presentation from the book “From the Heart of Medicine: A Tribute to Gonzalo Herranz”
Gonzalo Herranz, Department of Medical Humanities , and Ethics, University of Navarra
high school Medical Officers / University of Navarra Alumni
Valladolid, November 29, 2013
First Topic: The Book's Origins and " development "
Second topic: a few brief comments on the preliminary notes
Third topic: Comments on a few points from the interview and the lectures
Greetings and thanks
It is very difficult for the author to speak objectively about his book. He would first have to kill his ego. It would be better for him to keep quiet and leave the task to the serious and knowledgeable readers of subject.
If that’s the case, one can’t help but wonder: why on earth did this guy come here? To justify my presence, I have a solid alibi. “From the Heart of Medicine” isn’t a book I wrote. For starters, it doesn’t have a copyright notice—I don’t own the copyright to it. Furthermore, I didn’t write it—others did. It was compiled by committee publishing house , although largely using my own materials. In addition, “From the Heart...” lacks the classic title page with basic bibliographic information (author, degree scroll, publisher, place, and year of publication). On the book’s cover, we see degree scroll, a stethoscope whose rubber band forms a symbolic profile heart shape, a subtitle that reads: “Tribute to Gonzalo Herranz,” and, in one corner, the OMC logo. There is no author listed.
To make sure, I consulted the Catalog of the Library Services of my University: in the corresponding file, the usual "Author" box had been eliminated. Fortunately, in the one corresponding to secondary authors, the six components of committee publishing house appear. In conclusion: it seems that I am very involved in the book, but I am not, at least "officially", the author. I feel, therefore, entitled to speak freely about it, immune to the risks of self-promotion or conflict of interest of any subject, including financial ones.
“From the Heart...” consists of three parts. The first, introductory part brings together notes (presentation, testimonials, and a biographical sketch) written by members of the committee publishing house or guest authors. The second part contains the extensive interview conducted with me by José María Pardo, who holds doctorates in medicine and theology. The third part brings together 15 lectures—most of them previously unpublished—that members of the committee publishing house selected from among many others.
In this talk, I will address three issues. I will begin by explaining how the book's project was born and grew. I will then make some brief but appreciative comments on the preliminary notes of homage and dithyramb. Finally, I will draw attention to a few points from the interview and the lectures.
First Topic: The Book's Origins and " development "
On page 48 of *From the Heart...*, José María Pardo recounts that one day a colleague of his, Prof. Juan Luis Lorda—who is obsessed with writing books and having others write them—suggested he put together an interview book about me; Pardo adds that, after mulling over the idea and devising a strategy to entice me, he presented me with a * project * that I rejected outright. I had plenty of reasons. I had recently read some interview books, and it seemed to me that they fell into two very different categories: some, like those by Ratzinger and Seewald, were an astonishing blend of intelligence and simplicity; others, on the contrary, were overflowing with egotism. The former were beyond my reach; the latter were cringe-worthy. “Interview books aren’t for me,” I told Pardo. But, against my better judgment, thanks to his and others’ steadfast persistence, I eventually gave in. As we all know, with the passing of the years, the powers of the soul—understanding and will, and not just the report —weaken.
And so we began: on Tuesdays he would come to my house, early in the afternoon, with a tiny tape recorder, and I would answer the questions he had asked me that morning. I was convinced that transcribing conversations is very difficult and that it would come to nothing. But I was wrong: after a few months José María appeared with a written transcript of our conversations. Neither of us knew what the fate of that draft would be. The truth is that I did not put much enthusiasm, though I did put a lot of responsibility, into the task of correcting the transcribed text. I removed a few details, added a few others, and, as always, a few typos crept in.
As I later learned, Dr. Pardo sent the monster to Rogelio Altisent for his opinion. And Altisent, in turn, sent it to Dr. Rodríguez Sendín. Nobody told me anything about these manoeuvres. And so, in complete ignorance, I found myself, one day in June 2012, having breakfast at the high school de Médicos de Navarra with Juan José Rodríguez Sendín, María Teresa Fortún, Rafael Teijeira, José María Pardo and Rogelio Altisent, who were part of the self-appointed committee publishing house . Also invited to the breakfast at work were Dr. Pilar León, professor of the history of medicine at my School, and Teresa Alfageme, from the WTO press office.
They told me they were going to publish the interview, but that they wanted it to be accompanied by other writings of mine: the purpose of the meeting was to finalize the book’s table of contents. They debated among themselves who might write the customary introductions and praise. And they asked me to provide them with the texts of my lectures (more than two hundred, the vast majority unpublished) that I had stored more or less scattered across floppy disks and USB drives. Some members of committee publishing house would be in charge of reviewing them and selecting which ones would be included in the book.
A year went by. And, in July this year, while I was away from Pamplona, fleeing from the Sanfermines, José María Pardo brought me a couple of copies of the book with the ink, as they say, still wet. I was pleased to see it sturdy, discreet, well-made; above all I was pleased to see that it is not an author's book, but rather a book of homage and tribute: in other words, it was, however you look at it, a gift, albeit an undeserved one. That is its story.
Second topic: a few brief comments on the preliminary notes
Some readers will take it for granted that the five testimonies and the biographical sketch that occupy the first 45 pages of the book are the usual string of laudatory appraisals, sincere and heartfelt no doubt, but loaded with the exaggeration that is common among the lauders of the day. They are not without reason. The natural thing, for many, would be to skip them and get to the point. I would advise against it, as they can be approached differently. Rather than praise for the honoree, I prefer to see them as a testimony of lived collegiality. Basically, they reveal that the medical profession is, as I like to repeat, a moral community, an entity for committee and discussion, in which it is possible to work together, in a friendly and polite manner, each with his or her own mentality, sometimes disagreeing, but never in a bad way or in a bad mood. And that leaves its mark.
Juan José Rodríguez Sendín’s * presentation * is, above all, a testament to friendship, forged initially through a few lengthy conversations we had years ago, when he was Secretary- committee -General. During those conversations, he allowed me to think aloud, freely, about my views on the OMC; about the characteristics and ethical nature of leadership; about my hopes that one day the organization would become truly participatory, a fair defender of the rights and freedoms of its members, a persuasive guide to their duties, and, ultimately, a voice for the ethical values of the profession. It adopted some of my views, and I am grateful for that. And I’ve had to put on a brave face when, for various reasons, it rejected others.
Professor Enrique Villanueva, who declares himself to be very sparing in his praise, has written a few pages in which sample shows how the friendship with which he distinguishes me made him lose his objectivity, if not his head. Something similar happens with Rogelio Altisent, although, in my opinion, his judgements are a little more nuanced. Both, each with their accredited independence and staff , select some memories of the years when we coincided in the Central Commission. Some readers, good critics, will say to themselves as they read their testimonies: "It will be less", and they are not far wrong.
I am particularly grateful for the words that Diego Gracia dedicated to me, in which he praised the incalculable human and humanising value of friendship, the marvel that is "friendly friendship", capable of allowing kind and frank dissent, without the disagreement diminishing mutual appreciation one iota, but on the contrary, increasing it. I consider it one of my best achievements to have persuaded Diego Gracia to join the Central Commission. He then made the admirable gesture of joining the Commission and submitting himself to the elective process to become a member. And, in it, he understood and appreciated collegial ethics, which says a lot about his intellectual generosity.
grade Marcos Gómez Sancho, current President of the CCD, adds a touch of humour to his testimony when he describes with a masterful hand the circumstance in which our friendship began: a National Defence Health congress , held in Santiago de Chile in 1993, well into the democratic transition after the Pinochet dictatorship, to which I was invited to speak on the ethics of organ donation for transplantation. They admired Spain's example. And they followed it: two years later, the congress approved Republic Law 19.451 on organ transplantation and donation.
Finally, Dr. Pilar León gives a semblance of my academic life. She built it up by patiently and tenaciously searching for scattered papers in chaotic and abandoned archives. It became clear that I had done nothing to make work easy for historians. I have to admit that, in this portrait, Dr. León has done me a great favour.
But the testimonials don't end there. There is one included right at the beginning of the interview—very brief, but one I hold in high regard. Prof. Edmund Pellegrino sent it to José María Pardo’s application when he was already very ill. I considered Pellegrino—and continue to consider him—the leading figure in medical ethics. I met him in March 1985 at a bioethics congress held in Beersheba, Israel. We had a couple of long and, for me, eye-opening conversations at that time. He offered to send me a list of his publications so that I could request the ones I wanted. From the list he sent me, I selected many; he sent them all to me; and, I say this without reservation, that was the medical-ethical nourishment I absorbed. For this reason, I echo a few lines from the tribute paid to him by Mildred Solomon, current President of the Hastings Center: “He [Pellegrino] influenced us—me and many others—not only through his immense body of work and his ability to connect with people, but above all by offering us the example of a life filled with noble aspirations, in which exceptional leadership was combined with exceptional humility. Losing a person of such authenticity is always painful; but it is all the more so today, when there are so few examples of respectful dialogue between secularists and believers; when efforts to integrate science and medicine with Humanities are so scarce; when the social pull toward action without reflection and without faith is so strong.”
Third topic: Comments on a few points from the interview and the lectures
The interview is very long—it spans more than 150 pages—and the collection of lectures is even longer: it fills nearly another 200 pages. It is not possible to cover all the topics discussed in them, but only a few points.
Regarding the interview. It's a shame that the corresponding table of contents wasn't included. I'll limit myself to mentioning just three topics that seem significant.
First topic. I would say—and this is something that may cause a stir—that in recent years, bioethics, as an academic discipline , seems to be losing momentum, as if it were tired and unmotivated. Many of its practitioners, especially in the United States, have imposed such a utilitarian bias on it that any bioethic discussion t inevitably ends up concluding that everything is permissible, everything justifiable. This implies repetitive argumentation—always the same—an imitation of the approach introduced by Peter Singer more than a quarter of a century ago. In such a context, where the solution is known in advance—since the “nihil obstat” of permissiveness has already been granted—what takes on decisive importance is originality in inventing problems: the emphasis shifts to the creation of extravagant scenarios, fanciful thought experiments, and post-human scenarios increasingly distant from what is realistically possible. This enormous waste of ingenuity eventually becomes tedious. Until a few years ago, I found the quarterly or bimonthly publication schedules of bioethics journals to be a drag. I still keep an eye on them; I still glance through them, now almost always on the computer. But few articles stimulate me or make me think. Perhaps it’s just another ailment of old age, but I seem to perceive a morbid tendency in recent bioethics. An example: not long ago, three bioethicists debated in the *Journal of Medical Ethics* whether bringing children into the world is merely irrational or also immoral. Another example: The latest “ issue ” (Nov–Dec 2013) in the American Journal of Bioethics addresses the future of “anti-love” biotechnology (pills to stop loving, neurobiological interventions to induce emotional breakups), with the “ purpose ” of deciding which actions and under what circumstances might be ethically justified—or even morally required. Human love is thus reduced to mere Biochemistry —a matter of molecules. Such developments raise the suspicion that the golden age of bioethics is a thing of the past.
The second issue in the interview I’m going to discuss is the dialogue between science and faith. There is data to suggest that what might be called “public opinion” in science (the editorials, commentaries, interviews, and letters to the publisher published by major journals) is becoming increasingly sectarian and anti-religious. It seems as if we were in the midst of a new Kulturkampf. The Catholic ethical tradition, which advocates respect for life, for the weakest members of the human family, and for the dignity of human procreation, has received very bad press. I firmly believe that there can be no contradiction between true science and true faith. And I hope for a lively, fluid, friendly, thoughtful, and at the same time critical dialogue between the two—a dialogue that could bring immense benefits. But it is no easy task. It requires theologians and scientists to set aside their prejudices and study—very thoroughly and very critically—what each side professes: only in this way can they understand one another. But, it seems, there are hardly any theologians or scientists left who have the time or the inclination to do so: the “ multidisciplinarity ” is a thoroughly arduous task.
I’ll give a real-life example. I mention it in the interview when referring to the preimplantation embryo, but at the time I did so, I hadn’t yet published an “ article ” on the chronology of monozygotic twinning—which appeared in May 2013 in the journal *Zygote*—and the book *The Fictitious Embryo: History of a Biological Myth* hadn’t even been published yet. In the article and in the book, I review the history of how, between 1922 and 1955, the “dominantmodel ” we all know was established—the theory that links the supposed moment of the embryo’s division into two with the structure of the fetal membranes; namely, that cleavage occurring on days 1 through 3 post-fertilization gives rise to DC twins1 DA2; on days 4 through 8, MC3 DA; on days 9 through 12, MC MA4model ; and after day 12, conjoined twins. The initial idea occurred to George Corner in 1922, as an intuition, a mere exercise of the imagination. But in 1955, the “ model ” seemed so reasonable to Corner himself that he felt it was a good description of what actually happens. Over the years, it evolved from a plausible hypothesis into an undisputed description of reality—a reality that, however, no one has ever seen or verified. When one examines and identifies the embryological inconsistencies of the model, one must acknowledge that, despite its rationality and internal logic, the theory—which explains why no one doubts it—is, nevertheless, biologically untenable. Having shown that the “ ” is indefensible, I thought it appropriate to offer, as a replacement, a theory proposing that twinning could occur at the end of fertilization, when, upon division, the zygote gives rise not to the first two blastomeres, as normally happens, but to two new zygotes, which from that moment on begin their “ development ” as monozygotic twins.
Zygote's article (the same as the book) is very innovative and, I still think, should have aroused some curiosity among scientists. I had hoped that it would be severely criticised, I wanted to be beaten to a pulp. To that end, I sent the virtual text of article to more than 300 scientists (biologists from development, physicians, geneticists, bioethicists and moralists) who, in the last 5 years, had subscribed to the conventional chronological model in their publications on twins and twinning. I have had a few responses, some very flattering, from leading embryologists and geneticists. But more numerous have been those of a mere polite acknowledgement and, I say with regret, a much higher rate of silences. Openness to the scientific or ethical discussion does not seem to be going through a good moment.
I realise that time is short and that many scientists, philosophers and theologians are busy with matters that cannot wait. I know that I have no right to be answered, as no one is obliged to reply to unsolicited mail. It may also be the case that quite a few will not like the ethical implications that follow from my critique of the dominant traditional model , which leaves the concept of the embryo without ethical status in its first two weeks of life seriously wounded. We will have to give time to time.
To conclude this point: science and faith are, in my view, two synergistic forces. Both helped me persevere for years in the humble task of seeking data and evidence, and to publish an work that, perhaps, financial aid will help revive a theory that has stifled ideas about monozygotic twinning for 60 years. I suspect that certain acts of scientific rebellion can only be initiated by those who possess the binocular vision provided by both science and faith.
My third and final comment on the interview concerns professional ethics, to which the interview devotes 20 pages—too few, it seems to me, given the high regard I hold for the subject. I will address a point that is particularly dear to me. Article 63.2 of the 2011 Code of Ethics imposes on medical professors the duty to “take advantage of any circumstance [...] to instill in students the ethical values and the knowledge of the Code.” This mandate must not fall on deaf ears. If professors at medical Schools and mentors of physicians at training fulfilled this duty, the flourishing of professional ethics—and, with it, the moral leadership of the medical associations—would be assured.
A concrete example: if ethical values and the contents of the Code were taught, what is today in many hospitals the ridiculous routine of filling in the paperwork imposed by Law 41/2002 (and its regional versions), would become an ethical opportunity to promote and express respect for the person of each patient and their individual dignity. Assuming that the teacher is the true skill, and going beyond what the law mandates or the patient's legal rights demand, educating in ethical respect implies teaching students and residents to talk to patients; to do so with a sincerity and a human tone capable of inspiring the trust required for ethical consent. The skill of professor to take advantage of any circumstance to inculcate ethical values in its students should be taken as a basic factor in the scale for academic promotion: it should appear, if not ahead, then next to the list of publications in prestigious journals. Will article 63.2 of the Code be able to change the strange, erroneous disdain for the academic evaluation of the ability to teach "humanity" and which is so important for patients, and also for students who want to learn to respect their patients?
For years, I have been repeating that the presidents of the colleges and the deans of the Schools must join forces to fulfil this serious duty of the "collegiate-teachers", which is, at the same time, a privileged right of the "student-future collegiate members". A request: please read the article "Recent advances" by Michael LaCombe which I copy on pages 275 to 277 of "From the heart of medicine".
So much for the interview.
About the lectures. Their topics are diverse, just as medical ethics itself is diverse: they range from the “ teaching ” of medical ethics and the ethics of medical students to the ethics of healthcare strikes and the role of ethical expertise in the administration of justice.
What would you highlight from them? Seen from a bird's eye view, it is easy to spot some of "my obsessions". They are concepts that I talk about many times, themes that I return to on occasion (and sometimes not).
One of these concepts is that of respect as a fundamental ethical attitude of the physician, with its many manifestations: the ethical—and not merely courteous—respect that governs relationships with the patient and their loved ones; that inspires relationships with colleagues and professional institutions (hospitals, medical associations, scientific societies); the almost sacred respect that the physician must feel toward himself (as a person and as a professional); the physician’s specific, preferential respect for the most vulnerable; respect for the life of every human being; and respect for science as it seeks to approach the truth.
Another recurring theme I return to time and again is the acknowledgment and correction of doctors’ mistakes. I see that this favorite topic appears in both the oldest (1988) and the most recent (2012) of the collected lectures; it is also the “ topic ” of a lecture titled “ lecture ” that I gave here in Valladolid in 2008. Perhaps it’s an obsession, but I still think what I thought 25 years ago: we must overcome the hypocritical culture of concealing errors in order to discover the immense human value of acknowledging and confessing the truth. It seems we still haven’t fully grasped that to err is human. We should all acknowledge this—doctors and patients, judges and lawyers, media professionals and ordinary people—so that, together, we can humanize medicine, ridding it of the scourge of defensive or cunningly deceptive medical practices. And, instead, create the atmosphere of sincerity, intelligence, and justice necessary to compensate for objective harm, identify the source of errors, and implement measures to prevent their recurrence.
And, to wrap up, I would like to draw attention to the lecture , which addresses the human rights of physicians. In it, I describe—in a very tactful manner—the circumstances that sparked my interest in this issue. It so happened that medical organizations in major European countries decided to ignore repeated reports of racist harassment inflicted on a physician of Asian descent by his superior. I will be a bit more explicit here. This doctor—the victim—wrote a letter to the BMJ’s “ publisher ,” briefly recounting his story and lamenting that the organizations of which he was a member—as well as the ethics subcommittee of the Permanent committee of European Doctors itself—had not deigned to address the complaint he had filed against his superior. I was then vice-chair of that subcommittee, and I asked the chair that we discuss this matter at a “ meeting ” meeting we were to hold shortly thereafter in Brussels. I tell this story with regret. In good faith, I could not have imagined the Degree of manipulation that could take place within the Permanent committee . When I arrived at the subcommittee meeting, two colleagues were waiting for me outside to inform me that the matter had been transferred a few hours earlier to another subcommittee and had already been resolved. I told them I deeply regretted what they had done, as it went against established rules and regulations : the subcommittee in question lacked jurisdiction over subject. Furthermore, I felt compelled to explain the reasons for my actions. They had no choice but to allow me to speak at the meeting of the ethics subcommittee. My failure was spectacular: not a single voice was raised in favor of investigating whether there might be any truth to that allegation of racism. I never found out whether the Asian doctor who filed the complaint was a victim of mistreatment by his boss or simply paranoid. In compensation, they asked me to draft a draft charter of human rights for physicians. Its fate was a sad one. After many postponements and amendments, the text became C. A fleeting victory: under pressure from some national medical organizations—apparently stung by my gesture in defense of a humiliated colleague—the document was removed from the file of the committee without a trace. I believe it was a wise decision—not an act of revenge—that the committee publishing house of the book included the lecture on physicians’ human rights vis-à-vis professional organizations, along with the Bill of Rights to which I just referred. It can be found on pages 286 through 293 of the book.
Final point: my final and irrevocable conclusion is this: that, in spite of all the pains, which are not few, deontology is worthwhile: it is humanly very beautiful.