conference proceedings of congress International Bioethics 1999. Bioethics and dignity in a pluralistic society
Table of contents
Table of work III: Problems at the end of human life
Moderator:
Dr. José Luis del Barco Collazos, Prof. Titular de Philosophy Moral, Universidad de Málaga.
Speakers:
Dr. Antonio Pardo Caballos, Associate Professor del department de Humanities Biomédicas, Universidad de Navarra.
Dr. José Miguel Serrano Ruiz Calderón, Professor of Philosophy del Derecho, Universidad Complutense de Madrid and corresponding member of the Royal Academy of Jurisprudence and Legislation.
Dr. Francisco León Correa, Secretary of the association Española de Bioética, Director of the journal "Cuadernos de Bioética".
summary prepared by Antonio Pardo.
In his presentation, José Luis del Barco reflected on the substance of bioethics. As a result of a lecture he had to pronounce, he shuffled through manuals without much success; he concluded that bioethics is the solicitous guardian of existence in distress. Or, to put it another way, the fundamental concern of bioethics is fragile life; he thus focused his role on the end of life, the object of the roundtable.
Professor Antonio Pardo focused his intervention on clarifying the concept of euthanasia. He indicated that, as presented in the Madrid declaration of the World Medical Association association , euthanasia is an action that must always be defined intentionally, i.e. it cannot be adequately covered by a mere description of material facts, but must include the voluntary decision to bring about death. Such a decision is usually made with generally compassionate intentions, but it is the decision that is decisive in establishing that an act is euthanasia.
In this way, it is possible to clearly delimit what is euthanasia and what is not, an issue which, unfortunately, is often rather confused in the professional literature. Thus, actions that result in the death of the patient as a tolerated effect (when carrying out any therapeutic intervention or when trying to relieve the patient) cannot be qualified as euthanasia. However, the terminology "letting die" is widely used to refer to end-of-life medical actions. This terminology is deeply ambiguous, as "letting die" can include such disparate issues as omitting a treatment that has already proved useless or, on the contrary, withdrawing a vital and effective medicine to treat a disease.
The idea of including intentionality in the definition of actions also served to solve one of the difficulties that arises with the current discussions on the relevance of the concept of brain death: if the brain-dead patient is alive, then removing his or her organs would be homicide, and this should be left internship. However, including the decision in the definition of what is done proves that the action of transplanting an organ is not the execution of a homicidal decision, but that the death of the donor is only a tolerated effect of the action, an effect that is morally admissible in the case of brain-dead donors, as has been published more extensively on the internet1. The same applies to aggressive interventions on patients in failing health, where there is little hope of survival: they are neither euthanasia nor homicide, since the doctor's decision is not to kill them, even if such an effect is very often the result of his intervention.
In his speech, Professor Serrano Ruiz Calderón reflected on the curious phenomenon observed in the legal consideration of euthanasia. There seem to be two opposing positions: one, the majority, in favour of its criminalisation, and the other, a minority, in favour of its social acceptance. However, it can be observed that the minority position aspires, and is in fact succeeding, in imposing itself socially through the law. To what can this phenomenon be attributed?
First of all, he noted that the two opposing positions, rather than a view of the concrete problem of euthanasia, correspond to a global view of life. The majority has a view of human life as something sacred, and sees weakness as something worthy of respect and valuable in the human community. The minority view, on the other hand, would be predominantly based on radical individualism, which seeks that the other members of society fundamentally let me do what I want - although the question would need a lot of qualification.
Given that our society is more identified with the radical liberal stance, it is logical that its arguments have more penetration in our society. Thus, the radical individualist position is more attractive and progressive, and has the upper hand in a confrontation with the other, for several reasons. Firstly, because its argument is presented as a defence of individual freedom and the non-interference of third parties in one's own decisions; furthermore, because we currently consider the position that involves less criminalisation to be more reasonable or advanced; finally, the individualist position does not require great efforts or sacrifices, providing quick and conclusive solutions. The position in defence of human dignity, on the other hand, tends to produce burdens (on the patient, the family, the hospital), seems to interfere with individual freedom, and, finally, is a more complex position: it takes much longer to argue it convincingly than the individualist position.
He argued that, however, these pros, seen in detail, are not such. Thus, liberal state intervention is not necessarily minimalist if it takes some values as something to be encouraged in social life (consider, for example, the issue of tobacco). On the other hand, the alleged decriminalisation, defending liberties, turns out, on careful analysis, to be legalisation, which will automatically generate subjective rights to claim euthanasia, with the consequent obligation to kill on the part of someone: this is inescapable. Finally, the pluralism of the liberal position is very relative, as emerging positions often tend to impose themselves simply by appealing to their modernity, overriding freedom of expression.
Finally, he explained how the defence of life that ends is sustainable from a legal point of view, without having to go back to a critique of the global vision of man that underlies the liberal position. Thus, it could be argued that not every subjective right is automatically permissible (think of a request for suicide due to a love crisis). Therefore, decriminalisation has to guarantee the fundamental rights of the weak, and supporters of euthanasia find this very difficult. And this way of reasoning is not the argument of the slippery slope but the experience of the human condition: thus, the work of minors, who cannot work, even if they want to, is forbidden.
He concluded by stating that the pro-euthanasia action, as has been repeatedly stated, creates a fictitious subject in a fictitious world that manifests a fictitious autonomy and pretends that the legal system guarantees this, instead of guaranteeing values that we know, that we see, and that we constantly observe.
Dr. Francisco León Correa initially commented on his opinion about the morning's discussion on brain death, leaning towards the correctness, not only pragmatically but also theoretically, of this concept. He also referred to an aspect of the discussion on euthanasia that is often neglected: when talking about the right to life and the right to health, they are spoken of as rights that imply obligations on the part of others, and it is often omitted that they also imply obligations on the part of the subject of the right himself; preserving health is not only a right that implies the obligation of others to provide care, but a duty for the subject himself. And the same is true of the right to life: my life is not something I can dispose of as I please, but something I must take care of. Seen in this light, talk of a right to die is completely meaningless.
He then focused his speech on the role of bioethics as an instrument for providing positive solutions in the humanisation of health care. Rather than the role of a censor of incorrect behaviour, bioethics leads to a search for the positive demands presented by the interpersonal relationship between the doctor and the terminal, chronic or elderly patient. This requirement can be articulated around the principles of bioethics commonly used in American bioethics, but giving them a precise meaning. Thus, with regard to euthanasia, the principle of non-maleficence would prevent us from considering it as just another option for "treating" the patient. The principle of justice would lead us not to consider geriatric or terminal patients as second-rate patients when it comes to providing them with care. The principle of autonomy should lead us to consider the opinion of the sick until the end of their days, but not as an absolute datum, but counterbalanced with medical opinion (the doctor also has his autonomy), and without harming the basic rights of the person. In this sense, much remains to be done to make informed consent a reality in our medical care and not just an administrative requirement. Finally, the principle of beneficence has a very direct application at the end of life: palliative care, the importance of which we will never tire of insisting on.
In the discussion that followed between the congressmen and the members of the Bureau, Professor Ollero pointed out how it is possible, from a political point of view, to stop the advance of the legal acceptance of the so-called right to die, by calmly studying the problems and showing the arguments that can be made to defend the life that is coming to an end. A purpose of the intervention of a Dutch congresswoman, commenting on the distressing status of her country, Dr. Herranz emphasised the importance of the right to death. Herranz emphasised the terminological confusion about euthanasia, which sometimes seems deliberate; contrary to what is heard, there is no such thing as passive euthanasia; surveys of doctors contain leading questions of unclear meaning; there is no indirect euthanasia or shortening of life by administering painkillers according to modern guidelines; and it seems that journalists are determined to distort reality in order to obtain news with more morbidity.
The rest of the discussion was position by Dr. Martínez Lage, a neurologist present at conference, and Dr. Herrando. Both vehemently defended the theoretical coherence and internship of the current praxis of diagnosis of death by neurological tests. Dr. Herrando also provided a theoretical anthropological model to support this position. Dr Shewmon replied, refuting each of the arguments put forward2 on the basis of his clinical experience, which he has written down in several articles, some of them particularly incisive and published in Neurology, in which he review a series of clinical cases that are incompatible with the theoretical explanation that currently supports the practice of diagnosis of death by means of cerebral criteria alone. He left discussion open for future meetings.
Notes