The ethics of palliative care

Gonzalo Herranz, department of Bioethics, University of Navarra.
Session at the Master's Degree de Bioética, within the module "El respeto a la vida terminal".
Universidad de La Sabana, July 1997.

Index

Introduction

1. What is palliative care?

2. Ethical texts relating to Palliative care

3. The ethical foundations of Palliative Care

a. Respect for and protection of weakness

b. The finite nature of aggressive interventions

4. Palliative care, a vaccine against euthanasia

Introduction 

The fundamental bioethical significance of palliative care is its decisive role in the rational solution of euthanasia and medical financial aid suicide. A correct understanding of the role that palliative medicine plays within medicine as a whole is essential for two things. One internship: to refute the dangerous prejudice that life-ending medical interventions are genuinely professional and compassionate. The other theoretical: that, compared to the euthanasia mentality, the traditional medical respect for human life is based on a more real and more humane, i.e. more intelligent foundation of man and his nature.

The topic needs to be studied, calmly debated by all. By those of us who work in health care, by legislators, by the people in the street, especially by patients and their families. In Colombia's current status it is necessary to reflect deeply, to talk a lot, not only about terminal illness as a painful tragedy, but also about palliative care, which is today a magnificent reality and, above all, a sure hope.

It is precisely in the field of the technique and ethics of palliative care that the most decisive battle for the future of the health professions will be fought, a battle that will determine whether medicine and nursing are to remain a service to all people, including the incurable and dying, or whether they are to become an instrument of socio-economic engineering or of libertarian ideology.

The current situation is enormously exciting. We are living in one of those historic moments in which very important things about the future of humanity are being decided in a few years. As we shall see, euthanasia, for an increasingly large sector of society, is ceasing to be a problem, because it is becoming a very advantageous solution. Opinion polls show a steady, persistent growth of issue of those who believe that compassionate homicide or medical financial aid suicide is the most humane and dignified solution that can be offered to many terminally ill patients, especially when they ask for the doctor's financial aid to end their lives.

Justifying that palliative care is the valid ethical response to the challenge of euthanasia is why our topic this morning is urgent and exciting.

To bring some order to this introduction to our workshop, I will deal with several questions in turn: I will first show briefly what palliative medicine is. I will then refer to how medical organisations have characterised the ethics of palliative care. I will then attempt to outline what I see as the ethical basis of palliative medicine, and conclude with a consideration of the ability of palliative medicine to counteract the thrust of the pro-euthanasia movements.

1. What is palliative care? 

In the influential report of a World Health Organisation Expert committee on Cancer Pain Relief and Palliative Care, published in 1990, palliative care is described as "active and total care of patients whose illness no longer responds to curative treatments". Of utmost importance in palliative care is the relief of pain and other symptoms, and the care of psychological, social and spiritual problems. The purpose of palliative care is to achieve the best possible quality of life for patients and their families. Many aspects of palliative care can be applied earlier in the course of illness, in conjunction with treatment for cancer [or other illness with a poor prognosis]. Palliative care:

• It affirms life and regards dying as an ordinary process;

• It does not hasten or postpone death;

• Provides relief from pain and other distressing symptoms;

• It integrates the psychological and spiritual aspects of patient care;

• It provides a support system to help patients live as actively as possible until the moment of death;

• It provides a support system to help the family cope with the patient's illness and the bereavement following their death.

2. Ethical texts relating to Palliative care 

Palliative care is, in a way, a modern phenomenon. In Greco-Roman medicine, the terminally ill patient was abandoned, but with Christianity, the care of the dying, especially the spiritual care that progressively takes the form of the ars moriendi, takes on a special importance. There has always been terminal care: of relief and consolation. But it was extremely limited by the scarcity of therapeutic remedies or by ignorance of their rational use. Until thirty years ago, doctors used painkillers and anodynes, words of encouragement and hope, to soothe anxiety and pain, and the firm conviction that euthanasia had no role to play in the medical internship . The prohibition of euthanasia (I will not give to any patient, even if he asks me, a deadly poison, nor will I suggest its use) and the abstention from anything that is not beneficial to the patient were proclaimed from the Hippocratic Oath.

But therapeutics was then dominated by a lack of effective resources or a lack of intelligence about their rational use. We had to come up with the Hospice movement. With them, palliative care was born, which was logically incorporated as an activity of plenary session of the Executive Council right to the medical internship , and which logically participates in the ethics and general deontology of medicine.

However, the question is: is there a special ethics of palliative medicine? In reality, there should be no specific ethics for terminally ill patients. He or she is just another patient, who is not excluded from the general obligations of health professionals to provide attendance to the sick and from the human right not to be discriminated against in relation to other people.

Suffice it to quote, given the international character of this congress, a specific Declaration of the World Medical Association association : The Venice Declaration on Terminal Illness of 1983 states 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 will not admit any exception to this principle, not even in the case of incurable disease or malformation; that this principle does not prevent the following rules from being applied: 3.1. 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 withholds curative treatment, but such withholding of treatment does not release the physician from his duty to attend the dying person and to give him the necessary medicines to mitigate the terminal phase of his illness.

The codes of ethics and deontology for health professionals promulgated in the last decade establish, with varying degrees of emphasis, the professional dignity of palliative care. The 1981 Norms on Medical Ethics of the Colombian Medical Federation tiptoes over palliative medicine. It states in its article 13: The physician shall use the methods and medicines at his disposal or within his reach, as long as there is hope of alleviating or curing the illness. This contrasts with the 1995 Israeli Rules of Medical Ethics, which state that, In the case of terminal illness, the patient's independence and will must be respected. The physician is to alleviate his physical and mental suffering, to ensure the quality of a life that is approaching its end, and to be the guardian of the dignity of the dying person. There is a wide gap in intensity and attitude to end-of-life medicine between the two formulations of conduct.

Although it must be admitted: terminal care, perhaps by virtue of its nature, more caring than healing, has received more attention in the codes of the nursing profession than in those of the medical profession. The Deontological Code of the Spanish Nursing Profession includes in very precise and beautiful words the deontology of terminal care. Its article 18 reads as follows: 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 or her life, with skill and compassion, the necessary care to alleviate his or her suffering. She will also provide the family with the necessary financial aid to enable them to cope with death when it can no longer be avoided.

Thus, and in summary, the conduct prescribed by the codes of conduct of health professionals towards the terminally ill is defined by the duties not to discriminate against them and to care for them with application. They may not provoke death, but must refrain from aggressive treatment with futile therapies. They must never disregard the life of their patients, but respect it, accepting the inevitability of 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 therapeutic gestures lacking in reasonableness and good judgement, which seek a cure that is already impossible and which may be established out of ignorance, for commercial interests, or for political reasons, are strictly forbidden. These are the basic texts of palliative deontology, on which doctors and nurses should often reflect.

From this reflection we can draw some points for consideration.

- One is how to improve, through well-designed and collaborative 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 very broad outlook for research and, consequently, for professional service. The following are ethical mandates to which we must respond:

- the constant assessment of the validity of the care provided;

- the stratification of care for the incurably ill into palliative and purely terminal measures;

- the extension of the benefit of specific palliative care to all potential candidates for palliative care, i.e. to the many incurables suffering from long and painful but non-oncological illnesses;

- optimising the cost/benefit ratio of palliative care

- the development of formal and informal methods of teaching the science and general art of palliative care. Very much in line with the technocratic mentality of much of academic medicine, palliative care is conspicuously absent from the medical curriculum.

- the development of teaching postgraduate, in Medical and Nursing Schools, which provides the knowledge, technical skills and human attitudes needed for palliative care and enables a confident and correct relationship within the interprofessional team.

Suffice it to say that this is a brief commentary on the ethical texts on palliative care. Let us now consider

But it is time to move on to the core of this lesson.

3. The ethical foundations of Palliative Care 

Palliative care, in addition to being part of the good official document of the general practitioner and the generalist nurse, and being an essential instrument of certain specialties, has now reached the status of a medical and nursing specialization program . In fact, it is genuine and recognised Medicine and Nursing. And although it would therefore not need to be legitimised, it nevertheless seems appropriate to look more deeply into the ethical justification of palliative medicine. Among other reasons, because, as we all know, today certain professional and social sectors, which offer euthanasia as the most rational and efficient solution for the terminal phase of the illness, question the usefulness and efficiency of palliative care. And they do so with a very strong utilitarian argument: palliative care is inevitably doomed to failure, biologically and economically, because of its leave profitability when the results are measured with the biological metre of the fees of cure or survival, or by cost/benefit ratios or years of life evaluated by quality.

It should be pointed out that this utilitarian attitude is grossly alien to the most genuine medical ethics, because, in my opinion, palliative care is based on two main ideas of the doctor's ethics, it is a typical and natural development of two fundamental concepts of medical ethics. One is the ethical respect for the weakness of the sick person, which must be accepted and protected as part of human existence. The other is the inexorably limited, finite nature of aggressive medical interventions, which, when inadequate, must give way to palliative care as a wise and compassionate response to the incurable and terminally ill patient. It is worth considering in detail these two mother ideas.

a. Respect for and protection of weakness 

Palliative care is applied to terminally ill, terminally ill patients. Sometimes, their ruin is predominantly physical and characterised by uncontrollable progression of organ failure. At other times, the most salient feature is the deterioration of relational life, dementia, persistent vegetative state. The doctor and the nurse know that they can no longer recover these lives and restore them to health. How are they to cope in such situations?

For some, inside and outside medicine, the answer is clear: these human beings, so impoverished by illness and pain, should not only be denied curative interventions, already useless, but death should be anticipated through active euthanasia or the suspension of minimal care. In order to soften this harsh response, a more moderate formulation has recently been suggested, which is presented as a third way average, apparently intermediate between that of the defenders of the intangibility of life and that of the promoters of voluntary euthanasia or of the medical financial aid suicide. This third way consists in the acceptance by doctors, nurses and families of the patient's spontaneous or induced refusal of nutrition and hydration, whether oral or parenteral. Such behaviour would be a respectful acceptance of the patient's free choice, which can be justified by the ethical difference between killing and letting die, between acts and omissions, between what the patient asks for and what he or she refuses, between natural death by starvation and death by other means, and, in particular, by the widely shared conviction that death by starvation and dehydration is not necessarily a painful death: on the contrary, it is claimed that death by starvation appears to the observer as analgesic, placid and comfortable, in stark contrast to the suffering that may be caused by attempts to keep venous lines, nasogastric tubes or even the new percutaneous endoscopic gastrostomies permeable.

It is true that in the hours preceding the very end of life, nutrition and hydration may be considered useless, even unseemly: the palliative comfort symbolised by moistening parched lips suffices. But in patients who are not dying, the decision to fail nutrition and hydration implies serious ethical responsibilities. Doctors and nurses are then aware that death can no longer be attributed to the biological factors of the terminal illness, unavailable to therapeutic control, but to the suspension of measures that, by their nature, lie between the ordinary human attention towards the sick and medical artifice or technology. Someone, not without a touch of humour, has argued that the prototype of artificial feeding is the infant's bottle. In any case, even if the bottle or the nasogastric tube can be considered as a device or technology, feeding a human being is a basic ethical obligation.

Maintaining nutrition and hydration in the non-dying patient is not an unfair and artificial prolongation of suffering. Giving in too easily to the demands of the patient too possessed of his or her autonomy tends to overshadow the professional nature of Medicine and Nursing. These are vocations that serve the man of agreement with a deep understanding of the value of health and human life, that seek first and foremost to satisfy the genuine health needs of the patient, not to slavishly indulge his wishes and whims. Dialogue with the patient is crucial in order to coordinate and reconcile his or her legitimate control over treatment with the objective demands of the physician's science and professional ethics. Excessive subservience to the demands of patient autonomy tends to make medicine and nursing a mere mercenary activity.

If health professionals are not the patient's slaves, neither are they their masters. Their role is to judge the capacity of the means at their disposal, not the value of the lives entrusted to them. Some doctors and nurses, I insist, consider that some lives are 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. Medicine, as a science and as a profession, was born from this idea. And yet, despite almost two millennia of Judeo-Christian cultural influence, respect and service to the weak still meet with resistance within each of us and within society. Today, the rejection of weakness is being accepted and exercised on an unprecedented scale.

In the Christian deontological tradition, being weak was degree scroll enough to be worthy of protection and respect. Today, for people with a libertarian and individualistic mentality, weakness is a stigma that marks one for programmed destruction. And, to achieve this, they propose to change the aims of medicine. Medicine, they say, can no longer have as its exclusive aim to cure the sick or, at least, to alleviate their suffering and console them. The doctor's office and the hospital wards are to function as repair shops: either they repair more or less satisfactorily the damage caused by illness to the body and mind of man, or they assign those condemned to live a precarious and terminal existence to the scrap heap. Medicine thus becomes an instrument of social engineering, tool of the new, enlightened and aristocratic mentality of well-being and high quality of life.

We need to understand that our first ethical duty, respect for life, usually takes a special, specific form: ours is a respect for weakened life. In every relationship with our patients, respect for life is almost constantly linked to the acceptance of man's essential vulnerability and fragility, and often to the recognition of the inevitability of death, of something that can no longer be fought. We do not have to deal with the healthy and strong, but with the sick and weak, with human beings who are experiencing the crisis of losing their physical vigour, their mental Schools , their life. The ethical respect of doctors and nurses who administer palliative care is respect for the suffering, declining life; the work of doctors and nurses consists of caring for people in a more or less intense Degree of weakness.

Faced with the terminally ill patient, a riddle must be solved: that of discovering and recognising in the terminally ill patient all the dignity of a human being. Terminal illness tends to eclipse dignity: it hides it and even destroys it. If health gives us, in a certain way, the capacity to reach a certain human fulfilment, being ill means, in a thousand different ways, a limitation of the capacity to develop the project of man that each one of us cherishes. A serious, incapacitating, painful illness, which diminishes our humanity, especially a terminal illness, does not consist only of molecular or cellular disorders. Nor can we reduce it to an experiential journey through the phases 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 is not only about avoiding pain and alleviating the symptoms that come from Structures and biological functions that are ruined, but also about suppressing the threat of loneliness and helplessness that the sick person perceives, about communicating peace and human warmth.

Res sacra miser. This name of Christian-Stoic origin, revived by Vogelsanger, 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 is a wonderful expression of the coexistence of the sacredness and dignity of all human life with the misery caused by illness. When the sick person is seen in this light, as both worthy and miserable, we can recognise his or her inviolable and needy condition. This, in my opinion, is the ethical foundation of palliative care.

Someone has pointed out that the expression palliation, according to an old and happily abandoned usage, comes to mean that something must be hidden, concealed, as when wearing a cloak, a pallium. Today, the notion of palliation demands frank sincerity. Weakness is not to be hidden as something unworthy, but to be publicly acknowledged, by all, as part and heritage of humanity. And yet, the attempt to hide and deny weakness is very current. The hedonistic mentality, intolerant of suffering and handicap, as well as the evolutionary philosophies of the biological and social survival of the best endowed, or the praxis of the competitive struggle for power and opportunity, and, finally, the emphasis on the accelerated production-consumption Economics , carry within themselves the germ of contempt for the sick, the weak, the unproductive. Many today think that euthanasia is the most coherent behaviour in the face of the growing issue of elderly people, many of them paradoxical victims of medical progress, avid but inefficient consumers of the finite resources allocated to health care, because they believe that money should not be spent on the terminally ill and irrecoverable, for whom the facilitation of death is an ethical and economic alternative as valid as respect for life. There are sectors of advanced societies that are very little removed from the postulate of Nietzschean ethics: care for the weak, compassion for them, for those who are little, are typical of 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 skills, for there is an obligation of justice to care for each patient as he is, without discriminating against him because of who he is.

All of us frequently need to review our attitude to the ethical principle of non-discrimination. I often put my students through a test, in which I use an episode, recounted by Paul E. Ruskin, to get them to take an honest look at whether their commitment to non-discrimination is sound.

Ruskin once asked nurses attending a course on 'Psychosocial Aspects of Old Age' to describe honestly what their state of mind would be if they had to attend with cases like the one he described below: This is a patient, who looks 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, some say. The more motivated ones point out that such a case is a very hard test on the patience and vocation of the doctor or nurse. Of course, if all patients were like the case described, the geriatric specialization program would be for saintly doctors and nurses, but not for ordinary doctors and nurses. When told that 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 outright rejection.

Ruskin's test ends by circulating among the students the photograph of the patient in question: a beautiful six-month-old baby. Once the protests of the many who have been deceived have died down, it is time to consider whether the solemn and self-gratifying commitment to non-discrimination, to feeling oneself a liberal and unbiased person, can yield to differences in weight, age, life expectancy, or to the subjective feelings inspired by the physical appearance of the various patients, or whether, on the contrary, it must overcome these circumstantial data .

It is obvious that many students and professionals have to change their overly sensory, sentimental way of looking at their patients. They must 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.

Let us now turn to consider the second pillar on which the arc of palliative care rests:

b. The finite nature of aggressive interventions 

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 we are, in fact, neither technically all-powerful nor can we fix everything. We must 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 efficacy, there comes a time when our resources and actions are inoperative, inevitably finite; the second is to understand that neither therapeutic obstinacy nor the patient's withdrawal are ethical responses to terminal status : palliative care is.

Work is now actively underway to define, in clinical protocols and in ethical terms, the notion of medical futility. There is diagnostic futility, just as there is therapeutic futility. This establishes the possibility of diagnostic overkill, just as there is therapeutic overkill. The borderline 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 perform. There will always be a more or less wide band of uncertainty, where it will be necessary to decide in the indeterminacy and to lean towards giving the patient the benefit of the doubt. But doctors and nurses will always keep in mind in their work that they will inevitably reach a point where the gains from their interventions will be disproportionately small in relation to the suffering they cause or the economic expense they cause.

In order not to lose their ethical orientation, their sense of relevance and depth, throughout the course of their relationship with the terminally ill person, the physician and nurse providing palliative care must see their patient with a binocular vision. They must maintain an awareness of the fundamental fact that they are dealing with a human being: that their relationship with the patient is one of person to person, whose aspirations, wishes and convictions must be taken into account and fulfilled as far as is reasonable. This relationship staff must also extend to those close to the patient. They 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 disarranged molecules or bewildered organs, or to a chaotic and ruined pathophysiological system. But he is these things and, at the same time, a human being. The doctor's binocular vision must integrate, superimpose, the image of this pathophysiological 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. To simultaneously see man, in order to stay ahead of him, and to simultaneously see the wreckage of his biology, in order to refrain from taking useless measures. Doctors and nurses always need this double vision, as their double condition as carers of mankind and cultivators of natural science demands it. 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 greatest possible detachment from all emotional or affective ties. It would not be possible to be a good health professional if, in this scientific, objectifying moment, compassion and empathy were not put aside, in order to be able to calculate objectively and even-handedly the appropriate terms in which to intervene.

The scientific-objective indicators state at a given moment that the process of pathophysiological maladjustment is already irreversible, that the terminal phase of the illness has begun, with no turning back. The idea of cure must then be abandoned in favour of official document, which is very demanding of science, of skill and of humanity, of palliation, of care. The act of recognising that there is no longer anything curative to do may be hard, but it is a clear and profound manifestation of humanity, a lofty ethical action, 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 . The patient may then feel the need for a second opinion and should never be hindered from calling a competent colleague.

People are increasingly coming to understand that their trust in their caregivers can no longer be based primarily on whether doctors and nurses indulge them with their easygoing and indulgent sympathy, but 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, on their tempered Withdrawal to the futile, and, where appropriate, on their mastery of palliative care.

4. Palliative care, a vaccine against euthanasia 

Pro-euthanasia activism is also gaining ground among doctors and nurses. According to sociological surveys, there is, among health professionals, a sector that accepts the idea that it is justified, even virtuous or morally obligatory, to end certain human lives that are lacking in quality. And some of them are willing to do so, either by administering euthanasia drugs or by withholding nutrition and fluids. If they do not do so, it is because of the legal risks they may incur.

What would happen if legislation came into force authorising euthanasia, decriminalising homicide by disease?

My thesis is clear: any legislation tolerant of euthanasia, however restrictive it pretends to be on paper, leads to an increasing brutalisation of medical care, degrading it ethically and impoverishing it scientifically.

The ethical decline is not difficult to calculate. In the dynamics of legal permissiveness, decriminalising euthanasia begins to mean that killing without pain 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 and pro-euthanasia activism, decriminalisation ends up meaning that killing for compassion is a de facto accepted therapeutic alternative. And so effective that doctors cannot morally refuse it. The reason is obvious: euthanasia - a clean, quick, 100 per cent efficient, painless, compassionate intervention, much more comfortable, aesthetic and economical than palliative treatment - becomes an invincible temptation for certain patients and their relatives. And for some doctors and nurses too, because the sweet death of one or another of their patients saves them a lot of time and effort: the time they invest in following the case day by day, in palliating their symptoms, in visiting them, in accompanying them in the difficult final moment.

Once euthanasia is decriminalised, the serious thing for doctors and nurses is that their specific virtues - compassion, prevention of suffering, non-discrimination between their patients - are turned against them, so that they are driven by their own professional virtues to apply this supreme therapeutic with ever greater zeal: they cannot deny a patient the liberating death which, in similar circumstances, they have already given to others; nor can they delay until later what is already now presented as the most effective remedy. The concept of terminal illness will become wider and wider; the indications for euthanasia will become more extensive and earlier and earlier.

Whoever has succumbed to the temptation of sweet death and performed euthanasia, either repents definitively, or will no longer be able to stop killing. Because if he is ethically congruent with himself, and believes that he is doing something good, he will do it in less and less dramatic cases and, in the name of ethics, by skirting legal barriers. For if the law, as seems likely in the first generation of euthanasia laws, only authorises euthanasia or financial aid to suicide for those who ask for it freely and voluntarily, what reasons can be given by those who have practised it according to the law to deny it to those who are incapable of asking for it, but whose life is more degraded or much more burdensome for others? He is certain that the insane person, the person sleeping in an irreversible coma, the victim in a chronic vegetative state, would undoubtedly ask for it if they had a moment of lucidity. Once euthanasia is authorised, the virtues of the doctor are turned against him. 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 mandators of terminally ill patients. Faced with a patient who is unable to express his or her will, they reason thus in their hearts: "It is horrible to live in such precarious biological or psychological conditions. I wouldn't want to live like that. That is not life. It is better to die. Therefore, I decide that the best thing for them is a sweet death". But the utilitarian judges that there are cases in which the desire of certain patients to go on living may be irrational and capricious, because they have an abhorrent prospect ahead of them. He reasons thus: the lives of certain patients capable of making decisions 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 very easy to expropriate the patient's freedom to choose to go on living.

With each passing day, I am convinced that palliative care contains an ethic of great density: it is in itself a dimension of Medicine and Nursing that cultivates and enriches the most intimate and basic ethical values. It is also the antidote that can protect us against the temptation of euthanasia, which is both frightening and attractive.

A highly effective antidote. Even the most upright doctor and nurse need to guard against the excesses of their virtues. To decriminalise euthanasia would be to plunge medicine into the self-aggressive disease of counterfeit compassion. The obligation to respect and care for all human life is a wonderful and inspiring moral force. With it, we must develop the theory and the internship of palliative, scientific and humane care, which will uproot from our hospitals the scandalous error of therapeutic overkill and which will highlight, by contrast, the cold inhumanity which, disguised as compassion, is hidden in euthanasia.

If nurses and doctors were to work in an environment where they knew that they could not get away with treating or killing certain patients, they would become indifferent towards certain types of patients, and research would wither in vast areas of pathology. For if the senile patient or the Alzheimer's patient is given sweet death as the first option, who can be motivated to study the causes and mechanisms of brain ageing or the constellation of factors that determine dementia? If the advanced cancer patient is offered cooperation with suicide as a valid therapy for his disease, who is going to be interested in the mechanisms of metastatic dissemination, in the metabolic disorders induced by the mediators of cachexia? All the mental and moral effort, the sometimes exhausting tension to fulfil the Hippocratic precept of seeking the good of the patient - "I will do what I know and can for the benefit of the sick, and I will endeavour not to do him harm or injustice" - would, in a society tolerant of euthanasia, suffer atrophy by disuse.

I must conclude. The scientific values of medicine are impoverished when part of them are absorbed into euthanasia. And so does humanity, which is expropriated from death, because euthanasia, if widespread, would become the final solution to the unfathomable mystery of death. Death will no longer be a destiny staff, but a simple, neatly executed, routine technical gesture.

While you are working in hospitals and at home, you are doing a lot for the ethics of the health professions. I would like to thank you personally 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.