Euthanasia and dignity in dying
Gonzalo Herranz
department of Bioethics, University of Navarra
conference International Bioethics Seminars:
Bioethics and Dignity in a Plural Society
Pamplona, October 21-23, 1999
I. The dominant interpretations of the idea of dignity when speaking of the dignity of death
1. The Dignity of Dying in the Pro-Life Context
c. The ethical-deontological rules and regulations of medicine
3. Dignity of Dying in the Pro-Euthanasia Context
II. The peculiar human dignity in the trance of terminal illness and in the dying process.
The framework imposed by the general degree scroll of these conference, Bioethics and Dignity in a Plural Society, makes it necessary to deal with euthanasia and the dignity of dying from the various and conflicting perspectives that circulate in today's ethically fragmented society. I have been given the task of referring to how the concept of dignity is used in the intense and never-ending discussion around euthanasia.
The task is not easy. In the first place, because much has been written about topic: in the database Bioethicsline (up to the end of 1998) there are more than three hundred bibliographical references on euthanasia and dignity. Secondly, because the word dignity has acquired a special rhetorical force in the debates on euthanasia or financial aid medical suicide, and, logically, it has been used for persuasive purposes both by those who promote and those who reject it: what is the dignity of dying has become the main question confronting the opposing cultures of life and death.1. Third, because the terms euthanasia and the dignity of dying are themselves victims of a harsh and deliberate polysemy: they mean, in different contexts, different and confusing things.2. Thus, in addition to the abundance of material available, there is lexical confusion and dialectical polarization.
subject And yet, since the misleading idea of dying with dignity is so closely linked to the behaviour (palliative or euthanasic) of the doctor caring for the terminally ill and dying patient, it is understandable that, from the point of view of medical ethics, we are facing a major topic . The medical profession cannot avoid a serious discussion of death and dying in their relationship to human dignity.
Since, at the beginning of our meeting, an analysis of the notion of human dignity in the bioethical context was made, in what follows I will limit myself to dealing with two issues: one is to gather, simplifying things to the maximum in two polar positions, the essence of the interpretations that are made, in today's plural society, of the dignity of dying; the other is to rehearse a personal interpretation of the peculiarity that human dignity acquires in the trance of terminal illness and in the process of dying.
I. The dominant interpretations of the idea of dignity when speaking of the dignity of death
Today's different attitudes towards the relationship between human dignity and death can be reduced to two polar positions.
One proclaims the intangible dignity of every human life, even in the trance of death: all human lives, for their entire duration, from conception to natural death, are endowed with an intrinsic, objective dignity, possessed equally by all: this dignity surrounds every moment of human life with an aura of nobility and sacredness that is unmistakable.
The other affirms that human life is a precious good, endowed with an excellent dignity, which is unequally distributed among human beings, and which, in each individual, undergoes fluctuations over time, to the point that it can be extinguished and disappear: dignity consists in quality of life, in a well-founded aspiration to excellence. When quality falls below a critical level, life loses its dignity and ceases to be a highly estimable good. Without dignity, human life ceases to be truly human and becomes dispensable: such life is no longer life.3. Anticipating death, then, is the desirable solution when life loses its dignity.
Curiously, pro-life and pro-euthanasia attitudes coincide on a major point: the condemnation of therapeutic incarceration which, besides being bad medicine, is always a serious attack on the dignity of the dying person.
1. The Dignity of Dying in the Pro-Life Context
As noted above, in the ethical tradition of respect for life, human dignity is invariable: it is not diminished by illness, suffering, malformation or insanity. Moreover, biological or psychological adversity can be an occasion for further ennoblement: as John Paul II affirms, man's great dignity is confirmed in a special way in suffering.4. Man does not live in a paradise of friendly ecology. He lives with risk and hardship, in a natural environment to which he is exposed and in which his vulnerability and strength, his finitude and dignity, must be integrated.
In the pro-life context, the notion of dignity in dying receives support from the religious tradition, from the culture of human rights, from the professional ethics of medicine, and from bioethical reflection.
The biblical-Christian tradition proclaims respect for life, affirms that human dignity is shared equally by all people, and assures that this dignity does not succumb to the passage of time or be degraded by illness and the dying process.
In this tradition, man, every man, is a being of intrinsic value and dignity, a moral agent, manager and free, who, being imago Dei, is absolutely resistant to ontological degradation.5. God, mysteriously, creates us in his image and likeness also when our appearance and biological value are decayed by illness or malformation. Thus, in the book of Exodus, Yahweh says: "Who has made man's mouth, and who has made him mute, or deaf, or seeing, or blind? Was it not I, the Lord?"6.
This understanding of man as the image of God, even in spite of his handicaps and deficiencies, gave an immense moral superiority and incomparable humanity to the Mosaic law, when compared to other legislation of antiquity. What is distinctive about it is that it is no longer acceptable to mark as unworthy the weak, the poor and the blind, widows and orphans, slaves and foreigners.
With Christ and through his Incarnation, humanity is further dignified, because, with the call to adoptive divine filiation, man's likeness to God is reinforced. He is not only the image of God: man is invited to become a son of God, a dignity that is impossible to surpass, for there is no more room for nobility, no more value. The recognition of the value of human weakness is, in the biblical tradition, universal, for God is no respecter of persons.7. All members of the human family, the strong as well as the weak, are of equal value before God: we all possess the same dignity. "There is but one race: the race of the children of God," said Blessed José María Escrivá in a synthesis that sums up the whole anthropology of dignity, a dignity that comes to each and every one of us, without distinction and mysteriously, from sharing in the divine filiation....8.
The Encyclical Evangelium vitae, based on biblical sources, highlights the dignity of the entire temporal journey of every human life: it speaks to us of the dignity of the unborn child and of the halo of prestige and veneration that surrounds old age. The supreme weakness of Christ on the Cross is not only the full revelation of the Gospel of life, but it is precisely the moment that reveals his identity as the Son of God and manifests his glory.9.
It is worth considering for a moment what this revolutionary novelty meant for the world at the time, since modern movements in favor of euthanasia incorporate, in a certain sense, neo-pagan ideas. Ancient medicine was blind to the dignity of dying. Extreme, irreversible weakness did not then seem worthy of attention. The doctor's sentence "nothing more to do" was followed to the letter in antiquity. The physician abandoned the incurable. In the Hippocratic tradition, the physician refrained from giving poison to his patient in order to end his life. That was all: the physician had no medicines, neither heroic nor euthanasic, with which to help him. Therapeutic futility obliged to respect the natural course of the untreatable disease. Plato summarizes the attitude of Greek medicine, including the school of Hippocrates, with these words: "Aesculapius taught that medicine was for those of a healthy nature who were suffering from a specific disease. He delivered them from their malady and commanded them to live normally. But to those whose bodies are always in an unhealthy internal state, he never prescribed a regimen that might make their life a more prolonged misery. Medicine was not for them: even if they were richer than Midas, they should not be treated."10.
This blindness to weakness as a specifically human attribute continues to affect today's rationalist and pragmatic-minded people, the followers of the philosophies of efficiency, power or vitality. In the face of incapacitating illness or approaching death, they feel an instinctive distaste: life, physically or intellectually impoverished, causes them much unease and a flight reaction. They prefer to ignore or extinguish it. Nietzsche took this rejection to the extreme. Based on the demands of reason, feeling and instinct, he made the fundamental will to be healthy the fundamental principle of human dignity. It is not difficult to find a Nietzschean fibre in the complex fabric of today's pro-euthanasia mentality. The vital and sure will of instinct does not incite to respect the sick, to pity the weak. On the contrary, it impels to contempt, even to annihilation, for helping the weak is the morality of slaves.
Human dignity was never, in pagan antiquity, a universal human attribute. There was certainly among the classics a sense of dignity, but it was the dignity of the excellent, virtuous man, who lived in conditions to develop his virtues and his human excellences. The Roman concept of humanitas was used to describe the dignity of a balanced and educated personality, which was found exclusively among the most outstanding individuals of the Roman aristocracy. Dignity was not intrinsic, nor were human rights. Extensive social groups lacked them. Inequality was a natural feature of society. It was accepted as an inevitable reality that there were slaves or foreigners, destined to hard or degrading work, who could be tortured or consumed in productive labor or entertainment. Physical plenitude was an essential element of this aristocratic human dignity: the chronically ill, the crippled or the deformed were considered unworthy and their death was propitiated by the exhibition and the withdrawal11.
It should be noted, however, that the notion of the universal dignity of man and, in particular, that of the dying, is not only religious: it has also become part of the law. Thus, for example, a Recommendation of the Parliamentary Assembly of the European Parliament committee on the rights of the sick and dying invites governments to "define precisely and grant to all the right of the sick to dignity and integrity".12. The Parliamentary Assembly has recently reinforced its position at the end of a recent discussion (June 1999) on the protection of the human rights and dignity of the terminally ill and the dying.13by reiterating the absolute prohibition of active euthanasia and affirming that "the wish to die of terminally ill or dying patients does not constitute a legal right to die at the hands of another person. What is more, respect for life and human dignity constitutes, according to some, a right that must be respected all the more when the dying person is weaker. Indeed, the French committee National Ethics Committee for Life and Health Sciences, in a declaration on the internship of experiments on patients in a chronic vegetative state, pointed out that14that "patients in a chronic vegetative coma are human beings who are all the more entitled to the respect due to the human person because they are in a state of great fragility". The concept of the direct proportional relationship between frailty and dignity is precisely expressed here: the greater the weakness of the patient, the greater the respect of the physician.
c. The ethical-deontological rules and regulations of medicine
The ethical precept of not killing the patient has been present and fully preserved in the professional ethics of physicians since its very origin in the Hippocratic Oath. A comparative analysis of the rules on medical care of the terminally ill patient in the codes of ethics and deontology of 39 national medical associations in Europe and America has shown the profound unity of the common tradition: along with the unanimous condemnation of euthanasia and medical suicide financial aid and the firm rejection of therapeutic incarceration, quality palliative care is recommended as a measure proportionate to the dignity of the dying person. Indeed, many codes invoke the protection of the human dignity of the chronic or terminal patient as a fundamental reason for the diligent treatment of pain or suffering.15.
The argument in favour of the inextinguishable dignity of every human being and, in particular, of the dying, has been the subject of study since the birth of bioethics. Moreover, it must be acknowledged that some of the most inspired and profound reflections were produced in the early years of the young discipline.
One of them is due to Paul Ramsey. Distrustful of the possible perverse uses of the phrase "to die with dignity", as an ideal and as a right, and disconsolate about the loss of human dignity that all death is, he rebels against the idea that there is an intrinsic dignity in death and the dying of man, because both as the end of bodily life and as the end of life staff, death is the Enemy: true humanism is linked to the fear of death. Therefore, Ramsey concludes, it is better to accept the indignity of death than to try to dignify it, for we will always take better care of the dying if, in addition to relieving them of pain and suffering, we recognize that death is a mourning that no resource within man's reach is capable of alleviating.16.
The answer that Kass17 to Ramsey, both in his analysis of the notion of dignity and in his rehabilitation of the death-dignity conjunction in his natural and biblical instructions , is an essential starting point for understanding the valid meaning of death with dignity. Years later, in 1990, already in times of vigorous propaganda in favor of euthanasia, Kass further developed his ideas by analyzing the connection between the sanctity of life and human dignity and reanalyzing in its light the ideas of death with dignity that were already swarming at that time.18. It is necessary to appreciate, by direct reading, the tempered dialectical force of his arguments against the pretensions of the promoters of euthanasia, when he assesses the risk of hubris of modern medical technology, the temptation to put an aggressive and technological end to the failure of death, and of the need to accommodate oneself to living with the idea of mortality and finitude. Kass argues vigorously that, in the presence of incurable and terminal illness, there always remains a residue of human wholeness that, however precarious it may seem, must be cared for. If we wish to oppose the rising tide that, driven by the pro-euthanasia mentality and the ethics of free choice, threatens to dissolve the human dignity of the terminally ill, we must learn that human finitude is no misfortune and that the dignity of man must be attended to and cared for until the end.
In more recent times, the concept of dying with dignity has not ceased to be analyzed and deepened. Many are trying to wrest it from the hands of the promoters of euthanasia who have tried to appropriate its exclusive use.
Among these analyses, two are worth mentioning. Sulmasy19after concluding that the essence of dignity is nothing more and nothing less than the esteem and honor that human beings deserve simply because they are human, addresses the analysis of what the value and dignity of being mortal can be. To seek always and at all costs to prolong merely biological human life is to deny the truth of human mortality and, therefore, to act against the dignity of man. In the same way, to put a patient to death, even when he is already dying, is to say that the life of that man has lost all meaning and value: but this is to act against human dignity, for this does not depend on social standing, freedom or pleasure, but on the fact of being human. Human dignity is not something subjective: no one can increase, diminish or annihilate at whim his own dignity, nor can he do so with the dignity of another. The same is true of illness and dying: they can humiliate, diminish self-esteem, embarrass and even create a feeling of unworthiness. But these assaults do not do away with it, they do not diminish it: they disturb us precisely because they raise the issue of whether human life has meaning and value, has dignity.
Sulmasy describes how different in the expression of dignity patients' deaths can be: from those who face dying with courage, hope and love, to those who do so in fear, rebellion, despair or self-loathing. Both must be treated with dedication and respect. It is a tremendous task refund to give certain patients faith in their own dignity and to make them feel, in the terminal status , sometimes totally lacking in aesthetics, that their life still has value and dignity. That is a hard test for the doctor and the nurse, but that is what caring for the dying is all about. As Sulmasy says, "there would be no greater assault on human dignity and, ultimately, no greater suffering than to say to one of these patients, looking them in the face, 'Yes, you are right. Your life is meaningless and worthless. I will give you death, if you want it'". The dying should know that, for their physicians, they never lose their human dignity and that they remain in possession of all their value and esteem: their lives always retain a full measure of meaning and dignity.
Stolberg20concludes that the notion of human dignity cannot be sustained only by the Kantian's capacity for rational self-management, nor by the existentialist's freedom that persuades us that we are not mere things. To do so would lead to the pessimistic conclusion that the dying and the comatose would lack human dignity. Indeed, to say that human dignity can be diminished or lost because of illness and suffering is tantamount to saying that human dignity depends on the ability to control uncontrollable things such as aging, handicap, or terminal illness. Stolberg argues, analyzing the relationship between human dignity and equality, that man cannot cease to be human, which means that dignity is part of his nature. The idea of considering natural phenomena as degrading or demolishing human dignity is based on the false dualism that presents dignity and nature as antagonistic, which turns the natural into an enemy and destroyer of what is properly human. This is equivalent to identifying dignity with physiological well-being or even with the psychic integrity that makes possible the exercise plenary session of the Executive Council of rationality, autonomy or self-awareness. But these qualities are very differently distributed in those who are going to die, so they cannot be a basis for equal rights and dignity in the trance of death. In order to restore a truly realistic and indisputable foundation for the radical equality of human dignity, Stolberg turns to G. Marcel's idea of seeking in the mortality and precariousness of man the yardstick of the common human condition. Mortality and precariousness place us all at the same level of value, in an essential equality. From the confrontation with the finitude that awaits us all comes the awareness that we men coincide and identify with each other in the experience of pain and sorrow, of sickness, aging and death; an experience that amalgamates us all in the experience of common dignity. Stolberg concludes that whoever maintains that these circumstances threaten human dignity, understood as an egalitarian value, falls into contradiction.
2. The universal condemnation of therapeutic incarceration, an attack on the dignity of the dying person.
The obligatory reference to the ethical condemnation that therapeutic incarceration has received barely deserves more than a few lines. The condemnation is universal: it comes from pro-life bodies as well as from the ranks of pro-euthanasia; from professional organisations of doctors and nurses as well as from national and international bioethics committees. The B thing is that all these condemnations, wherever they come from, point out that therapeutic obstinacy is an attack on the dignity of dying.
No one today doubts that therapeutic obstinacy is a medical and ethical error that is very difficult to justify. Everyone shares the idea that deliberately useless treatment when there is no longer any reasonable hope of recovery, particularly when it causes pain and isolation, violates the dignity of the dying person.
The bibliography on medical futility is nowadays inexhaustible. It has been fed by the infinity of comments on the dramatic death of certain public figures, by the prolific jurisprudence on particularly complex clinical cases, and by the multitude of guidelines issued by different professional bodies.
Suffice it for sample two testimonies on the connection between dignity in dying and therapeutic moderation, which come from antipodean ethical positions. At one pole, the Declaration Iura et bona, of the Congregation for the Doctrine of the Faith21which succinctly described this connection as follows: "It is very important today to protect, at the moment of death, the dignity of the human person and the Christian conception of life against a technicality that risks becoming abusive. In fact, some speak of the 'right to die', an expression that does not designate the right to procure or have death procured at will, but the right to die with serenity, with human and Christian dignity".
At the other pole, the critic of medicine, Richard Taylor, expressed himself with acerbic harshness about the therapeutic abuse of the intensive care units of the seventies, in these terms: "Rows of physiological preparations, also known as human beings, lie surrounded by an astonishing issue of mechanical contraptions [...] Through innumerable tubes liquids of a thousand colors are injected or drained. Ventilators impel gases, dialysis machines roar, monitors set off their alarms, oxygen bubbles in humidifiers. The unfortunate prisoners of technology, fortunately oblivious to what is happening around them, due to medication or disease, lie helpless, while the ritual desecration of their dignity is executed."22.
3. Dignity of Dying in the Pro-Euthanasia Context
It is not easy to find in the publications of euthanasia advocates an articulate and coherent doctrine on the dignity of dying. A search in the glossaries that the pro-euthanasia movements maintain on the Internet is fruitless: neither in the extensive glossary of the Scottish Voluntary Euthanasia Society23nor in that of ERGO, the intellectual arm of Exit, the powerful North American group led by Derek Humphry, does it include entrance Dignity24.
The use, on the part of euthanasia promoters, of the expression dying with dignity has a more opportunistic and rhetorical than substantive purpose . Although dying and death constitute for many people today an unmentionable taboo, in the dynamics of the pro-euthanasia movements they lose their negative meaning and, when combined with the word dignity, are transmuted into a new and acceptable one. And so it turns out that many of the associations that advocate the decriminalization of euthanasia and of medical financial aid suicide have called themselves with terms that combine death and dignity.25. And, curiously, the only law in force in the world authorizing physician-assisted suicide internship , passed in the State of Oregon, is called, by a manipulative play on words, the Death with Dignity Act.26.
The ideological project underlying the mentality of death with dignity or the right to a dignified death consists in the acceptance that human dignity is undermined, or even treacherously destroyed, by suffering, weakness, dependence on others and terminal illness. It is therefore necessary to rescue the dying process from these degrading situations by means of resource to euthanasia or physician-assisted suicide.
The decision to avoid the final deterioration of the quality of life and to maintain control of oneself and one's dignity in the final days is favored by the peculiarity of the sources of information about death available to people today. On the one hand, very few have the opportunity to witness a peaceful death. The death of loved ones, apart from being a phenomenon that everyone has the opportunity to witness very rarely in his or her life, usually happens today in the hospital, not at home. The lack of interpersonal intimacy that this entails is aggravated by the intense medicalization of dying. On the other hand, the media inundate us with stories and images of a thousand forms of gratuitous, violent or tortured deaths. This creates a collective rejection of death, since no one would ever want to die in any of these ways. And since it is necessary to die, we all, in principle and by instinct, want to do it with dignity and decorum, preserving the nobility proper to man.
Against this background, the pro-euthanasia mentality constructs its notion of dying with dignity by assigning moral suffering, physical pain, incapacity, dependence on others, and terminal illness a negative value, destructive of human dignity. Dignified death is the only solution to put an end to the permanent indignity of living these lives overloaded with negative values, devoid of vital value.
We also live in a time in which medical decisions are made on the basis of the patient's active and informed choice of the treatments he or she accepts or rejects. Consequently, the right of patients to decide, together with the fear of finding themselves in painful agony and usurping self-control, leads to making the desire to die with the maximum comfort and mastery of circumstances a right. This creates the right to die with dignity27.
The right to die with dignity is invoked as a right that guarantees the possibility of living and dying with the inherent dignity of a human person, and as resource that frees from agony, from the possibility of living in a state of emotional or psychological misery. Biological decay, not being able to fend for oneself and depending on others for the most common actions and functions, are considered, in the mentality of death with dignity, as sufficient reason to claim the right to die, in order to prevent human dignity from being undermined and ruined by extreme disability, dependence and suffering.
But is human dignity really lost when one is very sick, very weak, or if one cannot continue to live except with the help of others financial aid ?
Basically, the notion of dignity proper to the euthanasia mentality is totally alien to the concept of dignity of the pro-life mentality. The latter has an ontological basis: dignity is intrinsic, universal, inalienable, immune to the influences of fortune or grace, refractory to the process of dying. The former, although important, is accidental. Social dignity is a variable dependent on numerous circumstances: the passage of time, the possession of money, influence, physical prestige, class or titles; it is possessed, but can diminish below a critical value until it is lost. It is especially sensitive to social and aesthetic influences.
This submissiveness to social and subjective influences is the reason why the dignity of dying continues to be invoked as a right at a time when progress in palliative medicine should have brought about the decline of the notion of euthanasia as a liberation from unbearable pain.
The pro-euthanasia movements have therefore been forced to put aside the paradigm of killing out of compassion for the intolerable sufferer as a thing of the past and take a new direction: that of presenting the dignity of dying as a right expressing one's absolute mastery over one's own life, or as a sign of decorum staff. In the new context, the enemy is no longer advanced disease, which, through pain, suffering or the total weakness of cachexia, encircles human dignity: the new enemy is the loss of self-sufficiency, the inability to live independently of others, having to die renouncing one's own social image, until then prestigious and aesthetic.
Terminal illness can severely wound that social dignity, the image that one exhibits of oneself before others. It is not surprising, therefore, that in recent years the pro-euthanasia movements have tended to present the demand for the right to die with dignity as the crowning achievement of ethical progress, of distinguished, clear-sighted and forward-thinking people who form a cultural elite, a minority emancipated from prejudices and superstitions.
Some surveys have shown that there is a close correlation between social class and Degree of intellectual self-esteem, on the one hand, and adherence to pro-euthanasia activism on the other. In pamphlet literature and on Internet pages, euthanasia promoters present themselves as the leaven in the dough, as leaders and liberators who will transform society. The arguments and examples deployed by euthanasia advocates, usually overloaded with strong rhetoric, remain, both in society and in the health professions, the preserve of a minority.
Medical professionals have pointed out a serious risk of this elitist attitude: that of endangering the palliative care of entire groups of people (the elderly, the disabled, terminally ill patients) by means of a skillful manipulation of feelings in favor of euthanasia by a small elite. In the final analysis, the pro-euthanasia mentality seeks to force society to choose between provoked and painless death, as a supposed means of preserving human dignity, and the care and attention of the terminally ill, with the vicissitudes and precariousness of life that is being extinguished.28.
It is therefore not surprising, though comforting, to learn that, according to some surveys, adherence to euthanasia is, compared with the general population, markedly lower (50%) among those affected by functional impairments, those who feel a burden on the family, or those who see their life as futile. In the United States, support for physician-assisted suicide is markedly lower among the elderly, African-Americans, the poor, and those who practice the religion29.
Pro-euthanasia activists repeat ad nauseam that the option to die with dignity is closely linked to the right to choose the time and manner of one's death according to the criteria of a hedonistic ethic. As the Plea for Beneficial Euthanasia of the American Humanist association paradigmatically pointed out, when life lacks dignity, beauty, promise and meaning, and death is delayed with interminable periods of agony and vital degradation, it cannot be said that this is the life of a human being, because to tolerate or accept unnecessary suffering is immoral.30. Unfortunately, there are many physicians who, through ignorance of the advances in pain treatment and palliative care, can become provocateurs or accomplices in the request for euthanasia.31.
Elitist arrogance and fascination with death32 of the pro-euthanasia mentality could, should euthanasia achieve legal sanction, deprive many patients of the benefits and dignity of palliative care, a humble but immensely humane branch of medicine and nursing. One can only speak of true freedom of choice when palliative medicine is practiced with skill and offered as a humanizing alternative to all who need it.
II. The peculiar human dignity in the trance of terminal illness and in the dying process.
This second part of discussion paper is dedicated to present some considerations on the human dignity of the terminally ill patient.
The terminally ill and the dying are a riddle for relatives and strangers, for doctors and nurses. They are often an enigma, because they impose on us the difficult task of discovering and recognising, beneath their decrepit appearance, all the dignity of a human being.
For a view that only sees appearances, terminal illness, so often accompanied by pain, anguish and anxiety, tends to eclipse the dignity of the sick person: it hides it, it even seems to have destroyed it. For if, in a certain sense, health gives us the capacity to attain a certain measure of human fulfilment, being seriously ill limits, in different ways and at Degrees , that important dimension of dignity, as nobility, which is the capacity to develop the project of man that each one of us cherishes.
It is not difficult for the physician to cooperate in the restoration of his patient's health while there is hope of achieving it. But it is very difficult today for many physicians, other than those competent in palliative care, to recognize the value of their work when, in the trance of terminal illness and the dying process, there is no longer room for that hope. It is very difficult to recognize, in today's medical environment, interested in healing outcomes and process costs, that serious, disabling, painful illness and, to an even greater Degree extent, terminal illness, can be of interest. Dominated by a pathophysiological culture, it is difficult for many physicians to understand that terminal illness is not only molecular or cellular disorders that are beyond repair, but also a human problem in which respect for the dignity of the patient imposes the duty to care for the dignity of his or her dying.
Nor is terminal illness limited, beyond the merely biological, to an experiential journey through certain stages that mark the psychological reactions of the patient to the announced and inevitable death, reactions that require understanding, support and accompaniment.33.
The terminal status constitutes, above all, a threat to the integrity of man, to his dignity staff, which puts the patient and his caregivers at test . And when this is understood, the results are not long in coming. One of the great promoters of palliative care, that professionally medical way of respecting the dignity of those who are about to die, stated that, in his opinion, one of the strongest arguments against euthanasia is the good use he had seen many patients and their families make of the final days of their existence, after the pain had been alleviated and before death arrived. To eliminate, by an act of merciful death, that dignifying opportunity would be to deprive the family and society of the value and dignity that is concentrated precisely in the final stretch of human life.34.
It should be noted that the role of health professionals is to weigh the value, efficacy and proportionality of the means at their disposal, not to judge the value of the lives entrusted to them. And yet some doctors and nurses, who are deeply imbued with a radical idea of quality of life, believe that some lives are so lacking in quality and dignity that they are not worthy of medical care and are deserving of compassionate death.
Such an attitude subverts the ethical tradition of the health professions, one of the most fruitful and positive elements of which, both in the progress of medicine and in that of society, consists in understanding that the weak are important, that they fully possess the dignity of all men and women.35. This idea, it is not difficult to intuit, was present at the beginning of the civilizing process and at the birth of medicine. In the deontological tradition, being weak was degree scroll enough to be worthy of respect and protection. Even being economically weak ceased to be a mark of discrimination for medical care. The socialization of medicine constitutes one of the most important historical efforts in homage to the human dignity of all. Today, however, this effort seems to be affected by an intense ethical fatigue and there is open talk of reducing the admittedly gigantic costs of health care. partner There is open talk of rationing medical care and of stratifying care, not according to its benefit/cost ratio, but according to the economic conditions (age, ability to pay, state of health) of the patients. Discrimination is thus introduced that affects the very core of the relationship between physicians and patients: the latter are no longer invested with the unique and supreme dignity of man, but can be distinguished into different categories: the weak will be discriminated against.
Medicine thus runs the risk of becoming an instrument of social engineering. But that is an idea that is totally alien to the ethics of health care. What is specific to doctors and nurses is to help, with their knowledge and skills, the sick and weak, human beings who are experiencing the crisis of losing their physical vigour, their mental Schools , their life. In medicine, respect for human dignity takes on a peculiar and specific form: respect for the 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 proximity of death. The ethical respect of doctors and nurses who administer palliative care is respect for declining life; their work consists in caring for people in the Degree extreme of weakness.
Res sacra miser. With this denomination of Christian-Stoic origin, recovered by Vogelsanger3636 , it expresses in a magnificent way the special status of the humanity of the sick person in the field of tensions of the terminal illness. It translates marvelously the coexistence of the sacred and indeclinably worthy of all human life with the misery caused by the illness. When the sick person is seen in this light, as both worthy and miserable, we can recognize his or her condition as both inviolable and needy. This is the ethical foundation of the terminal care owed to every patient, the moral justification for palliative care.
Notes
(1) John Paul II. Encyclical Letter Evangelium vitae. Vatican City: bookshop Editrice Vaticana, 1995.
(2) Johnson PRS. An analysis of "dignity". Theor Med Bioethics 1998;19:337-352.
(3) Hersch J. La vie à son juste prix. Schweiz med Wschr 1982:112(Suppl 13):29-30.
(4) John Paul II. Apostolic Letter Salvifici doloris. Vatican City: bookshop Editrice Vaticana, 1984.
(5) Ferngren GB. The Imago Dei and the sanctity of life: the origins of an idea. In: McMillan RC, Engelhardt jr HT, Spicker SF. Euthanasia and the newborn. Dordrecht: Reidel, 1987:23-45.
(6) Ex 4:11.
(7) Rom 2:11.
(8) Escrivá de Balaguer J. Furrow. Madrid: Ediciones Rialp, 1986: point 303.
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