Medical ethics and recovery of human values. A task for patients and physicians

Gonzalo Herranz, group of work of Bioethics. School of Medicine. University of Navarra
lecture delivered at the congress UNIV 87
Rome, April 12-19, 1987

When I was invited to give this discussion paper, I was very hesitant. There are so many interesting things in medical ethics today to reflect on aloud with university students that for a few days I experienced what some call the "smörgåsbord syndrome", that kind of paralysis of the ability to decide that attacks us when there are too many possibilities to choose from. Finally, I decided to deal with a very general and very basic topic : the role of Ethics in the recovery of human values in Medicine. I want to awaken everyone's interest in medical ethics and to tell everyone that he or she has certain responsibilities to assume in this field.

I. The decline of human values in medicine.

It has often been said that medicine is the most human of the sciences. But, in the opinion of many, experts and people in the street, medicine is becoming impoverished lately in human values. Despite spectacular advances in knowledge and technology, there have never been so many patients so dissatisfied with the care they receive in hospitals or doctors' offices. Paradoxically, despite the very high level of health achieved by advanced societies, there seem to be more errors and negligence on the part of physicians than ever before. Nor have there ever been so many malpractice lawsuits. Sometimes exaggerated but shocking reports are published, showing hospitals as pain factories and turned into chaos by strikes and indifference of doctors and nurses. It seems that trust, an essential element in the relationship between doctors and patients, has been eroded.

People's dissatisfaction with medicine has different origins. In part it is because we expect too much from medicine. We place more and more value on health. Health has become the first value, the most precious good, and it is logical that this should be the case in societies dominated by hedonism. In these societies, subsistence is no longer a problem and the public aspires to good health. Many Constitutions include health among the fundamental rights of the citizen. It follows that we all have the right to be healthy and not in any way, because, according to the doctrine of the World Health Organization, we should aspire to a state of perfect physical, mental and social well-being and not simply to be free of disease. It is not surprising, then, that some people go to the doctor with an almost legal demand for well-being and expect the doctor to remedy not only their ailments, but also all their problems. Medicine cannot satisfy such exaggerated expectations and this leads to disenchantment.

But I think that most of this discontent does not stem from the fact that medicine does not work miracles. It stems from the fact that patients do not feel that they are treated like people. That is why it has become a cliché to say that medicine has become dehumanized. When we ask patients why they are not satisfied, they usually say that the doctor devotes little time to them, that he is not interested in the problems that really concern them, in their fears or apprehensions. They add that the doctor tends more to prescribe than to listen, to look at their X-rays than to look them in the face.

When so much is said about the dehumanization of medicine, it does not mean that physicians have become careless and negligent, but rather that there is an eclipse of humanity in the doctor/patient relationship. And in the darkness of this eclipse, medicine, the most humane of sciences, goes astray and jeopardizes its ethical ideals. We should pause for a few moments to consider this truly nuclear idea.

II. The dignity of the sick person

Everything in Medicine is based on the idea that the sick person is invested with a particular dignity. The ethical quality of medicine is not result direct from the value of its science or its professional traditions. Its greatness is borrowed: it comes from the dignity of the sick person, to whom the physician must attend with respect and skill. The dignity of the patient demands from the physician, over and above the demands of the general dignity of man, a supplement of appreciation proportionate to the weakness or the danger that his illness represents.

The physician is not born with the ability to understand the human dignity of the patient and to respond to it. He acquires and develops this capacity thanks to a demanding asceticism, because illness is neither sympathetic nor easy to understand. It is difficult for man to discover that his sick brother has a particular dignity. This is very clear in some primitive cultures and also in certain very modern attitudes, and very rational in appearance, which react to the sick with rejection or contempt. Suffice it to bring to report as a button of sample the Tarpeian rock or the eugenic abortion of today. The ancient and modern philosophies of pleasure, utility and power, are a test that there is in man an instinctive repugnance to disease, especially when it degrades and disfigures its victims.

In addition to its inestimable value staff , the dignity of the sick person is a social treasure. I like to repeat that, in my opinion, the most valuable element of the social progress of humanity is the acceptance of the weak as privileged members of the human family. Much of the Christian Education is aimed at teaching us that the weak are very important. We should not be surprised if we still have much to learn, for we all carry within us an old man, a little hedonist, terribly reluctant to sacrifice himself for the weak.

Let us now do a short practical exercise. Think, as realistically as you can, what would be your first reaction to a sick person - a mentally handicapped person or an incoherent and agitated elderly person, for example - looking for a seat on a train. Would I go ahead and offer him the seat next to me and take care of him or, on the contrary, would I want him to pass me by and disappear from my sight? This simple test crudely measures our capacity to welcome or reject human weakness. The danger of inhumanity threatens us all more or less closely. For this reason, we should not miss opportunities to cultivate our appreciation for the dignity of the sick person, not with fine words, but with deeds and in truth. I take the opportunity - I always do - to say that better than theorizing about illness is to visit the sick in order to learn to listen to them, to distract them and to console them. I would like to add, in closing this digression, that I am persuaded that visiting the sick is not only a work of mercy for which God will reward us on the day of judgment. It is already here one of the most genuinely human and enriching experiences that one can give oneself.

Let us retain this idea from the foregoing: medicine has a human and ethical quality because the patient is a being endowed with a special dignity.

III. The doctor/sick person relationship is a one-to-one relationship.

Any physician with a little experience knows how unpredictable the sick are. Many episodes of illness are vented in the epidermis of the soul and do not give rise to any crisis staff. But at other times, when the illness is long or incapacitating and threatens in some way the freedom or human fulfillment of the patient, then it is an event that changes people. For some, the disease ennobles them, for others it irritates them, for some it degrades them. The physician knows this and has, therefore, the moral obligation not to close himself to the human values that the disease endangers.

From this we can infer that the doctor/patient relationship is a profoundly human relationship. In the interrogations, examinations and treatments to which he must be subjected, the patient is, in appearance, objectified, reduced to an object of technical manipulation. But not for a moment does he cease to be a human being to be taken seriously. The physician is the guarantor of his needy and threatened humanity. The essential aspect of the doctor/patient relationship is that it is always and in all circumstances a person-to-person relationship, a face-to-face relationship.

This is the true source of the patient's rights. As a human person, the patient has the right, above all, to have his freedom respected, to have his beliefs respected, to know the truth about his illness and to participate in making decisions that concern him. It would be tantamount to expropriating his freedom by withholding information to which the patient attaches particular ethical significance. The physician can never abuse his power and impose a decision that hurts the patient's conscience.

IV. The formidable power of the physician

It is important to know that today the doctor, any doctor, has a fabulous power. The public has only a very partial and anecdotal idea of the physician's capacity to change the way of life of his patients and to intervene on the deepest layers of their personality. The power of medicine does not consist mainly in its spectacular triumphs reported by the media. The power of Medicine has become capillarized, it is already everywhere. The enquiry of any doctor, rural or urban, is an agency with an enormous capacity to transform humanity. Let us see with a couple of examples how, depending on the doctor's moral convictions, so is his professional conduct.

Example 1. In a simple office, a doctor notices that, under the ordinary appearance of the patient in front of him, a cunning simulator is hiding. Doctor A comes to the conclusion that his patient is a social parasite, much more in need of a strong reprimand or a penal correction than of any medical treatment subject . Doctor B will try to socially reintegrate the pseudo-sick person and will make sure that his personal, family or work problems receive due attention. Doctor C, finally, thinks that opposing the deception will lead nowhere, since the patient will reoffend in his behavior: he decides, therefore, to prolong his work leave and to condescend to the patient's wish to spend a few days in the hospital.

As we can see, each physician's reaction is defined by his or her ideas about whether and where the boundary separating pathological and criminal behavior exists.

Example #2. Doctors' ideas about when to prescribe psychotropic drugs are as different as the quantities they prescribe. Some doctors are of the opinion that people have the right to rely on Chemistry to overcome life's difficulties and conflicts and to treat themselves to happiness through psychopharmacological hedonism. Others believe that psychopharmaceuticals should be used very sparingly, since some anxiety is a normal ingredient of human life, which is by essence a restless being. Consequently, they believe that the abuse of psychotropic drugs is not only a way of wasting money, but also a way of impoverishing human life and culture. They suspect that, if they had been treated with anxiolytics, neither Dostoevsky, Wagner nor Tchaikovsky would have left us their art. In fact, psychopharmacological manipulation can extinguish the inner life. In the lives of many men, psychopharmacological drugs are taking the place of virtues in the struggle to achieve peace. The Chemistry replaces asceticism.

If we had time, we could multiply the issue of examples and consider situations in which the physician acts as an accomplice and cover-up with the applause of the permissive society. One doctor can "medicalize" an abortion on demand and dress it up as legal. Another doctor can in exactly the same circumstances and for medical reasons save that same innocent life. If we had time, we could observe how a certain subject of physicians practice euthanasia because they themselves, or their patients, or their patients' families, have come to the desperate conclusion that there are lives without value or dignity. But we would also see how there is another subject of physicians who have acquired a formidable skill in the care of the terminally ill patient and who affirm that, for them, the main professional argument against euthanasia is precisely the moral and human quality that this short but significant end of life may have for the patient or his or her family.

As we see, the physician has formidable power. He can choose between being employed in the service of the sick man and being a protector of his threatened humanity or becoming deaf to man's noblest values.

V. The growing power of the sick

Today, however, the power of the patient is no less important or less decisive than that of the physician. Since the 1960s, the movement in favor of the so-called rights of the sick has been spreading almost everywhere. There are among them certain just claims derived from the human dignity of the patient, and also some lofty demands of the consumerist mentality. This movement has already had some beneficial effects: it has enlivened the ethical conscience of the patient because, by vigorously asserting his autonomy, his right to be informed in order to be able to decide, it makes the patient assume a freer and more moral attitude manager .

But the patient, too aware of his rights, runs the risk of giving the doctor/sick person relationship a ruinous bias. He may abuse his rights and become arrogant, make decisions on his own and demand that the physician bow to his demands. Thus arise the inhuman and immoral demands of voluntary sterilization, abortion on demand, cooperation in suicide.

We cannot forget that today, due to the socialization of medicine, the patient is not alone. Behind him there is a very powerful bureaucracy, through which the Ministries of Health control the gigantic complex of the health industry. The figure of the physician is dwarfed, while the patient, either as a consumer of services or as a citizen who votes for his or her rulers, becomes the referee of status. The doctor/patient relationship is losing the benign, paternalistic and friendly character of yesteryear and becomes something cold, contractual and potentially contentious.

It is a pity that what began as a movement to consolidate the ethical immunity of the sick ends up as a conspiracy against the moral conscience of the physician or as a safe-conduct for the patient's self-degradation.

VI. The recovery of human values in Medicine

An inevitable conclusion must be drawn: things do not seem to be going well in medicine. Medicine, one of the most beautiful human enterprises, is in urgent need of a thorough overhaul. We need, as the Holy Father John Paul II has so often affirmed, to recover the truth of man and place it at the center of our field of vision. This is a message that we must live deeply and transmit without fear to everyone, especially to doctors and the sick.

We must tell people that there is one truth about man, the truth revealed to us by Jesus Christ. To do this, the first thing is to firmly reject the blackmail of cultural relativism. Today's tolerant society demands from everyone submission to its supreme rule: "It is forbidden to proclaim, or even to suspect, that one's own convictions are true". It is branded as bad Education or as repugnant ethnocentrism to manifest with simplicity that one firmly believes in truths that can save man.

We have them. John Paul II has spoken to us about them. He told us that the world cannot go on much longer on the path it is on. That we must mobilize consciences to make them capable of facing the terrible tension between good and evil to which we humans are subjected at the end of the twentieth century. We must persuade everyone of the priority of ethics over technology, of the primacy of the person over things, of the superiority of the spirit over the subject.

Medicine is one of the fields where this tension is at its hardest. For this reason, all of us who are involved in it, doctors and patients alike, have to ask ourselves, stubbornly, time and again, if what we do or what is done to us really makes men more human; if medical progress and the work in hospitals and outpatient clinics contribute to making man better, that is, if they make him more spiritually mature, more aware of his dignity, more open to others.

As a training exercise, let us analyze a very topical status . The Ministries of Health have started to proclaim, by means of multimillion-dollar advertising campaigns, that precautions must be taken to contain the AIDS epidemic. They point out that sexual promiscuity must henceforth be practiced under the protective safety of condoms. Such campaigns scandalously ignore not only the human value of chastity, but even its technical value as a prophylactic. I believe that I am not exaggerating when I say that this is the greatest operation ever seen to "veterinarize" medicine, since it is based on the idea that, as an agent of public health, the physician should refrain from moralizing and limit himself to treating. This is tantamount to forbidding the physician to establish relationships with his patients as persons and to limit himself to treating them as simple biological objects. It is also tantamount to telling the patient that he is considered incapable of moral life, unfit for virtue. In contrast to other combative campaigns (anti-smoking, anti-salt, anti-environmental pollution, anti-animal fats), sexual promiscuity is not considered a voluntary health risk, but is proclaimed as a normal lifestyle, as an inalienable right. The anti-AIDS campaign is likely to place our Ministries of Health at the top of the list of sex industrialists, since they include among their recommendations that of alternating the gratifying pleasures of fornication with resource to certain deviant sexual practices, aberrant, but with less risk of contagion.

I conclude. Medicine is a formidable sounding board for human values, and its greatness comes from being the guardian of man's dignity. Never, perhaps, has there been more urgency to remind men that they have been rescued from animality at a very high price. Nor have Christians ever been offered more opportunities to do so. Mother Teresa has already opened a home for AIDS victims and her example is beginning to spread. We are not going to stand hand in hand. Everyone must participate in a campaign against this calamity. In point 121 of The Way, Monsignor Escriva de Balaguer gives us a very ambitious goal , full of promises:

"A crusade of virility and purity is needed to counteract and nullify the savage work of those who believe that man is a beast.

-And that crusade is your doing."

My intervention this morning was only intended as a framework to encourage us to mark this purpose. Thank you very much.