The rational foundations of medical ethics: respect for life and human dignity
Gonzalo Herranz, department of Bioethics, University of Navarra.
lecture Delivered at the association Guatemalan Bioethics Centre.
Guatemala, April 1995.
I. Respect, a fundamental ethical attitude in medicine
a. Respect as a Rational Basis for Physician Ethics
b. What is the ethical respect of the physician?
c. The late effects of the Declaration: the relativisation of Medical Ethics
II. The dignity of the person in a medical context
b. The biblical-Christian root of human dignity
c. The utilitarian volatilisation of human dignity
At the outset, I think it is worth clarifying that my intervention is not intended as a philosophical analysis that attempts to identify and characterise the rational foundations of bioethics. That is beyond my scope. It will be a description of what a physician concerned with the ethics of the profession has been able to see and discern about what physicians have agreed to constitute the foundation of their professional conduct.
Most of us doctors try to conform our actions to professional ethics as contained in the codes of ethics. I do not know whether here in Guatemala there is any solemnity surrounding the moment of graduation from university or joining the professional high school. In many places, in the course of the academic ceremony or at the annual celebration of high school, new doctors solemnly proclaim their adherence to the timeless ethics of medicine by reciting the Hippocratic Oath or some other oath or promise. Increasingly used are formulas derived from the Declaration of Geneva, a modern-day version of the Hippocratic Oath, in which the physician pledges to live a professional life bound by certain principles.
In most of the European Medical Colleges, the submissionof the Code of Ethics and the Statute of the high schoolprofessional is also a ceremonial part of the ceremony, a gesture that symbolises that the new doctors recognise, accept and commit themselves to comply with the ethical rules of the profession.
Well, when analysing the contents of codes of medical ethics and deontology, in the midst of the diverse cultural, religious and political diversity of our planet, one can trace the constant presence of a few basic ideas that we can call the rational foundations of medical ethics.
An ethical system based on the four principles of autonomy, beneficence, non-maleficence and justice is widespread. I prefer to build on the cornerstone of ethical respect. It is based, on the one hand, on service to human life damaged or threatened by illness, and on the other hand, on the recognition of the specific dignity of the sick person. I will therefore have to show what ethical respect in medicine is and what it consists of, in order to respond to the subjectstated in the degree scrollof my speech: respect for the life and dignity of the person.
I. Respect, a fundamental ethical attitude in medicine 
a. Respect as a Rational Basis for Physician Ethics
The moral core of medicine is respect for the life and dignity of the patient, whoever he or she may be. This is the inescapable conclusion to be reached when one reviews, as I have just pointed out, today's codes and declarations on the professional ethics of physicians.
Respect explicitly enters into codified medical ethics at the hands of the World Medical Association ( association) with the Declaration it promulgated in Geneva in September 1948. It is worth considering for a moment what happened then, because it has had and continues to have a determining effect on the way modern medical ethics has evolved.
Fifty years ago, the Second World War was coming to an end. In the course of the war, doctors had, alongside heroic gestures of self-sacrifice and righteousness, been involved in some shocking abuses. The ethics of medicine had been ruined in the public eye by the atrocities committed by Nazi and Japanese doctors, as revealed in the war crimes trials.
It was in this climate that the World Medical Association ( association), which had not long before been established, wished, with the Declaration of Geneva, to set out the guidelines for the future ethics of physicians, and thus establish a new and universal medical-ethical order, valid for all and acceptable to all. A moral order so that atrocities such as those condemned at Nuremberg and Tokyo would never happen again.
The Geneva Declaration of 1948 seeks to be, first and foremost, a modern version of the Hippocratic Oath. It translates into modern language the timeless clauses of the Hippocratic Oath. Respect is the subjectof which the whole document is made. Respect governs the physician's relationship with his teachers and colleagues. Respect for the patient's convictions is manifested in the prohibition of discrimination on the basis of race, religion, sex, social classor political conviction. The physician must respect the secrets entrusted to him. The utmost respect for human life from the moment of conception is specifically required.
Since the Geneva Declaration, respect has been present in medical codes of ethics all over the world: in the liberal Belgian Code of Ethics as well as in the Islamic Code of Medical Ethics or in the Blue Booklet of the British General Medical Council; in the Principles of Medical Ethics for Europe of the lectureInternational Council of Medical Orders, as well as in the Principles of Medical Ethics of the associationAmerican Medical Association; in the new Russian code, which seeks to dignify a profession that suffered greatly under a political regime that instrumentalised it, as well as in Castro's Cuba, even though it defines the physician as an active agent of the socialist revolution. It can be said that, since Geneva, the entire moral law of medicine can be summed up in the two commandments of science and respect. It can be concluded that respect is a universal concept in medical ethics.
b. What is the ethical respect of the physician?
What do we mean when we talk about respect for the life and integrity of the person? Many people think that this respect consists of good Educationand polite attention. Good Educationis certainly very important, because it not only makes living together more bearable and pleasant, but it is also a sampleof appreciation for people whose cultural and social values are shared. attentionAs it is their job to deal with the sick, doctors are particularly obliged to be polite and attentive, correct in their manner and demeanour, punctual, as they should always be assumed to be a person with a high level of humanity, who treats those suffering from the crisis of illness with sensitivity.
But it is not only good Educationthat professional respect is made up of. Respect is like the nervous system of the ethical organism. All moral life depends, in its abundance and quality, on the capacity to grasp, evaluate and respond to moral values, which is achieved if sensitivity, good judgement and readiness to act are activated by respect. Only if we respect our patient will we be able to listen to him, to give importance to his anxieties and fears. Good medical histories, which are the right path to diagnosis, are written by respectful doctors. Physical examination is an exercise in respect for the body, which reveals itself to us if we treat it with delicacy.
Respect is not just sensitivity. It is a high-precision apparatus that integrates moral stimuli into an image free of aberrations, faithful to what man is. Ethical respect leads us to recognise in every human being, in every human life, something of inestimable value, someone who exists and has worth in his or her own right. Respect is a powerful inhibitor of ethical subjectivism, of the duplicity of treating people according to the scientific interest of their illness, the amount of the fee I can pay, the social prestige they confer on me. Respect tells us that everyone is equally important, equally valuable.
Respect inclines me to respond to everyone according to their real needs. The attitude of service, so closely linked to the doctor's official document, is characteristic of the respectful man. To serve is not to submit to power or money. Nor is it a timid abdication in the face of bureaucratic threat, but rather a dignified response to the value contained in every human being. Respect is, at final, a position of openness that allows one to perceive, accept and respond to the moral values embedded in others.
Codes based on ethical respect tell us that physicians must respect human life, the biological integrity and staffof their patients, their legitimate freedom of choice, their confidences, their reasonable demands. The duty to respect human life is paramount and without exception. The physician is therefore obliged to recognise it in the healthy and the sick, in the elderly and in children, in the embryo no less than in the adult. They are all human lives, enjoyed by human beings, supremely and equally valuable. The physician must respect them all, not because he or she is an activist for the right of all to health, but because he or she recognises in each a unique and irreplaceable value. All must be cared for, without discrimination on grounds of sex, age, social class, political membership, religion, nationality or sexual orientation. In time of war, it cannot distinguish between those on its own side and those of its enemies: it must serve each according to the urgency of his or her needs. To all he seeks to heal and, when healing is impossible, to all he owes the all-important operations of palliative relief, human consolation and accompaniment to the end. The weaker or more defenceless the patient, the more attentive and punctual, the more competent and scientific the doctor's service to him must be.
c. The late effects of the Declaration: the relativisation of Medical Ethics
In the years after 1948, the Geneva Declaration was widely and favourably received. It is logical: ethical respect was strongly rooted in the Judeo-Christian morality of love of neighbour, of respect for man as imago Dei. In that sense, it could be accepted by believing doctors. It also connected with rationalist ethics, especially that of Kant, which had contributed so much to establishing the idea of respect in the moral Philosophy. It was therefore acceptable to agnostics.
The Declaration was thus addressed to physicians in a world that was already highly secularised, ethically pluralistic, but increasingly integrated into a unity. The ideals of the Declaration were in keeping with the noble traditions of the past, while aspiring to direct the ethos of the profession of the future.
But, no longer religiously based, without resourceto the absolute, respect for the Declaration could not stand the test of time. We cannot forget that respect for Kantian ethics, with its emphasis on the autonomous character of man as a moral agent, with its insistence on equating man's dignity with his capacity for decision and self-direction, does not provide a sufficiently broad basis for the peculiar conjuncture of being ill. The Kantian Achtung is a great moral value, but insufficient. The life of many sick people tends to lose the specific dignity of self-determination. In illness, this capacity tends to be degraded or lost.
Moreover, given its secularising and universalist intention, the new formula could not be an Oath that takes God as its witness. This explains its status as a Promise that the doctor makes for his own honour, which has incalculable consequences: the fact that it is no longer an Oath, but a Declaration of Intent, which is no longer the polar star that guideis the doctor's work, has meant a complete turnaround, a Copernican turn, in medical ethics.
There is an enormous distance between an Oath taken as a witness to God and a Declaration made on one's own honour. It is the difference between acting in a religious context and working under the gaze of God who penetrates to the marrow of the soul, or doing so in a secularised society, with immanentist coordinates, in which witnesses and judges are mutable men, moved by changing interests. Since Geneva, medical ethics is running the risk of relativisation.
The respect promised to God is, as an ethical attitude, a basic, fundamental, absolute component of the believer's relationship with things and people. In both, man recognises, through respect, God's imprint, and does so in the conviction that God also respects the creatures he has created.
On the other hand, when human honour is the guardian of moral life, one runs the risk of succumbing to one's own feelings, of falling victim to emotions, of negotiating in search of consensus in order to satisfy various, sometimes contradictory, options and opportunisms. It is inevitable to fall into relativism: what was respectable yesterday is no longer respectable today, everything is negotiable, nothing is worthy of absolute respect. It is easy to fall into the ethics of consensus: the World Medical Assembly can determine, by majority vote, what is, at any given moment, considered to be correct or what has become reprehensible; it can go back on its own decisions and deny today what it affirmed yesterday.
Thus sample, for example, the mutation of the aforementioned clause, I will show the utmost respect for human life from the moment of conception, by the new formula, approved in Venice in 1983, I will show the utmost respect for human life from the moment of its beginning. It is left to the free interpretation of each individual, to that of each National associationof doctors, to that of the Ethics Committees of political or health institutions, to fix the moment at which life begins, the moment at which the obligation to respect emerges from non-respect to relative respect and to respect plenary session of the Executive Council. There are no longer absolute rules.
I recognise that the tone of my lecturemay seem too firm, too radical. I speak, however, not out of passion, but out of observed evidence of what happens when the value of human life is relativised. Let us look at it.
d. The statusin the Netherlands, a demonstration that the utmost respect for human life cannot be abandoned.
Eight years ago in the Netherlands, the Royal Dutch Society of Physicians issued apparently very restrictive rules for the internshipof euthanasia. What was a professional rulebecame the Euthanasia Act at the end of 1993. In 1994, the law was expanded for the first time: not only terminally ill patients suffering from unrelieved suffering are candidates for euthanasia, but also those suffering from mental suffering for which no remedy can be found.
What happens when a doctor is authorised by law to administer a compassionate death? At the request of the Public Prosecutor, a very rigorous programs of studyhas been carried out on the internshipof euthanasia, of financial aidsuicide and of what are called end-of-life medical acts. From the different programs of studypublished, it can be deduced that, for example, only 6% of doctors are totally against internshipeuthanasia; that the annual number of euthanasia cases issueis around 2500; that there are more than 1500 cases of financial aidmedical suicide, more than 1000 cases of euthanasia in incompetent individuals (which is strictly forbidden by law), and that in about 40,000 cases medical acts are carried out around the end of life, consisting of failor not starting treatment or applying opioid doses, all with the express intention of anticipating death. In particular, general practitioners shorten the lives of more than half of their terminally ill patients. The patient is involved in the process of deciding the end of life in about half of the cases. In 40 per cent, this is not possible because of weakened consciousness or dementia, while in the remaining 10 per cent the patient is not allowed to intervene for paternalistic reasons.
The "I will give no man deadly poison even if he should ask me" of the Hippocratic Oath, the "I will show the utmost respect for human life" of the Declaration of Geneva have been forgotten. Euthanasia, in its various forms, has been trivialised, to the extent that it has been proposed on a congressof general practitioners that the euthanasic elimination of some particularly demanding cases of terminal care, which overburden the doctor's daily diary, can be an effective procedureto alleviate the burden of workon general practitioners.
Among the many alarming articles reporting on euthanasia in the Netherlands, one particularly struck me. Published in J Med Phil, it is signatureby Dr Kimsma, a general practitioner. It is entitled Clinical ethics in assisted euthanasia: avoiding misuse internshipin the application of medicines. After making some mistakes in the selection of euthanasia agents and observing the reactions of relatives and bystanders, Kimsma advises on the good internshipof euthanasia. It is necessary, he says, to determine what the wishes of the patient or his relatives are regarding the speed or slowness of the provoked death. Unpleasant scenes of respiratory distress and convulsions should be avoided. The different euthanasia drugs must be known and handled with the same science as antibiotics or antihypertensives. Euthanasia needs to be administered with skill. Media reports of some cases of incompetent euthanasia internshipprompted the Royal Netherlands Society for the Advancement of Pharmacy to publish a monograph entitled Euthanasia manager, in which it points out that the physician must know how to handle the different groups of euthanasia drugs (curarinics, barbiturates, opioids and insulin). He stresses the need for well-controlled clinical trials of euthanasia drugs and the need to continue the search for the ideal euthanatic, a substance whose administration by different routes (oral, intravenous, intramuscular, subcutaneous or rectal) would regularly and consistently cause rapid, gentle and calm euthanasia. Such a substance, simple to apply, should ensure its rapid, sufficient and reproducible efficacy, administered by different routes. deadlineThe amount to be administered should be as small as possible; it should induce in a maximum of 30 minutes a deep and irreversible coma, leading to death within a couple of hours; its use should be reserved exclusively to doctors, or through medical prescription; it should have no undesirable physical or psychological side effects; its possible emetic action should be effectively prevented; and its lethal effect should be 100% guaranteed.
I recognise that this Dutch scenario may seem too exotic and futuristic in Guatemala. But that does not stop us from asking ourselves
e. What happens when legislation comes into force authorising euthanasia, which decriminalises the killing of some sick people?
My thesis is clear: any legislation tolerant of euthanasia, however restrictive it pretends to be on paper, causes, with the loss of respect for life, an increasing brutalisation of medical care, because it degrades it ethically and impoverishes 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, one hundred percent efficient, painless, compassionate intervention, much more comfortable, aesthetic and economical than palliative treatment - becomes an invincible temptation for certain patients and their relatives. And for some doctors as well, 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 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 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 aidsuicide to those who ask for it freely and voluntarily, what reasons can be given by those who have practised it in accordance with the law to deny it to those who are incapable of asking for it, but whose life is more degraded or much more burdensome for others? He is sure that, undoubtedly, the insane, the one who sleeps in an irreversible coma, the victim in a chronic vegetative state, would ask for it if they had a moment of lucidity.
Once euthanasia is authorised, the doctor's virtues turn 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 mandataries 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 these conditions of biological or psychological precariousness. 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 continue living may be irrational and capricious, because they have an abhorrent life 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.
But ethical respect does not judge any human life as dispensable or unworthy of being lived. It does, however, make a lucid judgement of the technical means available and recognises their finiteness, their ineffectiveness. And if they are ineffective, he refrains from using them. When they are doubtful, he observes carefully or investigates to determine their usefulness area. Respect believes in the value of terminal life and attends to it with palliative care. With each passing day, I am convinced that palliative medicine contains an ethic of great density, which cultivates and enriches the most intimate and basic ethical values of all medicine.
Absolute respect for life is a core value. Even the most upright physician needs to guard against the excesses of his or her virtues. The obligation to respect and care for all human life is a wonderful moral force that also inspires the biomedical research. If doctors were to work in an environment in which they knew they could not be punished whether they treated or killed certain patients, they would become indifferent towards certain types of patients, and the researchin vast areas of pathology would wither. 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? What interest can prenatal diagnosis have, or spending huge amounts of dollars on the projectHuman Genome, if neonatal euthanasia can rid the world of the malformed and the genetically moronic? All the mental and moral effort, the sometimes exhausting strain of fulfilling 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 to do him no harm or injustice" - would, in a society tolerant of euthanasia, suffer atrophy by disuse.
Suffice it to say what has been said about respect for human life. I would now like to refer briefly to
II. The dignity of the person in a medical context
a. Res sacra miser
There is an expression of uncertain origin - it is not certain whether it is Stoic (perhaps by Seneca) or by St. Augustine - that attempts to define the sick person: Res sacra miser, to include simultaneously and inseparably the two dimensions of dignity and impairment that accompany human illness. A dignified but violated being is the one who moves the doctor to intelligent compassion. No misery, no regression, no immaturity can obscure the recognition of the human dignity that inhabits the sick person.
Through respect, it is possible never to forget that beneath the biological and pathophysiological objectification of disease disorders lies the intrinsic dignity of a human being. It is good to stop and think from time to time about the extraordinary powers granted to us doctors. We are allowed to pry into privacy in a way that no one else is tolerated. We ask questions of our patients that, in any other context, would be considered uneducated, aggressive or insulting. This is permitted to the doctor because he has to reduce the biography staffof the patient to clinical anamnesis. The doctor explores the naked body with his eyes, his hands and his instruments, he objectifies it, he makes it the object of observation, because that is what the physical examination demands. He needs to reduce the personal datato abstract categories in order to arrive at a diagnosis.
But none of this is an affront to dignity, as it might be in another context. Palpation is never a caress, nor is interrogation an affective dialogue. They are operations required by objective observation and the scientific search for data. The doctor can never lose sight of the patient's dignity. He cannot turn him, for example, into an object of erotic enjoyment. This would not simply be a regrettable concession to concupiscence, but a grave injustice.
As a student, the doctor needs to learn to have a kind of binocular vision that allows him to see simultaneously with the scientific eye data(clinical findings, pathophysiological mechanisms, causal relationships, but also demographic figures and legal norms) that he has to evaluate in his technical decision-making. And, with the ethical eye, he must see the human being invested with dignity, who is to be respected, as someone who, although miserable, is always worthy of infinite respect.
Respect for the dignity of every human being, whoever he or she may be, is truly a rational and universal concept. For every human being is willed by God. Each of us is entrusted with an individual destiny, unique and unrepeatable, original and creative. The world, with its wonders and its tragedies, is lived by each human being in a core topicstaff , singular, proper and, in a certain way, ineffable: in the interiority, more or less rich, of each human being the world is seen, heard, thought, understood, enjoyed with absolute and exclusive ownership. A song, the taste of a coffee, the fear of a threat, the recitation of a prayer, everything is experienced, felt or statementin an original and unique way. What makes us unique and valuable beyond measure is not having an original and unrepeatable sequence of nucleotides in our DNA endowment, but being human beings, having body and soul, a life that each one lives within himself and in attentionwith others, the conversation of each one with himself, with others, with God: this is our intrinsic dignity. Each human being is a universe that enriches humanity, that completes the world: therein lies, in my opinion, the reason for the dignity of man, the sourceof respect for each and every human being.
Human dignity is a subject to which we should pay much more attention. Human dignity is an expression that is everywhere: in constitutional texts, in ethical guidelines, in slogans of activists of a thousand different things. The promoters of the recognition of human and civil rights speak of "respect for human dignity", of "attacks on human dignity", of "the right to dignity". Euthanasia advocates write on their banners "death with dignity for all" and form movements calling for the "right to die with dignity".
But even if the notion of human dignity is subject to inflationary depreciation at the hands of politicians and sociologists, human dignity contains moral values of the highest order, full of meaning and operability. The word dignity refers reference letterto the inherent nobility and value that has always been accorded to man, to the human person. I think it is worth pausing for a few moments to review the history of the concept of "human dignity", because it can help us to go a little deeper into the question.
b. The biblical-Christian root of human dignity
The idea of human dignity has biblical-Christian roots. The Genesis account, the creation of man in the image and likeness of God, brings into the world the notion of the supreme dignity of man. Man is God's vice-regent in the world, he is crowned with glory and honour. Being imago Dei confers on him exclusively, among all the creatures of the earth and despite the original fall, rationality, self-consciousness and free will, which are participations of the divinity, which give him the capacity to transform the world and to educate himself, to be a moral agent managerand free.
All men enjoy this supreme and identical dignity. To destroy a human body is to destroy a human personality and is therefore an affront to the dignity of God reflected in the imago Dei which is every man.
In contrast to this biblical-Christian doctrine that every human life, every human being, possesses its own intrinsic excellence, classical Greco-Roman thought defined personality in juridical terms of citizenship, that is, of belonging to a family, state, city or tribe. According to this mentality, man is not worth what he is in himself, but his dignity is lent to him from outside, by virtue of the juridical decision of an institution which, at its discretion, accepts or rejects him, dignifies or destroys him. Plutarch recounts, in the Life of Lycurgus, that in Sparta, if "the elders found the newborn well-shaped and strong, they ordered the parents to raise them. But if they were born deformed or weak, they would throw them into a precipice at the foot of Mount Taigeto, convinced that the life of one whom nature had not equipped well from the very beginning with health and strength was of no use either to himself or to the state".
In Israel, however, the elimination of defective newborns was regarded as a serious crime, a violation of the law. The penetration of Christianity into ancient society, and with it the idea that all men are children of God, brought with it, among many other things, the disappearance of abortion, infanticide and the withdrawalof children. From then on, even if some doubted whether certain extremely deformed monsters were real human beings, in whom it was very difficult to discern the image of God, the Western tradition accepted the belief, explicit in the Christian teaching, that every newborn child must be protected, cared for and loved.
The value of a man is above all calculation, because he is the image of God. According to rabbinic exegesis, God created only one man in order to teach us that whoever destroys one human life, God imputes a sin to him as if he destroyed all mankind, and whoever saves the life of one man, God holds him as if he saved the whole world. Somewhere in the book of Sanhedrin, it is explained that he who kills a man or a child kills also the children, and the children of the children of that man. When you kill a man you kill his offspring, you kill mankind.
God mysteriously creates us in his image and likeness even when our appearance and biological value are diminished by illness or malformation. Thus Moses says in Exodus 4, 11: Who made man's mouth, and who made him mute, or deaf, or seeing, or blind? was it not I, the Lord? It is this understanding of man as the image of God, even when man is deficient, that gives the immense moral superiority and incomparable humanity to biblical ethics.
In the Christian tradition we reach the summit of human dignity. The Incarnation of Christ dignifies humanity, saves it and reinforces in us, through divine filiation, the likeness of God. Man is no longer merely an image and likeness: he is and is called the son of God: there is no greater nobility and no greater dignity.
c. The utilitarian volatilisation of human dignity
What happens when the notion of human dignity shared by all men equally is lost? What happens when universal dignity is replaced by the new aristocratism of quality of life? What happens when the concept of wrong life, of life devoid of vital value, is accepted?
The loss of perspective is alarming. There is an overturning of values. One of the starkest experiences I had, before I became an ethicist, full-time, was following a trial in Leicester of a paediatrician, Dr Arthur, for euthanising a Down's syndrome neonate. The defence's experts tried to justify the defendant and extolled his skill, his generous compassion, his sincerity and moral courage, for having acceded to the parents' pleas to give the child a sweet death. A true paediatrician," said one of the witnesses, "is one whose patient is not only the child, but the family. He does not turn a blind eye to the problem of a painful and unhappy life, which overshadows and makes unhappy the lives of others. The good paediatrician takes pity on the child and the parents. He does not wash his hands like Caiaphas, he does not turn a blind eye to the suffering of others like the priest and the scribe on the road to Jericho in the Gospel parable: he bends down like a Good Samaritan before the suffering of that family and, at the risk of his prestige and his safety, knowing that he is spied on by pro-life activists, he frees the child from his useless and hopeless life and the family from the unbearable burden of a helpless child with no future".
Very few voices were raised in defence of the dignity of the disabled in the summer of 1981. In a courageous Declaration the Bishops of England and Wales proclaimed that "every innocent human being has a fundamental right to life, possessing an essential dignity. Such a right and dignity are wholly independent of the wishes of others, or the judgement of society. It does not matter whether the innocent person enjoys plenary session of the Executive Councilvigour or is handicapped, whether his or her life has just begun or is nearing its end..... Such literally fundamental dignity is not assigned or conferred on human beings by the laws of the land. No human legislation, no legal judicial sentence can ever morally justify an action that deprives such dignity, that deliberately destroys the life of an innocent individual".
The discussionabout human dignity often takes the form of discussionabout the notions of quality or sanctity of life. Many utilitarian philosophers have been trying for years to set limits to dignity, to establish standards of humanity, to desacralise human life. The overwhelming experience of abortion has desensitised many people: seeing the discretionary destruction of unborn human beings as a matter of course cannot be reconciled with an unconditional respect for postnatal life. Accepting abortion opens the door to condoning neonatal euthanasia. Peter Singer, an Australian utilitarian, says in his Ethics internship: "If we are prepared to kill a foetus at any stage of gestation when we judge it to be at risk of serious malformation; and since the dividing line between a developed foetus and a neonate is not a decisive moral boundary, it is very difficult to rationally support the conclusion that worse than abortion is killing a neonate known to be malformed". Recovering a dialectic previously expressed by John Lachs (there are children whose sensibility and intelligence are inferior to those of a pigeon or a sparrow), Singer affirms that in terms of sensibility, capacity for self-determination, there are deficient children who are inferior to those of a pig or a dog. Consequently, and in accordance with his anti-speciesist mentality, once the notion of the superior dignity of man has been disallowed, once the ethical frontier that distinguishes man from other animal species has been demolished, the euthanasia of the profoundly deficient is self-justified on the grounds of the intellectual-affective precariousness of his potential victims, inferior to that of so many animals that are sacrificed when they are sick and suffering uselessly.
This is possible because human lives have ceased to be mysteriously valuable and have become, in the utilitarian context, simply evaluable. John Fletcher had designed the quality of life yardstick with his indicators of humanity, a heuristic procedureto classify human lives on a spectrum of greater or lesser dignity and quality of life. With these indicators of humanity it becomes possible to objectify, almost quantitatively, the prospective or actual value of a life. Lives can be valued in cold figures. The idea of incommensurability, of inestimable value, of the unique dignity of each human life, easy to justify in a logic of sanctity of life and in an existential understanding of man, whoever he may be, is replaced in the utilitarian imaginary by a quantitative, objectifiable technique of evaluation, in which the physical, intellectual and affective components of each real life can be appraised on quality scales, which yield a numerical sum total.
Then, and inevitably, the tables of quality point, in every historical circumstance, in the changing economic conjunctures, to a dividing line that separates acceptable lives from lives that do not comply with the requirementsof humanity of the moment. Those lives lacking in value, insufficient in dignity, are dispensable.
Epilogue
In respect for the life and dignity of every human being, medical ethics finds a rational basis, a universal commandment, in which there is no room for exceptions or reductions. The opposite idea, the acceptance of human beings whose life lacks vital value, of homunculi with reduced dignity, leads to the conclusion that the foetus, the deformed newborn, the demented or decrepit old man, the patient asleep in a persistent vegetative state, are beings destined for elimination because they lack the minimum quality of life required. The ethical, psychological and cultural continuity between abortion, neonatal euthanasia and adult euthanasia is therefore inevitable.
Respect for the life and dignity of every human being has been the inner force that has made medicine great, the engine of its science. We cannot allow these values to be lost or forgotten.
Thank you very much.