conference proceedings of congress International Bioethics 1999. Bioethics and dignity in a pluralistic society

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Table of work III: Problems at the end of human life, complete transcript

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".

José Luis del Barco presented the table of work commenting: About a year ago I was asked by the Torres Cardenas Hospital Complex in Almeria to give a talk at lecture on the Bioethics of suicide; one of the first things that came to my mind when speaking at this event was to try to rethink what Bioethics is, a word that we probably use very frequently and sometimes perhaps not very accurately. After reading many of the manuals and books on the market on these issues, result was completely dissatisfied. I did not understand what Bioethics is.

Then it occurred to me to do something I usually do after having read a lot: to try to assimilate it. As I matured the question, I came up with the following formula to express what Bioethics is: it is the solicitous formula of existence in distress. Or, to put it another way, it occurred to me that the fundamental topic of Bioethics or the fundamental concern of Bioethics is fragile life. This led me to publish a work on fragile life, which naturally includes the suicidal.

And what are those moments when life is particularly fragile, particularly helpless? I believe that, above all, at birth and at death. And it is about one of these moments of life's constitutive fragility, which, I repeat, is one of the essential issues of bioethics, that the various speakers at this afternoon's round table are going to talk about, and without further ado I will introduce them.

Professor Antonio Pardo then took the floor: In my introductory remarks to this roundtable, I will reduce my intervention to an aspect that seems to me fundamental in the current discussion on topic: euthanasia, like any human action, is a question that must always be defined intentionally. I will continue by explaining the exact meaning of this expression, which can be misunderstood.

Human actions can be described physically. However, such a physical description is an incomplete description, because human actions are an inseparable mixture of voluntary acts (intentions and decisions) with physical actions. Only a description that includes voluntary acts can give us a coherent description of man's actions. Thus, to say that a man puts one foot in front of the other in succession tells us nothing about whether he is walking or going to work. We are left without knowing what is really happening, because what is happening is not a physical act, but a physically executed decision, which is quite another matter.

I will apply this precision, which is very important, as we shall see, to the doctor's decisions regarding the end of human life, specifically to euthanasia and the action of the doctor who takes organs for transplantation.

The definition of euthanasia, as established by the World Medical Association ( association ) in the Declaration of Madrid, is as follows: Euthanasia, i.e. the deliberate act of ending a patient's life, even at the patient's own request or at the request of relatives, is unethical. This does not prevent the physician from respecting the patient's wish to allow the natural process of dying to take its course in the terminal phase of his illness.

Euthanasia is therefore a deliberate act, i.e. voluntary and free. And the will of this act is directed towards the death of the patient, such as goal. This "aiming at a goal" is what, in Philosophy, is known as "intentional": euthanasia can only be defined intentionally.

However, there are two distinct voluntary acts (both intentional, like all voluntary acts, i.e. "aiming at"): attempting and deciding. Attempting is the voluntary act that aims at more or less ultimate goals, at ends. Deciding is the voluntary act that aims at means, i.e. at actions that are directly executed.

The intentional act that makes it possible to define euthanasia is not the intention, but the decision or choice. To paraphrase the definition of the association World Medical Association, to euthanise would be to bring about someone's death by a free and voluntary decision whose content is precisely the death that is to be brought about. The motivation (or intended purpose) is variable. The WMA mentions the request of the patient or the patient's relatives, but it can be any other. What is clear is that no purpose, however lofty, justifies such a decision, which is always wrong.

Unfortunately, the decision is often confused with the results of executing the decision. To mention a recent anecdote: my colleagues in a certain hospital treated a friend of mine, suffering from bladder cancer, in his last moments. Faced with proposal to perform palliative surgery to create a functional bladder to avoid the catheters he had to wear permanently, they argued that it would be euthanasia, since, given the Degree of development of the tumour, a high mortality was expected in this patient in the immediate postoperative period.

As is obvious from what we have said above, such an action would not be euthanasia: the doctors would not be killing my friend, but performing a very risky intervention on him, which they preferred to omit because of the high rate of death (tolerated undesirable effect) it produced. However, from a purely material point of view, death follows both from the internship of euthanasia and from the performance of the palliative intervention, which are equated, creating confusion B.

This ambiguity reigns everywhere in medicine. Suffice it to recall the expression "let die", which is widely used in medical literature. From a material point of view, it seems clear what it means: to do nothing and let the patient die. But from the intentional, voluntary point of view, the action has not been described. The intentionality of "letting die" can be "omitting the application of disproportionate means given the status" (rejection of therapeutic incarceration and, therefore, good medical internship ), or "voluntarily deciding the death of the patient" and consequently not applying measures that could prolong his life in a reasonable way (and we are in a case of euthanasia).

This misunderstanding leads to disastrous consequences for the medical internship . If "letting die" is always considered euthanasia, the doctor would always be obliged to apply all available measures to prolong life: therapeutic overkill would be morally obligatory, which is contrary to good medical internship . And if "letting die" is not interpreted as euthanasia, we would leave the door open to its internship for omission of due treatment, since euthanasia would only be the internship of the patient's death by means of an active physical action. As can be seen, the confusion can take on dramatic overtones in everyday medical care.

Let us now turn to the second application of the initial statement (human actions can only be defined intentionally). It refers specifically to the action of taking organs from a donor for transplantation. But first, it is necessary to make a small orienting recapitulation.

The criterion of brain death, although massively accepted by the medical profession, is far from being well founded. The simultaneous existence of several criteria that are theoretically incompatible with each other, or the resistance shown by certain countries to its adoption (in Japan, transplantation with organs from brain-dead donors has been possible for barely a year), suffice it to say sample . In addition, there are now many voices that question whether the brain-dead patient is really dead, as we heard this morning.

At first glance, one might think that, if this is indeed the case (the brain-dead patient is alive), any transplantation of his or her organs is morally wrong. It would result in the death of a person and would amount to murder. This apparently correct conclusion leads to resisting the theoretical argument that the brain-dead person is alive: rather than condemning the usual medical internship , one prefers to look for alternatives to the theoretical conclusion that brain death is a disease, not death.

The problem loses much of its difficulty if we consider the intentionality of human actions. Instead of going directly into it, we will first look at other situations whose resolution requires consideration of the intentionality (of the decision) of the person who acts.

A status self-defence is a correct action, even if it results in the death of the aggressor, as long as the aggressor posed a proportionately great threat. The one who defends himself aims to kill, but the intention is to defend himself. From a physical point of view, however, both actions are identical (and, in a simplistic way, condemnable, as they involve the death of a person as result).

In emergency medicine, the triage system is well known. To give an example, when a doctor arrives at a place where, after a disaster, there are many patients to be treated, the first step is to briefly examine all the patients within reach. Once this examination has been carried out, he should leave untreated the mildly ill (because more staff will come later to treat them) and the very seriously ill, who would absorb all his efforts, and treat the seriously ill in an attempt to save them. By acting in this way, he is voluntarily accepting that the very seriously ill patients could die before reinforcements arrive, but the alternative is worse: if he were to treat one very seriously ill patient, who would absorb all his efforts, he would leave several seriously ill patients unassisted, who could also die. In short, triage attempts to optimise the performance of medical care. But, in taking this approach, the physician is not killing the most seriously ill patients: his action (the description of his choice) is to help others. In no case is his choice the death of anyone: he is helping some, and he accepts that others will die, though he wishes they would not, but he can do nothing about it.

In fact, many medical actions end in the death of the patient, and no one doubts its propriety: it is a calculated risk worth taking in a given case, given the various circumstances. The death of a patient as a result of a very aggressive but essential surgical intervention is not homicide from an ethical point of view. Homicide is deciding and executing the death of someone. In this case, the decision is not the death of the patient, but the carrying out of an aggressive intervention.

Applying these concepts to the case at hand, in the case of performing a transplant, the doctor is not committing a homicide, he is performing a transplant (helping a patient by performing a transplant). That is the description of the decision he has made to perform the intervention. In the case where the donor is dead, there are no particularly serious ethical problems. In the event that reflection on the donor's condition leads one to doubt that the donor is dead (as Dr. Thomas expressed in his speech) or to the conclusion that the donor is alive (as Dr. Shewmon explained), the physician is not killing the donor (it is not his decision), although the decision to transplant always results in the death of the donor. Therefore, his action cannot simply be described as morally wrong (his decision is a good one). The problem that arises is whether such a death tolerated as a necessary effect is acceptable under the circumstances. In my view, if the irreversible brain damage that we call brain death exists, it is an acceptable effect, although to show this in detail now is beyond the scope of this roundtable. A more detailed review of the issue can be found on the Internet1 .

But regardless of whether this action, taken as a whole, is correct or not, it is clear that the decision to take organs from a donor is not to kill him, even if he dies. The door remains open for reflection that considers the living donor, without condemning the usual medical practice from an ethical point of view.

Next, Professor Serrano Ruiz Calderón, Senior Associate Professor of Philosophy of Law at the Complutense University of Madrid, took the floor. He is also a corresponding member of the Royal Academy of Jurisprudence and Legislation.

First of all, I wanted to dispel an expectation that had been raised: it is not true that I am now going to make a decisive contribution on the topic of brain death, which I believe is the one that has brought us practically all together here. Consider my intervention simply as an hors d'oeuvre centred on the topic of euthanasia. I would like to say to Antonio that I found his observation on apparatus and organs very interesting, but, in order to further fuel the controversy, I, who am in favour of the seizure of automobiles when it comes to acting on the assets of individuals, am not so much in favour of the seizure of legs.

Without further ado, I will go to the topic that I think should be dealt with here, which is to bring up comments on the presentations made this morning by some of the speakers, and especially on that of the philosopher of Law who spoke this morning, Prof. Ollero. If I have not misunderstood his intervention, it seems that the position we are starting from, which I fundamentally agree with agreement, is that we have a status in which there are two moral positions, or several moral positions, in conflict, which aspire to have a legal translation in the penal code; in this status, although we cannot speak of a conspiracy in any way, there is a minority position which, surprisingly, seems to aspire to impose itself through the law and not only tries to do so, but often succeeds in imposing itself. This is the topic that interests me: why, what is the reason that produces this effect, if it is not attributable to our stupidity, or in this case to mine, that I have written about this topic from the position that we could describe as the majority position, why one position tends to have so much capacity for political translation and not the other. Or what tendency, or what is the reason why certain radical tendencies in terms of individual autonomy are so successful in contemporary society, and why reasoning from different positions is so difficult to transcend. Because one would have to recognise a special inability to translate them into the media on speech or into political activity, or one would have to recognise that there is something that decisively biases the discussion. This is the topic to which I am going to devote myself exclusively.

We can start from budget that the position on euthanasia tends to manifest itself in a relatively neutral way, i.e. it tends to manifest itself as a position that can be assumed from different moral points of view, without specifically relying on any of them; however, what justifies the position on euthanasia, both for and against, is usually a global moral vision.

The position against euthanasia would be based, and much has been written about this, on the sacredness of human life and normally on a transcendent conception of man, as opposed to a merely immanent conception of man, and on the social value of weakness and solidarity, i.e. the social value of illness, weakness and the importance of solidarity for the existence of a political community with such a name.

On the contrary, the opposite stance would be based predominantly on radical individualism, of enormous weight in contemporary society, on hedonism as a basic ethical stance on this topic, and on a certain stance of social atomisation, in which, what I fundamentally expect from the other, apart from good words, intentions and courtesy, and manifestations or acts of solidarity such as the chant of "Close the wall", is something else: what I really, deeply expect from him is to leave me alone to die, or to leave me alone to live or to do what I want, and nothing else. This would be the other position.

I am extraordinarily summarising the varied features of both positions because it is true that they are not the same, but, even if they differ, their substance is very nuanced, and I do not have time in a quarter of an hour to go into too much detail, because nuancing is relatively difficult.

As some contemporary philosophers have pointed out -I am going to follow McIntyre's position here- the current outline of the social discussion, the current order of the position that Americans call liberal, which has a relatively important theoretical load, necessarily benefits the triumph of one of the positions. In other words, this is not so much an accident as a fact that is not accidental, but intrinsic to a certain way of understanding order in contemporary society. It would not be our clumsiness alone - it is a certain consolation - but that there is something in the social order that favours the position in favour of euthanasia.

From a purely tactical point of view and from the point of view of exhibition in the media, we can observe that the position of the radical individualist when he globally supports his position is more attractive than the position of the supporter of dignity and respect for human life when he globally supports his position. In a confrontation of global positions, the former is more progressive and more acceptable. Why is this the case? It is a curious fact and one should try to find out why.

Firstly, because it upholds some fundamental points that are widely accepted in contemporary society. Radically, individual freedom without interference. The supporter of euthanasia is normally a supposed defender of individual freedom and non-interference of a third party in the individual act.

Secondly, because in our society there seems to be a widespread position that less criminalisation seems preferable. In other words, the principle of minimum intervention makes the lesser penalty seem a more socially open or more advanced position than the greater penalty.

Thirdly, because the individualist stance does not demand any dose of heroism from the subject. It is not a stance that demands any subject of a life sacrificed over time, of pain, of support for a third party, but seems to seek a quick and conclusive solution.

On the contrary, the opposite position, the position in favour of human dignity, seems to present a series of characteristics that are widely rejected in contemporary society.

Firstly, it tends to produce burdens: burdens on the hospital, burdens on families, burdens on the patient himself, and this is frowned upon, one might say.

Secondly, it seems to interfere on behalf of one's conscience, because the one who claims the freedom of his act seems to have, in our way of reasoning, a priority or preferable position to the position of the one who claims the prohibition of an act. The one who simply asks to be allowed to do a thing seems freer than the one who says that the one who does a thing must be sanctioned or acted against.

Finally, the position in favour of human dignity is a complex position: the defence of the dignity of human life from conception to natural death -whatever that may be, because... I came here a little more convinced of what natural death was and I leave without having that much of an idea- requires a complex effort. I don't know what your experience is like staff, but those of us who have experience in the teaching, to explain the value and dignity of human life, what is good, what is the good life from the Aristotelian point of view to a group of first or fifth year law students, we have a lot of work and difficulties. And we find it difficult to work because it is a complex rational explanation, which requires us to base positions, to base concepts, to accept even ontological and anthropological positions, which are constructed in a complicated way that is difficult to follow; a lazy person would not become an Aristotelian in any case, it is preferable to be a utilitarian, it is much easier and simpler. I do not mean by this that all utilitarians are necessarily lazy; only that this position is much more complex to explain than the other; and in the social discussion it is much easier - McIntyre has analysed this at length, so I am not going to insist on it too much - for a radical individualist, in a televised discussion , to defend his position with little more than a few shouts, than a person, such as Prof. Gonzalo Herranz, for example, whom I see as a person who, in the social , is much easier to explain his position with little more than a few shouts, than a person who, for example, is a radical individualist. Gonzalo Herranz, who I can see in the front row, has to make a complex construction of his position, which necessarily takes more time and effort than the other position. This is a disadvantage.

However, I would like to make some clarifications to some of the instructions of this status so peculiar and so unfavourable to the advocates of an anti-euthanasia stance.

Firstly, it is not true that in a radical "liberal" society intervention is minimal. What happens is that there is no intervention in certain non-quantifiable aspects, or there is often no intervention in the protection of the weak, there is no intervention when the social value is not fashionable or is not an exaltable social value, because intervention can be maximal. Almost all of us who smoke have a clear awareness of how the intervention of the liberal state can be terrible on any subject. To put it jokingly, between the liberal state and Iberia they are going to put an end, in this sense, to any hint of freedom.

This, which seems like an anecdote, is not an anecdote. I mentioned it with regard to tobacco, but the intervention of the state gives us lessons with regard to sexual life, it gives us lessons with regard to what can be said and what cannot be said, it intervenes in the right of a person to regulate access to a place and it arrests him for violating individual rights, it takes him to court if that person expels two men who are kissing - a case that happened in Spain three weeks ago; By this I mean that the State, when it goes after a value, goes very strongly in a society like ours and even more so in more radical societies; therefore, it is not true that intervention is minimal for certain values and maximum for others.

Secondly, and in response to an idea that was raised here yesterday, which was not openly stated, but which was dropped tangentially, it is not true that decriminalisation does not imply legalisation. I remember when there was a debate on topic on the decriminalisation and legalisation of abortion, every time some people spoke of legalisation of abortion, they were told "No, it's decriminalisation, it's a different thing". The decriminalisation of certain behaviours and their favouring or protection, or their acceptance in a public service system generates two types of consequences that are equivalent to legalisation, and it is enough to see the reality of the jurisprudence to realise this. First, it generates a subjective right: "I have the right to have this done to me here"; therefore, if euthanasia were decriminalised, we would find people who would say "I have the right to have euthanasia done to me in this hospital". But, secondly, it generates, in the public servant, in the national health systems, and also in the private systems if they have certain rules regarding their patients, an obligation on the subject, it generates the obligation to comply with that request. It is a normal, known process, which, despite what we are told, necessarily occurs. In other words, if euthanasia were decriminalised in certain cases and had to be carried out in hospital systems, this would generate, firstly, a subjective right of the patient to demand it and, secondly, an obligation on someone to carry it out; we don't know whose, but someone's, and this must be made clear.

Finally, I should also clarify that new social definitions or new social positions have tendencies of imposition, of strong imposition. Therefore pluralism is often relative. For example, the option that homosexuality is morally indifferent may generate tendencies whereby the public exhibition that it is an immoral activity may have legal consequences for the one who does it, despite the existence of a system of freedom of expression. This is likely and should therefore be made clear: once a radical position is accepted, it generates immediate legal effects, especially in societies like Spain's, with little tradition of freedom of expression, where freedom of expression is usually understood to mean that I can speak and the other cannot: "Now we speak, now it's our turn, now it's our turn" or any other similar expression.

Fortunately, however, I do not think it is essential for discussion to start from the legal point of view on the issue of euthanasia from the point of view of the clash of global positions on morality. This would be extremely complicated for us. I think it is possible to make legal arguments from the point of view of the law and the function of the law, whereby the burden of the test defence of euthanasia would be much stronger than it is, and the social values defended, such as the protection of human life, would be more evident, so that we could say that anti-euthanasia activity would appear as what it really is, a position of defence of the weak in a society, a defence of values against economic interests, etc.., i.e. as a very socially presentable and even very acceptable position.

First of all, we must start from a basic premise in this respect: in the social sphere it does not seem acceptable, even in pro-euthanasia positions, that the legal system should accept or guarantee any subject right of the patient to be killed on demand. Even the most radical do not think that if a seventeen-year-old girl or a boy in a love crisis asks a cousin doctor to give him a lethal injection, this is a relevant question. In other words, limits must be set: even the most radical positions do not support an autonomy that consists in the fact that any subject can ask for any reason for his or her own elimination.

On this basis, it is clear, and it has been said this morning quite rightly, that the legal proponent of a decriminalisation action in this respect should ensure that his proposal safeguards the humanitarian values he claims to defend and does not in any way affect cases that we generally accept should not be affected. It is up to the proponent of decriminalisation to explain to us how it is going to guarantee that in no case does its action affect the defence of fundamental rights of people in a weak status position. This is extraordinarily complex, to the extent that recently one of the arguments that has had the greatest weight in the pro-euthanasia discussion , in a way that is changing its bias, is precisely the difficulty of offering guarantees. And this is not a slippery slope theory, whereby once you decriminalise one thing, you decriminalise another and so on and so forth, a theory which, as has been said this morning, is easily criticised. It is a theory that starts from social experience.

Let's see it with an example: Why is work forbidden for minors? Why can't a minor work for a higher development staff , or because he wants to work, or as a right to a better training? Why was the maximum workshop set at work? It is absurd; if a person wants to work more, why shouldn't he work more? Because experience sample has shown that without such measures subject a fundamental freedom or a fundamental right, a minimum basis that society considers should be guaranteed, cannot be guaranteed. Our legal system is full of prohibitions in which individual autonomy is strongly limited, and this is not because of a theory of the slippery slope but because of experience. Why shouldn't a person be able to sell himself? Because, as soon as you get to know a society, you will know that the person who sells himself will not be a person we could call a millionaire aesthete - as McIntyre would say - who wants to sell himself to see how he feels, but that the person who will end up selling himself will be a subject in a terrible, desperate status , on whom the legal system must act to improve his status and not, on the contrary, allow him to sell himself.

The pro-euthanasia action, as has been said repeatedly, and is one of the great findings, 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.

I do not have time now to develop a couple of other ideas I had to say in this regard about the fact that the anti-euthanasia position guarantees or seems to guarantee fundamental values recognised by our society, such as the value of the protection of human life, which is very important, the value of security and social protection, the integrity of the medical profession and of the health system itself, and at the same time avoids the construction of a legal system of authorisations for intentional death, which would really be repugnant to our law and our system, because you realise that, having banned the killing of major criminals, I think quite rightly so, we would have a legal system in which one of the most common or relatively common activities would be to authorise a person to kill someone close to them, or for a person's wish to be killed to be carried out by a doctor. If I may make a terrible macabre joke, we would end up with a society in which we are allowed to kill loved ones, which is what we usually do not want, and we are prevented from killing unloved ones, which is what we usually want.

Dr. Francisco León Correa takes the floor. First of all, I would like to talk fundamentally about terminal patient care, which was one of the issues raised this morning by Dr. Gonzalo Herranz, and not so much about euthanasia, because I think that euthanasia is not currently a clinical problem of frequent occurrence. Gonzalo Herranz, and not so much to focus on the topic of euthanasia, because I think that euthanasia is not currently a clinical problem worthy of attention; not only do I think so, but one of the members of the group of research, who is director of a Paediatric ICU, in all his years of medical experience had only had one case of application of euthanasia, while the great ethical dilemmas that arose were the proportion or disproportion of the means to be used in specific cases. Therefore, it seems to me that Bioethics can contribute a great deal, provide positive solutions, which is its mission statement, to the humanisation of health care and, above all, in the case that affects us, of the terminally ill.

reference letter However, in order to position myself within this roundtable, and also in reference to the morning's speeches, I would like to say two things about the issues that have been discussed previously.

First of all, it seems to me that there are no brain-dead patients; it seems to me that there are dead people, i.e. corpses of people, human beings, whose vital functions are being artificially maintained. I therefore endorse the position expressed yesterday by Enrique Prat and oppose the position expressed this morning by Dr Shewmon: I think that the description of brain death is not only pragmatic, but also scientifically correct. It is also ethically correct. With this I have already placed myself on one side of the argument. I also have very direct contact with the clinicians who perform liver transplants in Santiago de Compostela at contact and they do not have the slightest doubt nor do I think there is the slightest ethical dilemma if the measures currently in force to define encephalic death are strictly observed and complied with. It is a different matter if they are not complied with. It seems to me that the greatest ethical danger is not the definition of brain death but the new neocorticalist death currents that say that brain death could already be decreed with the lack of activity of the cerebral cortex. This is the real ethical problem that may arise in the ICU in the future, and not the criteria for brain death.

Secondly, as far as euthanasia is concerned, to touch on it very briefly, I usually approach the issue from the point of view of fundamental human rights. The right to life, the right to health, the right to freedom of thought and the right to property are not positive rights: I do not have the right to live forever, nor do I have the right to be healthy forever, nor do I have the right to own everything I want; I do have a negative right, that my health is not violated, my life is not violated, my freedom of belief or thought is not violated, and my legitimate property is not violated.

But it is not only this: for the person, for the human being, these fundamental human rights are protecting goods and values of one's own person that are duties of each one of us towards oneself. My right to life is at the same time a duty to take care of my life. This, which is core topic at topic on euthanasia, is very well understood in the other rights, but I don't know why at discussion on euthanasia it is not so well understood when applied to the right to life or the right to die. Because, as far as the right to property is concerned, it is quite clear that I cannot do whatever I want with my property. There are ethical limits to the exercise of the right to property, manager , which is a duty that everyone has towards others. It is exactly the same with the right to health: in preventive medicine we are being reminded not only about smoking but also about many other measures. I have the right to have my health looked after and to have a fair, equitable health system that looks after my health, but I do not have the right to my health, I cannot do whatever I want with my health; in other words, there is no right to take drugs; you can take drugs and ruin your health, but there is no right to take drugs.

Similarly, as applied to the right to life, there is no right to commit suicide. There are ethical limits. It is both a negative right and a positive duty of the individual. Therefore, I have no ownership over my life or my health. Nor is there absolute freedom in freedom of thought and belief, although this is a question that is separate from our topic: I must reasonably seek the truth and the good, and therefore I must reasonably seek what ethical norms and ethical ideals I am going to propose to myself as a person. Otherwise, there is no ethics.

Therefore, it seems to me that, at the heart of discussion on euthanasia, there is a misunderstanding of the right to life: there is no right to one's own life and therefore no right to one's own death.

Bioethics is not just about establishing negative issues or prohibitions. Bioethics is a science that tries to analyse, reflect and establish general criteria on the ethical requirements of respecting and promoting the dignity of human life in the biomedical field: in the field of medical research on the human being and in the field of clinical care. Therefore, the promotion of and respect for the dignity of human life is the main purpose of Bioethics. This, applied to clinical bioethics and to the care of terminally ill patients, leads us to seek what set of positive demands exist in the interpersonal relationship between the doctor and the terminal, chronic or elderly patient; these are the major problems that are already being posed to us in the care of these patients, increasingly numerous for a health care staff , who has a series of ethical duties towards the patient and towards the institution for which he or she works.

Therefore, it seems to me that it should be understood that Bioethics does not seek to establish a series of criteria, of rigid rules that will impede the practice of medicine or health care or research, in whatever field. No; it is about helping the relationship between patient and doctor to have a higher professional and human quality.

Where do all the ethical principles we are developing in Bioethics and applying to the clinical setting lead us? Firstly, to clearly establish non-maleficence and justice as absolute duties in the healthcare professional-patient relationship. Clearly, non-maleficence, in the field of the terminally ill, rules out both euthanasia and therapeutic incarnation, as Dr. Herranz commented this morning, so I am not going to expand any further: the useless medical act is an act that is ethically incorrect to undertake or continue. Therefore, there is no problem from an ethical point of view in fail a treatment that is already useless or in not starting a treatment that is not going to be useful. And this is not utilitarianism, it is different.

Therefore, it is not only the criteria that were mentioned earlier, and which are having a great influence, of the scarcity or lack of means to provide certain treatments or not, but there is also an ethical criterion that emanates from the medical activity itself, from the diagnosis made of the patient; therefore, the dilemma that the director of the paediatric ICU posed to me comes into play, when he told me that he had learned from the internship when the means are proportionate or disproportionate. He had had to learn, from his own development as a professional and as a scientist, to discover and solve the ethical dilemmas that arose.

Justice would be to establish criteria of equity or non-discrimination in health policy, and here we are going to face important problems, such as the possible discrimination of patients on the basis of age: there are more and more patients who are much older, the whole field of geriatrics and gerontology is constantly growing, there are also more and more patients who reach a terminal status with much greater demands for medical interventions and technical possibilities for action than before, and also much more expensive than before. This raises the question of how far to go in such cases, and how far society should go in providing this attendance health care or using all possible means in the case of terminally ill patients.

I think that it is necessary to establish, and it is the clinicians who ask for this the most, standards of fairness given from outside; so to speak, clinicians ask Bioethics to tell them what standards they should have in order to act correctly, and to allow them to know what is right or wrong. From a practical point of view, what has been done wrong when it could have been done right is medical malpractice and is easy to regulate from the point of view of the law. Justice is much more difficult, but I think that this is where bioethical reflection contributes a lot in terms of equitable distribution, non-discrimination on the grounds of age and non-discrimination on the basis of the patient's own status : we will have to see in each case status whether the means are proportionate or disproportionate and we will also have to establish some general or specific criteria. This is also where the social discussion comes in: what kind of health care subject is wanted, how far the health care attendance will go, because the supply of technical means is increasing, but these means are also becoming more and more expensive. This poses a problem. It does not seem to me to be as relevant a problem in our western world as it might be in developing countries development. When it is sometimes argued that there may be problems in the medical care of terminally ill patients in Spain due to a shortage of resources, it seems to me a little absurd or out of place: those who maintain such positions would have to visit some hospitals in Latin American or African countries to find out what a shortage of resources or a lack of equity and justice in health care really is.

Bioethics defends the autonomy of the patient, but also the autonomy of the doctor. Until now, especially in American bioethics, autonomy was the principle that took precedence over the others, which has not been the case in the reception of bioethics in Europe, where it has been established that autonomy is indeed a very important principle, also with terminal patients, who are people until the end of their lives and, therefore, their consent must be obtained if they can give it, or with the consent of their relatives; the terminal patient must be given information, and this is one of the major ethical dilemmas: doctors do not dare to inform cancer patients; although theoretically they say that it is ethically correct to inform, later, at the time of the clinical internship , in many cases they do not do so. This is where an ethical dilemma arises, and bioethical reflection can help to establish better channels of speech between healthcare teams and patients.

Consent will underline the information staff, not the bureaucratic one, between doctor and patient. It is not a question of signing a piece of paper, as is sometimes claimed, or of protocolising consent. Informed consent protocols are needed in hospitals, in the different specialties, but let us not stop at protocol.

It is also necessary to establish criteria for action in the ICU. These criteria already exist: the Spanish Society of Intensive Care has its own ethical standards for action, for defining proportionate or disproportionate means, and I think this is extremely important, because they also establish principles of justice and principles of beneficence.

I could say more about autonomy, but I am running out of time. It is something very important in contemporary medicine, which has been introduced in recent times, but there is still a long way to go to respect the autonomy of the patient and, in particular, that of terminal patients: there are many people who die without knowing that they are going to die. There is also the right not to know, and this can be exercised by the patient. But what is not right is to arrogate to oneself the right not to inform, either on the part of the doctor or on the part of the family itself. The patient must be involved.

Finally, I would add that bioethics also acts with the principle of beneficence. And this is where I think it is most important to emphasise in the current status the positive impact that ethical reflection can have in the field of care for the terminally ill: we cannot stop at justice regulations, criminal rules on malpractice and maleficence, and respect for autonomy. Patient care, and even more so if the patient is terminally ill, where autonomy has enormous problems, which any clinician can put on the table: cases of full patient autonomy are very rare. In view of the principle of beneficence, ethical reflection is in fact already leading medicine itself, because it is part of its purpose as a science, to very positive approaches that I think should be emphasised from an ethical point of view: palliative care, and the consequent duty of all doctors to learn palliative care, and not only those who work in the palliative care section.

A Chilean doctor recently raised with me, in indignation, a proposal law in his country on intensive care specialists. It was intended in this project that only the Intensive Care physician was qualified to decide whether or not to continue with the patient's care, without taking into account the specialists who had brought the patient to the Intensive Care Unit (nephrologists, oncologists, etc.). On the other hand, it gave Intensive Care specialists the degree scroll as specialists in death. Some Spanish authors have spoken of specialists in dying. Professionals who do palliative care or intensive care are not specialists in dying. No doctor is a specialist in dying: they are specialists in patient care and, in the case of palliative care, in the humanisation, I would not say not so much of death, but of the end of the patient's life. This also entails a series of ethical requirements to learn palliative care, but in the knowledge that other specialists, and not only the intensive care unit, must also deal with the terminal patient.

And for another reason: we would then pass on to palliative care all the problems that arise in the hospital, and all patients would die in palliative care, whether they are in pain or not. This is not the case: palliative care has its own purpose.

This also raises other ethical questions: the involvement of the family in the care of the terminally ill patient, topic which must be analysed; there are a series of ethical duties on the part of the patient's family towards the patient, and these must be taken into account when establishing what is to be done with terminally ill patients.

There is also the non-hospitalisation of the terminally ill: why should they necessarily die in the intensive care unit? More and more people are in favour of home care medicine and I think that, from an ethical point of view, this is an important question: what is the greatest good for the patient? The principle of beneficence will lead us to look for what is best, and the best will often not be to be in hospital with two others dying next to you.

Finally, I will mention the human financial aid in the process of facing one's own death, which we will all have to do at the end of our lives. Here it is necessary for health professionals, doctors and also nurses, to be very clear about their ethical duty to continue with the care of the patient beyond what is merely curing or not curing, and of emotional support to the family, or bereavement support. I refer to an extraordinary experience, written by a French author, Marie de Genezel, with a foreword by François Mitterrand, with the degree scroll of The intimate death. It describes everything that health professionals can do to live the final moments of a patient's life with great respect for their intimacy, which is the best way to humanise medical care and to attend to and respect the value and dignity of this human life until the end.

The congress participants then took the floor. The first of them, a doctor, thanked Professor Ollero for his intervention and commented on some of the points of his discussion paper of the morning. For example, euthanasia is not really an important problem now, there are no major cases here in Spain, with a few exceptions, such as the case of the quadriplegic in Galicia, which was given a great deal of attention advertising, but it is an important issue in other places, for example in Holland, in Oregon - which has drawn up a law - and I also think that euthanasia will be not only important, but very important in a few years' time here in Spain. In my opinion, faced with this panorama, politicians should do something they never do, which is to foresee.

When you build a motorway, you have to foresee whether it will be congested in four years' time, and it seems that this is often not foreseen. When you talk about euthanasia, you don't seem to foresee what is going to happen either. So what can politicians do about euthanasia? Something like what they have not done about AIDS. AIDS in 1984 was not a problem in Spain, as there were 14 cases. Then urgent legislative action was requested from the government to prevent it from spreading and it was said that topic was not urgent. Now thousands of people have died and billions have been spent on treating the sick, unfortunately employee .

With regard to euthanasia, what can politicians do? Well, it occurs to me that they can do several things. Preventive medicine for euthanasia, consisting of providing information and, above all, introducing into health policy plans what you yourself said this morning, palliative care units, the typical English Hospices, or similar models here: pain treatment units, etc. But in large numbers. Because we are seeing so many sick people, and I am talking about my daily clinical internship , who have been turned away from hospitals and have been sent home to die, who can have a good quality of life if they get the right care. If politicians would propose to make a national geriatric plan, which there is not, and within that geriatric plan would include well organised palliative care units, which are cheap and inexpensive, to take care of patients together with pain management units, there would be very few requests for euthanasia in the future. I have never had a patient order killed, never, absolutely never in the forty years that I have been practising medicine.

The patient who experiences loneliness, or feels neglected by his or her children, is the one who I imagine is asking for his or her life to be ended. If that patient is cared for, if he is not in pain, if his dyspnoea has been removed (pain and dyspnoea are the most important symptoms that cause suffering), he will not ask anyone to kill him. I think that politicians, and I think you will agree with me at agreement , can do this preventive medicine, anticipating a little, as they have often failed to do, what is going to happen tomorrow, what is to come.

Professor Ollero replied to the comments by saying: I fully agree with agreement, as is clear from my own intervention this morning. As for the importance of euthanasia in Spain, we are back to virtual reality: I believe that there are some who are trying to give it more than it has and, therefore, one of the tasks of politicians must be to slow down this subject of manipulations so as not to give a license to problems that do not yet exist; and it should be noted that, on the part of some political groups, this has meant a B effort; if you have read the debates that have taken place on euthanasia in the congress, political groups that have voted against, when they spoke they made it seem as if they were going to vote in favour, because they are incapable of arguing against it. They vote against, but they do not argue against; they are incapable of arguing against, and I do not think it is because they do not know how, but because it clashes with a whole structure of progressive culture in which they are immersed and therefore they are not in a position to argue against. They are in a position, for the moment, to vote against it.

Well, we must indeed foresee. But, in this case, I believe that what is being done, and it is not being done badly, is not to create a bottleneck by creating problems that do not exist and to try to reduce it.

Informing: we must inform. This study commission, for example, would be useful for this purpose; however, the problem is that information is always provided half-heartedly. There is little point in having a study commission such as the one that is taking place in the Senate if the media on speech ignore it, as they are ignoring it in a striking way. In this sense, this morning I encouraged the media on speech to disseminate the content of these sessions, and I believe that anything that is done to get hold of these texts and disseminate them will be of interest. I am sure that if the interventions had been of a different nature, some would be doing so. Therefore, we must all report back.

As far as palliative care and geriatrics are concerned, these are issues that, as a politician, are outside my field, which is justice; but, undoubtedly, I think that in health policy Mr Romay should be dealing with it, and I am sure he will be dealing with it. Frankly, I am not that informed on the issue because it is not my field; but I promise him that next Tuesday I will tell him that he is encouraged to deal more with palliative care and geriatrics. I fulfil my role as an intermediary in that.

The second intervention came from a Dutch woman who commented: In the Netherlands, only people of faith are against euthanasia, and there are relatively few of them. I would like to make it clear that the mentality of a people cannot be changed in a moment, it takes time. I would like to know how we can give a training based on the natural law that allows not only people who believe to be against euthanasia, but also others, because it is against life.

Dr. León Correa replied to his question by stating that he had just been a few months ago in a hospital in Galicia with one hundred and fifty nurses and approximately half of them already admitted active euthanasia as something they were willing to accept or admit, not to carry out. By this I mean that the problem of euthanasia is not a problem of an act that arises in intensive care. Doctors in intensive care, emergency or palliative care are almost all against euthanasia, but the spread of the euthanasia mentality is already worrying even in Spanish medical sectors. There are doctors defending euthanasia, and there is a growing state of opinion in favour of it. As this has already happened in the Netherlands, it must be prevented to some extent by educating society itself.

Secondly, I have very good Dutch friends, not only Catholics, but also some Protestants, such as Professor Johensem of the Lindeboom Institute, who is also arguing against euthanasia from a rational position; I think that the reasoning I made earlier about fundamental human rights is valid for all those who really want to go deeper into these human rights and the ethical duties of the individual. If we start from utilitarian or other positions, dialogue and understanding of the wrongness of euthanasia becomes impossible. But it seems to me that there is a common rational basis for us to understand each other, not only among Catholics. There are no moral strangers, as Engelhardt claims. For me there are no moral aliens or moral strangers.

Professor Herranz added: In this respect, I would like to insist on one point: even here, in order to start talking about euthanasia, we would have to reach a prior consensus on terminology to know what we are talking about. That one hundred and fifty nurses in a hospital in Galicia say at least that they are flirting with active euthanasia - this is what I have understood - gives the impression either that things have changed dramatically in my region - which can happen - or that they do not have a clear idea of what euthanasia is.

It seems to me that there is a positive interest in keeping the concepts blurred, in insisting again and again on the existence of what is called passive euthanasia. There is no such thing as passive euthanasia.

It is necessary to go to agreement because, in the vast majority of surveys - the famous one of the Barcelona doctors and many others that are carried out - apart from the fact that the questions asked are tricky, and I completely agree with this agreement, a meta-analysis of the opinion on euthanasia should be carried out because the crude data are just that, crude, they have not been refined, the questions are tricky, asked very quickly and obtaining answers against the grain.

The Central Commission of Deontology presented a Declaration that was approved by the General Assembly stating that there is no notion of passive euthanasia, not even of distanasia. The idea of a clear, absolute condemnation of therapeutic overkill, of the use of useless, futile, irrational therapies, is fundamental. fail treatment that serves no purpose is essential. I omit to mention examples for the sake of brevity.

I would ask those theologians who continue with the residual notion of indirect euthanasia, i.e. that life can be shortened by treatment, to realise that they cannot give the enemy the slightest support for their ideas, and that there is no such thing as indirect euthanasia. I would like to say that it is a myth from the past, from the old pharmacology, to claim that the rational, competent use of pain treatment in accordance with the art of medicine can shorten life. It has been seen that the nervous system and the respiratory nuclei and the pain pathways and centres adapt and become refractory or resistant to the effect of morphine, and the dose needs to be increased to be effective. A massive dose of morphine in a patient who has been on an escalating course of treatment for some time does not have the slightest depressant effect on the respiratory centre and does not shorten life.

The first dose can be active in this sense. But once the first five days have passed, which are always a trial and error of escalating doses to achieve analgesia and patient comfort, once this phase has passed, there is a very close correlation between the amount of doses to treat pain and the amount of doses to produce respiratory depression. In fact, it can be stated that the idea of indirect euthanasia, i.e. that the effect of treatment can lead to a shortening of life and an anticipation of death - thereby supporting the idea that there are ethically acceptable ways of killing or anticipating death - has been challenged by developments in modern pharmacology, and is a myth that belongs to the past.

In this sense, it seems to me that, whenever we start talking about euthanasia, we should clarify what we mean by euthanasia, because if we are talking in a status of semantic indeterminacy, in which one understands one thing and another another, rational discussion is obviously not possible.

However, this rational discussion is deliberately marginalised by many people. I remember, in a television programme, in which quite a few people were present, euthanasia was discussed. At the end of the programme, which lasted more than two hours and average, and which was attended by many people of high cultural standing and few bioethicists, I said to the programme's director : unfortunately, I think we have contributed to confusion rather than to clarification. The response was along the following lines: but what planet have you fallen from? Television is there to create chaos and to keep people discussing euthanasia until five o'clock in the morning (the programme ended at one o'clock and average); we are not pedagogues. We are not pedagogues. We simply move in the field of opinion.

If people knew that there was a conspiracy of journalists ... I am a friend of journalists (I don't know if there are any journalists here), but the tendency of many journalists is to highlight the bizarre, the abnormal, the marginal. This makes the rational discussion on euthanasia not newsworthy. The preponderance of "a man bites a dog" over "a dog bites a man" largely dominates news reporting. And it is very difficult to get adequate media impact from speech. The idea that one can be marginalised, left out, not helped to participate, is an experience I have very directly from some of the programmes on this subject.

Professor Ollero, for his part, in response to the question, commented: I believe that there are three different fronts of argument. The first, which I see as very difficult, is to try to convince people that the right to life does not include the disposition of life. I find that very complicated or very complicated to argue from a non-transcendent point of view. Another second front of argument is the following: people ask to die; should we maintain a society where people ask to die or change it? Because there is nothing more strange, marginal and newsworthy than people who want to change a society in which people are asking to die. In other words, what needs to change in society and in the health profession so that people do not ask to die? And thirdly, the practical consequences: are people willing to facilitate a regulatory change that leads to people dying who do not want to die?

The next speaker was Professor Thomas, speaker of congress who commented:

Just two caveats, which have nothing to do with brain death, which is the topic that concerns us. The opinion polls in Germany show that result is 70% in favour of euthanasia, and in the Netherlands more than 80%. I live not far from the Dutch border, and the hospitals in Germany close to the border are full of patients from Holland who do not want to be killed in their clinics. It must be that they survey other people.

With regard to what Professor Ollero has pointed out, I think there is a gap within the legal system, and that has to do with the figures in these surveys: the gap is the legal system of decriminalisation of assisted suicide; at least in Germany this is the case. Thus, Kevorkian, who has continually made a fool of the entire legal system, is well known internationally, because he has increasingly narrowed the gap between euthanasia and suicide. In the end, it should be legally permissible for me to put something in the patient's language and he only has to swallow, and it would only be financial aid to suicide. Without closing this gap, the euthanasia issue cannot be stopped.

With regard to what Dr Pardo said, I think that his final remark is a little dangerous. You mentioned earlier the role of intention and decision in the human act and, at the end, already with regard to the justification of transplantation in the case of the brain dead being alive, you have legitimised it solely on the basis of intention. This is a very dangerous approach, very topical, but it has its roots, according to Mrs. Anscombe of Cambridge, in David Hume, and it is a position that is spreading. According to this way of reasoning, a fellow gynaecologist could apply the same reasoning in obstetrics and, with the intention of having an uncomplicated delivery, could crush the head of the child. Perhaps the example is a bit extreme, but he makes it clear that the substance of the act must first be defined; in the case of certainty that the brain-dead is alive, I would be very doubtful whether his arguments would then apply.

Professor Pardo replied: Perhaps I did not explain myself adequately before. When I spoke of intentionality as a component of action I was referring to the intentionality or "aiming towards" of the decision, not the intention. In addition to this decision, in human action there is the intention of a goal, the toleration of undesired effects, and the physical execution of that action that has been decided upon. What I was trying to say was that the performance of a transplant (executed decision) carries with it the tolerated effect of the death of the donor, which seems to me to be proportionate in this case, given his condition, because if we did not perform the transplant, we would simply have to turn off the respirator, for reasons of uselessness or for reasons of using these medical resources for other patients.

Professor Ollero added that, in the Spanish case, there is no such difference between euthanasia and financial aid to suicide. On the contrary: euthanasia is not mentioned in the Penal Code and is rather considered as cooperation to suicide. There is no such double figure. In any case, I think that, from an argumentative point of view, the points to work on would be, firstly, the problematic nature of consent on the part of the person requesting suicide, to what extent this is not a pathological depressive condition (I can think of one example); and, secondly, the difference between the autonomy of the suicide's will and the transitive action of the person who kills another and, therefore, to put an absolute stop to actions of this nature subject. In theory, the Code only contemplates punishing someone who is going to commit suicide, not an action that is properly transitive.

A question was then posed to Dr. Shewmon by one of the attendees. He was referring to the case of the patient he had presented in the morning on his lecture. He showed us that the TK child had no brainstem or cerebral cortex function. Don't you think that staying on the ventilator at status is a case of therapeutic overkill?

Professor Shewmon replied: Thank you for the question. Some people have misconceived from my thesis , explained in this morning's speech, that these people should be kept alive indefinitely. However, I meant no such thing. If there is one status where medical financial aid should be interrupted by extraordinary means, it is brain death. These 176 patients who survived for more than a week should not necessarily have been kept alive; I have only collected the cases as they occurred, without claiming that what was done should have been done.

Which cases should be kept alive? I think that pregnant women should be kept alive, in order to save the lives of their children. Some of them, actually many of them, are kept alive regardless of whether there is a law concerning brain death. Also in Japanese culture, where there is a more "vital" sensibility than in Western culture, one would think that there is more of this duty for cultural reasons. Some of the cases were children whose parents did not accept the fact that their child was dead, and insisted on maintaining life support. In many cases where the family insisted, the doctors listened to them, thinking that, even if they continued life support, the patient would end up going into cardiac arrest after a few days, so they continued the medical financial aid in the belief that the result would be the same. However, in some of those cases that were kept alive according to the parents' wishes to avoid arguments and lawsuits, the patient did not suffer a cardiac arrest, and the clearest case is the boy who survived for 16 years that I showed this morning: his mother takes care of him at home, without financial aid from anyone, being a burden only for her. But I do not advocate that such behaviour is what has to be undertaken in this subject of patients.

Professor Martínez Lage, clinical neurologist at department of Neurology of the Clínica Universitaria de Navarra, followed: I am really happy to be able to speak in this session, even if it is to disagree with my dear friend Alan Shewmon, with whom I had the good fortune to share those days in 1988 that he remembers; moreover, I have witnessed the saga staff that he has described in his discussion paper.

To give the public some background, the topic of brain death will be forty years old in 1999: in 1959, in France, when the Resuscitation Services arrive, colleagues of mine begin to think that they are looking at a corpse because the patient has an infectious inflammatory process in her orbits, in her eyes, with a tremendously aggressive process in her lungs, in which the respirator continues to provide her with the gaseous exchange , and the heartbeat is maintained. These illustrious men of Parisian neurology commented among themselves, in great doubt: I think this patient is already dead. And this was in 1959.

Now, in 1999, it seems to me that it is somewhat risky to raise this question, especially when it is done at degree scroll staff on the experience of the meta-analytical study carried out by Dr. Shewmon in his casuistry published in the prestigious journal Neurology, which also motivated a splendid publishing house of the journal.

In this country, in 1988, the Spanish Society of Neurology drew up neurological criteria for death, and did not use the expression brain death because death has no qualifier. So, when this morning's discussion paper states that only a legal definition of circulatory and respiratory death can possibly be universally accepted, this statement remains at the level of a reflection staff made by your enormous experience and your great dedication to topic, but which is not supported by any scientific association or by doctors specialising in Intensive Care Medicine, or by neurologists, to indicate the people who deal most directly with this status.

The Spanish government is preparing a new decree on brain death2, as the Diario de Navarra said very well this morning in a letter signed by Dr. Antonio Pardo. I am taking great care in my speech, for which I apologise to moderator for being a little long, not to mention at all the problem of organ donation, not to mention at all the relationship with the persistent or permanent vegetative state, not to mention at all the relationship of this problem with euthanasia because the problem of death (without qualifiers) will never be solved either by the philosopher or by the doctor. There is no proprietary concept of death, because it would be crass ignorance if the contribution of Philosophy and the contribution of Medicine were to go their separate ways; as crass ignorance as invoking philosophical principles to define a medical problem.

Death is not a moment, death is a process. And if we take this process to its ultimate consequences, according to your point of view, as presented here, we would have to demand that all the cells of a person's organism, absolutely all of them, down to the last one, be dead, in order to consider him or her deceased. This means that even his own DNA could not be used in 20,000 years' time to determine his type. The corpse, after eight or ten days - everyone here knows this - grows fingernails and hair. We cannot go so far as to place the point of no return, which is critical here, at "every cell, every last one, dead".

You have made the point very well that the substratum of the person cannot be put in the brain either, because the spirit informs much more. But, when it was discovered - and I go back to 1959 - that the human being can die connected to a respirator and maintained artificially, then academic community discovered that there is a different way of dying, which is not cardiorespiratory arrest, but brain arrest, cerebral arrest, irreversible and total brain failure. And this, at the moment, and excuse me for stating it so emphatically, is indisputable in the world academic community .

I advise Professor Shewmon, colleague and friend, to speak to degree scroll staff and not to sow, with this point of view staff the concern in doctors meets the precise criteria and with an impeccable protocol , because of the consequences it has, some stupendous, for Medicine and for his development. Moreover, the record case reported by you in the meta-analysis study, the case of the four-year-old child with meningitis that led to brain death and who is now alive at the age of 20, did not meet the criteria for brain death in the United Kingdom, Spain or committee in Europe at the time. All you have to do is violate these protocols on a single point, because when you go to examine him, logically, you cannot perform the test apnoea test - I don't know if he was on a respirator at the time or not; furthermore, he had vegetative reactivity at the time: in your recruitment of cases for this meta-analytical study there are methodological flaws, and you cannot elevate what, in my opinion, after this meta-analysis, is purely anecdotal to a category.

Professor Shewmon's rejoinder followed, stating: I think it is sufficiently clear that what I have presented is my opinion. But it is not only my opinion, but a growing opinion in the field of medicine, that the empirical evidence supporting brain death to this day needs to be re-examined. Many are speaking on this issue today; at the association International Bioethics Symposium in San Francisco; or, in 1996, at a Symposium devoted exclusively to topic brain death, I was the only one to present some evidence that went against the concept. In fact, there were several speakers who, like me, had been changing their views on this issue, including the Symposium organiser himself, Dr Younger. You mentioned that I have been changing my mind on this issue: indeed I have. During lunch this afternoon and afterwards, I was able to talk to several participants in these conference who told me that they have changed their minds and join the growing civil service examination to the concept of brain death (curious expression).

During the II International Symposium on Brain Death, held in Havana in 1996, there was a clear lack of consensus on why brain death should be considered death. The most coherent reason, which emerged towards the end of the sessions, was a reason that dealt with the concept of personality and its reductionist conception which is much in vogue today. Many of the speakers, at the end, when asked about the relevance of the integrated organic unit, replied that it was an irrelevant question, as it is not a person, there is no life there staff. This is the intellectual outlook of many who approach the topic of brain death today. Surely, I am not the only one to have expressed myself along these lines this morning.

I have many points raised by Dr Martínez Lage.

As to whether my position implies that every brain-dead person is not really dead: that is a feature of my position. Unfortunately, you did not have the opportunity to see presentation this morning, but I think that, if you have read my article, you can see clearly what I have stated this morning.

You mentioned that death is a process. I have no choice but to radically disagree with this. And I think all the philosophers present here will also disagree. And so will the theologians. Death is not a process, but a one-off event. There is the process of dying that leads to that moment and a subsequent process of decomposition. Unfortunately, we are not in a position to pinpoint exactly when it happens, to the millisecond, but it is certainly a one-off event. We can say at most that it has taken place at some point in the past, or that it has taken place in a limited framework of time.

With regard to the validity of the cases I have collected on article, and especially the case we have referred to - T. K., who has still been alive for 16 years, we must distinguish between using the diagnostic criteria as a kind of legal cookbook and using the criteria to determine whether the brainstem is destroyed or not. It is true that I did not perform an apnoea test in that case, and not for lack of desire to have done so, but simply because it could not be done. In fact, I would not have included him among the cases had I not had other solid reasons to reassure me that his brain stem was completely destroyed. This reason was the existence of an X-ray tomography. I was interested to know whether an X-ray scan had been performed, and that test had been performed when the patient had been brain dead for some time, and again when he had been brain dead for a long time. The image sample shows the skull without any traces of brain stem. In this case, given that the purpose of the apnoea test is to determine the functioning of the brain stem, as there is no brain stem, there is no functioning of the brain stem, and it is not necessary to perform the test apnoea test, which is quite irrelevant in this case, given that his brain stem is destroyed and liquefied.

In many of the cases on report a formal apnoea test was performed - if you look at the table, the data are not on the article, but they are available from the sources indicated, and I can send you a copy -, and they achieve a p CO2 that meets the criteria for brain death. Among the long survival cases, there is one from Pittsburg; in my article I have pointed out all along that I did not have access to the medical records, but I know the p CO2 values that were reached with the apnoea test: after the article was published I had access to the medical records, and the p CO2 value was 70, which far exceeds the values required for the apnoea test. The neurologist at the University of Pittsburgh who performed the test, and who is involved in transplantation, said that it was not brain death, but rather a serious injury.

There are many other cases where the criteria required by neurologists are not met, such as some emergency cases, and others. In many cases, however, I have not had access to the medical records. This does not mean that the neurologist who makes these diagnoses and who asks the family for organ donation is doing things wrong. I simply did not have access to many data, but I think my colleagues were doing things correctly. Moreover, if the organs were taken legitimately, these cases could not be included in my study.

With regard to the issue of not creating concerns among physicians who currently apply the neurological criteria for brain death, I do not want anyone to confuse my attitude towards physicians who do not agree with my position agreement . After all, I was a physician with whom I now disagree agreement. Any doctor here who diagnoses brain death and participates in organ transplantation procedures, I am perfectly sure, is doing the right thing if he or she is so convinced in conscience: nothing I have said this morning in any way implies any question of conscience or any question of changing the behaviour of anyone here, or of anyone in my own status. I am a neurologist and work in a transplant centre. My colleagues involved in performing transplants are acting in an ethically correct manner if they are acting in conscience.

When it is said that my doubts confuse ideas, or confuse consciences, I am not talking about anyone here or any of my colleagues. I am talking about many people I have spoken to who tell the neurologist or the doctor that the patient is alive, while the doctor who has diagnosed brain death insists that the patient is dead and can be a donor of his organs; their reaction is not to believe that statement and to react by telling the doctors that they must stop the patient from dying. They think the patient is alive until the ventilator is stopped. Brain death, in their eyes, is a mere legal fiction. Indeed, there is a lot of confusion out there.

I do not judge anyone's conscience here. I myself have held the opposite opinion in full rectitude of conscience for years. I would not like to be misunderstood in this respect.

For his part, Professor Pardo added: I would like to publicly confess my hypocrisy, because Dr Martínez Lage praised me in a letter published in the Diario de Navarra this morning explaining some questions about brain death, in which he reassured readers' possible doubts that we doctors were removing organs for transplants from living patients. As has become clear from my exhibition, that is not my view. I made a mental restriction and omitted the word "legal" in one sentence and I seem to think something else entirely.

I think that, obviously, we have to give a different image to the outside world of the academic discussion that can take place, as Dr. Prat pointed out the other day.

Continuing with the same topic, and addressed to Dr. Shewmon, Dr. Prat de la Riba stated: First of all, I must say that I greatly admire Prof. Shewmon, not today, but for many years, and that his work in The Thomist in 1985 is a work that I would like many to read, although I am not at agreement with that work, as I am not at agreement with the later works. I really believe that there will be few neurologists - perhaps Dr. Martínez Lage will dispute this - who have devoted themselves to this topic with such intensity. You only have to look at the number of footnotes in his works that show that he has read the Philosophy, the psychology, the history, etc. of the issue. It is a truly acribic work .

Prof. Shewmon's pathway , as impressive as it is, sample also that there has been a shift: there has been a first Shewmon, a second Shewmon, and I trust that there will also be a third Shewmon, and I would like to contribute with all my effort and energies to this shift, and not because I am or am not a follower of Hegel and his dialectic of thesis , antithesis ... but I think the synthesis can be found if we think a little bit about what is the theory of medical science. Here it seems as if medical science - as Dr. Martínez Lage has already said - defines death in a philosophical way.

You, Alan, have put three planes, the philosophical, the philosophical-medical and the medical. agreement According to the criteria of the Philosophy of science, the philosophical plane will never meet one hundred percent with the medical plane or the medical-philosophical plane, but there will always be a evaluation and a agreement. Therefore, the topic of death will always be something that will always have a conventional value.

This means that we must have the courage to do evaluation and not limit everything to a science. As you have done today, you have taken some cases, you have evaluated them by applying some concepts that are evaluations, and you have given a solution. This is what, after Popper, Kuhn and Lakatos, in the theory of science is called conjecture. They have no more value than conjectures, although they are very valuable, like everything scientific. This is a very important reductionism in science.

I think in the first Shewmon there was a reductionism that I would call radical, which I found invaluable: when I read article of The Thomist I said to myself: this is a conscientious scientist who is incorruptible, who goes to the very end.

The second Shewmon came along and, with the same radicalism, took revenge on the first Shewmon and said: now I am not a reductionist, I am a holist, and I apply completely different criteria, which, in my opinion, are not adequate either.

As time is short, I will confine myself to a brief philosophical critique of the criteria you set out this morning.

The criterion issue one says (in the translation I made from the Journal of Philosophy and Medicine, which may be somewhat different from the one made here): An organism possesses integrative unity and is therefore an organism if it possesses at least one emergent property at the level of totality (holity): emergent if it derives from interaction and total if it is not predicable of one of the parts but only of the totality.

This criterion refers us philosophically to the predicate of relation, from which emerges a predictable property of the whole, which may or may not be a quality. A culture of a compound of several cells, a reaction Chemistry, a dead person by the most classical definition (whose hair and nails continue to grow as we have heard), have such an emergent property. This is with respect to the first criterion. So this first criterion is not reduced to an organism.

The second criterion is more interesting. A body that requires less technological attendance to maintain its vital functions than a similar body that is commonly accepted as living, must have the same robustness of integrative activity and therefore also be a living being.

I believe that this corollary cannot be accepted by a doctor, who often sees that it requires much more effort and much more technical attendance to make a small regulatory change in one part of the functioning of the patient's organs, than when there has been a multifunctional arrest which, with a special technical attendance , can be resolved.

On the other hand, I believe that there is a petitio principii in this corollary, because if we do not assume that both are alive, then we can never reach this conclusion; therefore, I would advise rethinking these two criteria to see if they are really applicable to topic.

The third question concerns the alluded article of Bonelli and myself; in his work he said with regard to our criteria that, in order to be a valid definition, they have to be applicable both to brain death and to the case of a brainstem lesion. He comments on page 14: "Therefore, whatever definition we want to give to the concept of the integrative unit or organism as a whole - this is a definition that, if I had more time, I would like to discuss, because I think it is one-sided - if they can be appropriate for bodies with a section of the spinal cord, they must necessarily be appropriate for bodies in a state of brain death". The study that Bonelli and I have done, I think, makes it clear that the case of brain death is death, and is not comparable.

Professor Shewmon thanked for the comments and replied: "Maybe there could be a Shewmon issue three, I am not closed to that possibility. The example of nail and hair growth is not an example of fulfilling the criterion issue one, which involves the organism as a whole.

I am not radically attached to the criteria issue one or issue two, and we could talk to arrive at different criteria. In my work on brain death I have observed a gap in criteria, but I do not intend to fill it completely with my individual response. But it is necessary to start from some clear operational criteria, such as unity and the organism as a whole, and to examine how bodies do or do not fulfil these properties.

If anyone disagrees with my conclusion, I would repeat average sentence from my work: For any definition we could give of the concept of integrative unity and of the organism as a whole, if it is feasible to apply it to organisms with a medullary section, it must necessarily be applicable to organisms in a state of brain death. With this sentence I do not intend to put an end to it, and I will be happy to discuss any other criteria you would like to propose to me.

Notes

(1) In Brain death and the ethics of transplantation.

(2) In fact, on 30 December 1999, Royal Decree 2070/1999 (BOE, 4.I.2000) was issued, with Annex I graduate: "Protocols for Diagnosis and Certification of death for the removal of organs from deceased donors".