lecture of Dr. Gonzalo Herranz at the presentation of the book "Desde el corazón de la Medicina".
Tribute to Gonzalo Herranz.
high school Official Doctors / Alumni University of Navarra.
Valladolid, 29 November 2013.

1. Greetings and thanks

2. Introduction

It is very difficult for the author to speak objectively about his book. He would first have to kill his ego. It would be better for him to keep quiet and leave the task to the serious and knowledgeable readers of subject.

If that is the case, one must inevitably ask: why has this gentleman come here? To justify my presence, I have a good alibi. "From the Heart of Medicine" is not my book. To begin with, it is not copyrighted, I do not own the author's rights to it. Besides, I didn't do it: others did. It has been composed by committee publishing house , although, to a large extent, with my own materials. In addition, "Desde el corazón..." lacks the classic title page with the basic bibliographical information (author, degree scroll, publisher, place and year of publication). On the cover of the book we see the degree scroll, a phonendoscope with a symbolic cordiform profile , a subtitle that reads: "Homage to Gonzalo Herranz", and in one corner, the WTO logo. There is no author.

To make sure, I consulted the Catalogue of the Library Services of my University: in the corresponding file, the usual "Author" box had been removed. Fortunately, in the corresponding box for secondary authors, the six members of committee publishing house are listed. In conclusion: I seem to be heavily involved in the book, but I am not, at least "officially", the author. I therefore feel entitled to talk about it freely, immune to the risks of self-promotion or conflict of interest of any subject, including financial ones.

"From the heart..." consists of three parts. One, preliminary, brings together the notes (presentation, testimonies and biographies) written by members of committee publishing house or guest authors. The second part contains the long interview with me by José María Pardo, doctor of medicine and theology. The third brings together 15 lectures, most of them unpublished, which the members of committee publishing house selected from among many others.

In this talk, I will address three issues. I will begin by explaining how the book's project was born and grew. I will then make some brief but appreciative comments on the preliminary notes of homage and dithyramb. Finally, I will draw attention to a few points from the interview and the lectures.

3. Issue 1: Birth and development of the book

On page 48 of "Desde el corazón...", José María Pardo tells how one day a colleague of his, Prof. Juan Luis Lorda, addicted to writing books and having others write them, suggested that I write a book-interview; Pardo adds that, after maturing the idea and the strategy to tempt me, he presented me with a project which I flatly rejected. I was not lacking in reasons. I had recently read some interview-books, and they seemed to me to belong to two very different categories: some, like those of Ratzinger-Seewald, were an astonishing synthesis of intelligence and simplicity; others, on the contrary, were full of egomania. The former were beyond my reach; the latter were embarrassing. Interview books are not for me, I told Pardo. But, against my better judgement, thanks to his and others' firm determination, I eventually gave in. As we all know, with age, the powers of the soul, the intellect and the will, and not only report, weaken.

And so we began: on Tuesdays he would come to my house, early in the afternoon, with a tiny tape recorder, and I would answer the questions he had asked me that morning. I was convinced that transcribing conversations is very difficult and that it would come to nothing. But I was wrong: after a few months José María appeared with a written transcript of our conversations. Neither of us knew what the fate of that draft would be. The truth is that I did not put much enthusiasm, though I did put a lot of responsibility, into the task of correcting the transcribed text. I removed a few details, added a few others, and, as always, a few typos crept in.

As I later learned, Dr. Pardo sent the monster to Rogelio Altisent for his opinion. And Altisent, in turn, sent it to Dr. Rodríguez Sendín. Nobody told me anything about these manoeuvres. And so, in complete ignorance, I found myself, one day in June 2012, having breakfast at the high school de Médicos de Navarra with Juan José Rodríguez Sendín, María Teresa Fortún, Rafael Teijeira, José María Pardo and Rogelio Altisent, who were part of the self-appointed committee publishing house . Also invited to the breakfast at work were Dr. Pilar León, professor of the history of medicine at my School, and Teresa Alfageme, from the WTO press office.

They told me that they were going to publish the interview, but that they wanted it to be accompanied by other writings of mine: the purpose of meeting was to finalise the table of contents of the book. They discussed among themselves who could make the usual introductions and praise. And they asked me to make available to them the texts of my lectures (more than two hundred, most of them unpublished) which I kept more or less scattered on floppy disks and pen-drivers. Some members of committee publishing house would see them and select the ones to be included in the book.

A year went by. And, in July this year, while I was away from Pamplona, fleeing from the Sanfermines, José María Pardo brought me a couple of copies of the book with the ink, as they say, still wet. I was pleased to see it sturdy, discreet, well-made; above all I was pleased to see that it is not an author's book, but rather a book of homage and tribute: in other words, it was, however you look at it, a gift, albeit an undeserved one. That is its story.

4. Second issue: a few brief comments on the introductory notes

Some readers will take it for granted that the five testimonies and the biographical sketch that occupy the first 45 pages of the book are the usual string of laudatory appraisals, sincere and heartfelt no doubt, but loaded with the exaggeration that is common among the lauders of the day. They are not without reason. The natural thing, for many, would be to skip them and get to the point. I would advise against it, as they can be approached differently. Rather than praise for the honoree, I prefer to see them as a testimony of lived collegiality. Basically, they reveal that the medical profession is, as I like to repeat, a moral community, an entity for committee and discussion, in which it is possible to work together, in a friendly and polite manner, each with his or her own mentality, sometimes disagreeing, but never in a bad way or in a bad mood. And that leaves its mark.

Juan José Rodríguez Sendín's presentation is, above all, a testimony of friendship, initially forged in a few long conversations we had, years ago, when he was Secretary of committee General. In them, he allowed me to reflect aloud, freely, on what I thought of the WTO; on the features and ethical nature of the leadership role; on my hopes that one day the organisation would become truly participatory, a fair defender of the rights and freedoms of its members and a persuasive teacher of their duties, and a spokesman, in short, for the ethical values of the profession. She adopted some of my views, and I thank her for that. And I have had to put on a good face when, for various reasons, she dismissed others. But she has always treated me with a deference that I believe comes more from her liberality than from my merits.

Professor Enrique Villanueva, who declares himself to be very sparing in his praise, has written a few pages in which sample shows how the friendship with which he distinguishes me made him lose his objectivity, if not his head. Something similar happens with Rogelio Altisent, although, in my opinion, his judgements are a little more nuanced. Both, each with their accredited independence and staff , select some memories of the years when we coincided in the Central Commission. Some readers, good critics, will say to themselves as they read their testimonies: "It will be less", and they are not far wrong.

I am particularly grateful for the words that Diego Gracia dedicated to me, in which he praised the incalculable human and humanising value of friendship, the marvel that is "friendly friendship", capable of allowing kind and frank dissent, without the disagreement diminishing mutual appreciation one iota, but on the contrary, increasing it. I consider it one of my best achievements to have persuaded Diego Gracia to join the Central Commission. He then made the admirable gesture of joining the Commission and submitting himself to the elective process to become a member. And, in it, he understood and appreciated collegial ethics, which says a lot about his intellectual generosity.

grade Marcos Gómez Sancho, current President of the CCD, adds a touch of humour to his testimony when he describes with a masterful hand the circumstance in which our friendship began: a National Defence Health congress , held in Santiago de Chile in 1993, well into the democratic transition after the Pinochet dictatorship, to which I was invited to speak on the ethics of organ donation for transplantation. They admired Spain's example. And they followed it: two years later, the congress approved Republic Law 19.451 on organ transplantation and donation.

Finally, Dr. Pilar León gives a semblance of my academic life. She built it up by patiently and tenaciously searching for scattered papers in chaotic and abandoned archives. It became clear that I had done nothing to make work easy for historians. I have to admit that, in this portrait, Dr. León has done me a great favour.

But the testimonies do not end there. There is one inserted at the very beginning of the interview, very brief, but which I value highly. It was sent to application by Prof. Edmund Pellegrino, when he was already very ill. I considered Pellegrino, and will continue to consider him, as the leading figure in medical ethics. I met him in March 1985, at a Bioethics congress in Beer-Sheva, Israel. We then had a couple of long and, for me, revealing conversations. He offered to send me a list of his publications so that I could ask him for the ones I wanted. From the list he sent me, I pointed out many: he sent me all of them; and, I say it unabashedly, that was the medical-ethical milk I sucked. I therefore endorse a few lines from the tribute paid to him by Mildred Solomon, current President of the Hastings Center: "He [Pellegrino] influenced me and many others, not only by his immense work and his ability to relate to people, but above all by offering us the example of a life full of noble aspirations, combining exceptional leadership and exceptional humility. To lose a person of such authenticity is always painful; but it is even more so today, when there are so few examples of respectful dialogue between secularists and believers; when there are so few efforts to integrate science and medicine with Humanities; when the social pull of action without reflection and faith is so strong.

5. Third issue: commentary on a few points from the interview and lectures

The interview is very long, taking up more than 150 pages; the collection of lectures is even longer: it fills almost another 200.

About the interview. It is a pity that the corresponding table of contents was not included. I will limit myself to mentioning only three topics that seem significant.

First topic. I say, and this may cause a scandal, that in recent years, bioethics, as an academic discipline , seems to have lost vigour, as if it were tired, unmotivated. Many of its cultivators, especially in the United States, have imposed on it such a utilitarian bias that any bioethical discussion ends up hopelessly in the conclusion that everything is permissible, everything is justifiable. This implies a repetitive argumentation, always the same, imitating that introduced by Peter Singer more than a quarter of a century ago. In such a context, where the solution is known in advance, since the nihil obstat of permissibility is already granted, what becomes decisively important is originality in inventing problems: the emphasis shifts to the creation of extravagant scenarios, of fanciful thought experiments, of post-human assumptions ever more distant from what is realistically possible. Such an enormous waste of ingenuity eventually becomes boring. Until a few years ago, the quarterly or bimonthly periodicity of bioethics journals used to take me a long time. I still pay attention to them, I still keep an eye on them, now almost always on the computer. But there are few articles that stimulate me and make me think. Perhaps it's just another of the ailments of old age, but I seem to perceive an unhealthy inclination in recent bioethics. One example: not long ago, three bioethicists discussed in the Journal of Medical Ethics whether bringing children into the world is only irrational or also immoral. Another example: In the latest issue (Nov-Dec 2013) of the American Journal of Bioethics, the futuristic anti-love biotechnology (pills to stop loving, neurobiological interventions to cause emotional breakdown) is addressed, with the purpose to decide which actions and under which assumptions could be ethically justified, or even morally enforceable. Human love is thus reduced to a mere Biochemistry , a matter of molecules. Such things arouse the suspicion that the golden age of bioethics has passed.

The second issue in the interview that I am going to discuss is that of the science-faith dialogue. There is data to suspect that what might be called "public opinion" in science (the editorials, commentaries, interviews and letters to publisher published by the big journals) is increasingly sectarian, more anti-religious. It seems as if we are in a new Kulturkampf. The ethics of the Catholic tradition, which advocates respect for life, for the weakest members of the human family, for the dignity of human procreation, is getting a very bad press. I firmly believe that there can be no contradiction between true science and true faith. And I wish for a lively, fluid, friendly, thoughtful and yet critical dialogue between the one and the other, a dialogue that could bring immense benefits. But it is not easy. It requires theologians and scientists to shed their prejudices and to study each other's professions very thoroughly and critically: only in this way can they understand each other. But it seems that there are hardly any theologians and scientists who have the time and humour to do this: multidisciplinarity is a very difficult task.

I will give a vivid example. I talk about it in the interview, referring to the pre-implantation embryo, but, when I did so, I had not published a article on the chronology of monozygotic twinning, which appeared in May 2013 in the magazine Zygote, nor had the book "The fictitious embryo. History of a biological myth". In the article and in the book, I review the history of the creation, between 1922 and 1955, of the "dominantmodel " that we all know, which relates the supposed moment of the splitting of the embryo in two and the structure of the foetal membranes; namely, cleavage on days 1 to 3 post-fertilisation gives rise to DC DA twins; on days 4 to 8, MC DA; on days 9 to 12, MC MA; and after day 12, conjoined twins. The initial idea occurred to George Corner in 1922, as an intuition, a mere exercise of the imagination. But in 1955, the model seemed to Corner himself so reasonable that it seemed a good description of what actually happens. Over the years, it evolved from a plausible hypothesis to an uncontested description of reality, a reality that no one has seen or verified. When one looks for and identifies the embryological incongruities of model, one has to recognise that, despite its rationality and internal logic, which explains why no one doubts it, it is nevertheless biologically untenable. Having shown that the model is indefensible, I thought it convenient to offer, to replace it, a theory that proposes that twinning could occur at the end of fertilisation, when, when the zygote divides, it gives rise not to the first two blastomeres, as normally happens, but to two new zygotes, which already, from that moment on, begin their development as monozygotic twins.

Zygote's article (the same as the book) is very innovative and, I still think, should have aroused some curiosity among scientists. I had hoped that it would be severely criticised, I wanted to be beaten to a pulp. To that end, I sent the virtual text of article to more than 300 scientists (biologists from development, physicians, geneticists, bioethicists and moralists) who, in the last 5 years, had subscribed to the conventional chronological model in their publications on twins and twinning. I have had a few responses, some very flattering, from leading embryologists and geneticists. But more numerous have been those of a mere polite acknowledgement and, I say with regret, a much higher rate of silences. Openness to the scientific or ethical discussion does not seem to be going through a good moment.

I realise that time is short and that many scientists, philosophers and theologians are busy with matters that cannot wait. I know that I have no right to be answered, as no one is obliged to reply to unsolicited mail. It may also be the case that quite a few will not like the ethical implications that follow from my critique of the dominant traditional model , which leaves the concept of the embryo without ethical status in its first two weeks of life seriously wounded. We will have to give time to time.

To conclude this point: science and faith are, in my view, two synergistic forces. One and the other helped me to persist for years in the humble task of searching for data and evidence, and to publish a work that, perhaps, financial aid to bring out of the morass a theory that has stagnated for 60 years the ideas about monozygotic twinning. I suspect that certain scientific rebellions can only be initiated by those with the binocular vision of science and faith.

My third and final comment on the interview concerns collegial ethics, to which the interview devotes 20 pages, too few, it seems to me, for the esteem in which I hold it. I will allude to a point that is particularly dear to me. The 2011 Code of Ethics, in art. 63.2, imposes on medical teachers the duty to "take advantage of all circumstances [...] to inculcate in students the ethical values and the knowledge of the Code". This mandate should not fall into a vacuum. If teachers at Schools and mentors of physicians at training were to fulfil this duty, the flourishing of professional ethics and, with it, the moral leadership of the Colleges would be assured.

A concrete example: if ethical values and the contents of the Code were taught, what is today in many hospitals the ridiculous routine of filling in the paperwork imposed by Law 41/2002 (and its regional versions), would become an ethical opportunity to promote and express respect for the person of each patient and their individual dignity. Assuming that the teacher is the true skill, and going beyond what the law mandates or the patient's legal rights demand, educating in ethical respect implies teaching students and residents to talk to patients; to do so with a sincerity and a human tone capable of inspiring the trust required for ethical consent. The skill of professor to take advantage of any circumstance to inculcate ethical values in its students should be taken as a basic factor in the scale for academic promotion: it should appear, if not ahead, then next to the list of publications in prestigious journals. Will article 63.2 of the Code be able to change the strange, erroneous disdain for the academic evaluation of the ability to teach "humanity" and which is so important for patients, and also for students who want to learn to respect their patients?

For years, I have been repeating that the presidents of the colleges and the deans of the Schools must join forces to fulfil this serious duty of the "collegiate-teachers", which is, at the same time, a privileged right of the "student-future collegiate members". A request: please read the article "Recent advances" by Michael LaCombe which I copy on pages 275 to 277 of "From the heart of medicine".

So much for the interview.

About the conferences. Their subject matter is as varied as medical ethics itself: it ranges from the teaching of medical ethics and the ethics of the medical student, to the ethics of the health strike and the role of ethical expertise in the administration of justice.

What would you highlight from them? Seen from a bird's eye view, it is easy to spot some of "my obsessions". They are concepts that I talk about many times, themes that I return to on occasion (and sometimes not).

One of these concepts is that of respect as a doctor's fundamental ethical attitude, with its many manifestations: ethical respect, and not only polite respect, which governs relations with patients and their relatives; which inspires relations with colleagues and professional institutions (hospitals, colleges, scientific societies); the almost sacred respect that doctors must feel for themselves (as individuals and as professionals); the doctor's specific, preferential respect for the weakest; respect for the life of every human being; respect for science, which seeks to approach the truth.

Another topic to which I return many times is the recognition and reparation of doctors' mistakes. I see that this favourite topic appears in both the oldest (1988) and the most recent (2012) of the collected lectures; and it is, moreover, the topic of a lecture I gave here in Valladolid in 2008. Perhaps it is an obsession, but I still think what I thought 25 years ago: it is necessary to overcome the hypocritical culture of concealing error, to discover the immense human value of recognising and confessing the truth. We don't seem to understand that to err is human. We should all recognise this: doctors and patients, judges and lawyers, social communicators and ordinary people, in order to humanise medicine by ridding it of the plague of defensive or cunningly misleading medicine. And, in its place, to create the atmosphere of sincerity, intelligence and fairness that is necessary to compensate for objective harms, identify the source of errors, and apply measures to prevent their recurrence.

Finally, I would like to draw attention to lecture which deals with the human rights of doctors. In it I recount, in a very sensitive way, the circumstances that motivated my interest in this issue. It happened that the medical organisations of the major European countries decided to ignore the repeated allegations of racist abuse inflicted on a doctor of Asian origin by his hierarchical superior. Let me be a little more explicit here. This doctor-victim wrote a letter to publisher of the BMJ briefly telling his story and regretting that the organisations of which he was a member and the ethics subcommittee of the Permanent committee of European Doctors itself did not deign to address the complaint he had made against his superior. I was vice-chairman of that subcommittee at the time and asked the chairman to discuss the matter at a meeting shortly afterwards in Brussels. I tell this story with regret. In my good faith, I could not have imagined what kind of manipulation Degree could lead to in the committee Permanent . When I went to the subcommittee meeting, two colleagues were waiting for me outside to tell me that the matter had been transferred a few hours earlier to another subcommittee and that it had already been resolved. I told them that I very much regretted what they had done, as it was against the established rules and regulations : the subcommittee in question was incompetent on subject. In addition, I felt obliged to explain the reasons for my action. They had no choice but to allow me to speak at the meeting of the ethics subcommittee. My failure was spectacular: not a single voice was raised in favour of investigating what might be true in this allegation of racism. I was never able to find out whether the complaining Asian doctor was a victim of mistreatment by his boss or paranoid. In return I was asked to prepare a draft human rights charter for doctors. His fate was a pitiful one. After many postponements and amendments, the text was C. A fleeting victory: under pressure from some national doctors' organisations, apparently hurt by my gesture in defence of a humiliated colleague, the document was removed from file of committee without leaving a trace. I think it was a good thing, not revenge, that the committee publishing house of the book included the lecture on the human rights of doctors vis-à-vis professional organisations, together with the Charter of Rights to which I have just alluded. It is on pages 286-293 of the book.

Final point: my final and irrevocable conclusion is this: that, in spite of all the pains, which are not few, deontology is worthwhile: it is humanly very beautiful.

Thank you very much for your attention.