conference proceedings of congress International Bioethics 1999. Bioethics and dignity in a pluralistic society
Table of contents
Euthanasia and the dignity of dying
Gonzalo Herranz.
Director from department de Humanities Biomédicas.
University of Navarra.
II. The dominant interpretations of the idea of dignity when talking about the dignity of death
1. The Dignity of Dying in the Pro-Life Context
- Religious tradition
- Human rights culture
- The rules and regulations ethico-deontology of medicine
- Bioethical reflection
3. Dignity of Dying in the Pro-Euthanasia Context
III. The special human dignity in the trance of terminal illness and the dying process
The framework imposed by the general degree scroll of these conference, Bioethics and Dignity in a Plural Society, makes it necessary to deal with euthanasia and the dignity of dying from the various and conflicting perspectives that circulate in today's ethically fragmented society. I have been given the task of referring to how the concept of dignity is used in the intense and never-ending discussion around euthanasia.
The task is not easy. Firstly, because much has been written about topic: the database Bioethicsline (up to the end of 1998) contains more than three hundred bibliographical references on euthanasia and dignity. Secondly, because the word dignity has acquired a special rhetorical force in the debates on euthanasia or financial aid medical suicide, and has logically been used with purpose to persuade both those who promote and those who reject it: what is the dignity of dying has become the main question confronting the opposing cultures of life and death1 . Thirdly, because the terms euthanasia and the dignity of dying are themselves victims of a harsh and deliberate polysemy: they mean, in different contexts, different and confusing things2. Thus, in addition to the abundance of material available, there is also lexical confusion and dialectical polarisation.
subject And yet, since the misleading idea of dying with dignity is so closely linked to the behaviour (palliative or euthanasic) of the doctor caring for the terminally ill and dying patient, it is understandable that, from the point of view of medical ethics, we are facing a major topic . The medical profession cannot avoid a serious discussion of death and dying in their relationship to human dignity.
Since, at the beginning of our meeting, an analysis of the notion of human dignity in the bioethical context was made, in what follows I will limit myself to dealing with two issues: one is to gather, simplifying things to the maximum in two polar positions, the essence of the interpretations that are made, in today's plural society, of the dignity of dying; the other is to rehearse a personal interpretation of the peculiarity that human dignity acquires in the trance of terminal illness and in the process of dying.
II. The dominant interpretations of the idea of dignity when talking about the dignity of death 
Today's different attitudes towards the relationship between human dignity and death can be reduced to two polar positions.
One proclaims the intangible dignity of every human life, even in the trance of death: all human lives, for their entire duration, from conception to natural death, are endowed with an intrinsic, objective dignity, possessed equally by all: this dignity surrounds every moment of human life with an aura of nobility and sacredness that is unmistakable.
The other affirms that human life is a precious good, endowed with an excellent dignity, which is unequally distributed among human beings, and which, in each individual, undergoes fluctuations in the course of time, to the point where it can be extinguished and disappear: dignity consists in quality of life, in a well-founded aspiration to excellence. When quality falls below a critical level, life loses its dignity and ceases to be a highly esteemed good. Without dignity, human life ceases to be truly human and becomes dispensable: that life is no longer life3 . Anticipating death, then, is the desirable solution when life loses its dignity.
And yet, pro-life and pro-euthanasia attitudes coincide on one major point: the condemnation of therapeutic incarceration which, in addition to being bad medicine, is a serious attack on the dignity of the dying.
1. The Dignity of Dying in the Pro-Life Context
As noted above, in the ethical tradition of respect for life, human dignity is invariable: it is not diminished by illness, suffering, malformation or insanity. Moreover, biological or psychological adversity can be an occasion for further ennoblement: as John Paul II affirms, man's great dignity is confirmed in a special way in suffering4. Man does not live in a paradise of friendly ecology. He lives with risk and hardship, in a natural environment, to which he is exposed and in which his vulnerability and strength, his finitude and dignity, must be integrated.
The dignity of dying, in the pro-life context, is supported by religious tradition, the culture of human rights, the professional ethics of medicine, and bioethical reflection.
Religious tradition
The biblical-Christian tradition proclaims respect for life, affirms that human dignity is shared equally by all people, and assures that this dignity does not succumb to the passage of time or be degraded by illness and the dying process.
In this tradition, man, every man, is a being of intrinsic worth and dignity, a moral agent, manager and free, who, being imago Dei, is absolutely resistant to ontological degradation5. Consequently, respect for the intangible dignity of every human life extends also to the time of death: all human lives in their entire duration from conception to natural death are endowed with an intrinsic, objective dignity, possessed equally by all: this dignity surrounds every moment of human life with an aura of sacredness.
God, mysteriously, creates us in his image and likeness also when our appearance and biological value are diminished by illness or malformation. Thus, Yahweh says to Moses6: "Who has made man's mouth? And who has made him dumb, or deaf, or seeing, or blind? Was it not I, the Lord?"
This understanding of man as the image of God, even in spite of his handicaps and deficiencies, gave an immense moral superiority and incomparable humanity to the Mosaic law, when compared to other legislation of antiquity. What is distinctive about it is that it is no longer acceptable to mark as unworthy the weak, the poor and the blind, widows and orphans, slaves and foreigners.
With Christ and through his Incarnation, humanity is further dignified, for, with the call to adoptive divine sonship, man's likeness to God is strengthened. Man is not only the image of God: man is invited to become a son of God, a dignity that cannot be surpassed, for there is no more nobility, no more value. The recognition of the value of human weakness is, in the biblical tradition, universal, for God is no respecter of persons7. All members of the human family, the strong as well as the weak, are of equal value before God: we all possess the same dignity. "There is only one race: the race of the children of God", said Blessed José María Escrivá in a synthesis that sums up the whole anthropology of dignity, a dignity that comes from each and every one of us participating, without distinction and mysteriously, in the divine filiation8.
The Encyclical Evangelium vitae, based on biblical sources, highlights the dignity of the entire temporal journey of every human life: it speaks of the dignity of the unborn child and of the halo of prestige and veneration that surrounds old age. The supreme weakness of Christ on the Cross is not only the full revelation of the Gospel of life, but it is precisely the moment that reveals his identity as the Son of God and manifests his glory9.
It is worth considering for a moment what this revolutionary novelty meant for the world at the time, for the modern euthanasia movement incorporates somewhat neo-pagan ideas. Ancient medicine was not blind to the dignity of dying. Extreme, irreversible weakness did not then seem worthy of attention. In antiquity, the doctor's dictum to the dying person "nothing more can be done" was followed to the letter. The doctor abandoned the incurable. In the Hippocratic tradition, the physician refrained from giving poison to his patient in order to end his life. That was all: the physician had no medicines, neither heroic nor euthanasic, with which to help him. Therapeutic futility made it necessary to respect the natural course of the untreatable disease. Plato sums up the attitude of Greek medicine, including the school of Hippocrates, with these words: "Aesculapius taught that medicine was for those of a healthy nature who were suffering from a specific disease. He delivered them from their malady and commanded them to live normally. But to those whose bodies are always in an unhealthy internal state, he never prescribed a regimen that would make their life a more prolonged misery. Medicine was not for them: even if they were richer than Midas, they should not be treated"10.
This blindness to weakness as a specifically human attribute continues to affect today's rationalist and pragmatic-minded people, the followers of the philosophies of efficiency, power or vitality. In the face of incapacitating illness or approaching death, they feel an instinctive distaste: life, physically or intellectually impoverished, causes them much unease and a flight reaction. They prefer to ignore or extinguish it. Nietzsche took this rejection to the extreme. Based on the demands of reason, feeling and instinct, he made the fundamental will to be healthy the fundamental principle of human dignity. It is not difficult to find a Nietzschean fibre in the complex fabric of today's pro-euthanasia mentality. The vital and sure will of instinct does not incite to respect the sick, to pity the weak. On the contrary, it impels to contempt, even to annihilation, for helping the weak is the morality of slaves.
Human dignity was never, in pagan antiquity, a universal human attribute. There was certainly a sense of dignity among the classics, but it was the dignity of the excellent, virtuous man, who lived in a position to develop his virtues, his human excellences. The Roman concept of humanitas was used to describe the dignity of a well-balanced and educated personality, who was found exclusively among the most outstanding individuals of the Roman aristocracy. Dignity was not intrinsic, nor were human rights. Large social groups lacked them. Inequality was a natural feature of society. It was accepted as an inevitable reality that there were slaves or foreigners, destined for hard or degrading labour, who might be tortured or consumed in productive labour or entertainment. Physical wholeness was an essential element of this aristocratic human dignity: the chronically ill, the crippled or the deformed were considered unworthy and their death was encouraged by exhibition and withdrawal11.
Human rights culture
It should be noted, however, that the notion of the universal dignity of man, and in particular that of the dying, is not only religious: it has also become part of law. Thus, for example, a Recommendation of the Parliamentary Assembly of committee of Europe on the rights of the sick and dying invites governments to "define precisely and grant to all the right of the sick to dignity and integrity"12. The Parliamentary Assembly has recently reinforced its position at the end of a recent discussion (June 1999) on the protection of human rights and dignity of the terminally ill and dying13 , by reiterating the absolute prohibition of active euthanasia and affirming that "the wish to die of terminally ill or dying patients does not constitute any legal right to die at the hands of another person". What is more, respect for life and human dignity constitutes, according to some, a right that must be respected all the more when the dying person is weaker. Indeed, the French National Ethics Committee for Life and Health Sciences, committee , in a declaration on internship of experiments on patients in a chronic vegetative state14 , pointed out that "patients in a chronic vegetative coma are human beings who are all the more entitled to the respect due to the human person because they are in a state of great fragility". Here the concept of the direct proportional relationship between frailty and dignity is precisely expressed: the weaker the patient, the greater the respect for the doctor.
The rules and regulations ethico-deontology of medicine
The ethical precept of not killing the patient has been present and fully preserved in the professional ethics of physicians since its very origin in the Hippocratic Oath. A comparative analysis of the standards of medical care for the terminally ill patient in the codes of ethics and deontology of 39 national medical associations in Europe and America has shown the profound unity of the common tradition: alongside the unanimous condemnation of euthanasia and medical suicide financial aid and the firm rejection of therapeutic incarceration, quality palliative care is recommended as a measure proportionate to the dignity of the dying person. Indeed, many codes invoke the protection of the human dignity of the chronically or terminally ill patient as a fundamental reason for diligent treatment of pain or suffering15.
Bioethical reflection
The argument in favour of the inextinguishable dignity of every human being and, in particular, of the dying, has been the subject of study since the birth of bioethics. Moreover, it must be acknowledged that some of the most inspired and profound reflections were produced in the early years of the young discipline.
One of them is due to Paul Ramsey. Wary of the possible perverse uses of the phrase "dying with dignity", as an ideal and as a right, and disconsolate at the loss of human dignity that all death is, he rebels against the idea that there is an intrinsic dignity in human death and dying, for both as the end of bodily life and as the end of life staff, death is the Enemy: true humanism is linked to the fear of death. Therefore, Ramsey concludes, it is better to accept the indignity of death than to try to dignify it, for we will always take better care of the dying if, in addition to relieving them of pain and suffering, we recognise that death is a mourning that no resource within man's reach can alleviate16.
Kass's17 response to Ramsey, both in his analysis of the notion of dignity and in his rehabilitation of the death-dignity conjunction in his natural and biblical instructions , is an essential starting point for understanding the valid meaning of death with dignity. Years later, in 1990, already in times of vigorous propaganda in favour of euthanasia, Kass further developed his ideas by analysing the connection between the sanctity of life and human dignity and reanalysing in its light the ideas of death with dignity that were already circulating at that time18 . It is necessary to appreciate, on direct reading, the tempered dialectical force of his arguments against the claims of euthanasia advocates, when he assesses the risk of hubris of modern medical technology, the temptation to put a technological end to the failure of death aggressively, and the need to accommodate to living with the idea of mortality and finitude. He argues forcefully that, in the presence of incurable and terminal illness, there always remains a residue of human wholeness that, however precarious it may seem, must be cared for. If we are to oppose the rising tide that, driven by the pro-euthanasia mentality and the ethics of free choice, threatens to submerge the best hopes of human dignity, we must learn that human finitude is no misfortune and that human dignity must be attended to and cared for until the end.
In more recent times, the concept of dying with dignity has been constantly analysed and deepened. Many are trying to wrest it from the hands of euthanasia advocates who have tried to appropriate its exclusive use.
Among these analyses, two are worth citing. Sulmasy19 , after concluding that the essence of human dignity is nothing more and nothing less than the esteem and honour that human beings deserve simply because they are human. To seek always and at all costs to prolong merely biological human life is to deny the truth of human mortality and thus to act against human dignity. Similarly, to put a patient to death, even if he or she is already dying, is to say that the man's life has lost all meaning and value: but this is to act against human dignity, for human dignity does not depend on social standing, freedom or pleasure, but on the fact of being human. Human dignity is not subjective: no one can increase, diminish or annihilate his own dignity at whim, nor can he do so with the dignity of another. And so it is with illness and dying: they can humiliate, diminish self-esteem, shame and even create a sense of unworthiness. But these assaults do not kill it, they do not diminish it: they disturb us precisely because they raise the issue of whether human life has meaning and value, has dignity.
Sulmasy describes how different in the expression of dignity patients' deaths can be: from those who face dying with courage, hope and love, to those who do so in fear, rebellion, despair or self-loathing. Both must be treated with dedication and respect. It is a tremendous task refund to give certain patients faith in their own dignity and to make them feel, in the terminal status , sometimes totally lacking in aesthetics, that their life still has value and dignity. That is a hard test for the doctor and the nurse, but that is what caring for the dying is all about. As Sulmasy says, "there would be no greater assault on human dignity and, ultimately, no greater suffering than to say to one of these patients, looking them in the face, 'Yes, you are right. Your life is meaningless and worthless. I will give you death, if you want it'". The dying must know that, for their physicians, they never lose their human dignity and that they remain in possession of all their value and esteem: their lives always retain a full measure of meaning and dignity.
Stolberg20 , after concluding that the notion of human dignity cannot be sustained only by the Kantian's capacity for rational self-management, nor by the existentialist's freedom that persuades us that we are not mere things, because it would lead to the pessimistic conclusion that the dying and the comatose would lack human dignity. Indeed, to say that human dignity can be diminished or lost through illness and suffering is tantamount to saying that human dignity depends on the ability to control uncontrollable things such as ageing, handicap or terminal illness. Stolberg argues, analysing the relationship between human dignity and equality, that man cannot cease to be human, which means that he is part of nature. The idea of considering natural phenomena as degrading or demolishing human dignity is based on the false dualism that presents dignity and nature as antagonistic, making the natural the enemy and destroyer of what is properly human. This is tantamount to identifying dignity with physiological well-being or even with the psychic integrity that makes possible the exercise of rationality, autonomy or self-awareness plenary session of the Executive Council . But these qualities are very differently distributed among the dying, so they cannot be a basis for equal rights and dignity in the dying trance. In order to restore a truly realistic and indisputable basis for the radical equality of human dignity, Stolberg turns to G. Marcel's idea of seeking in the mortality and precariousness of man the yardstick of the common human condition that establishes the level of equal value and essential equality. From the confrontation with the finitude that awaits us all comes the awareness that we men share the experience of pain and sorrow, illness, ageing and death, an experience that brings us together in the construction of common dignity. Stolberg concludes that it is contradictory to argue that these experiences threaten human dignity, understood as an equal value.
2. The universal condemnation of therapeutic incarceration, an attack on the dignity of the dying person.
The obligatory reference to the ethical condemnation that therapeutic incarceration has received barely deserves more than a few lines. The condemnation is universal: it comes from pro-life bodies as well as from the ranks of pro-euthanasia; from professional organisations of doctors and nurses as well as from national and international bioethics committees. The B thing is that all these condemnations, wherever they come from, point out that therapeutic obstinacy is an attack on the dignity of dying.
No one today doubts that therapeutic obstinacy is a medical and ethical error that is very difficult to justify. Everyone shares the idea that deliberately useless treatment when there is no longer any reasonable hope of recovery, particularly when it causes pain and isolation, violates the dignity of the dying person.
The bibliography on medical futility is nowadays vast, as commentaries on the dramatic death of certain public figures, on the jurisprudence on particularly complex clinical cases, and on the multitude of guidelines issued by different professional bodies have multiplied.
Suffice it for sample two testimonies on the connection between dignity in dying and therapeutic moderation, which come from opposite ethical positions. The Declaration Iura et bona of the Congregation for the Doctrine of the Faith21 described it succinctly as follows: "It is very important today to protect, at the moment of death, the dignity of the human person and the Christian conception of life against a technicality that risks becoming abusive. In fact, some speak of the 'right to die', an expression that does not designate the right to procure or have death procured at will, but the right to die with serenity, with human and Christian dignity". The medical critic, Richard Taylor, expressed himself with acerbic harshness about the therapeutic abuse of the intensive care units of the 1970s in these terms: "Rows of physiological preparations, otherwise known as human beings, lie surrounded by an astonishing issue of mechanical contrivances ...] Through innumerable tubes, liquids of a thousand colours are injected or drained. Ventilators pump out gases, dialysis machines chug, monitors set off their alarms, oxygen bubbles in humidifiers. The unfortunate prisoners of technology, fortunately oblivious to what is going on around them, either because of the drugs or their illness, lie helpless, while the ritual desecration of their dignity is performed"22.
3. Dignity of Dying in the Pro-Euthanasia Context
It is not easy to find an articulate and coherent doctrine on the dignity of dying in the publications of euthanasia advocates. A search in the glossaries that pro-euthanasia movements maintain on the Internet is fruitless: neither the extensive glossary of the Scottish Voluntary Euthanasia Society23 , nor that of ERGO, the intellectual arm of Exit, the powerful American group led by Derek Humphry, includes entrance Dignity24.
The use by euthanasia advocates of the expression dying with dignity has a more opportunistic and rhetorical than substantive purpose . Although dying and death are for many people today an unmentionable taboo, in the dynamics of pro-euthanasia movements they lose their negative meaning or transmute it, when combined with dignity, into a new and acceptable one. And so it turns out that many of the associations that advocate the decriminalisation of euthanasia and of the medical financial aid suicide have called themselves with terms that combine death and dignity25 . And, curiously, the only law in force in the world authorising physician-assisted suicide internship , passed in the State of Oregon, is called, by a manipulative play on words, the Death with Dignity Act26.
The ideological project underlying the mentality of death with dignity or the right to a dignified death consists in the acceptance that human dignity is undermined, or even treacherously destroyed, by suffering, weakness, dependence on others and terminal illness. It is therefore necessary to rescue the dying process from these degrading situations by means of resource to euthanasia or physician-assisted suicide.
The decision to avoid the final deterioration of the quality of life and to maintain control of oneself and one's own dignity in the last days, is favoured by the peculiarity of the sources of information about death available to people today. On the one hand, very few have the opportunity to witness a peaceful death. The death of loved ones, apart from being a phenomenon that everyone rarely has the opportunity to witness in their lifetime, usually happens today in the hospital, not at home. The lack of interpersonal intimacy that this entails is aggravated by the intense medicalisation of dying. On the other hand, the media inundate us with stories and images of a thousand forms of gratuitous, violent or tortured deaths. This creates a collective rejection of death, because no one would ever want to die in any of these ways. And since it is necessary to die, we all, in principle and instinctively, want to do so with dignity and decorum, preserving the nobility proper to man.
Against this background, the pro-euthanasia mentality constructs its notion of dying with dignity by assigning moral suffering, physical pain, incapacity, dependence on others, and terminal illness a negative value, destructive of human dignity. Dignified death is the only solution to put an end to the permanent indignity of living these lives overloaded with negative values, devoid of vital value.
We also live in a time when medical decisions are made on the basis of the patient's active and informed choice of the treatments he or she accepts or refuses. Consequently, the right of patients to decide, together with the fear of finding themselves in a painful agony and usurping self-control, leads to a desire to die with the maximum comfort and mastery of circumstances: in other words, a right to die with dignity is created27.
The right to die with dignity is invoked as a right that guarantees the possibility to live and die with the inherent dignity of a human person, and as resource to free oneself from the agony of living in a state of emotional or psychological misery. Biological decay, not being able to fend for oneself and being dependent on others for the most common actions and functions, are considered, in the death with dignity mentality, as sufficient reason to claim the right to die in order to prevent human dignity from being undermined and ruined by extreme disability, dependency and suffering.
But is human dignity really lost when one is very ill, very weak, or cannot go on living except with the help of others financial aid ?
Basically, the euthanasia mentality's notion of dignity is totally alien to the pro-life mentality's concept of dignity. The latter has an ontological basis: dignity is intrinsic, universal, inalienable, immune to the influences of fortune or grace, refractory to the process of dying. The former, though important, is accidental. Social dignity is a variable dependent on numerous circumstances: the passage of time, the possession of money, influence, physical prestige, class or titles; it is possessed, but can diminish below a critical value until it is lost. It is especially sensitive to social and aesthetic influences.
This submissiveness to social and subjective influences is the reason why the dignity of dying continues to be invoked as a right at a time when progress in palliative medicine has led to the decline of the notion of euthanasia as a release from unbearable pain. The pro-euthanasia movements have therefore been forced to put the paradigm of killing out of compassion for the intolerably suffering in the background and to take a new direction: that of presenting the dignity of dying as a right expressing one's absolute mastery over one's own life, or as a sign of personal decorum. In the new context, the enemy is no longer advanced disease, which, through pain, suffering or the total weakness of cachexia, encircles human dignity: the new enemy is the loss of self-sufficiency, the inability to live independently of others, having to die while renouncing one's previously prestigious and aesthetic social image.
Terminal illness can severely wound one's social dignity, one's image in the eyes of others. It is not surprising, therefore, that in recent years, pro-euthanasia movements have tended to present the demand for the right to die with dignity as the crowning achievement of ethical progress, the crowning achievement of far-sighted, forward-thinking people who form a cultural elite, a minority emancipated from prejudices and superstitions.
Surveys have shown that there is a close correlation between social class and Degree of intellectual self-esteem on the one hand, and adherence to pro-euthanasia activism on the other. In pamphlet literature and on websites, euthanasia advocates present themselves as the leaven in the dough, as leaders and liberators who will transform society. The arguments and examples put forward by euthanasia advocates, usually overloaded with strong rhetoric, remain, both in society and in the health professions, the preserve of a minority. Medical professionals have pointed out a serious risk of this elitist attitude: that of endangering the palliative care of entire groups of people (elderly, disabled, terminally ill patients) by skilfully manipulating their feelings in favour of the euthanasia of a small elite. Ultimately, the pro-euthanasia mentality aims to force society to choose between provoked and painless death, as a supposed means of preserving human dignity, and the attention and care of the terminally ill, with the vicissitudes and precariousness of life that is coming to an end28 .
It is therefore not surprising, but comforting, to learn that, compared to the general population, adherence to euthanasia is markedly lower (50%) among those affected by functional impairments, those who feel a burden to the family, or those who see their life as futile. In the United States, support for physician-assisted suicide is markedly lower among the elderly, African-Americans, the poor and those who practise religion29.
Pro-euthanasia activists repeat ad nauseam that the choice to die with dignity is closely linked to the right to choose the time and manner of one's own death according to the criteria of a hedonistic ethic. As the Plea for Beneficial Euthanasia paradigmatically pointed out, when life lacks dignity, beauty, promise and meaning, and death is delayed with endless periods of agony and vital degradation, it cannot be said that this is the life of a human being, because to tolerate or accept unnecessary suffering is immoral30. Unfortunately, there are many doctors who, through ignorance of the advances in pain treatment and palliative care, can become provocateurs or accomplices in the call for euthanasia31.
The elitist arrogance and fascination with death32 of the pro-euthanasia mentality could, should euthanasia achieve legal sanction, deprive many patients of the benefits and dignity of palliative care, a humble but immensely humane branch of medicine and nursing. One can only speak of true freedom of choice when palliative medicine is practised with skill and offered to all who need it.
III. The special human dignity in the trance of terminal illness and the dying process
This second part of the article is devoted to some considerations about the specific human dignity of the terminally ill patient.
The terminally ill and the dying are a riddle for relatives and strangers, for doctors and nurses. They are often an enigma, because they impose on us the difficult task of discovering and recognising, beneath their decrepit appearance, all the dignity of a human being.
For a view that only sees appearances, terminal illness, so often accompanied by pain, anguish and anxiety, tends to eclipse the dignity of the sick person: it hides it, it even seems to have destroyed it. For if, in a certain sense, health gives us the capacity to attain a certain measure of human fulfilment, being seriously ill limits, in different ways and at Degrees , that important dimension of dignity, as nobility, which is the capacity to develop the project of man that each one of us cherishes.
It is not difficult for physicians to cooperate in the restoration of their patients' health while there is hope of achieving it. But it is very difficult today for many physicians, other than those competent in palliative care, to recognise the value of their work when, in the trance of terminal illness and the dying process, there is no longer any room for such hope. Degree It is hard to recognise, in today's medical environment, concerned with cure outcomes and process costs, that serious, disabling, painful illness and, even more so, terminal illness, can be of any interest. Dominated by a pathophysiological culture, it is difficult for many doctors to understand that terminal illness is not just a molecular or cellular disorder that is beyond repair, but also a human problem in which respect for the dignity of the patient imposes a duty of care for the dignity of the patient's dying.
Nor is terminal illness limited, beyond the merely biological, to an experiential journey through certain stages that mark the psychological reactions of the patient in the face of the announced and inevitable death, reactions that need understanding, support and accompaniment33 .
The terminal status constitutes, above all, a threat to the integrity of man, to his dignity staff, which puts the sick person and those who care for him at test . And when this is understood, the results are not long in coming. One of the great promoters of palliative care, that most professionally medical way of respecting the dignity of the dying, stated that, in his opinion, one of the strongest arguments against euthanasia is the good use he had seen many patients, and their families, make of the final days of their existence, after the pain had been alleviated and before death came. To remove, by an act of merciful death, that dignifying opportunity would be to deprive the family and society of that unique value and dignity that is concentrated in the final stretch of human life34.
It should be noted that the role of health professionals is to weigh the value, efficacy and proportionality of the means at their disposal, not to judge the value of the lives entrusted to them. And yet some doctors and nurses, who are deeply imbued with a radical idea of quality of life, believe that some lives are so lacking in quality and dignity that they are not worthy of medical care and are deserving of compassionate death.
Such an attitude subverts the ethical tradition of the health professions, one of the most fruitful and positive elements of which, both in the progress of medicine and in that of society, consists in understanding that the weak are important, that they fully possess the dignity of every human being35. This idea, it is not difficult to imagine, was present at the beginning of the civilising process and the birth of medicine. In the deontological tradition, being weak was a sufficient qualification to be worthy of respect and protection. Even being economically weak ceased to be a mark of discrimination in medical care. The socialisation of medicine is one of the most important historical efforts to honour the human dignity of all. Today, however, this effort seems to be suffering from an intense ethical fatigue and there is open talk of reducing the admittedly gigantic costs of health care. partner There is open talk of rationing medical care and stratifying care, not according to its benefit/cost ratio, but according to the economic conditions (age, ability to pay, state of health) of the patients. Discrimination is thus introduced which affects the very core of the relationship between doctors and patients: patients are no longer invested with the one supreme dignity of man, but can be distinguished into different categories: the weak will be discriminated against.
Medicine thus runs the risk of becoming an instrument of social engineering. But that is an idea that is totally alien to the ethics of health care. What is specific to doctors and nurses is to help, with their knowledge and skills, the sick and weak, human beings who are experiencing the crisis of losing their physical vigour, their mental Schools , their life. In medicine, respect for human dignity takes on a peculiar and specific form: respect for the weakened life. In palliative medicine, respect for life is almost constantly conditioned by the presence of essential vulnerability, by the extreme fragility of man, by the recognition of the inevitability and proximity of death. The ethical respect of doctors and nurses who administer palliative care is respect for declining life; their work consists in caring for people in the Degree extreme of weakness.
Res sacra miser. This name of Christian-Stoic origin, revived by Vogelsanger36 , expresses in a magnificent way the special situation of the humanity of the sick person in the field of tensions of terminal illness. It is a wonderful translation of the coexistence of the sacred and indeclinably dignified nature of all human life with the misery caused by illness. When the sick person is seen in this light, as both worthy and miserable, we can recognise their inviolable and needy condition. This is the ethical foundation of the terminal care due to every patient, the moral justification of palliative care.
Notes
(1) John Paul II. Encyclical Letter Evangelium vitae, bookshop Editrice Vaticana, Vatican City, 1995.
(2) P.R.S. Johnson, An analysis of "dignity", "Theor Med Bioethics", 1998, 19, 337-352.
(3) J. Hersch, La vie à son juste prix, "Schweiz med Wschr", 1982, 112(Suppl 13), 29-30.
(4) John Paul II. Apostolic Letter Salvifici doloris, bookshop Editrice Vaticana, Vatican City, 1984.
(5) G.B. Ferngren, The Imago Dei and the sanctity of life: the origins of an idea, in R.C. McMillan, H.T. Engelhardt jr, S.F. Spicker, Euthanasia and the newborn, Reidel, Dordrecht, 1987, 23-45.
(6) Ex 4, 11.
(7) Rom 2:11.
(8) J.M. Escrivá de Balaguer, Surco, Rialp, Madrid, 1986, point 303.
(9) John Paul II, Encyclical Letter Evangelium vitae, LEV, Vatican City, 1995, points 44, 46, 50 and 51.
(10) Plato, The Republic.
(11) Ferngren, loc. cit., 34-38.
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