The protection of weakness. A fundamental ethical value in medicine
Gonzalo Herranz. group of work of Bioethics, University of Navarra
discussion paper at the International Right to Life Federation pro-life Conference
Palma de Mallorca, February 12-14, 1988.
First of all, I would like to thank the International Right to Life Federation, the Spanish Federation of Pro-Life Associations and Mallorca ProVida for inviting me to participate in this meeting. That my gratitude is sincere is obvious, as spending a few hours with such good friends as Aznar, Casini, Dorenbos, Ferragut, Schepens, Sherwin, Dr. Voltas and Willke is an extraordinary gift. Thank you.
Introduction
My talk today is meant to be a wake-up call to the growing danger that the weak are running in our contemporary society. It has been said that the most fruitful and positive element, both of the progress of society and of the Education of every human being, consists in understanding that the weak are very important. The most brilliant moments in history are those in which men have endeavored to put on internship the generous conviction that we are all wonderfully equal, unrepeatable, endowed with a singular dignity. It is not easy to live this doctrine, which has always met with resistance to acceptance. Unfortunately, however, we are witnessing today a rapid deterioration of what has taken so many centuries to conquer and affirm. Today and in many places, the weak are the losers. In the medical deontological tradition, being weak was degree scroll enough to be entitled to privileged protection; now, in the rarefied atmosphere of the new libertarian and individualistic ethics, it can be the stigma that marks one for programmed destruction.
We are gathered here because in the present time many physicians, betraying their vocation as protectors of human life, try to rationalize the elimination of the weak by means of increasingly sophisticated forms of abortion or with rationalized systems of applying various forms of euthanasia to different types of the elderly or infirm.
To this cold destructive passion, we must oppose the message of respect for life and, more specifically, for debilitated life, as a fundamental ethical value in medicine. That is the object of my talk. I will first try to show you how in medicine respect for life is indissolubly linked to the acceptance of man's essential vulnerability, his fragility. I will then go on to show some examples of how respect for the weak is scorned in today's medicine. And I will conclude with some considerations on how to rebuild medical respect for the weak.
Medical respect is a respect for the weak human being.
Today there is much talk of respect as a core element of biomedical ethics. If one reviews the documents in which medical ethics has crystallized since the Declaration of Geneva, one easily discovers that respect is assigned a central position in the moral conduct of the physician. In Codes and Declarations it is mentioned time and again: respect for the secrets entrusted to the physician on the occasion of his meeting with patients; the utmost respect for human life from the moment of conception and respect for the integrity staff of the patient. It even speaks of respect for teachers.
What does this ethical respect imposed by the professional deontology of the physician consist of? Although much, and quite disparate, has been said about respect in Philosophical Ethics since Kant, to simplify things and as a starting point, we can accept that the respect most congruent with the Ethos of Medicine is a basic moral attitude of the physician who perceives, integrates and responds to the moral values enclosed in people and their circumstances. The abundance and quality of the physician's moral life depends on his or her ability to perceive ethical values, but only the physician who cultivates respect has his or her sensitivity and moral judgment sufficiently attuned. On the contrary, the lack of respect makes us rude or blind to the ethical problems of medicine. Moreover, respect prevents us from distorting reality and making capricious calculations about the worth of others: it cures us of the temptation to manipulate and dominate patients. Respect, finally, allows us to respond with proportionate actions to the ethical demands of the sick, not because they can impose such responses on us by force, but because the respectful physician bows in all dignity before the value he recognizes in others, in a gesture plenary session of the Executive Council of intelligence and professionalism. In the Hippocratic tradition, respect is of a purely ethical nature and has little or nothing to do with the legalistic submission to patient autonomy about which so much is written today.
Genuine respect for human life impels the physician, in the first place, to be an expert in perceiving it under the pleomorphic appearances in which it presents itself, to discover it in the healthy and the sick, in the elderly and the terminally ill patient as well as in the child, in the embryo no less than in the adult at the height of its fullness. In all cases, it has before it human lives, enjoyed by human beings, all of whom are, irrespective of their legal rights, supremely and equally valuable. Whatever these human beings may lack in size, in intellectual wealth, in beauty, in physical fullness, all these, including all their deficiencies and handicaps, are made up for by the physician with his respect.
This is a constant of the physician's work . He does not have to deal with the healthy. To him go the sick, the handicapped, those who live the crisis fearful of losing their vigor, their Schools or their life. The physician is always surrounded by pain, by deficiency, by incapacity. His respect for life is respect for the suffering life. His proper role is to be the healer and protector of weakness.
This idea is very clear to the physician who follows the Hippocratic tradition. Respect for all patients without distinction was included in the Declaration of Geneva precisely in a clause of inexhaustible ethical content: the one that enshrines the principle of non-discrimination, by virtue of which the physician cannot allow his service to the patient to be interfered with by considerations of creed, race, social status, sex, age or political convictions of his patients, and undertakes to provide to all of them equally competent attendance .
But reality seems to deny that physicians are willing to comply with such a lofty commandment, as there are many who cynically violate it or consider it to be of an unaffordable moral stature. For this reason, it should be emphasized that the prohibition of discrimination is an absolute precept, which includes all human beings without exception. In other words, the right to life and health is the same for everyone, it is possessed by the simple fact of being human. The physician does not discriminate. He does not submit to the strong man because he has the power to demand his right to be respected, or disregard the weak man because he lacks strength and rights. He treats and serves everyone equally, not because he is an activist for political or social egalitarianism, but because Withdrawal, faced with the fragility that illness creates in everyone, rich and poor, he takes advantage of his position of power in front of them.
For those of us who fight for respect for life, the letter and spirit of the Declarations of Human Rights and of the Charters of the Rights of the Sick are clear and do not admit any attenuation. We consider unethical the conduct of those physicians who select their patients, who discriminate among them, who accept some and reject others, who care for some and abandon others. The ethical tradition admits, however, not exceptions, but priorities within the rule of non-discrimination. One, for example, is created by the status emergency. The physician must first attend to the urgent case, the one most in need of financial aid. But this is a technical reason, since all patients are equally worthy in terms of their dignity. Another is the one that orders the patients according to a scale of weakness, in order to give more attentive and solicitous care to the one who appears more seriously damaged by the disease.
Today, the appreciation of weakness is at a low ebb. The medical profession, born precisely as a response full of humanity to the vulnerability of man, seems disinterested in the pain and handicap of the weak and allows itself to be dragged into an alliance with the powerful.
Contempt for the weak
Many physicians have decided to ally themselves with the powerful and have ceased to respect everyone equally. To justify their disrespectful behavior, they need to disguise it as respectability. More than eighty years ago, Chesterton wrote with his characteristic shrewdness that, in the modern world, Science serves many purposes, but one of the main ones is to provide long words to cover the mistakes of the rich. Those long words - Chesterton gave the example that if it is a rich man who steals he is not a thief, but a victim of kleptomania - those long words have a respectable appearance. They are words we all know, such as quality of life, health for all or technological imperative, all sounding, modern, of noble academic cradle, until it is discovered that they are serving as a cover for inhuman business.
The radical application of the concept of quality of life leads, for example, to the desperate conclusion that there are lives lacking in quality and so overburdened with weakness that they are not worth living and, consequently, must be eliminated.
The notion of health as a state of perfect physical, psychological and social well-being to which everyone should aspire leads us to consider living with limitations as a failure, which is the only true and real health attainable in this world. Consequently, irreversible deficiencies, irreparable disorders turn the weak into human scrap, whose repair is a useless waste and whose appearance must be prevented at all costs. Thus the way is paved for the euthanasia of the deficient.
The technological imperative is becoming an end in itself, even if the applications of new techniques sometimes serve only to humiliate or destroy human beings.
Many physicians have placed themselves at the service of the powerful to the detriment of the weak. They have allied themselves with fertile parents to eliminate by means of abortion or neonatal infanticide the deficient children or those with the modern and incurable weakness of being unwanted. They have allied with infertile parents to create for them an ardently desired child through assisted reproductive techniques. It does not matter that the price is a hecatomb of embryonic siblings, sacrificed as if they had no destiny staff in the Cosmos. They sterilize deficient girls in order to forcibly expropriate them of the possibility of becoming mothers, the noblest human capacity they still retain, and thus reduce them to the condition of sexual objects at the disposal of the first aggressor. In conclusion: some physicians have become agents at the service of the strong to expropriate the weak of their remaining human dignity.
Let's take a look at three significant examples of how these physicians act.
The first alerts us to the risk that, under the guise of a cutting-edge biomedical project , transplants of embryofetal cells and organs, there is a risk of a regression to a new form of cannibalism. It started with the effects produced by certain fetal neurons implanted in the brains of senile rats: the old animals seemed to remember better and learn faster. That opens the way to treat millions of elderly people with senile dementia! Other fetal neurons are able to reconnect the ends of the severed optic nerve: exaggerating a lot, it was said that some blind people will be able to see refund . To treat certain blood diseases, it is more immunologically advantageous to transplant hematopoietic tissue from fetal liver than to transplant adult bone marrow. We are assured that embryofetal tissues will remedy many diseases and will be more important in medicine than antibiotics or psychotropic drugs.
In the face of so much promise, human embryos and fetuses are seen by some as promising banks of tissues and organs for transplantation, but very few have asked themselves about the ethical consequences of the utilitarian exploitation of these human beings. New applications demand high quality for the materials they employ. It is not simply a matter of rummaging through the bucket of aborted fetuses and picking out the best-looking ones to make use of their cells or extracts. Living, intact material from unusable or rejected neonates is needed. At the moment, it is the turn of the anencephalons. Those that until recently were considered the most qualified candidates for third trimester abortion are now carefully delivered and transferred directly from conference room to operating room - as they have no brain, there is no need to anesthetize them - for live scrapping and removal of the liver, heart and kidneys. There is no other choice but to proceed in this way, because, although it may seem cruel, it is not advisable to wait for them to die, as their more or less long agony would reduce the quality of the organs.
But, in any case, there are very few anencephalics. For this reason, there are now plans to conceive fetuses in order to abort them. This will make it possible to produce tailor-made fetuses, which have undeniable advantages over the bulk fetuses offered by fetuses aborted in any clinic. A news item, published last August in the Wall Street Journal, stated: "A woman, whose father suffers from kidney failure, has order to be artificially inseminated with the father's sperm to abort the fetus in the third trimester and donate the fetus' kidneys to her father. Doctors believe that the tissue compatibility would be almost perfect."
We see how the technological imperative transforms some scientists into lesser gods. It amplifies their power and, with it, their capacity for moral error. It exalts them to the point of placing them among the inhabitants of the pagan Olympus, but assigns them a place of Saturn, who obtained his strength by devouring his own children.
The second example is, unfortunately, more familiar to us. Our Executive Secretary, William Sherwin, has invited us to intervene forcefully at topic. Mifepristone, the "RU 486", is not only a weapon Chemistry that annihilates the human embryo, as Philippe Schepens has rightly called it, nor only a teratogen or a drug with unwanted effects on the woman's physical health, nor a form of abortion that reduces to almost zero the psychological trauma of going through a operating room. In addition to killing the embryo, induced abortion with Mifepristone desecrates it, degrades it to the negative status of a waste product and equates it with fecal subject . In the same way that a laxative is capable of relieving the lazy intestine of its contents, the new pill will free the pregnant uterus from the embryo growing in it. Disconnected from the mother by an efficient mechanism of molecular competitiveness between antihormone and hormone and squeezed out of the uterus thanks to the action of a prostaglandin, the embryo ends its brief existence in the sewer network . In this way, the transmission of human life, that supreme participation of the creative power of God by which man is made capable of making other men, is converted into a banal operation, of the same physiological, psychological and moral rank as urination or defecation. I am unable to decide which of the two affronts of RU 486 is greater: the annihilation of the embryo or the degradation of motherhood.
The third example is intended to show how the obsession to apply the advances of science causes in some physicians an acquired intolerance to weakness. Prenatal diagnosis is becoming, thanks to the screening of the weak, a shooting contest on moving targets, where the rule of "point and shoot" reigns. This is clearly demonstrated in the case of prenatal diagnosis of albinism. Thanks to the ingenious procedures of Genetics Biochemistry we are learning more and more about the different varieties of this disorder. At the same time, the procedures, no less ingenious, that allow albinos to adapt to their deficiency, so that they can lead a normal life and work in normal jobs, continue to improve. Of course, they will never be able to excel in certain activities, but it seems that thanks, among other things, to their superior use of the report, they can reach higher social and economic levels than their normally pigmented brothers. A method for prenatal diagnosis of albinism has been developed. Some clinical geneticists are not resigned to the new technique being left out of the panoply of eugenic abortion. And since the selective elimination of albinos is unlikely to be accepted in temperate Western countries, they are offering the new procedure to tropical countries, where the sociocultural, ocular and skin problems of albinos seem incompatible with the dignity due to a human life.
The elimination of the weak seems to have become the dominant passion of some scientists. I believe that with the same tenacity we must spread our message of respect for weakness.
The reconstruction of respect for the weak: a program for study
It is evident that the weak have few true friends and this may be due to the fact that today very little is thought and written about the dignity of the weak. Perhaps there are very few medical schools in the world that dedicate at least one class hour in some corner of the curriculum to teaching the ethical meaning of weakness. It is interesting, therefore, to develop the theory and the internship of respect for weakness, to collect ideas and experiences on this topic and to prepare, from the pro-life perspective, a didactic package to teach our students and young graduates respect for weakness. I believe it will be a very interesting and valuable tool educational .
It is necessary to explain and enrich, for example, the doctrine contained in Codes and Declarations. Let us take an example. It does not seem very opportune, if only in parenthesis, to invoke today and here the moral authority of the French national advisory committee for life and health sciences. William Sherwin has asked us order to write to the President of committee, Professor Jean Bernard, to reproach him for his unfortunate decision of committee on RU 486. Well: in striking contrast to that reprehensible Statement, the committee published in March 1986 another one about experiments on patients in a chronic vegetative state. In it, the French advisory committee makes a strong defense of sick human beings and attaches a high ethical value to their weakness. It says among other things: "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. They may not be used as a means for scientific progress, whatever the interest or importance of the experiment that is not aimed at improving their condition". The concept of the direct proportional relationship between weakness and respect is precisely expressed here: the weaker the patient, the more the physician must respond with greater dedication, with attendance more careful care.
Another field to be explored, in order to try everything and retain the good, is that of the literature of handicap. In addition to the harshly critical programs of study on the social marginalization of the handicapped, a good issue of testimonial stories have been published lately, with the physically disadvantaged, the terminally ill or those who care for them as protagonists. Some of these biographies or autobiographies are like epics of willpower or hymns to muscular virtues, which have allowed heroes or heroines wounded by illness to triumph over their own weakness in spite of it and against it; denying it, not making it part of their personality. This literature of supermen is not always consoling and hope-generating. But there is no lack of truly human stories that tell, live and get ahead with their limitations, normal men and women, of different age and cultural level, who have learned to overcome with wit, good humor and will to live the daily difficulties of a deficient existence, revealing the kind and familiar face of weakness. After reading these writings, one is even more firmly convinced that the world would be impoverished in humanity and compassion if our weaker brothers and sisters were to disappear from it.
Finally, it is necessary to offer a serious philosophical justification of the phenomenon of human frailty and biological handicap, whose presence in this life is absolutely inevitable and whose acceptance is the most human of adventures. No matter how much progress is made in rehabilitation techniques, no matter how generous the budgets for health and prevention services, no matter how attentive the response to everyone's right to health may be, all this together will never be able to eliminate frailty from the earth, nor will it be able to abolish suffering, illness and death. It is an illusion to think that the slogan "Health for all" can change the essentially weak and vulnerable condition of man, since being a man is tantamount to accepting pain and deficiency as inevitable. The life of every man, his human destiny, includes the capacity to suffer and the acceptance of limitation and suffering. Faced with the inexorability of weakness in the world, the physician strives to reduce the pain, anguish and incapacities of his patients, knowing that he will never know enough to completely defeat his enemies. Herein lies the human core of medicine. As demanding of science and skill is the operation of applying the most modern therapeutics, almost miraculous in their efficacy, as that of administering palliative care, which requires a great deal of knowledge and mastery of what I believe to be the most difficult part of the medical art: knowing how to tell the sick that man is made to bear the wounds in his body and spirit caused by illness and the passing of the years, that the acceptance of these limitations is part of the process of humanization. One is not truly human if one does not accept a certain Degree of weakness in oneself and in others. This is required of us as part of fulfilling the duty of being human.
I will end now. Someday the accounts of what our time has meant for the development of Science, of truly human Science, will be drawn up. Lewis Thomas, that most brilliant and paradoxical figure of American biological thought, has given us a revealing part of that judgment. "A society may be judged by the way it treats its most unfortunate members, the least liked, the insane. As things stand, we are going to be regarded as a very sad lot. It is time to make amends for our mistakes.
That is what we want: for our message of respect for life to ring in a thousand different ways in people's ears, so that many will make amends for their mistakes. With this talk today I simply wanted to say this: that I think that many physicians would base their conduct on respect for life if we are able to make them understand the wealth of professional, ethical and human values that include the protection of weakness.