progress of both medicine and society has been the realisation that the weak are important. It is precisely from this idea that civilisation and medicine were born. However, as we approach the third millennium, respect and service for the weak continue to meet with resistance within each of us and within society. Today, the rejection of weakness is being accepted and practised on an unprecedented scale.
In the Christian deontological tradition, being weak was degree scroll enough to be worthy of respect and protection. Today, for people with a libertarian and individualistic mentality, weakness is a stigma that marks one for marginalisation. Medicine thus runs the risk of becoming an instrument of social engineering, following the new mentality of well-being and high quality of life.
But that is an idea totally foreign to the ethics of health care. As doctors and nurses, we need to understand that our first ethical duty, respect for man, usually takes a peculiar and specific form: ours is a respect for weakened life. In palliative medicine, respect for life is almost constantly conditioned by the presence of essential vulnerability, by the extreme fragility of man, by the recognition of the inevitability and nearness of death.
We do not have to deal with the healthy and the strong, but with the sick and the weak, with human beings who live the crisis of losing their physical vigour, their Schools mental vigour, their life. The ethical respect of doctors and nurses who administer palliative care is respect for the suffering, declining life; their work consists of caring for people in the Degree extreme of weakness.
Res sacra miser. This is an expression that magnificently describes the special status of the humanity of the sick person in the field of tensions of terminal illness. It is a wonderful translation of the coexistence of the sacredness and dignity of every human life with the sometimes extreme misery caused by illness. When the sick person is seen in this light, as both dignified and miserable, we can recognise his or her condition as both inviolable and needy. This, in my opinion, is the ethical foundation of palliative care.
Someone has pointed out that the expression palliative, besides its common meaning the remedies applied to incurable diseases to mitigate their violence and restrain their rapidity, had an ancient and happily abandoned usage, meaning that which should be concealed, disguised, as when one wears a cloak, a pallium.
Today, the notion of palliation demands frank sincerity. Humanity and, more specifically, human rights have reached sufficient maturity so that weakness does not have to be hidden as something unworthy, but publicly recognised, by all, as part and inheritance of humanity. And what, strangely enough, happens in the intellectual and ethical sphere in the acceptance of pluralism and extravagance, fails very sadly in the biological and health sphere. Weakness is frowned upon. Hiding and denying weakness is very current, imposed by the hedonistic mentality, intolerant of suffering and handicap, by the evolutionary philosophies of the survival of the fittest, by the praxis of the competitive struggle for power. These ideologies carry within them the seeds of contempt for the weak. The issue of citizens for whom euthanasia is coherent behaviour is growing in the face of the issue growing number of decrepit elderly, irrecoverable or hopelessly ill people, many of them paradoxical victims of medical progress, avid consumers of the finite resources allocated to health care. We are now only a short distance away from making Nietzschean ethics official: care and compassion for the weak and for those who are of little importance belong to a morality of slaves, of a decadent humanity, impoverished in its instincts. The ethics of will, of force, of power is imposed.
And yet, the ethical tradition of medicine tells us that medical respect for the patient must be proportionate to the patient's weakness: the terminally ill patient has a privileged right to the doctor's attention, to his time, to his capacity, to his abilities, for there is an obligation to care for each patient as he is, without discriminating against him for being the way he is. This is what the French Republic's committee National Consultative Council for Life and Health Sciences states in one of its reports: "They (referring to the patients in a persistent vegetative state on whom Dr. Milhaud had performed risky experiments) are human beings, who are all the more entitled to the respect due to the human person because of the fragility of the state in which they find themselves".
All of us need to frequently review our attitude to the ethical principle of non-discrimination. To my students, I often offer a test, given by Paul E. Ruskin, to ask them to honestly consider whether their commitment to non-discrimination is sound.
Ruskin once asked nurses participating in a course on 'Psychosocial Aspects of Old Age' to describe honestly what their state of mind would be if they had to deal with cases such as the one he described below attend :
The patient appears to be her chronological age. She does not communicate verbally, nor does she understand the spoken word. She babbles incoherently for hours, seems disoriented as to her person, space and time, although she gives the impression that she recognises her own name. She is uninterested and uncooperative in her own grooming. She has to be fed soft foods as she has no teeth. She is incontinent of faeces and urine, so she has to be changed and bathed often. She drools continuously and her clothes are always stained. She is unable to walk. Her sleep patron saint is erratic, she wakes frequently at night and wakes others with her cries. Although most of the time she seems calm and gentle, several times a day, and for no apparent reason, she becomes very agitated and has unmotivated crying spells.
The response from students is generally negative. Caring for such a patient would be devastating, a waste of doctors' and nurses' time, most say. Of course, if all patients were like the case described, say a few, the geriatric specialization program would be for saintly doctors and nurses, but not for ordinary doctors and nurses. The more motivated point out that such a case is a very hard test on the patience and vocation of the doctor or nurse. When told that many of these responses are not only incompatible with the Ethics of non-discrimination, but also grossly exaggerated and unfair to reality, the comments are often dismissive or dismissive.
Ruskin's test ends by circulating among the participants the photograph of the patient in question: a beautiful six-month-old baby. Once the audience's protests of feeling cheated have subsided, it is time to look inside, to consider whether the solemn and self-gratifying commitment to non-discrimination must yield to differences in weight, age, life expectancy, or the subjective feelings inspired by the physical appearance of different patients, or whether, on the contrary, it must overcome these circumstantial data .
My experience staff is that many students have to change their overly sensory, not to say sentimental, way of looking at their patients. They have to be convinced that the elderly patient is, as a human being, as worthy and kind as the child. The sick who are consuming the last days of their existence, and those incapacitated by senility and dementia, deserve the same care and attention as those who are beginning their lives in the incapacity of early childhood.
b. The finiteness of aggressive interventions and the place of palliative care
It is essential for doctors and nurses to recognise the practical and ethical limits of our power. It is not enough for us to know that, in fact, our techniques cannot do everything; they have a physical limit. We must also be aware that there are ethical limits that we must not overstep, because our actions would be not only futile but also harmful.
Two things are necessary for this: the first is to have a precise idea that, despite their aggressiveness and effectiveness, there comes a time when the available resources become inoperative, because, inevitably, they are finite; the second is to understand that neither therapeutic obstinacy nor the patient's withdrawal are ethical responses to terminal status : palliative care, on the other hand, is.
Work is now actively underway to define, in clinical protocols and in ethical terms, the notion of medical futility, futility, to use an Americanism. There is diagnostic futility, just as there is therapeutic futility. Diagnostic overkill is therefore possible, as is therapeutic overkill.
The boundary between right palliative behaviour and the error of excessive zeal is not clear in many clinical situations. Nor do we know exactly how many new interventions will perform. There will always be a more or less wide band of uncertainty, in which a decision will have to be made. In the indeterminacy, we may be inclined to give the patient the benefit of the doubt.
But we must always bear in mind that, inevitably, in the care of certain patients, we reach a point where the gains from our interventions are disproportionately small in relation to the suffering they cause or the economic expense they generate.
In order not to lose their ethical orientation, their sense of relief and depth, throughout the course of their relationship with the terminally ill patient, doctors and nurses must see their patient with binocular vision. They must keep their awareness awake to the fundamental fact that they are dealing with a human being: that their relationship with the patient is a relationship of one person to another person. And their aspirations, wishes and convictions must be taken into account and fulfilled as far as is reasonable. This relationship staff must also be extended to those close to the patient. Doctors and nurses must see this with their human-sensitive retina and staff of their patient.
But at the same time, doctors and nurses have to attend to the needs and limits of the terminal patient's precarious biology, of the life that is ebbing away. With their scientific eye, they must see beneath the skin of the terminally ill patient a seriously disturbed biological entity. The patient can never be reduced to a mere collection of bewildered organs, never a mere chaotic and ruined pathophysiological system. But it is that and it is, at the same time, a human being.
The binocular vision of doctors and nurses must integrate, superimpose, the image of this biological system, damaged beyond repair, with that of this human being who cannot be abandoned, who must be respected and cared for until the end.
This is the greatness and the risk of palliative care. Simultaneously seeing the human being, in order to stay ahead of him, and simultaneously seeing a sinking biology, in order to refrain from taking useless measures.
Doctors and nurses always need this double vision, as required by their dual role as carers of the sick person and as cultivators of natural science. The clinical assessment of biochemical parameters, the monitoring of functional constants, symbolise this element goal in the doctor/patient relationship, which, by its very nature, requires the maximum possible detachment from all emotional or affective ties. One cannot be a good health professional if, in this scientific, objectifying moment, compassion and empathy are not set aside, in order to be able to calculate objectively and even-handedly the appropriate terms in which to intervene.
When the objective indicators at a given moment indicate that the organic maladjustment is already irreversible, that the terminal phase of the illness has begun, with no turning back, it is necessary to abandon the idea of curing, and to use the official document, very demanding of science, of skill and of humanity, of caring, of palliating. The act of recognising that there are no more curative resources to draw on may be hard, but it is a clear and profound manifestation of humanity, a just judgement, an ethical action that is lofty, truthful and full of application. It can be a very difficult juncture for the patient and his or her family to accept, which puts their trust in doctors and nurses at test . It is logical that the patient feels the need for a second opinion. And they should never be prevented from calling a competent colleague.
People are increasingly coming to understand that their trust in their caregivers can no longer be based primarily on doctors and nurses pleasing them with their easy-going and indulgent sympathy. They tend to rely rather on their scientific objectivity, on the reliability of their knowledge, on their technical skill , on their familiarity with accepted methods of diagnosis and treatment. And also in their tempered Withdrawal to the useless, and, if necessary, in their mastery of palliative care.
Palliative care, a vaccine against euthanasia
Palliative care provides a priceless service to the health professions: it protects them from the danger of falling into the destructive dynamics of euthanasia.
Judging by the findings of sociological surveys, there is, among health professionals, a sector, of indeterminate size, that accepts the idea that it is justified, even virtuous or morally obligatory, to put an end to certain human lives lacking in quality. And some of them are willing to do so, either by helping the patient to voluntarily end his or her life, or by euthanising him or her. If they do not do so, it is because of the legal risks they may incur.
I do not want to discuss here to what extent the new Spanish Penal Code has softened the punishability of homicide at the request of the patient or the effective financial aid to suicide. But I do believe that, in order to evaluate the inestimable value of palliative care by contrast, we should ask ourselves what happens when euthanasia and financial aid medical suicide are legally authorised.
My thesis is clear: any legislation tolerant of euthanasia, however restrictive it pretends to be on paper, brings about a brutal change, affecting the principles and the internship of medical care. It profoundly disturbs it, degrades it ethically and impoverishes it scientifically.
The ethical decline is not difficult to calculate. In the dynamics of legal permissiveness, and in the conscience of the doctor, decriminalising euthanasia begins to mean that painless killing is an exceptional way of treating certain illnesses, which is only authorised for extreme and very strictly regulated situations.
But, without delay, inexorably, as a result of social habituation, media gluttony speech, and pro-euthanasia activism, restrictive decriminalisation ends up meaning that killing for compassion is a de facto accepted therapeutic alternative, with more indications than originally thought. And it is so effective that doctors cannot morally refuse it. The reason is obvious: euthanasia - a clean, quick, one hundred percent efficient, painless, compassionate intervention, much more comfortable, aesthetic and economical than palliative treatment - becomes an invincible temptation for certain patients and their relatives.
Once euthanasia is decriminalised, the serious thing for a issue of doctors and nurses is that their specific professional virtues - compassion, the prevention of suffering, a sense of justice, the duty not to discriminate between their patients - are turned against them, so that they are driven by their own professional virtues to increasingly apply this liberating therapy: one cannot deny a patient the definitive relief that, in similar circumstances, has been given to others; nor is it operative to delay until later what is now presented as the indicated and effective remedy. The concept of terminal illness will become wider and wider; the indications for euthanasia will become more extensive and earlier.
The doctor or nurse who has succumbed to the temptation to kill out of compassion and carried out euthanasia is faced with a stark choice: either they repent sincerely, or with the same sincerity they will no longer be able to stop killing. For if they are ethically consistent with themselves, and believe that they have done something good when they ended their patient's life, they will not be able to refuse, out of consistency, to continue to do so. And they will do so in less and less dramatic cases and more and more easily bypass legal barriers in the name of their ethics.
For if the law, as seems likely in the first generation of euthanasia laws, only authorises euthanasia or financial aid suicide to those who ask for it freely and voluntarily, what reasons can be given by those who have practised it in accordance with the law to deny it to those who are incapable of asking for it, but who are in a biological status as impoverished or more impoverished, or whose care is much more burdensome for others? He is sure that, undoubtedly, the one who has left an explicit living will, the profoundly demented or the comatose oncologist, would ask for it if they had a moment of lucidity. No matter how careful he is of his patients' autonomy, no matter how much he respects their capacity to choose, if he thinks that there are lives so lacking in quality that they do not deserve to be lived, he will conclude that sometimes there is only one thing left to choose: the death of the extremely weak. If a doctor or a nurse were to consider euthanasia as a superior remedy to palliative care, they could not help but become subjective agents of the terminally ill patient. For, faced with a patient unable to express his or her will, they reason thus in their hearts: "It is horrible to live in these conditions of biological or psychological precariousness. I would not want to live like that. Such a life is not life. I would prefer to die a thousand times. The best, the only decent thing I can do for them is to put an end to their tragedy.
And if the doctor or nurse is driven by utilitarian reasons, sooner or later they come to the inevitable conclusion that there are patients, especially relatives of patients, whose desire to go on living or to help to live is irrational and capricious, because they have an abhorrent prospect ahead of them. They reason thus: the lives of certain patients, some capable of deciding and others incapable of doing so, are so lacking in quality that they are not worth living. To insist on living them is an unjust desire, which entails an irrational consumption of resources, economic and human: that money and that work effort could be much better spent. It is not difficult to construct seemingly rational arguments that expropriate the patient or those responsible for the patient from the freedom to choose to continue living.
These are not hypothetical situations. The social laboratory that is the Netherlands has already witnessed and, to a certain extent, confirmed, with case law, these four phases of the expansion of euthanasia.
With each passing day, I am convinced that palliative care contains an ethic of great density: it is a precious treasure of Medicine and Nursing, a force that embodies and defends their most intimate and basic ethical values. It is also the antidote that preserves us from the temptation of euthanasia, both frightening and attractive, and that saves our hospitals from the inhumane error of therapeutic overkill.
The obligation of doctors and nurses to respect and care for all human life is a wonderful and inspiring moral force. As you work in hospitals and homes, you are doing much for the ethics of the health professions. I want to personally thank you for your interest and dedication to Palliative Care. Your care is saving medicine from the great danger of becoming an accomplice of the strong against the weak.
Moreover, curiously and paradoxically, you have chosen a specialization program full of future. Thank you very much.