Rights of the Strong and Rights of the Weak: the Doctor at the Stake

Prof. Dr. Gonzalo Herranz, Department of Bioethics, University of Navarra, Pamplona, Spain
Round Table on Medicine and the State
Congress on Medicine and Human Rights
World Federation of Doctors who Respect Human Life
Rome, December 1-3, 1989

I would like to share with you today some of my worries and hopes. Ours is an exciting time: never before have we doctors been offered more promising opportunities and more appealing challenges, but never have we been threatened by so many risks and dangers. I am deeply convinced that this time we have been given to live in is the best of all, but it is also a season of contradictions. Never before have we doctors had at our disposal more wonderful means to care and cure, but never have we been more forgetful of the ends of Medicine. Enormous amounts of money are spent in the care of important people and, at the same time, austere stinginess is exercised in the delivery of health services to the poor and the frail. At no other time there has been so much talk about human rights and never before human rights have been more disregarded. 

One thing is clear: there is a double-talk in the realm of human rights. Many influential international agencies and health care administrators act in a two-faced way. They pay lip-service to human rights rhetoric, launch "health for all" campaigns, and promulgate new and lofty-styled patient rights charts. But they are insincere. In cold blood, they degrade some people to the condition of non-persons, deprive unhappy children or aged people of humanhood and human rights, and discard them as unworthy to life. To justify such actions, they tell us that there is not enough money to pay for the needs of everyone. Applying the tools of social Darwinism, parliamentarians and bureaucrats alike stealthily spoliate the weaker (the unborn and the feebleminded, the bodily handicapped, the elderly and the destitute) of their share, to get more and more for the stronger.

This is an alarming trend. Until recently in the western tradition, the whole process of education (medical education included) tried to fix in all of us the idea that weak people are very important and entitled to our utmost respect. It has been said that we are born little savages and require a long educational process to imprint in our souls the concept that the weak also matter. But at present, within both society and medicine, there is a trend to despise the debilitated as if their feelings and needs were worthless and despicable. There is everywhere a mounting intolerance towards the weakling.

Let us see this with an example to illustrate my assertion. If a nonhadicapped individual revealed his intention to commit suicide, his decision would be rejected as unfounded and help would be given him to overcome his crisis. But if a disabled or chronically ill person announced the same desperate intent, many people would tend to accept that this poor person is acting rationally because he or she is a living proof, confirming their euthanasiast bias, that people like him are better off dead. This example shows how deep is the social intolerance for weakness and how eroded is the respect for the rights ot the feeble.

That is the result of the unopposed spreading of some (in)moral infectious opinions and practices: the innate tendency to underestimate the intellect of physically disabled people; the hedonistic radical rejection of suffering and defficiency; the selective health resource allocation with its outcome of an affluent medicalized aristocracy (test-tube babies, middle-class AIDS patients) and a medically neglected proletariat (Third World contraception victims, unwanted children, babies with multiple or deep handicap, demented elderly patients), who are seen by some doctors, philosophers and medical economists as human refuse, lacking in dignity, and unsuitable to receive medical treatment. Some of them are silently eliminated everyday, in hospitals or at home, through open euthanasia or cryptanasia, by neonatal rejection, abortion or selective reduction.

A note now considered to be of social and scientific high-standing is the search for new tools aimed at the cleaning of the race. But this attitude is running the risk of becoming laughable, as the tale of a doctor who developed a test for the prenatal diagnosis of albinism reveals. Understandably he was anxious for fame and earnestly desired to find the widest application of his new procedure in eugenic abortion. He was upset at discovering that in temperate climate communities people affected by albinism are very well adapted to the common circumstances of life and work and, apparently, there is no real need for their prenatal elimination. Our distressed geneticist found some comfort when he fancied that the new test could find wide use in tropical developing countries, where ocular, cutaneous and cultural problems of albinism could make life unbearable. Fortunately, the dreams of our doctor were not fulfilled. Poor people in developing countries cannot afford such sofisticated and outlandish methods as fetoscopy, histochemistry and electronmicroscopy. They can protect albinos against solar irradiation by means of clothing, sunglasses, and indoor jobs, which is cheaper and more humane.

In the present circumstances, we, Doctors who respect human life, must plead for the underdog and strive to grant full human rights to the medically oppressed. A difficult task indeed and one that can jeopardize one's reputation in the eyes of the powerful and wise of this world. In some sectors of modern medicine, the rights of the poor and frail are always imperiled, because there is no limit to the greediness of the strong. A very recent case is worth mentioning now.

In England, the Royal College of Physicians has recently published a report entitled "Prenatal diagnosis and genetic screening: Community and service implications". Its message is clear: caring for a child with genetic disease places frequently enormous economic and emotional burdens on both family and society. The report shows graphically by means of charts and diagrams how cost-efficient genetic screening is when coupled with abortion, and assumes that most people will do whatever they can to avoid the birth of affected children. It concludes that "prenatal diagnosis offers major financial advantages. The investment required is relatively modest and will conserve NHS resources for other uses".

This last paragraph shows us how forgotten are human rights among health promoters. A decade ago, we devoted a year to enhance worldwide concern towards handicapped people, to acknowledge that they are entitled to the same human rights as the rest of us. But apparently, all those good resolutions faded away almost completely in a few years.

The contrast between the text of Human Rights declarations and the present reality is shocking. In the European Community, for instance, all decisions taken by the medical associations of the member States must adapt to the Declaration of Nuremberg, an official position paper of the Standing Committee of Doctors of the European Economic Community on Article 57.3 of the Treaty of Rome, to guide its members on the practice of the profession within the Community. I read three paragraphs of the Declaration, to show you how unprofessional are some current policies towards the weak and the poor:

- Human life from its beginning and the human person in its integrity, both material and spiritual, must be the object of total respect".

- "Every man has the right to obtain from the social institutions and the medical corps the help he needs to preserve, develop or recover his health".

- "Technical progress, the basis of our industrial civilization, and economic expansion which is its fruit, have as their natural end, especially thanks to a health policy, to bring about full physical and spiritual development of man, of all men".

In opposition to these claims, the planners of Health systems betray their first duty: to serve the needs of the most vulnerable in society. The Health Systems were created to help those more in need, not the affluent. But, everywhere, deprived people are subjected in many ways to oppressive discrimination.

As members of the World Federation of Doctors who respect Human Life we must strive at two levels to redress so many wrongs: within Medicine and in the open arena of public policies.

One of the main manifestations of medical respect for human life is the preservation of the human in our dealings with the material basis of humanhood: behind the human genome, the human embryo, the disease processes is always present one man. Inside us dwells the danger of reductionism, that subtle temptation to identify man as a tangle of cellular activities and the diseases of man as the derangement of complex molecular interactions. We begin to yield to reductionistic temptation when, for instance, we boil down some human beings to mere diagnostic tags. When a doctor refers to a handicapped foetus or newborn as a mere pathologic condition, he is in the way to become the easy prey of destructive reductionism. When the human right to have a name is violated, then the victims become automatically depersonalized and reduced to an abstract, non-human entity. When a doctor says colloquially: "This morning I aborted one Down", there is no room in his mind for the human meaning of deficiency. He denounces himself as unable to think in personal terms: he thinks only in terms of chromosomes, but ignores the plain fact of the happy and innocent existence of those suffering from trisomy 21.

For us, Doctors who respect human life, this is another reason, besides rational compassion, to resist stubbornly the imperialistic imposition of the "rights" of the strong: the systematic elimination of handicapped life has a paralysing effect on scientific development. The presence of suffering has played a decisive role in the past in inspiring and energizing the advancement of Medicine. To start our research, we need to have in front of us the victims of disease. The elimination of incurable patients will damp our scientific alertness and indifference will pervade extensive areas of medical research. 

Eugenic fanaticism is in itself not only an aggression to the equality of human rights, but also, and still worse, a violent derogation of the most human of human rights: the right to have defects, the right to be truly human.

Diversity is the salt and pepper of life. Genetic and cultural diversity bestows on each human being the privilege to be different and original, unique and unrepeatable. Thanks to individual diversity, many blessings -biological, personal, and social alike- accrue to humankind, allowing us to adapt ourselves to infinitely varied circumstances. The wonder of diversity is given to us with the DNA we receive at the very instant of conception and increases with familial and social nurture and with our interaction with environmental stimuli. But what is truly great with diversity is the fact that each human being can make of the universe and of all things therein contained an unique and unrepeatable translation, an interpretation performed according to each one's personal key.

We pay for the treasure of biological diversity a high price. The molecular and cellular mechanisms endowing each of us with our uniqueness get sometimes damaged, and, consequently, manifest themselves as a variegated diversity of anomalies and disease. Genetic disease is life's unavoidable accompaniment. As Lewis Thomas puts it: "...The capacity to blunder slightly is the real marvel of DNA. Without this special attribute, we would still be anaerobic bacteria and there would be no music. Viewed individually, one by one, each of the mutations that have brought us along represents a random, totally spontaneous accident, but it is no accident at all that mutations occur; the molecule of DNA was ordained from the beginning to make small mistakes.

To err is human, we say, but we don't like the idea much, and it is harder to accept that erring is biological as well. We prefer sticking to the point, and insuring ourselves against the change. But there it is: we are here by the purest chance, and by mistake at that. Somewhere along the line, nucleotides were edged apart to let new ones in; maybe viruses moved in, carrying along bit of other, foreign genomes; radiation from the sun or from outer space caused tiny cracks in the molecule, and humanity was conceived".

We could not be such as we are if we had not paid the price for the shortcomings and failures. Abnormalities in our genetic machinery are the unavoidable accompaniment of the incredible advantages we have acquired. The blunders are so intrinsic to our nature as the successes.

Thereby, the right to be defective, to have some blemishes and handicaps ranks among the basic rights of man, because error is part of our biological make-up. All of us have the moral duty to show understanding towards our neighbour's errors, since nobody is free from them. They are part of our very existence.

I am hopeful that we will find ways to tell this truth to our colleagues and to all our fellow men. As doctors, we need much more science and much more compassion to cure and alleviate genetic and degenerative diseases. In the meantime, we must become activists of greater tolerance towards biological diversity, with its flaws and bloomers and its successes and wonders. A tolerance that is as essential to our society as are religious or ideological understanding and whose conquest is similarly difficult. This is, in my opinion, the challenge we, doctors who respect human life, must assume in this time of conflict between the rights of the strong and the rights of the weak. Happily, we have made our choice.

Thank you.