Pain management in the elderly and medical ethics
Gonzalo Herranz, department of Bioethics, University of Navarra
Intervention in workshop Gerontology: Pain in Older Adults
Navarre Society of Geriatrics and Gerontology
Pamplona, November 8, 1996
1. The deontological mandate not to discriminate
2. The deontological duty to respect individuals
3. The duty to know more and better
7. The duty not to incur unjustified expenses.
8. Pain, euthanasia and medical suicide financial aid
The Declaration of the World Medical Association ( association ) on the management of severe chronic pain can serve as framework for this intervention. Although it refers to the terminally ill patient, it is applicable, mutatis mutandis, to the geriatric patient. It was promulgated in 1990 and still retains all the force and authority that comes from its origin.
The Preface states: The care of terminally ill patients with severe chronic pain must include medical treatment that allows them to end their lives with dignity and awareness. We have available today analgesics, opioids and non-opioids, which, if used properly, can provide the vast majority of terminally ill patients with effective pain relief. It is incumbent upon physicians and all who care for terminally ill patients suffering from severe chronic pain to have clear insights into the dynamics of the pain experience, the clinical pharmacology of analgesics, and the needs of patients and their families and loved ones. It is also imperative that governments ensure the supply of opioids in the quantities necessary for appropriate treatment of severe chronic pain.
The Declaration continues with the Principles of the clinical management of severe chronic pain, from which I highlight the most salient phrases:
When a patient is terminally ill, the physician must focus his or her efforts on alleviating the patient's suffering. Pain is only one component of that suffering, the impact of which on the patient's life can range from tolerable discomfort to a crushing and exhausting feeling. Treatment must be individualized to meet the patient's needs and to keep the patient as comfortable as possible. The physician must know the potency, duration of action and side effects of the analgesics available, in order to select the most appropriate in each case. And he must also know which is the administration plan that can assure the patient the maximum relief of his pain. The combination of opioid and non-opioid analgesics can provide greater pain relief in patients in whom non-opioid analgesics are no longer sufficient. Such enhanced relief can be achieved without concomitant increase in unwanted side effects. The development of tolerance to the analgesic effects of an opioid agonist can often be overcome by switching to another opioid agonist. The appearance of iatrogenic dependence in a patient should not be considered a major problem in the treatment of severe chronic pain in neoplastic disease. Such an eventuality can never be a sufficient reason for fail strong analgesics in patients who can benefit from them.
This Declaration was proclaimed with the aim purpose to provoke a profound change in the way of thinking and acting of many physicians when faced with the pain of their patients. The WHO analgesic scale was already 5 years old, but the truth is that it had been accepted and put on internship only by very few physicians. Today, many more physicians have learned to treat pain with the necessary energy, but it is still true that there is still a long way to go.
What is the ethical basis for this necessary change in the physician's thinking and behavior in the face of pain? I believe it is closely related to some strong ideas brought about by modern medical ethics. I will devote my entire speech to dealing with them
1. The deontological mandate not to discriminate
This is a mandate to which justice obliges us: to give to each his due. What do we owe the elderly in pain? In my opinion, a great deal.
The demographic importance of the elderly and the high frequency with which the elderly suffer pain, both acute and, above all, chronic, highlights the great extension and the strong intensity of the deontological mandate to pay serious attention to pain in the elderly. A recent data from the United States clearly shows this. The prevalence of the pain symptom among adults aged 60 and over is twice as high (25% vs. 12%) as among adults under 59 years of age. Among the elderly hospitalized or living in long-term care institutions, the prevalence of pain ranges, according to different studies, from 45% to 80%. Among subjects over 65 years of age, more than 80% suffer or have suffered from joint pain.
The problem of pain in the elderly is therefore of great quantitative importance. It cannot be left aside. This is established by the deontological mandate of non-discrimination, one of the first and most important, as it is the one that most directly incorporates human rights in the medical internship . Art. 4.1 of the Code of Medical Ethics and Deontology formulates it as follows: The physician must care with the same conscience and application for all patients without distinction. Age does not appear - although it is understood - among the non-discrimination factors in the current Code of Medical Ethics and Deontology. But it will appear in the next edition.
This criterion of non-discrimination imposes both intellectual and practical duties. First of all, it obliges us to respond to the right of the elderly to receive care like that received by others, free, therefore, of biological prejudices. There is, for example, a tendency to think that the elderly, like group, are no longer entitled to expensive medical interventions. A pessimistic idea about the ability to recover from aggressive interventions tends to dominate, they understand that their pain perception mechanisms are disturbed, that they have stoically adapted to a kind of background pain that no longer disturbs them. Such a prejudice leads one to think that they have little need for their pain to be treated. But that is a false assessment, based on the assumption that the elderly form a group generally affected by dementia.
It is always good to take a brief look at our conscience and examine our dispositions: in our case, the esteem in which we hold the members of that very diverse population that are the elderly. It is an ethical exercise that never hurts.
I propose to my students an exercise to examine the sincerity of their convictions. I tell them that it is very easy not to be prejudiced against the very old if they do not encounter them in their family, or in the immediate environment in which they live. But when you meet real, non-fictional elderly people, things can change. There are seniors who can put to test the solidity of the commitment not to discriminate. I usually read to them every year a short note, published by Paul E. Ruskin in JAMA in 1983, which I use as a problem for attitude analysis.
The aim is to describe honestly and reasonably what one's state of mind would be if one were to lend attendance to cases such as the one described below:
This is a patient who appears to be her chronological age. She does not communicate verbally, nor does she understand the spoken word. She babbles incoherently for hours, seems disoriented as to her person, space and time, although she seems to recognize her own name. She is uninterested and uncooperative in her own grooming. She must be fed soft foods, as she has no teeth. She is incontinent of feces and urine, so she has to be changed and bathed often. She drools continuously and her clothes are always stained. She is not able to walk. Her sleep patron saint is erratic, she wakes up frequently at night and wakes others with her screams. Although most of the time she seems calm and gentle, several times a day, and without apparent cause, she becomes very agitated and has unmotivated crying spells.
The response students tend to give is, in general, negative. "Caring for such a patient would be devastating, a waste of doctors' and nurses' time," say some. The most motivated point out that "a case like this is a very hard test for the patience and vocation of the doctor or nurse. Of course, if many of the geriatric patients were like this, the geriatric specialization program would be for saintly doctors and nurses, but not for ordinary doctors and nurses".
The test continues with the projection of the photograph of the case described: a beautiful little girl of 6 months. There is usually a great commotion of protests mixed with laughter. Everyone is then asked to try to write down whether it is justified, and on what grounds, to treat as charming and full of promise, as a joy of existence, a healthy child who is just beginning her life, while a 90 year old woman is considered depressing, unpleasant or useless. But, according to the doctrine of non-discrimination, both human beings have the same status and dignity, the same rights, deserve the same attention proportionate to their needs and their "symptoms", not to their beauty or appearance.
This is a lesson to be learned in depth and to keep in mind for daily use. We are beginning to talk about age as a limiting factor in medical care, and lists are published of interventions to which those over a certain number of years of age no longer have access or are no longer entitled. The medical Economics needs to ration. The elderly are candidates for exclusion from benefits, which is fully justified in the case where those benefits are useless, but may in many others be seriously discriminatory behavior. In the minds of some, the elderly begin to present themselves as potential candidates, if not for euthanasia, then for some variant of so-called end-of-life medical decisions: non-initiation of treatment or deliberately restrictive treatment.
The duty of justice will often oblige us to act as advocates for the elderly, to oppose discrimination of greater or lesser amounts, so that they receive what is just, not more, but not less. Let us move on to consider a second duty.
2. The deontological duty to respect individuals
An important aspect of this duty is to recognize each one in his or her own peculiarity, to consider each one as a person. There is a physical, bodily level in which this duty towards the human person is expressed, which obliges us to recognize the special biology of the elderly and, in our case, the way of perceiving and evaluating pain in the elderly.
It is said that pain tends to be undertreated in all patients, in all clinical situations. But the elderly are born losers in the battle against pain. Both in acute situations and in chronic pain.
There is an ethical obligation to know the pathophysiology of pain in the elderly in order to treat it well. All physicians, but especially general practitioners and geriatricians, i.e., those who routinely care for patients suffering from pain syndromes, whether acute or chronic, are obliged to be competent in pain management.
Treating pain with skill is, beyond ethics, a duty of skill, a part of the lex artis required by the legal system. Failure to treat pain properly may constitute a crime of negligence.
The following story comes to mind here: the healthcare team of an institution for the reception and care of the elderly was ordered to pay a hefty, multimillion-dollar compensation for inadequate pain treatment to the heirs of a patient who was treated far below what his pain demanded. Those who treated him did not believe in his sincerity, did not believe he was a drug addict, did not give him the credit he deserved as a person. The thing, of course, happened in the United States. But it is very sobering. And, the way things are going here, something similar could happen here any day. That's why the story deserves to be told.
A 75-year-old man is in severe pain due to prostate cancer with multiple skeletal metastases in the spine and both femurs. He suffers from a pathological fracture of one hip. Since weeks ago the analgesic treatment had stabilized at 150 mg of oral morphine every three to four hours. When he was discharged from the hospital, he remained at home for a few months, with pain controlled with the same therapeutic guideline , to which paracetamol and dextropropoxyphene had recently been added. In order to provide him with more continuous care, he was transferred to the aforementioned institution. There, contrary to the opinion of his physician, expressed in a letter, in which he pointed out that the patient had a fatal prognosis and that his only problem was to alleviate his pain by maintaining the opiate treatment that had proved effective, and without consulting him, the director of the institution suspended the morphine, as she considered the patient addicted to opiates, and replaced it with a mild tranquilizer. The patient's pain became destabilized during those last four months of his life. Although he complained, the treatment he was given until he died was never enough to alleviate his pain.
In the condemnatory sentence of the director of the institution, it was defined what can be considered as ordinary, correct and accepted internship , to treat severe pain, in the following terms:
1. It is mandatory to continuously ask the patient about his pain and to believe the assessment offered by the patient. Pain - says the sentence with rare common sense - is a subjective experience that can only be described and measured by the patient; it cannot be the object of an impossible judgment goal made by doctors or nurses.
2. It is mandatory to administer analgesics in sufficiently high and frequent doses to subdue the pain.
3. It is mandatory to treat pain before it returns. This implies maintaining blood levels of analgesics on a permanent basis, which can be achieved by giving medication on a case-by-case basis, not at rigidly preset times.
In fact, such a sentence can change the behavior of doctors and nurses from the outside and give rise to a dangerous defensive pain medicine, as improper as the behavior it seeks to punish, since it destroys the trust between doctor and patient.
Let us remember that there is a deontological mandate, to which I will return later, which requires respect for the convictions of the patient and refraining from imposing one's own convictions on him or her. I think that this does not only refer to political, social or religious convictions, but to the very way of understanding the disease and therapeutic intervention. The legitimate interests of the patient must always be the physician's first concern. As the sentence made clear, to label a patient without objective evidence, imposing on him without further investigation the label of drug addict, is a very serious abuse of power on the part of the physician, it is a profound disregard for the patient's person. The physician can never be a naive and credulous victim of the patient's whims and obsessions. But the physician has the professional obligation to distinguish the authentic patient from the simulator, the drug addict from the patient who depends on opiate medication to relieve pain.
In conclusion, respect for people must lead us to recognize them for what they are, with their specific traits, which must be respected and taken into account as part of their biological personality. Respect for persons commands us to know the peculiarities of each one: also those of the elderly and their pain.
3. The duty to know more and better
We still know little about the pain of the elderly and this knowledge is applied in an unsatisfactory way because it is mixed with prejudices and myths.
We know little scientifically. Closs gives the following data: A review of 18 geriatric care treatises showed that, out of a total of 5000 pages, less than 18 were devoted to pain.
Moreover, we do little research. Of the more than 4000 articles published each year on pain, less than 1% are devoted to pain in the elderly. It is not easy to determine the reason for this neglect of topic so important, but it could well be that we let ourselves be carried away by myths and assumptions rather than by objective and critically evaluated data .
There is an obligation to free ourselves from prejudices and myths, to advance our knowledge and to treat each patient according to his or her needs. I have found three articles that deal with these myths, which must be denounced, which must be overcome. They are things like the following:
For example, that old age and pain are inevitable companions. It may also happen that the elderly person is regarded as a "bag of pain", a body where almost everything creaks and hurts: this tends to downplay the importance of any new pain and to fail to diagnose a new treatable disease. A painful knee due to advanced osteoarthritis does not become much more symptomatic because of suppurative inflammation.
For example, the fear of creating dependence or addiction. But in the case of the elderly, new disadvantages are added: there is a fairly widespread opinion that elderly patients are very vulnerable to the action of opioids, that they do not tolerate them well. It is true that the elderly are more sensitive to opioids, but the status is not solved by depriving them of these drugs, but by reducing the initial dose, in order to find the effective dose in small increments until it is found. It is important to be competent in combining opioids with non-opioids, closely monitoring the patient's response to ensure the efficacy of the treatment. It is not enough to limit oneself to a relaxed and deceitful vigilance: here, as in all medicine, the first thing is to do no harm. It is important to be vigilant so as not to overdo it or underdo it.
Another prejudice, for example, says that the perception of pain decreases with age and that the elderly do not need very intense treatments. It is true that the elderly, after 75 years of age, tend statistically to suffer less pain; and among those who have pain, they tend to have a lower proportion of persistent pain. But we do not know if this is due to an alteration in the genesis and perception of pain, or to a diminished psychic elaboration of pain, or to an adaptation of the elderly organism to the persistent pain status . It seems clear that, in the elderly, the longer the duration of pain, the less likely it is that the patient will complain or simply manifest it. Sometimes, the elderly person manifests persistent pain not in the form of complaints, but in a clinical picture that resembles that of depression: in isolation, apathy, inactivity, lack of communication. But, in any case, a statistical truth is not applicable to each specific case.
At summary, we do not know for sure whether and to what extent the perception of pain decreases with aging. But it seems clear that this idea tends to downplay the importance of pain in the elderly and to diminish the intensity with which it is treated. There may be, at times, a bit of gerontophobia in this.
The elderly are, in general, very unfriendly to creating problems, preferring to put up with rather than draw attention to themselves. They belong to more stoic generations. They often suffer from deficiencies of expression and perception linked to age-related mental changes or dependent on a more or less intense dementia. This makes it difficult to assess the intensity of their pain. In the elderly, the risk of being over- or under-treated is higher: there are excessive responses to age-related treatment and there is also a great deal of fear of them. Many elderly people tend to trust the doctors and nurses who care for them and think that they are always doing everything they can to relieve their pain, e.g., postoperatively. Doctors and nurses tend to believe that someone who doesn't complain doesn't have pain. But that is not true. Some elderly people fear that pain medication may make them drowsy or dizzy and that they may then fall, and they prefer to endure the pain. And the same goes for the dreaded constipation. They prefer to go without pain medication and suffer needlessly.
I think it is worthwhile, in order to reinforce the message, to remember the Ten Myths here1 listed by Edward Martin and which summarize the errors and misunderstandings that physicians and patients alike suffer about the pharmacology of pain, especially cancer pain.
Myth #1: Morphine dose cannot exceed a maximum. Morphine, like other opioid agonists, does not have a maximum dose. It can always be raised to the level necessary to achieve analgesia, while monitoring for side effects.
Myth #2. Patients soon become tolerant to morphine and always need higher and higher doses. In general, tolerance is not a clinical problem. The dose has to be increased because the disease progresses, creates new algogenic foci or intensifies the pain of existing ones. Stabilized patients can remain on the same dose for weeks and months.
Myth #3. Morphine is addictive and should be used with great caution. Addiction is an exceptional problem in the treatment of cancer pain. All patients develop physiological dependence over time, but that is not addiction. Just as there is a dependence on exogenous steroids, there is a dependence on opioids.
Myth #4. Morphine should be reserved for the final stages of the disease, otherwise it will lose its effectiveness. This is a widespread prejudice. Resistance to antibiotics can occur, but there is no resistance to morphine. Pain that is not fully relieved with one dose will be relieved with a higher dose. There is no reason to fail morphine to have it as a reservation weapon for later.
Myth #5. Morphine produces respiratory depression. It should not be used in patients with lung disease. The respiratory depressant effect of morphine wears off within a few days and does not usually create problems in the treatment of cancer pain. Moreover, everyone knows that morphine reduces dyspnea in cancer patients.
Myth #6. Patients who need more frequent or increasing doses of morphine or who continue to have pain despite morphine have become addicted. The reasons for that failure may be inadequate dosing, a decrease in the life average of morphine in that patient, or disease progression. But not that the patient has become addicted.
Myth #7. Parenteral administration of morphine is more effective than oral administration. It is true that the dose is different because of the destruction of detoxified morphine in its first passage through the liver. But oral administration is the ideal route: ease of administration, low cost, variety of fast-acting and slow-release forms, better patient control due to the stable blood levels obtained.
Myth #8. The patient treated with morphine becomes a zombie. This is the argument that, according to Dr. Kevorkian, is given by patients who ask him to help them commit suicide. Sedation is common at the beginning of treatment, but tolerance to this action soon develops. The vast majority of patients receiving morphine are awake and on their feet, and in any case present a very slight Degree sedation.
I believe that overcoming these myths is both an ethical obligation and a duty of skill professional. It is time to talk a little about the latter.
To prevent, to save pain, is an ethical attitude. Prevention is a dimension of great moral value. Pain prevention is important in perioperative status . Anesthesiologists know that pain can be treated very effectively before it occurs. In orthopedic procedures, which are almost always so painful, the amount of opioids needed for postoperative analgesia can be greatly reduced by premedication preoperatively, including regional nerve block analgesia, or with preoperative doses of nonsteroidal anti-inflammatory drugs. It has been seen that not only the postoperative pain is less and needs less doses to reduce it, but that postoperative rehabilitation can start earlier and be more intense, the follow-up invitations to take a deep breath, to blow hard through the spirometer are accepted much better than moving and wandering, or eating.
Pain and atonement. Hedonism and rejection of pain.
In our society today, as in the past, two polar attitudes of man in the face of pain are confronting each other. The one that finds no meaning in pain, considers it an incomprehensible tragedy, even as the only evil that must be rejected. And that which, going beyond the conviction that pain is not only part of the human condition, but that it has a purifying and sacrificial meaning, considers pain desirable in itself and as a means for the moral realization of the person.
In one case or another, pain, apart from the biological function of being a symptom that denounces the presence of disease and obliges therapeutic intervention, acquires a meaning, in the lack of it or in its exaggeration, that denaturalizes it. As opposed to hedonism and pain, pain has, in the Christian tradition and in many other cultures, a religious value: salvific and penitential, compatible with the human need to alleviate it.
What should the physician's conduct be in the face of a patient who wishes to suffer, to endure pain in a Christian way, and to give it a redemptive meaning? These are patients who wish to abstain from the use of painkillers, or to moderate it, in order to accept at least a part of the suffering and thus associate themselves consciously and voluntarily with the sufferings of Jesus Christ. As long as the pain is not alienating, respect for the autonomy of the patient who wishes to suffer obliges the physician to accept the status desired by the patient, while offering his partnership for when it is deemed necessary.
But there is no doubt that this attitude of acceptance has its limits. Unbearable, continuous pain becomes in the long run an obstacle to higher interests and goods, as Pius XII said. Pain that is too intense deteriorates the psychophysical integrity of the person, causes biological damage, and seriously impedes man's spiritual control over himself. For this reason, it is legitimate - and, beyond certain limits, ethically obligatory - for the physician to intervene to prevent, alleviate and eliminate pain. It is always right to try to bring pain under man's control. Analgesia, by eliminating the most aggressive and disturbing effects of pain, gives the person more control over himself, thus humanizing pain and making it a human experience.
Thus, the desire to suffer as long as the patient's dignity is not degraded should be respected. If pain reaches levels that are incompatible with that dignity, it should be treated. "Sometimes the use of analgesic and anesthetic techniques and medicines involves the suppression or diminution of consciousness and of the use of the higher psychic Schools . Insofar as such procedures do not directly aim at the loss of consciousness and freedom, but at the dulling of painful sensation, and are practiced within what is clinically necessary, they are to be considered ethically legitimate." Moreover, as Pius XII said as early as 1957 and as the Congregation for the Doctrine of the Faith confirmed in its declaration on Euthanasia in 1980, the use of painkillers is licit even when they might entail the risk of shortening life, provided that there is no other means of alleviating the pain; the use of painkillers that deprive the use of conscience is licit, provided that the patient has had time to fulfill his religious and moral duties towards himself, his family and society. But the dying person can never be deprived of his conscience unless there is a proportionately serious reason (Pius XII).
The voluntary acceptance of pain surprises the cultivators of medical ethics who have a hedonistic bias. It is not easy for them to understand that the voluntary acceptance of pain is a way of humanizing it and giving it its supreme meaning: sharing in the passion of Christ, of union with the redemptive sacrifice He offered for the world.
7. The duty not to incur unjustified expenses.
Wendy Stein has studied the problem of what poorly treated pain costs. She tells us about the costs to the patient, to families, and to health care professionals.
Poor or neglected pain treatment causes the patient much harm: it increases his or her psychological vulnerability and leads to more frequent need for psychiatric care and, consequently, to additional consumption of psychotropic drugs. Although suicide in the cancer patient is a rare event, in general and in comparison with other end-stage diseases such as AIDS, poorly treated pain, and the fear that the pain will be unbearable, are well identified and measured added risk factors. Hence the ethical importance of treating pain well and being available to treat it.
Pain depresses immune function: the first evidence that something similar is happening in humans is being added to the experimental data .
The patient's quality of life, its physical, functional, emotional, social and spiritual components depend on the quality of pain management. The WHO has stated in one of its documents that: Nothing has a more immediate impact on quality of life than pain relief, not only in the cancer patient, but also in their families. For this, it is sufficient to put on internship the accumulated knowledge in the field of palliative care.
Poorly treated pain affects the family. Even at the descriptive level. Ferrell's programs of study shows that family members do not describe pain only as something referred to the patient's Anatomy , but as something that is reflected in the family member himself: pain is desperate, crushing, worse than death, overshadows the future. The patient's pain, especially the pain that seems gratuitous or not mitigated by a well-adapted treatment, is suffered with identical intensity by the immediate family members. It is a moral pain for which they feel somewhat guilty.
Poorly treated pain takes a heavy toll on physicians and nurses. In an almost lapidary phrase, it has been stated that the most frequent form of narcotic abuse is undertreatment of the dying. It is still very high issue of physicians who under-treat the pain of the elderly.
Society pays a high price for this insufficiently treated pain. Failure to treat in time with simple forms of analgesic therapy leads to more expensive, invasive interventions, which instead of being carried out at the patient's home, have to be performed in the hospital, with emergency admissions. Five percent of emergency admissions to a group of American hospitals were made under the diagnosis of uncontrolled pain. Of these cases, a quarter were not admitted for the first time for this reason: they must have been admitted before. They were in hospital for an average of 12 days, which is a tremendous cost if data is extrapolated to a whole country. The possibility of saving suffering and money is a reason that must appeal to the physician's ethics and urge him or her to be an expert in the management of the primary and very effective procedures for treating pain.
No health Economics should be subjected to the terrible failure of paying the invoice of poorly treated pain.
8. Pain, euthanasia and medical suicide financial aid
The competent treatment of pain has an added ethical and social value of enormous importance: it is the main buttress of the wall that can oppose the introduction of euthanasia and the internship of the financial aid medical to suicide.
It has hardly been mentioned, but agreement with the new Penal Code, in force since last May, euthanasia is practically decriminalized in Spain. This is not the case, paradoxically, with financial aid to suicide. The legal argumentation is a bit laborious and this is not the place to adduce it. But my thesis is clear: either we physicians treat our patients diligently and with skill and we use ourselves thoroughly and sincerely in the treatment of pain, or we will contribute to increasing the social pressure in favor of euthanasia, given that the medical financial aid to suicide is a closed path in Spain.
And that would be a tragedy of incalculable consequences for our medical vocation. The social climate created by the tolerance of euthanasia causes a growing deterioration, even brutalization, 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 and social permissiveness, tolerating euthanasia begins to mean that painless killing is an exceptional way of treating certain diseases, authorized only for extreme and very strictly regulated situations. But, without delay, inexorably, as a result of social habituation and pro-euthanasia activism, decriminalization ends up meaning that killing for compassion is a standard and de facto accepted therapeutic alternative.
And so effective that physicians cannot morally refuse it. The reason is obvious: euthanasia -a clean, fast, one hundred percent efficient, painless, compassionate intervention, much more comfortable, esthetic and economical than palliative treatment- becomes an invincible temptation for certain patients or their relatives. And also for some physicians, since the sweet death of one or another of their patients saves them a lot of time and effort: the time and effort they invest in following the patient day by day, in alleviating his symptoms and pain, in visiting him, in accompanying him in the difficult final moment.
In this status, the serious thing for physicians is that their specific virtues - compassion, prevention of suffering, non-discrimination among their patients - are turned against them, so that they are driven by their own professional virtues to apply with ever greater zeal this very efficient therapy internship : they cannot deny a patient the liberating death that, 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 be dispensed with, as has been demonstrated by that social laboratory which is Holland with its legal tolerance of euthanasia, or it will be increasingly broadened; the indications for euthanasia will become more extensive and earlier.
The physician who has succumbed to the temptation of sweet death and performed euthanasia, either repents sincerely and definitively, or will no longer be able to stop. Because if he is ethically congruent with himself, and believes that he is doing something good, he will have to continue to do so in less and less dramatic cases and, in the name of his compassionate ethics, by skirting the legal barriers. For if the law only authorizes euthanasia to those who ask for it expressly, seriously and unequivocally, what reasons can the physician who has performed it in accordance with the law give for denying it to those who are incapable of asking for it, but whose life is more painful or more degraded or much more burdensome for others?
The utilitarian may conclude that there are situations in which the desire of certain patients to continue living may be irrational and capricious, because they have an abhorrent prospect of life ahead of them. He reasons as follows: the lives of certain patients capable of making decisions are so lacking in quality, cause such an exorbitant consumption of resources, are so abusive to others, that they are not worthy of being lived. To insist on living them is an unjust desire, which entails an irrational consumption of economic and human resources: that money and that work effort could be much better used.
It is repugnant, at first, to make this argument, but with time it becomes easier and easier to expropriate the patient's freedom to choose to continue living. In fact, in the Netherlands, in the study on euthanasia at internship in primary care, general practitioners confessed that 10% of euthanasias are performed on patients who are conscious and capable of consenting to or refusing the intervention, but to whom they say nothing for paternalistic reasons: they would not be able to understand the nature of the euthanasia intervention.
The loss to medicine is not only one of humanity. It is also a loss of science. If physicians 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 research in vast areas of pathology would wither away. For if the senile patient or the patient suffering from Alzheimer's disease could be given the sweet death, who would be motivated to study the causes and mechanisms of brain aging or the constellation of factors that determine dementia? If the patient with advanced cancer is offered death 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 or the future pharmacology of pain? No palliative treatment could compete with the cheapness of euthanasia. All the mental and moral effort, the tension, sometimes exhausting, to comply with the Hippocratic precept of seeking the good of the patient, to do everything the physician knows and can for the benefit of the patient, to strive not to do him harm or injustice, would suffer, in a society tolerant of euthanasia, an atrophy by disuse.
Once the law is in force, how long will physicians be able to resist, at first, the requests - later on, the demands - for homicide addressed to them by patients and their relatives? The legal penalty is so easy to bear, and the indulgence of the courts so likely, that a physician who objects to euthanasia may be regarded as not very humane, not very compassionate. I have no doubt: the scientific values of medicine are impoverished when part of them are absorbed in euthanasia.
With each passing day, I am convinced that terminal medical care, palliative care, contains an ethic of great density: it is in itself a dimension of medicine that cultivates and enriches the most intimate and basic ethical values. It is, moreover, the antidote that can protect us against the temptation of euthanasia, which is both frightening and attractive.
A highly effective antidote. Even the most upright doctor and nurse need to guard against the excesses of their virtues. To decriminalise euthanasia would be to plunge medicine into the self-aggressive disease of counterfeit compassion. The obligation to respect and care for all human life is a wonderful and inspiring moral force. With it, we must develop the theory and the internship of palliative, scientific and humane care, which will uproot from our hospitals the scandalous error of therapeutic overkill and which will highlight, by contrast, the cold inhumanity which, disguised as compassion, is hidden in euthanasia.
Doctors who, in hospitals and homes, apply palliative and geriatric care with humanity and science are doing much for the ethics of the health professions. The care they lavish on their patients is saving medicine from the great danger of becoming an accomplice of the strong against the weak.
[1] Dr. Herranz lists only 8. There are several variants of these myths.