Sowers of hope
Creation: lecture Spanish Episcopal Conference, Episcopal Subcommission for the Family and Defense of Life.
sourceAvailable at: lecture Spanish Episcopal Conference.
language Original: Spanish.
Copyright: No.
Publication: November 1, 2019.
Accessed December 4, 2019.
Sowers of hope
Welcoming, protecting and accompanying in the final stage of this life.
I. The social discussion on euthanasia, assisted suicide and dignified death
II. Ethics of the care of the sick: dignity, health, disease
III. Palliative medicine in the face of terminal illness
IV. The unlawfulness of therapeutic obstinacy
V. Euthanasia and assisted suicide are ethically unacceptable.
VI. Proposals for fostering a culture of respect for human dignity
VII. The experience of faith and the Christian proposal
God said to Moses, "Take off your sandals from your feet, for the place on which you are treading is holy ground" (Ex 3:5), in response to the phenomenon of the bush that burned without being consumed at the foot of Mount Horeb. If entering into the life of a person always constitutes walking on sacred ground, all the more so when this life is affected by illness or before the supreme trance of death. In the face of the discussion that has been revived lately about human life, euthanasia and assisted suicide, we want to propose in this document a hopeful look on these moments that close our vital stage on earth.
With this document we intend to help, with simplicity, to search for the meaning of suffering, to accompany and comfort the sick in the last stage of their earthly life, to fill with hope the moment of death, to welcome and support their family and loved ones and to illuminate the task of health professionals. The Lord has come so that we may have life in abundance (cf. Jn 10:10) and in Him we have been called to be sowers of hope, missionaries of the Gospel of life and promoters of the culture of life and the civilization of love.
The joy of the Gospel must reach everyone, especially those who live in suffering and prostration. We wish to acknowledge and thank those who dedicate time and effort to transmit this joy and hope of the Gospel to the sick and their families. In a particular way we want to show our gratitude to the teams of pastoral care of health in the different areas, to the chaplains, suitable people, professionals and volunteer activities in hospitals, residences and institutions, to the congregations that have as their own charism the care of the sick and the elderly.
Those who suffer and are facing the end of this life need to be accompanied, protected and helped to respond to the fundamental questions of existence, to approach their status with hope, to receive care with skill technical and human quality, to be accompanied by their family and loved ones and to receive spiritual consolation and the financial aid of God, source of love and mercy. Assisted suicide and euthanasia, which is the action or omission that by its nature and intentionally causes death in order to eliminate any pain, do not provide solutions to the suffering person.
The Tradition of the Church and her Magisterium have been constant in pointing out the dignity and sacredness of every human life, as well as the unlawfulness of euthanasia and assisted suicide. The Church offers various ways and forms of accompanying the sick and those who suffer, which have given rise to many charisms that have given rise to numerous institutions and congregations dedicated to their care, in addition to the generous response of the faithful who make their own the words of Jesus: "I was sick and you visited me" (Mt 25:36) and exercise charity after the example of the Good Samaritan (cf. Lk 10:25-37).
The text we present here is intended to be pedagogical and easy to read for everyone. For this reason, we have avoided burdening it with references and footnotes. For those who wish to go deeper into the Magisterium of the Church dealing with these matters, we refer mainly to the following documents: Pius XII, speech on the moral and religious implications of analgesia, 1957; St. John Paul II, Apostolic Letter Salvifici doloris on the Christian meaning of human suffering, 1984; Encyclical Veritatis splendor, 1993; Encyclical Evangelium vitae, 1995; Benedict XVI, Encyclical Spe salvi, 2007; Francis, speech to participants in the Plenary Assembly of the Congregation for the Doctrine of the Faith, 2018; Audience to the Italian Federation of the Colleges of Medical Surgeons and Dentists, 2019; Congregation for the Doctrine of the Faith, Declaration on Euthanasia, Iura et bona, 1980; Response to some questions from the U.S. Episcopal lecture on artificial nutrition and hydration, 2007; committee Pontifical for Health Care Workers: Palliative Care, status current, various approaches brought by faith and religion what to do?, 2004; New Letter to Health Care Workers, 2017; Catechism of the Catholic Church, nn. 2276-2283; CCXX Executive Council of the Spanish Episcopal lecture , Declaration on the occasion of the project of law regulating the rights of the person before the end of life process, 2011.
On October 28, 2019, the Joint Declaration of the Abrahamic monotheistic religions on end-of-life issues was published. It states that "care for the dying represents, on the one hand, a way of responsibly assuming the divine gift of life when no further treatment is possible and, on the other hand, our human and ethical responsibility to the person who (often) suffers in the face of imminent death. Holistic and respectful care of the person must recognize as a fundamental goal the specifically human, spiritual and religious dimension of death. This approach of death requires compassion, empathy and professionalism on the part of all those involved in the care of the dying patient, especially health care workers responsible for the patient's psychosocial and emotional well-being."
Pope Francis, in his audience to the Italian Federation of the Colleges of Medical Surgeons and Dentists last September 2019, affirmed that "it is important that the physician does not lose sight of the uniqueness of each patient, with his or her dignity and fragility. A man or a woman who must be accompanied with conscience, intelligence and heart, especially in the most serious situations. With this attitude one can and must reject the temptation - also induced by legislative changes - to use medicine to support a possible will to die of the patient, providing financial aid to suicide or directly causing his or her death by euthanasia. These are hasty ways of dealing with options that are not, as it might seem, an expression of the person's freedom, when they include discarding the sick person as a possibility, or false compassion in the face of a request to be helped to anticipate death. "There is no right to arbitrarily dispose of one's own life, so no physician can become tutor executive of a nonexistent right.""
The association World Medical Association (WMA), which represents the world's collegiate medical organizations, stated in its resolution adopted in October 2019 at its 70th General Assembly: "The WMA strongly opposes euthanasia and suicide by medical financial aid . For the purposes of this statement, euthanasia is defined as a physician deliberately administering a lethal substance or performing an intervention to cause the death of a competent patient at the patient's voluntary request. Suicide with medical financial aid refers to cases in which, at the voluntary request of a patient with decision-making capacity, a physician deliberately allows a patient to end his or her life by prescribing or providing medical substances intended to cause death. No physician should be compelled to engage in euthanasia or suicide with financial aid , nor should he or she be compelled to refer a patient with this goal".
We thought it appropriate to maintain the format of questions and answers to help a better understanding, as was already done in the document "Euthanasia. One hundred questions and answers on the defense of human life and the attitude of Catholics" that the committee Episcopal for the Defense of Life of the Spanish Episcopal lecture published in 1992. We have avoided technical language for the better understanding of those who lack specialized knowledge, without renouncing the depth and rigor of thought. The way we treat people in status of vulnerability, the way we welcome and support the weak, the elderly and the sick, the way we approach the last moments of our earthly life qualify the ethical quality of society. The Church, the servant of humanity, wants to offer the paschal light of the dead and risen Christ, capable of illuminating and filling with love, mercy and hope the most complex and often painful situations of human existence.
We have chosen to approach the question, in the first place, from a perspective that starts from the human condition, in order, in the second place, to open this question to the splendid luminosity communicated to us by the Lord Jesus, who has conquered death and has given us the Holy Spirit to know the meaning and fullness of our vocation in Him. We are aware that this approach has its limits. But we do so in order to emphasize that the questions raised by the end of this life, the drama of euthanasia and assisted suicide are profoundly human issues, which affect dignity and are not reduced solely to a religious question or for people who profess the Christian faith (cf. Evangelium Vitae 64). We are grateful to those who have helped us to prepare this text. We entrust to the maternal protection of the Virgin Mary, Health of the Sick and Help of Christians, the sick, their families and friends, health professionals, volunteers and so many people who collaborate in the pastoral care of health and the family, and all those who suffer in body or spirit.
I. The social discussion on euthanasia, assisted suicide and dignified death
1. What underlies the recent social discussion on euthanasia and assisted suicide?
Euthanasia and assisted suicide are nowadays the object of propaganda campaigns in their favor. The current discussion on these issues is not really a medical question, but rather an ideological one with deep anthropological roots. Indeed, at bottom we are faced with a certain conception of the human being and its family and social implications and a concept of freedom conceived as absolute will detached from the truth about what is good. The difficulty of finding a meaning to suffering and the way to fit it into people's life journey, and the consequences that these approaches have on the way of understanding social relations, political responsibility and their repercussions in the health field, are evident.
2. What aspects are promoted in the campaigns in favor of euthanasia and assisted suicide?
Campaigns aimed at eliciting opinions in favor of euthanasia and assisted suicide usually promote the following aspects:
- The first thing that is presented is a "borderline case". The search is for a terminal and dramatic status particularly striking that challenges the collective sensibility. Once this case is admitted, the profound reasons for not admitting other similar cases disappear, widening the casuistry.
- This is complemented by ideological and semantic euphemisms. Thus, expressions such as "causing the death of the patient" or "taking the patient's life" will be avoided. On the contrary, others such as "dignified death", "autonomy", or "liberation" are extolled.
- In addition, the defenders of life are portrayed as retrograde, intransigent, opposed to individual freedom and progress. In this way, a calm and constructive dialogue, which seeks above all the good of the patient, is avoided.
- Another element of the strategy consists of conveying the idea that euthanasia is a religious issue. Therefore, in a pluralistic society, the Church -or any religious denomination- cannot and should not impose its opinions.
- As a complement to these strategies, the aim is to transmit to society the idea that euthanasia is an urgent demand of the population and a demand of our times.
The Pontifical Academy for Life (9.XII.2000) denounced the campaigns and strategies in favor of euthanasia: "Campaigns and strategies have been developed - it says - along these lines, carried out with the support of pro-euthanasia associations at the international level, with public "manifestos" signed by intellectuals and men of science, with publications favorable to such proposals - some, accompanied even by instructions aimed at teaching the sick the different ways of putting an end to life, when it is considered unbearable-, with surveys that collect opinions of doctors or public opinion figures in favor of the internship of euthanasia and, finally, with proposals for laws submitted to parliaments, in addition to attempts to provoke court rulings that could lead to a de facto internship of euthanasia or, at least, to it not being punishable".
3. What are the main arguments used for promote the legalization of euthanasia and assisted suicide?
The different issues adduced for the legalization of euthanasia and assisted suicide can be traced back to four main arguments:
1. Unbearable suffering.
The defense and promotion of euthanasia and assisted suicide based on the unbearable suffering of the patient has been the argument invoked for many years. The accompaniment of the family is a very important element in helping the sick person to get back on his or her feet when faced with the onset of the disease, particularly if it is serious. partnership And, among other things, it is the duty of the physician and staff to alleviate the suffering and eliminate the pain of the patient, with the patient's own opinion and that of the family, especially when we are dealing with a person at the end of life. In this regard, it is important to warn that, if it is not guaranteed that the patient undergoing this status is pain-free, requests for euthanasia may inevitably arise. And clinical experience sufficiently demonstrates that, for such situations, the solution is not euthanasia, but adequate, humane and professional care, and this is the aim of palliative care.
2. Compassion.
The second banner raised by the movements in favor of euthanasia and assisted suicide is compassion. In order that the patient does not suffer, it is justified to end his or her life. Moreover, it is claimed that this contributes to the good of society, because it does not waste the limited health resources of the community, which can be used for other purposes. This means that quite a few people, at this time of life, may feel like a burden to others (their relatives and society), and do not want to continue living. Also, others may consider the life of dependence unbearable and lacking in dignity (in food, hygiene, transportation, lack of control staff) and think that in these conditions death is better. The solution presented in this context is euthanasia or assisted suicide. It is euthanasia out of compassion: so that he does not suffer, so that he stops living. But we soon realize that this is not the right attitude. The most humane thing to do is not to provoke death, but to welcome the patient, to support him in these moments of difficulty, to surround him with affection and care, and to provide the necessary means to alleviate suffering and suppress pain, not the patient. Authentic compassion is of a different order. Experience shows that, when one perceives the affection and care of the family, the importance of one's own life, which always contributes to the good of the family, of others and of society, the respect for the dignity of every human being regardless of his or her state of health or any other conditioning, and receives adequate palliative care, if necessary, a very low percentage of patients explicitly ask for euthanasia. Sowing true hope, alleviating loneliness with affectionate and effective companionship, alleviating anguish and fatigue, becoming position of the sick person "carrying him on one's own back", following the example of the Good Samaritan (cf. Lk 10:25-37), are expressions of true compassion.
3. Death with dignity.
The third argument of the pro-euthanasia movement is the concept of "death with dignity". Sometimes, with the expression "dignified death" or "dignity of death" what is meant is that "I am the master of my life; I die when I want to". That is to say, it is a question that makes reference letter to the concept of freedom, element core topic in the conception that each one has of life and the way to conduct it, also when suffering or death lurks. This expression is also related to the quality of life, which, in turn, is interpreted as the ultimate criterion of the dignity of life. According to this criterion, when the quality of life is poor, life is no longer worth living. It is easy to perceive that, from this perspective, human life is not worth living for its own sake. The quality of life is worth more than life itself. But, furthermore, by what yardstick is quality of life measured in order to affirm that it is worthless or not worth living?
4. The concept of absolute autonomy.
Related to the previous one is the fourth argument: patient autonomy, conceived as an absolute. In many of our contemporaries there is an idea of "autonomy" that refers to the conception that each person has of freedom, which is also transferred to the field of the end of life. It is basically an expression of a conception of an absolutist freedom detached from the truth about the good. Euthanasia would be a right of autonomy staff taken to the extreme: "I am the master of my life, I will die when and how I choose". Certainly, autonomy is a fundamental element. The human being is free and perfects himself by acting freely. But to conceive of the dignity of the person solely in terms of his or her autonomy is a reductive vision that leaves aside other fundamental dimensions. On the one hand, there are people who, in this sense, are not autonomous, such as children, dependent patients, people with serious mental disabilities, coma patients, etc. Do these people only have the dignity that others grant them? Do they not have it as such? If autonomy were the ultimate foundation of a person's dignity, many people would lack dignity. On the other hand, it is evident that the autonomy of the person is not absolute. Neither in the field of human relationships nor in family or social coexistence.
In the field of medicine, the concept of autonomy is not total either. The patient, especially the one in status terminal, or without the capacity to use reason, is not autonomous. The disease itself, medication and other circumstances necessarily limit the patient's capacity to make decisions.
4. Is the promotion of euthanasia and assisted suicide a recent phenomenon?
The request for euthanasia on the part of suffering patients dates back to the very origin of medicine, since the Hippocratic Oath explicitly rejects the practice of euthanasia. However, in the last century it has been promoted by associations and movements that seek its legal approval, as well as that of assisted suicide, and governments that accept the pressure exerted by these movements or institutionally encourage it. The recent origins of this phenomenon can be traced back to the Enlightenment ideas of the last three centuries. Societies advocating its legal approval date back to the first decades of the 20th century, and have been increasing at issue.
5. Isn't the acceptance of euthanasia and assisted suicide a sign of civilization?
A sign of civilization is precisely the opposite, that is, the foundation of the dignity of the person in the elementary fact of being human, independently of any other circumstance such as race, sex, religion, health, age, skill guide , mental or economic capacity. This essential vision of the human being represents a very important qualitative progress, which rightly distinguishes civilized societies from those that existed in times long past, in which the life of the prisoner, the slave, the disabled person or the elderly person, depending on the time and place, was despised. Euthanasia and assisted suicide do not make society better or freer, nor are they an expression of true progress.
With euthanasia or assisted suicide, the life of the suffering person is eliminated in order to stop suffering. And this is incompatible with true civilization, because a human being does not lose dignity by suffering. It is especially contradictory to defend euthanasia precisely at a time like the present, in which medicine offers alternatives, as never before, to treat and care for the sick in the last phase of their lives.
It is likely that this resurgence of euthanasic attitudes is a consequence of the conjunction of two factors: on the one hand, the advances of science in the prolongation of life; and on the other, a cultural environment that considers pain and suffering as the evils par excellence, to be eliminated at all costs. This is particularly true when there is no transcendent vision of life that helps to penetrate the mystery of suffering, which is inherent to all human life.
II. Ethics of the care of the sick: dignity, health, disease
6. What is the ethical foundation of the health professions?
To speak of dignity is the way to express the unique and irreplaceable value of each person. It is the profound reason why medicine cares for the sick. In the interpersonal meeting we discover the unrepeatable value of each person, his inherent and inalienable dignity. This also occurs in the relationship between the patient and the physician and with each of the people who make up the healthcare team. This interpersonal meeting constitutes the foundation of the ethics of the health professions. Once the patient and the physician establish a relationship, what is required of the latter is respect for the patient, recognition of his dignity and financial aid in a relationship of trust to fight the disease: a process of objectification in the context of meeting between two people seeking a shared good, which is to restore the patient's health.
7. What is meant by health and disease?
A sick person, in the etymological sense of the expression, is someone who cannot fully fend for himself (cannot stand on his own feet, is in-firmus) to a greater or lesser extent, i.e., who has difficulties in carrying out his daily life due to the limitations of the disease, from a slight discomfort that prevents few things to being bedridden in a dependent manner. Health care aims to restore health. To achieve this, medicine tries to find out the causes of the illness in order to provide the appropriate remedy, and its goal is that the sick person, after receiving treatment, can once again carry out his or her normal activity or, at least, with fewer limitations than before being treated.
Health does not always imply physical integrity, although the study of pathologies assumes that in disease there is an organic lesion. Although this idea has provided the core topic of many diseases, it has produced some confusion. Thus, there is a tendency to think that the goal of medicine is to cure, when the daily internship us sample that there are occasions when this is not the case: an analgesic can allow normal life without actually curing. There is also a tendency to focus on organic problems, which are exhaustively examined and correctly solved, sometimes compromising the proper and dignified human attention .
Health does not imply perfect well-being and, although a certain level of health is necessary to be able to live, it is possible to carry out daily activities with some discomfort. This is the human condition. Medicine must seek adequate wellbeing to be able to develop daily activities, without pretending the utopia of perfection and plenitude. This becomes clearer if we take into account that there are discomforts that are part of the human condition, such as sadness at the death of a loved one or fatigue with physical exercise; likewise, there are states of well-being that no one would consider healthy, such as the state after the administration of a dose of a drug.
8. Are pain and death part of human life or, on the contrary, are they obstacles to it?
Pain and death are part of human life from the moment we are born until we die: we cause pain to those who love us and we suffer from the very process that leads to death. This is attested to by the experience staff of each of us and by universal literature, in which this experience is not only a source of inspiration, but an object of constant reflection.
Throughout life, physical pain and moral suffering are present in a habitual way in all human biographies: no one is a stranger to pain and suffering. The pain produced by physical accidents - small or large - is a companion of human beings throughout their lives; moral suffering (the product of the incomprehension of others, the frustration of our desires, the feeling of impotence, the unjust attention , etc.) accompanies us from our earliest childhood to the threshold of death.
Death is the foreseen culmination of earthly life, although uncertain as to when and how it will occur. It is part of our biography, because we are affected by the biography of those around us and because the attitude we adopt towards the fact that we are going to die determines in part how we live.
Pain and death are dimensions or phases of human existence. An obstacle to life is the attitude of those who refuse to admit the presence of these constitutive facts of all life, trying to flee from them as if they were totally avoidable, to the point of turning such a flight into a supreme value. This is the denial of reality itself, which can become a cause of dehumanization and vital frustration.
9. Should, then, every person renounce to flee from pain in general, and from the pain of agony in particular?
The human being has been created to live and to be happy and, therefore, feels rejection in the face of pain and suffering. And, therefore, this rejection is just and not reprehensible. However, turning the avoidance of pain into the supreme and ultimate value that must inspire all conduct, at any cost and at any price, is an attitude that ends up turning against those who maintain it, because it means denying at the root a part of human reality.
It is only possible to face the appearance of suffering in the different stages of life if we are able to find some meaning in it, when we assume it for something or someone, because suffering is never an end in itself.
As Pope Benedict XVI affirmed in his encyclical on hope Spe salvi: "It is right to do everything possible to reduce suffering; to prevent as far as possible the suffering of the innocent; to alleviate pain and help to overcome psychological ailments. All these are duties both of justice and of love and are part of the fundamental demands of Christian existence and of every truly human life. We must do all we can to overcome suffering, but to eradicate it from the world completely is not in our hands, simply because we cannot free ourselves from our limitations, and because none of us is capable of eliminating the power of evil, of guilt, which, as we can see, is a continuous source of suffering" (n. 36).
These ideas are especially evident in the case of agony, of the pain that can eventually precede death and that must be appropriately addressed. But making the absence of pain the exclusive criterion, without taking into account other dimensions, for recognizing a supposedly dignified character of death can lead to legitimizing the suppression of human life - under the name of euthanasia.
Alleviating suffering, pain, anguish and loneliness in the status terminal illness, with the cooperation of the patient himself, his family and his environment, is an ethical duty of the first order.
Is it important to look for meaning in life and also in situations of pain and suffering?
Limitations and problems of all kinds subject are always present in life. What varies is the way in which people deal with them. This diversity has to do with the approach to the purpose of life, the meaning attributed to it, often in a way that is not fully conscious. Suffering often has more to do with the meaning of life than with the intensity of health problems (pain, disability, bothersome symptoms, etc.). In the context of living solely for enjoyment, limitations are seen as the most negative and undesirable, contrary to human dignity. However, in more reflective views on one's own life, it is quite different. This other view is marked by the question of "what am I here for", or better, "who am I here for". Like result, every human being discovers in some way what he or she is called to in life (with all the possible variations and psychological situations that accompany that finding). As Pope Francis states, "I want to remember what the big question is: Many times in life, we waste time asking ourselves, "But who am I?" And you can ask yourself who you are and spend a lifetime searching for who you are. But ask yourself, "Who am I for?" You are for God, no doubt. But He wanted you to be also for others, and He has placed in you many qualities, inclinations, gifts and charisms that are not for you, but for others" (Christus vivit, 286). If one accepts this sense of a life for others, one faces with hope the discomforts and sufferings that one's own existence may entail.
11. Can illness be an opportunity to question the meaning of life?
Illness forces a halt in daily activities and forces people to reflect on their lives, to reposition themselves in the face of this new status and to rethink their objectives. When caring for the sick, it is essential to take into account this facet that accompanies illness: it is a time of inner crisis. The sick person often raises fundamental questions about his or her life and needs to be supported and accompanied - mainly by family members and loved ones - so that the deep meaning of what he or she is experiencing can emerge and grow as a person facing a new status illness. It should be taken into account that, in the case of serious illnesses, answers of meaning do not easily appear. Spiritual accompaniment and the transcendent meaning of life help the sick person to find fundamental references for dealing with illness and disability. St. Paul referred the status of life and death to a much deeper foundation in which its meaning appears: "If we live, we live for the Lord; if we die, we die for the Lord; so whether we live or die, we are the Lord's" (Rom 14:8).
12. Is the fear of dying and how to die natural?
It is natural to be afraid of dying, since human beings are naturally oriented towards happiness, and death is presented as a traumatic rupture. The biblical explanation of death as an element foreign to the primordial nature of the human being fits perfectly with the collective psychology staff that accredits an instinctive resistance to death. Jesus himself, in Gethsemane, experienced fear and anguish before the imminence of his passion and death: "He began to feel sadness and anguish. Then he said to them, 'My soul is sorrowful even unto death; remain here and watch with me'" (Mt 26:37-38). Of course, it is natural to be afraid of a painful death, just as it is natural to be afraid of a life immersed in pain. The fear of a painful and dramatic way of dying can become so intense that it can lead one to desire death as a means of avoiding such a painful death status. But experience shows that when a suffering patient asks for death, he is basically asking for relief from suffering, both physical and moral, which sometimes surpasses the former, such as loneliness, lack of understanding, lack of affection and consolation in the supreme trance. When the patient receives physical relief, company, affection and psychological and moral comfort, the closeness and involvement of his own family and loved ones and social environment, as well as adequate medical and socio-health care, the experience sample that stops apply for to end his life.
13. As some believe, would not a painful death or a very degraded body be more unworthy than a quick death, produced when each one would wish it?
In their ultimate nature, pain and death contain the mystery of the human being, as well as the mystery of freedom and love, which are living and intimate realities, albeit intangible, and which cannot be sufficiently explained by physics or Chemistry. Pain and death are not adequate criteria for measuring human dignity, since this is proper to every human being simply by virtue of the fact of being human.
When the supreme moment of death arrives, we can help the protagonist of this trance to face it in the most adequate conditions possible, both from the point of view of physical pain as well as moral suffering. The affection and application of one's own family, moral consolation, companionship, human warmth and spiritual help are fundamental elements. The dignity of death lies in the way of facing it. For this reason, in reality, it would not be appropriate to speak of "death with dignity", but rather of people who face death with dignity.
14. Is there, therefore, a basic anthropological question in the attitude adopted in the face of pain and death?
The position one adopts in the face of pain and death depends on one's conception or idea of the human being, of human relationships and of life, and on the way in which one's own freedom comes into play. When the transcendent sense of life is lost, it is more difficult to recognize its sacredness and dignity. Without this sense of transcendence, it is more difficult for human beings to face suffering and pain and to find meaning in the difficult situations of life. In this status, the human being feels unable to find reasons to continue living when life is not easy, rewarding, productive.
Nor can we forget the social dimension of life itself. Human beings are constitutively open to communion and to living in community. Human life is not only a good staff, but also a social good, a good for others, in such a way that an attack on life also affects the justice owed to others. The ethical imperative "thou shalt not kill" protects the truth inscribed in the human condition of all times: to be faithful to the character of otherness of the human being in which life itself could not be maintained if it were not open to transcendence and to the other, that is, to the realization of the interpersonal communion inscribed in the human heart.
15. What are the needs of terminally ill patients at status ?
These are physical, psychological, spiritual, family and social needs.
Physical needs derive from bodily limitations and mainly from pain.
The psychic needs are evident. The patient needs to feel safe and loved, to have the security of the company of family and loved ones who support him and do not abandon him, he needs to trust the team of professionals who treat him, he needs to love and be loved: he needs to be listened to, cared for, valued and considered, which strengthens his self-esteem.
Spiritual needs are unquestionable. The believer needs God, to experience his closeness and companionship, to receive his strength and comfort, to welcome his mercy and be filled with hope and peace. Therefore, it would be an irresponsibility and an injustice if the religious care of patients were not ensured in hospital institutions, since it is a fundamental dimension of people's lives.
The family and social needs of the terminally ill patient are no less important. The terminal illness also involves for the patient and his or her family an emotional challenge, a significant economic effort and a great deal of family wear and tear of varying degrees. All the attention of the family members is generally focused on the sick member and, if the illness status is prolonged, the imbalance can be long-lasting. The patient sees it and also suffers from it. It is therefore very important not only to ensure the support of the patient, but also to provide adequate support so that the family can face the challenge posed by the illness of one of its members.
III. Palliative medicine in the face of terminal illness
16. What is palliative medicine?
It is a new specialization program of medical care for the terminally ill patient status and his or her environment, which contemplates the status end of life from a profoundly human perspective, recognizing his or her dignity as a person in the framework of physical, psychological, spiritual and social suffering that the end of human existence generally brings with it. It implies a change of mentality towards the patient in status terminal. It is to know that, when it can no longer be cured, we must still care and always alleviate. In this old aphorism of the 19th century is condensed the whole Philosophy of palliative care. It can be said that it is a way of understanding and caring for the terminally ill patients status , mainly opposed to two extreme concepts that remain outside medical praxis: therapeutic obstinacy and euthanasia.
17. How is palliative medicine organized?
Palliative medicine is not sufficiently contemplated in the Spanish healthcare organization, and it would be desirable for the public authorities to recognize this need with greater sensitivity and to promote it decisively. It is basically based on the recognition of the triple reality that shapes the process of imminent death in today's society: a patient at status terminal with physical pain and psychological, spiritual and social suffering; an anguished family that does not know how to manage status and suffers for their loved one; and a staff health care system that is fundamentally educated to fight against death and to confront and alleviate pain and suffering.
Palliative Care Units, which are care areas physically and functionally included in hospitals, provide comprehensive care to the terminally ill patient. A team of professionals assists these patients in the final phase of their illness, with the aim of improving the quality of life in this last stage, attending to all the physical, psychological, social and spiritual needs of the patient and his or her family, with the aim of goal . All the actions of palliative medicine are aimed at maintaining and, as far as possible, increasing the peace of mind of the patient and his or her family.
18. What is "adequacy of care"?
The healthcare professionals, in constant dialogue with the patient and his/her family, provide the diagnostic means, as well as the required therapeutic proposals based on the criterion of proportionality between the end sought and the means employed. By "adequacy of care" we mean the adaptation of diagnoses and treatments to the patient's clinical status so as not to fall into therapeutic obstinacy. It also includes the option of withdrawing, adjusting or not initiating treatments (or diagnostic tests) that are considered useless or futile, and therefore do not provide any benefit to the patient.
19. Isn't the dividing line between euthanasia and appropriateness of care very thin?
There is no shortage of people who wonder whether "adequacy of care" is not euthanasia in disguise. But it certainly is not. It is about the difference between the intention to bring about death (euthanasia) and the Admissions Office of our limitation in the face of illness and the circumstances surrounding it.
Only in rare terminal situations with no hope of cure can the appearance of the health professional's actions bear any resemblance to the two cases. However, the health professional knows, without any doubt, what is in his choice and ultimate intention: he knows whether what he is doing is intended to cause the death of the patient or whether, on the contrary, he is renouncing therapeutic obstinacy.
In the cessation or non-initiation of care considered useless or futile in the face of imminent death, the aim is to avoid a precarious and painful prolongation of life, without abandoning basic general care. The former -deliberately causing premature death- will never be admissible; the latter -accepting the inevitable advent of death- is.
20. What is meant by the term "basic general care"?
We refer to procedures that are performed in the usual internship such as non-invasive nutrition, hydration, analgesic supply, basic cures, hygiene, postural changes, etc. that are aimed at the survival of the patient. They are not a way of painfully extending the patient's life, but a humane and dignified way of respecting the patient as a person until the end.
21. Should enteral or parenteral nutrition and parenteral hydration be included in the basic care?
The forms of nutrition or nourishment deserve special attention, since the administration of water and food constitutes a fundamental means of preserving life. The New Charter promulgated in 2017 by the Pontifical committee for Health Care Workers summarizes synthetically the appropriate praxis for these cases: "Nourishment and hydration, even artificially administered, are part of the normal treatments that must always be provided to the dying person, when they are not too burdensome or of any benefit to him. Their undue suspension means a true and proper euthanasia. Providing food and water, even artificially, is, in principle, an ordinary and proportionate means for the preservation of life. It is therefore obligatory to the extent and for as long as it is shown that it fulfills its proper purpose, which is to provide hydration and nutrition to the patient. In this way, suffering and death resulting from starvation and dehydration are avoided" (n. 152).
22. Are there, therefore, any rights for the terminally ill patient at status ?
For most people, "dying with dignity" means dying without pain or other poorly controlled symptoms; dying at the natural time, without life being unnecessarily shortened or prolonged; dying surrounded by the affection of family and friends; dying with the possibility of having been adequately informed, choosing, if possible, the place (hospital or home) and participating in all important decisions that affect you; dying with the spiritual financial aid that you need.
And, certainly, the right to that "dying with dignity" includes:
- the right not to suffer needlessly;
- the right to have freedom of conscience respected;
- the right to know the truth about their situation;
- the right to participate in decisions about the interventions to which he/she is to be subjected;
- the right to maintain a trusting dialogue with physicians, family members, friends and people in the environments where he/she has developed his/her life;
- the right to have their privacy respected and to be present and attention with their family members;
- the right to have the matters that he considers fundamental to his life resolved;
- the right to receive attendance spiritual.
23. How can the suffering of the terminally ill patient be alleviated at status ?
One of the rights of the patient is that of not suffering unnecessarily during the process of his or her illness. But experience tells us sample that the patient, especially the terminally ill patient, experiences, in addition to physical pain, intense psychological or moral suffering, caused by the collision between the proximity of death and the hope of continuing to live that still lingers within him/her. The obligation of the health professional is to eliminate the cause of the physical pain or at least to alleviate its effects and, as far as possible, the psychological suffering by collaborating with the family.
In the face of physical pain, the health professional offers analgesia; in the face of anguish, he or she must offer comfort and hope; in the face of loneliness, he or she must make sure that loved ones and the careful attention of health professionals are not lacking. Medical ethics thus imposes the positive duties of alleviating the physical and moral suffering of the dying, of maintaining as far as possible the quality of life that is declining, of being the guardian of respect for the dignity of every human being. For believers, care for the spiritual and transcendent dimension is particularly important and must therefore also be offered in health care institutions.
24. How can pain treatment be adequately addressed?
The recurring idea of pain as an intractable problem that would force euthanasia does not fit reality: there is always the possibility of addressing it, even if in some cases it is only with the extreme resource of palliative sedation.
It is a different matter if the treatment of pain can be solved by any physician. In many cases, a specialist is needed who knows which drugs to combine, since the possibilities do not end when morphine or derivatives (known generically as opiates) have been used. Various combinations can solve problems that cannot be solved with analgesics alone, and this can also be said of the other symptoms, among which dyspnea (the sensation of suffocation when breathing) should be highlighted.
25. Is the treatment of pain lawful, even if it may result in a shortening of life expectancy?
It is a question that Pope Pius XII already addressed in 1957, in a speech to the IX International congress of the Italian Society of Anesthesiology, where he states that it is licit to resort to analgesics for the treatment of pain in the seriously ill or in status terminally ill if there are no other means and if, given the circumstances, this does not prevent the fulfillment of other religious and moral duties, even if this could result in a possible shortening of the patient's life.
Recent medical bibliography has studied this in detail, and has found that morphine does not shorten patients' lives. If it is used to treat pain at an adequate dose (which can be very high), this effect does not occur. And this is also true when it is used for the relief of dyspnea so that, despite respiratory distress, the patient breathes and oxygenates better with morphine than without it. In this field, as in so many others in science, one thing is proven data and another is theoretical deductions, which can easily fail.
If we add to this the modern electronically controlled administration systems, we can be sure that these undesired effects will not occur, since the dosage will be appropriate for that patient. Moreover, if it has been employee to treat pain that eventually disappears, it does not necessarily create addiction, provided that the patient has been properly evaluated and a concomitant depression has been ruled out, which could lead to an undesirable addiction.
26. What other aspects are essential to take care of in critically ill patients or in status terminally ill patients?
The collective imagination of the terminally ill patient does not include a problem that can be much more serious: loneliness. Not in the sense of the absence of people: there are people coming in and out of the patient's room and doing things, as well as the presence and attention of the family. It is something that we could rather call "vital loneliness": the patient must face the inner crisis that his illness is producing without having someone to lean on for this emotional process, which we have called the search for meaning.
The attitude of medicine to illness can be summed up in the adage we have already mentioned at reference letter : "Cure sometimes, relieve often, comfort always". With today's means, we cure often enough, and we can always soothe. But this technical efficiency has made us forget the last part, to console. This word refers in the first place to the company that brings human warmth to the status of illness, and makes the suffering more bearable.
The fundamental accompaniment is provided first and foremost by the patient's own family and friends. The staff healthcare provider is also called upon to provide this companionship. This is an aspect in which we still need to improve. This accompaniment, as well as the spiritual attendance when the patient requires it, can help him or her to face the crisis of the disease status and to reposition him or herself in the face of this challenge, maturing as a person and deepening the meaning of one's own life.
We would also like to refer to the difficulties that families experience when it comes to accompanying and supporting their loved ones during the illness. On many occasions they are disoriented about the decisions they have to make. It is necessary to be position of this difficulty and to offer them with delicacy adequate and realistic indications that facilitate the decision making on the way to proceed in every moment. It is necessary to make the families see that in difficult moments they are not alone and that they will be supported with the financial aid they need.
27. What dimensions or areas of the person should be attended to in the care to be given at the end of life?
Respect for their dignity - unique and inviolable, in any of the phases of their lives - demands that they be attended to and cared for from an integral or global viewpoint, taking into account, therefore, their physical-biological, psycho-emotional, partner-family and spiritual-religious dimensions. And the appropriate treatment of each of these dimensions includes clinical, psychological and spiritual help and care.
In order to help the patient and his family to take care of these dimensions, palliative medicine aims to humanize the dying process. To accompany until the end. This dimension of medicine aims to ensure that patients spend their last moments conscious, pain-free, with their symptoms under control, so that they spend them with dignity, surrounded by the people they love and, if possible, considering their clinical condition and the care they may need, in their own home.
28. What is palliative sedation?
Medicine always has resources for patients with pain and suffering, although not all physicians master all resources. It is the wisdom of the physician to realize how far his or her knowledge goes, to apply for the financial aid of a more skilled colleague in certain situations.
The proximity of death is not a sufficient reason to apply palliative sedation. Its indication has to do with the appearance of symptoms that are refractory to effective treatment and cause suffering in the patient. The clinical internship reveals that, in situations of incurable, advanced and irreversible disease, with a limited life prognosis or in status of agony, refractory symptoms may appear, which resist the treatment indicated to control it.
For such cases and in order to alleviate their suffering, palliative sedation is used: even if the problem cannot be treated directly, the patient can be made to lower their level of consciousness with financial aid of drugs so that they do not perceive intractable pain, suffering or distress.
Palliative sedation is therefore a treatment for specific, not generalized situations, in which it is necessary to know how to administer the medication in such a way that it is sufficient to sedate, but does not intentionally provoke death. It is not an action that should always be undertaken when life is approaching its end, but only when it is really necessary. Practicing it as a system spreads the impression among patients' relatives that it is the physician who is already putting an end to life at status terminal.
Sedation will be ethically acceptable when there is a correct medical indication, all other therapeutic resources have been exhausted and the patient and family have been explained what it consists of and its consequences, obtaining the required consent, which must be recorded in the clinical history. The drugs and dosage will depend on the symptom to be treated and the urgency, and will be reevaluated periodically according to the patient's status . It is important that the patient can previously resolve his civil, professional, family, moral and religious obligations.
29. What does deep palliative sedation consist of?
Deep palliative sedation is procedure aimed at total suppression of consciousness. It must be medically indicated, always with the consent of the patient or, if this is not possible, with that of the patient's relatives, at all times duly informed, excluding any euthanasia intentionality and when the patient has been able to resolve his moral, family and religious duties. Therefore, the patient should not be deprived of consciousness unless there are serious reasons. Deep palliative sedation should never lead to the suspension of basic care and its reversibility should be periodically evaluated if the patient's clinical condition improves status .
30. In the status of mental incapacity of the patient, is the advance directives document valid?
This question has long been raised mainly because of the possibility of the patient's mental deterioration Schools . It has also long been instituted in our healthcare system the possibility of drafting an advance directives document, formerly known as a living will. We propose the text C by the Spanish Episcopal lecture in 1989, which makes reference letter to the fundamental aspects that should be included in this document:
"To my family, to my doctor, to my priest, to my notary: If the time comes when I am unable to express my will about the medical treatments to be applied to me, I wish and ask that this declaration be considered as a formal expression of my will, assumed consciously, manager and freely, and that it be respected as if it were a will. I consider that life in this world is a gift and a blessing from God, but it is not the absolute supreme value. I know that death is inevitable and puts an end to my earthly existence, but from faith I believe that it opens the way to a life that does not end, together with God. For this reason, I, the undersigned, ask that, should my illness cause me to be at status critically irrecoverable, that I not be kept alive by means of disproportionate or extraordinary treatments; that active euthanasia not be applied to me, nor that my dying process be abusively and unreasonably prolonged; that I be given the appropriate treatments to alleviate my suffering. I also ask financial aid to assume my own death in a Christian and humane manner. I wish to be able to prepare myself for this final event of my existence, in peace, with the company of my loved ones and the consolation of my Christian faith. I subscribe to this statement after mature reflection. And I ask that those of you who have to take care of me respect my will. I am aware that I am asking you for a grave and difficult responsibility. It is precisely to share it with you and to relieve you of any possible feelings of guilt that I have drawn up and signed this declaration".
IV. The unlawfulness of therapeutic obstinacy
31. What is therapeutic obstinacy?
The purpose of medicine is not only to cure. Medicine is a care for the sick person to ensure that his or her condition causes the least possible limitation in his or her daily life. The main goal of medicine is to procure health, and this consists in being able to live human life. However, the frequent confusion of health with organic integrity can lead to a lack of focus in the medical internship . On the part of patients, because they sometimes seek a non-existent and impossible ideal in their lives, which leads to the medicalization of today's society. And, on the part of health professionals, trained mainly in the technical aspect of their profession, because they always pretend to cure.
This leads to trying to cure at a time when such a cure is no longer possible, and to stubbornly instituting treatments that are known to be ineffective. This is why it is called obstinacy or therapeutic stubbornness. This behavior is ethically unacceptable. The physician should only apply indicated treatments, that is to say, those that have real possibilities of improving the patient's status (not only of curing him/her). What is not useful should not be applied and, if it is already being applied and is futile, there is no reason to maintain it due to its ineffectiveness, so, except for objectively justified considerations, it should be withdrawn.
32. What does therapeutic obstinacy consist of in the context of a terminally ill patient at status ?
By the expression "therapeutic obstinacy" we refer to the attitude of the physician who, faced with the moral certainty offered by his knowledge that treatments or procedures of any nature no longer provide benefit to the patient and only serve to prolong his agony painfully, obstinately continues with medical procedures, preventing nature from following its natural course. This attitude is the consequence of an ill-founded excess of zeal, derived from the desire of health professionals to try to avoid death at all costs, without renouncing any means, ordinary or extraordinary, proportionate or not, even if this makes the dying person's status more painful. In any case, "therapeutic obstinacy" is not ethically acceptable, since it instrumentalizes the person by subordinating his or her dignity to other ends.
V. Euthanasia and assisted suicide are ethically unacceptable.
33. What is euthanasia?
In the public discussion on euthanasia, the terminology has sometimes become complex, so that the topic being discussed has become obscured. For this reason, the meaning of words and expressions must be clarified. According to the definition of the World Health Organization and the Spanish Society of Palliative Care, euthanasia is the intentional provocation of the death of a person suffering from an advanced or terminal illness, at the express request of the latter, and in a medical setting. Euthanasia is considered as a form of homicide, which is usually given out of compassion and in the context of an illness.
The Encyclical Evangelium vitae of St. John Paul II defines euthanasia as "the action or omission which by its nature and intentionally causes death in order to eliminate pain. Euthanasia is at the level of the intentions or methods employed" (n. 65).
In saying "intentionally" it is meant to affirm that there is no euthanasia if there is no will to cause death. The death of a patient as a consequence of a risky medical intervention is not euthanasia if none of those who intervened in it intended the patient to die.
34. Is the distinction between active and passive euthanasia valuable?
Sometimes a distinction is made between active and passive euthanasia. Active euthanasia would be that which causes the death of the patient by means of an action, and passive euthanasia would be that which causes death by means of the omission of an action that should have been carried out but was not done voluntarily, in order to cause the patient's death. This distinction adds little. Active euthanasia is not "more euthanasia" than passive euthanasia. If both voluntarily provoke the death of the patient, both are equally euthanasia, that is, homicide, and deserve the same ethical grade . For this reason, we will speak of euthanasia, without further ado.
35. What is meant when the expression "let the patient die" is used?
This expression is ambiguous. It can mean something like "to let the patient die because medicine no longer makes it possible to cure him, and it only remains to alleviate the patient's troublesome symptoms and to accompany him and his family with consolation". But it can also mean "to stop administering useful procedures that are still available, so that the patient dies" and, in this case, it would be euthanasia. For this reason, it is an expression to be avoided if we want to speak clearly.
36. Why are euthanasia and assisted suicide ethically unacceptable?
The intention to eliminate the life of the patient, on one's own initiative or that of third parties, written request , in order to prevent suffering, by using the means that make it possible, is always contrary to ethics: an evil is chosen, that is, to suppress the life of the patient, which, as such, is always a good in itself. This becomes clearer if we take into account that, in order to face suffering, other means can always be chosen: to alleviate discomfort, to control pain, to console suffering, to accompany and improve the vital status , etc.
The unlawfulness of euthanasia or assisted suicide does not only lie in the death of the patient to whom it is applied. It also lies in the wrongful decision of the person who performs it or collaborates in its performance. Since it is a moral act, it entails the acquisition of a moral quality for the person who acts.
Practicing euthanasia or collaborating in assisted suicide is not a simple detail in the physician's life or something that remains "outside" him, that has no repercussions on him. On the contrary, the internship of these actions produces an inner rupture and obscures the awareness of the good: on the one hand, the tendency to the good persists as something inscribed in the depth of the conscience; however, the new habit acquired inclines him again to freely choose the bad.
Euthanasia harms the physician who performs it and is one more element that reinforces the reason for its unlawfulness. From a sentimental point of view, it may appear to be a compassionate action towards their patients (and physicians should be compassionate). However, the perception of the value of the patient's life is obscured by its internship, especially if it is repeated. Practicing it is not merely an adaptation to new times or social customs. It produces obfuscation of authentic ethical sensitivity.
37. Does euthanasia affect the doctor-patient relationship?
The introduction of euthanasia into the panorama of actions that a physician can take undermines the relationship between physician and patient, which is the foundation of every medical act and which is always based on trust. When there is no possibility of euthanasia, the patient has confidence that the physician is trying to help him with his health problem, and will do everything reasonably possible in that regard, and will gladly accept his advice.
However, when the possibility of the physician causing death appears, and that, as sample experience in other countries shows, it happens without the patient's authorization, suspicion is the norm. This destroys the ethical foundation on which the doctor-patient relationship is built. And this, regardless of whether the physician report gives details of his position, since this information can be interpreted as a manifestation of rectitude, or as an attempt to pave the way for practicing it.
38. How does euthanasia affect the family?
All legal systems recognize - to one extent or another - the right of the next of kin to decide on behalf of the patient who is incapable of expressing his or her own will. And it is clear that euthanasia can introduce into family relationships a feeling of insecurity, confrontation and fear, alien to what the idea of family suggests: solidarity, love, generosity. This is especially true if one takes into account the ease with which selfish motives can be introduced when deciding for one another in end-of-life issues: inheritance, elimination of burdens and inconveniences, cost savings, etc.
From another perspective, in a family where one of its members is unjustly decided upon, the psychological and affective tension that is generated can be, and is in fact, source of problems and emotional instabilities, given the inevitable ethical connotations of such actions.
39. What are the consequences of euthanasia on the medical internship ?
Euthanasia harms medicine. Physicians, in addition to practicing euthanasia, should care for other patients. Trust between physician and patient is essential. If the physician considers eliminating the patient as a valid option, the trust between physician and patient is severely compromised.
A correct internship of medicine should try that the disease does not hinder the patient's life. If possible, by curing. If not, by alleviating (by far the most frequent) or consoling. Euthanasia does not fit into this approach, since it does not financial aid the patient to live, but eliminates the problem by causing his death. Euthanasia offers neither quality of life nor quality of death. For this reason, the introduction of euthanasia denatures medicine. The degradation of professional ethics that lies behind this change is enormous, and here it is worth recalling the Hippocratic precept of not administering poison to a patient, even if he asks for it. Medicine cannot renounce its purpose and give in to a misunderstood compassion; even more so today, when the possibilities for relief are immense.
40. Does the Admissions Office of euthanasia and assisted suicide for extreme cases open the door to its application to less and less extreme situations?
This is the clearest and most difficult consequence to refute on the part of those who accept the legalization of euthanasia and of the financial aid medical suicide. It is known that these figures, initially thought for dramatic cases, end up expanding and being applied to much less serious cases. This happens both at the legal level and at the practical level.
Legally, the conditions required are relaxed in subsequent amendments to the law and thus, from being practiced only at the express and conscious request of the patient, it is applied to persons incapable of expressing their consent. And, effectively, the psychology of the physician and of the healthcare staff , always compassionate towards their patients, ends up considering euthanasia as the most appropriate for some patients, even if they do not request it. If it is an accepted internship , it will be considered normal within the range of possibilities for the patient's treatment. In the case of patients who are in a worse state than those who asked to die, he will think compassionately that, if they were fully aware of their status, they would ask for it. This opens the door to the practice of euthanasia without the patient's request, something that has already occurred where it is legalized with theoretically guaranteeing regulations.
As we have stated above, the legal approval of euthanasia undermines the trust in the relationship between health professionals and the patient and burdens the conscience of the patient, who may come to think that his or her existence is an excessive burden on others. This status can be particularly painful for patients from particularly vulnerable families, who consider this procedure as a release from a responsibility they do not know how to face if they do not receive the financial aid they need.
On the other hand, if euthanasia is legally approved, it comes to be considered as a normal and acceptable procedure ; its peculiar bureaucratic controls end up being seen as an administrative burden, basically unnecessary. As a result, the legal obligation to report such cases in detail is being relaxed: in countries where laws permit euthanasia, in some periods it seemed that its internship was decreasing, but the relevant research sample shows that it is just not being reported any more. Correctly conducted statistics always show a progressive increase in its internship.
41. Can the "Dutch case" be considered significant for the legalization of euthanasia and assisted suicide?
It is, in the sense that sample clearly shows how the legalization of euthanasia and assisted suicide has been implemented and extended through what could be called an inclined plane. The first intention of the promoters of this legalization was not to arrive at what is now contemplated as causes (assumptions, situations, etc.) that even "demand" the legal internship of euthanasia.
In the Netherlands, euthanasia was legalized in 2002 under these conditions:
- terminal patients with "unbearable suffering";
- who have no hope of cure;
- over 18 years of age;
- who freely wish to end their lives.
However, in 2011, 13 psychiatric patients were euthanized in the Netherlands. Along the same lines is the protocol Gröningen in that country, which authorizes the euthanasia of newborn children with serious illnesses.
We have recently learned of cases of euthanasia for psychological and not physical problems, also in the Netherlands. It was authorized for reasons of "senile unhappiness" in the case of an 84-year-old person who requested euthanasia on the grounds of "not having the will to live". Another reason invoked is "existential pain": this is the reason why euthanasia was applied to a woman who requested it because of the pain and severe suffering caused by the divorce of her husband and the successive deaths of two adult children.
Along with this, there have been cases of non-voluntary euthanasia, i.e., without the patient's request, at the initiative of the physician or the family: for leave quality of life, to facilitate the family's status , to shorten the patient's suffering, to put an end to an unbearable spectacle for doctors and nurses, or because of the need for beds for other patients.
It can be seen, therefore, that what was born with a very restrictive rules and regulations has gradually become, as if on an inclined plane, a matter of interests.
42. If only voluntary euthanasia and assisted suicide were allowed: would there not be positive social effects?
This is a widespread misconception, which experience itself has disproved. In fact, the experience of the euthanasia cases that have been heard in the courts of the countries around us in recent decades shows that the supporters of euthanasia easily take the step from accepting a patient's voluntary request to be "helped to die" to "helping to die" someone who, in their opinion, should make such a request given his or her condition, even if in fact he or she does not request it.
The experience of the Netherlands cited above, where a permissive mentality towards euthanasia is established, is that an "underhand and insidious moral coercion" is created at the same time, which leads the terminally ill or those considered "useless" to feel inclined to apply for euthanasia. A group of severely disabled adults recently told the Dutch Parliament: "We feel that our lives are threatened. We realize that we are a very big expense to the community. Many people think we are useless. We often find that people try to convince us to wish for death. We find it dangerous and frightening to think that new medical legislation may include euthanasia."
When debates about the legalization of euthanasia and assisted suicide begin, there is often a paradoxical contradiction: there is an insistence on legalizing only voluntary euthanasia, but to illustrate the "borderline cases", examples of terminally ill patients who are unconscious and therefore incapable of expressing their will are also often proposed.
Nor can it be forgotten that public institutions have an obligation to protect their weakest citizens and cannot neglect this primary function. The laws on dependency and palliative care are a good antidote to the euthanasia mentality.
43. Does the accepted practice of euthanasia and assisted suicide end up weakening and relaxing legal safeguards?
The laws permitting euthanasia in countries around us enact legal guarantees that the patient must give prior consent, with numerous precautions, to avoid involuntary or careless application. In places where euthanasia is legal, its internship has also been extended by law to minors or mentally incompetent persons.
In addition to this weakening of legal safeguards, experience in places where euthanasia or financial aid suicide are approved sample shows that there is also a de facto relaxation. This is partly due to the legal vagueness mentioned above, which progressively opens the internship to any complex status . And partly due to understandable psychological mechanisms: those who practice it see that it "solves" the patient's problems in an effective way and, moved by their own professional compassion, end up advising or practicing it in increasingly more bearable situations. And this includes the shift from voluntary euthanasia to involuntary euthanasia, so as not to "distress" the patient with such a harsh decision. This phenomenon has led to the unanimous rejection of its legal acceptance by associations of people with disabilities.
44. What are the consequences of euthanasia and assisted suicide on society?
Euthanasia and assisted suicide harm society as a whole. It is not a purely private matter that concerns only the patient and his or her family. Individualism is a trait present in today's society, but non-interested interpersonal relationships that constitute true social bonds continue to emerge and progress, since the human being is a constitutively relational being called to communion. To propose euthanasia at will means that these relationships lose their value and social life is wounded and weakened: the constitutive bonds of society are attenuated and thus irremediably dehumanized.
VI. Proposals for fostering a culture of respect for human dignity
45. Is it necessary to rediscover the root that sustains human dignity?
The human person is always worthy, independently of any conditioning. His inviolable dignity and his transcendent vocation are rooted in the depths of his very being. This dignity, which is discovered particularly in interpersonal relationships, is admirably confirmed in the root and transcendent horizon of every human life. Indeed, human beings are created in the image and likeness of God, who, through the Incarnation of the Word, makes us sharers in his very nature, destined for the eternity of communion with him and with one another. Hence the dignity and sacredness of every human life.
46. Is Education necessary to properly assess the originality and value of human life?
The Education, designed for young people to become mature persons, is not always fun, comfortable or simple, since it requires a certain effort from an early age. It is a problem that every family has had to face since the dawn of time if it wanted to educate its children. Only with a demanding approach in the context of respect and love, with a view to good and human growth, can the Education be enhanced in virtues.
This does not mean that, as result of a Education that has, as one of its fundamental axes, virtue, young people will end up being virtuous: their free cooperation is needed. But, even if we do not count on this cooperation, this process educational is essential for them to be able to distinguish the reality of good and evil in action. Today there are already many people to whom the concepts of good and evil are alien and who are incapable of reasoning and acting with them.
47. Is it necessary to promote solidarity with those who suffer?
As we pointed out earlier, a feature of today's society is individualism. Everyone takes more care of his own and less care of others. There are many manifestations of this. Self-interested friendship, for example: we only maintain relationships with those who bring us pleasure or utility. When he stops offering us something, we leave him. The person does not matter as much as our benefit in relating with him.
In the final phases of life, the same thing can happen to us: when someone is down because of illness, without an interesting conversation, with only continuous complaints, we tend to diminish our relations with them. There may also be here a more or less unconscious flight from situations of suffering. It is therefore necessary to counteract this tendency with an authentic solidarity with the one who suffers, through the culture of meeting and the bond, in an attitude of service, of true compassion and human promotion.
48. Is sufficient attention given to training staff in the art of soothing and consoling?
Medical care today achieves many healings. In fact, most of the technical training of the degree program of medicine is oriented towards the goal of healing. Moreover, in ordinary life, aches and pains are usually of an intensity leave, and have reasonably simple relief. However, a competent physician may encounter cases that overwhelm his or her ability to relieve.
It is evident that the teaching in medicine today places little emphasis on the numerous existing knowledge on the art of soothing. Although the status has been improving lately, it is necessary that every health professional who finishes his or her programs of study from Degree has a solid knowledge of the most frequent problems that will require treatments aimed at relief, and that he or she has acquired basic competencies in his or her internship.
Accompanying and comforting the sick is also an art that needs to be taught and promoted among present and future health professionals. The therapeutic function of comfort and of the human and delicate attention with the patient is widely recognized in the internship of the health professions and should be encouraged and promoted.
49. In what aspects is it necessary to have an impact in order to extend a culture of life?
It is not surprising that a society in which a conception of life based on utilitarian pragmatism is widespread is characterized by an attitude inclined to dispense with those who are seen, beyond as vulnerable human beings, as source of expense or inconvenience and who contribute little usefulness to society; they may be perceived not as beloved members of the family, but as obstacles that condition the development staff , family or social; they may be considered not as patients, but as an unnecessary overload of work.
promote some proposals can help to rediscover the dignity of every human being, especially in the context of the status of serious or terminal illness:
- that death is not a taboo topic , but a natural fact that is part of human life. Degree No one - neither judges, nor legislators, nor doctors - can claim the right to decide that some human beings do not have rights or have them to a lesser extent than others, due to their limitations, race, sex, age, religion or state of health;
- that the family be respected and loved as a natural environment of solidarity between generations, in which, regardless of any conditioning, all its members are welcomed, protected and cared for;
- that the hospital organization should not be seen as an area in which we can ignore our obligations to the sick and the elderly;
- that the family and the home be the natural place of welcome in sickness and old age, and where the proximity of death is lived with affection and lucidity;
- that social initiatives for the care of the terminally ill emerge, in an environment respectful of the person and their families, adequately prepared to face death with dignity;
- that the health professions be oriented towards comprehensive care of the person throughout the life span;
- that public institutions and the powers of the State effectively protect the life of every human being, from conception to natural death, regardless of any conditions.
VII. The experience of faith and the Christian proposal
50. What does faith bring to the care of the terminally ill at status ?
Faith brings to the care of the terminally ill at status a new light in the consideration of the mystery of Creation and Redemption in Christ. Every human being is worthy of our respect and attention because, created in the image and likeness of God, we have been redeemed by the death and resurrection of the Lord Jesus. He gives meaning plenary session of the Executive Council to life and death, and opens the way to love, hope and mercy. As St. John Paul II affirmed in the Encyclical Evangelium vitae: "Man is called to a fullness of life that goes beyond the dimensions of his earthly existence, since it consists in sharing in the very life of God. The sublime nature of this supernatural vocation manifests the greatness and value of human life even in its temporal phase. In fact, life in time is a basic condition, an initial moment and an integral part of the whole unitary process of human life. A process which, unexpectedly and undeservedly, is illuminated by the promise and renewed by the gift of divine life, which will reach its full realization in eternity (cf. 1 Jn 3:1-2). At the same time, this supernatural call underlines precisely the relative character of the earthly life of man and woman. It is a sacred reality, entrusted to us so that we may guard it with a sense of responsibility and bring it to perfection in love and in the gift of ourselves to God and to our brothers and sisters" (n. 2).
51. How does Christianity conceive the dignity of human life?
This same encyclical of St. John Paul II that has just been quoted takes up the affirmation expressed in the conciliar constitution Gaudium et Spes when it states that "the mystery of man can only be clarified in the mystery of the Incarnate Word. For Adam, the first man, was a figure of him who was to come, that is, Christ our Lord. Christ, the new Adam, in the very revelation of the mystery of the Father and of his love, fully manifests man to man himself and reveals to him the sublimity of his vocation... This is the great mystery of man which Christian Revelation illumines for the faithful. Through Christ and in Christ, the enigma of suffering and death, which outside the Gospel envelops us in absolute darkness, is illuminated. Christ is risen; by his death he destroyed death and gave us life, so that, sons in the Son, we may cry out in the Spirit: Abba, Father" (n. 22).
Thus the Encyclical Evangelium vitae of St. John Paul II affirms that "every person sincerely open to the truth and to the good, even in the midst of difficulties and uncertainties, with the light of reason and not without the secret influence of grace, can come to discover in the natural law written in his heart (cf. Rom 2:14-15) the sacred value of human life from its beginning to its end, and affirm the right of every human being to see this primary good of his fully respected. The recognition of this right is the foundation of human coexistence and of the political community itself. Believers in Christ must, in a particular way, defend and promote this right" (n. 3).
52.financial aid faith to find meaning in life and, in particular, in suffering?
We have already seen how a vital goal can give meaning to the sufferings and difficulties of life, by showing them a "what for" (even if, on many occasions, it is only vaguely intuited) and above all, as Pope Francis recalled, a "for whom". The question of the meaning of life receives a profound and full answer in the Mystery of Christ, dead and risen. The question of the global meaning of life is also valid for a non-believer. It is prior to any ethical question, since it concerns life as a whole. We said that illness can be an occasion to "stop" and reflect on life as a whole, in order to be able to enter into its meaning. However, those who have grasped the supernatural dimension of suffering may be tempted to propose this solution to patients and not respect the reasonable pace of personal reflection and maturation in the face of illness. As we have seen, it is not possible to force answers about meaning, but it is possible to accompany and support the patient in his or her own journey of reflection and deepening.
What is the Church's doctrine on suffering and death?
For those who have faith and hope, the question of the evil that all human beings do to each other is more pressing, because the transcendent vision presents us with a God who loves each person and wants the best for him or her. The knowledge that God's loving providence for each person is compatible with the existence of pain and suffering necessarily indicates that pain - even if we cannot explain it in its full breadth and depth - has meaning.
When Christ was asked about the mystery of suffering, he said that it was not a divine punishment (cf. Jn 9:2-4). The book of Wisdom affirms categorically: "God did not make death, nor does he delight in destroying the living. He created all things to exist" (Wisdom 1:13-14). But Jesus, in addition to approaching, relieving, comforting and healing the sick and suffering, and speaking about pain and suffering, took them upon himself on the Cross, converting them, through his Paschal Mystery, into the Good News, giving it maximum meaning: that pain unto death gave full life and meaning to human history and to the universe.
We too can imitate Jesus: not to say many words about pain, but to live the experience of finding meaning in it, turning it into source of love and overcoming our own selfishness. We can approach, support, accompany and inspire hope in those who suffer. Christ did not theorize about suffering or pain: he loved and consoled those who suffer and he himself suffered even death on a cross. The Church does not theorize about suffering, but she wants to bring to humanity a vocation of preferential self-giving to those who suffer, accompanying and supporting them along the way, and also the experience that Christ communicates to us through his death and resurrection.
St. John Paul II, in his 1984 Apostolic Letter Salvifici doloris, speaks to us of the love of Christ that overcomes suffering: "Throughout the centuries and generations it has been seen that in suffering there is hidden a particular power that brings man closer to Christ" (n. 26). reference letter 26) This letter describes the "Gospel of suffering" and refers to the parable of the Good Samaritan as an expression of this Gospel: "The Good Samaritan in Christ's parable does not remain in mere shock and compassion. These become for him a stimulus to action that tends to help the wounded man. In financial aid he puts all his heart and does not spare even material means. It can be said that he gives himself, his own "I", opening this "I" to the other. We touch here one of the points core topic of all Christian anthropology. Man cannot find his own fullness except in the sincere submission of himself to others" (SD 28).
How can a Christian collaborate to promote a culture of respect for human life?
All Christians can and must collaborate with our words, actions and attitudes, and recreate in the fabric of daily life a culture of life and of meeting, rejecting the culture of discarding and exclusion. In particular, and without pretending to be exhaustive, we can all help in this immense task:
- welcoming suffering, pain and death with a supernatural vision, when it affects us personally. Faith leads us to know that those who suffer can be united to Christ in his passion and that, after death, the embrace of God the Father awaits us;
- by exercising, according to our means, possibilities and circumstances, an active support to those who suffer and their families: from a smile, affection, company to the dedication of time, resources and money, we can do many things to alleviate the suffering of others and help those who suffer to reborn love, joy, peace and hope;
- praying for those who suffer, for those who care for them, for the health professionals, for the politicians and legislators in whose hands it is up to them to act in favor of the dignity of those who suffer;
- facilitating the emergence of vocations for the Church's institutions which, by their foundational charism, are specifically dedicated to caring for suffering humanity and which constitute today - as centuries ago - a marvelous expression of love and commitment to those who suffer;
- welcoming with fraternal love, human affection and naturalness in the bosom of the family the suffering, sick or dying members, even if this entails sacrifice;
- by making ourselves present in the media and other forums of influence on public opinion, in order to make clear the characteristic notes of a culture of life and of meeting and rejecting the culture of discarding;
- taking part in the institutions and in political life, both by voting and by active participation in political formations, institutions and administrations, demanding the promotion of the culture of life in matters affecting the family, health, care for the sick, the elderly, the vulnerable, the impoverished, etc...;
- promoting among health professionals a concept of medicine and of health attendance focused on the promotion of the dignity of the person in all circumstances;
And we have at our disposal a sacrament - the Anointing of the Sick - specifically instituted by Jesus and deposited in the Church to relieve, sustain and strengthen the sick and, when the time comes, to prepare for a good death.
55. What is the Sacrament of the Anointing of the Sick?
This Sacrament gives the Christian a particular gift of the Holy Spirit, through which he or she receives a grace of strength, peace, consolation and hope to overcome the difficulties inherent in the state of illness or frailty of old age.
This grace renews faith and trust in the Lord in the one who receives it, strengthening him against the temptations of the enemy and the anguish of death, so that he can not only live his difficulties with fortitude, but also fight against them with hope and improve or even restore his health, if it suits his salvation.
Likewise, the Anointing of the Sick grants forgiveness of sins and the fullness of Christian penance. Anointing is the Sacrament of the Sick and the Sacrament of Life, a sacramental expression of the liberating action of Christ who invites and, at the same time, financial aid the sick to participate in this liberation.
It is advisable to receive this Sacrament in circumstances of risk (serious illness, old age, before undergoing surgery, etc.). Moreover, its administration can be repeated, even within the same process of illness, if the illness worsens, and should not be reserved for when the sick person is already unconscious, as the Council points out: "It is not only the Sacrament of those who are in the last moments of their life. Therefore, the opportune time to receive it begins when the Christian already begins to be in danger of death by illness or old age" (Sacrosantum Concilium 73).
Connected to this Sacrament, there is the "Viaticum" or reception of the Eucharist that financial aid the sick person to fill in the way to the Lord, perfecting Christian hope, "associating himself voluntarily to the passion and death of Christ" (Lumen Gentium 11).
56. What should be the attitude of a Christian in the face of death?
We Christians contemplate death as the definitive meeting with the Lord of Life and, therefore, with calm and confident hope in Him, even though our nature resists taking that last step to full life and final. Ancient Christianity rightly called the day of death "dies natalis", the day of the definitive birth to eternal Life. Pope Francis reminds us that our life does not end at a tombstone, but opens up to life through the resurrection of Jesus: "Today we discover that our journey is not in vain, that it does not end at a tombstone. A phrase shakes the women and changes history: "Why do you seek the living among the dead" (Lk 24:5); why do you think that everything is useless, that no one can remove your stones? Why do you give yourselves up to resignation or failure? Easter, brothers and sisters, is the feast of the removal of stones. God removes the hardest stones, against which hopes and expectations crash: death, sin, fear, worldliness. Human history does not end before a tombstone, because today it discovers the "living stone": the risen Jesus (cf. 1Pt 2:4). Tonight each of us is called to discover in the Living One the One who removes the heaviest stones from the heart" (Homily at the Easter Vigil of April 2019).
57. Are euthanasia and assisted suicide religious issues?
As we have seen throughout this document, euthanasia and assisted suicide constitute a human drama with deep anthropological roots and broad repercussions in the family, social, political and health care spheres. Insofar as they affect human life and the different spheres in which it develops, they have undeniable repercussions in the religious sphere, but it is an issue that pertains primarily to the current conception of the human being, his freedom and his destiny.
Those of us who believe in a God who is love, who is a communion of Persons, who has not only created human beings, but who calls them personally and awaits them for an eternal destiny of happiness, are convinced that euthanasia and assisted suicide imply deliberately ending the life of a human being who is dear to God, who loves them infinitely and who watches over their life and death.
Moreover, they constitute an offense against the human being and, therefore, against God, who loves every person and is offended by everything that offends the human being. This is the reason why God pronounced the precept "thou shalt not kill".
58. In certain situations, don't health professionals or believing family members face moral problems that are very difficult to solve?
Such problems may arise and may be difficult to resolve, as is the case in many other areas of life. But it is possible to act with rectitude when all those involved are people who have acquired the personal and professional virtues that enable them to make morally sound decisions. In these situations, it is important to strengthen the relationship between the patient, the family and the healthcare team. The presence, support and eventual indications of the patient's spiritual companion can help to shed light on complex situations. Many concerns and doubts are resolved through this dialogue and mutual support.
59. Can you summarize in a few words the Church's doctrine on the attitude toward the end of this life?
In summary, it can be formulated in these statements:
It is never licit to cause the death of a sick person, not even to avoid pain and suffering, even if the patient expressly requests it. Neither the patient, nor the health care staff , nor the relatives have the School to decide or cause the death of a person.
An action or omission that by its nature and intention causes death in order to avoid any pain is not licit (cf. EV 65).
3. It is not licit to prolong the life of a patient at all costs in the face of the moral certainty offered by medical knowledge that the procedures applied no longer provide any benefit to the patient and only serve to prolong the agony uselessly.
4. It is not permissible to omit basic general care: feeding, hydration, hygiene, postural changes, analgesia, etc.
5. A person may sign a document to express in advance his or her wishes regarding the treatment he or she wishes to receive when, due to deterioration of his or her health, he or she is mentally incapacitated. This advance directives document must respect the dignity of the person, must comply with the rules of good medical internship and must not contain euthanasia or therapeutic obstinacy indications.
6. In the face of a person approaching death, interventions should be avoided that alter the necessary serenity that the sick person needs, isolate him/her from any human contact with family or friends, and end up preventing him/her from preparing interiorly to die in a climate and context that is authentically human and, if necessary, Christian.
7. The staff physician must adapt diagnoses and treatments to the patient's clinical status in order to avoid obstinacy. This is what has been called "adequacy of care". It consists of adjusting, not initiating or fail treatments or diagnostic tests that are considered clinically useless. This decision leads to the implementation of palliative care, adapting it to the clinical evolution of the patient.
8. Certainly, the proper role of medicine is to cure. But it is also to care, soothe and console. Care and consolation are always necessary, but perhaps even more so at the end of life. Palliative medicine aims to humanize the dying process and to accompany until the end. There are no "untreatable" patients, even if they are incurable.
9. Palliative sedation will be ethically acceptable when there is a correct medical indication, all other therapeutic resources have been exhausted, the patient and his family have been informed, discussed and given their consent. Palliative sedation consists of administering drugs in appropriate doses and combinations, with the aim of reducing consciousness in a patient in the advanced or terminal phase, in order to alleviate suffering caused by refractory symptoms. It should not entail the suspension of basic care and should be periodically evaluated. Prior to this, the patient should be allowed to resolve his or her personal, civil, professional, family, moral and religious obligations.
10. Public institutions must serve and protect all human life, beyond any conditioning. Human life is a good that surpasses the power of disposition of any person or institution. Euthanasia constitutes a social defeat and an exponent of the throwaway culture.
60. How can a Christian contribute to increasing respect and evaluation for all human life?
We have already pointed out that every person is called, within his or her possibilities, to spread a culture that defends human life in all its vital course. In the case of the Christian, this duty is accentuated, since it is no longer a question of a merely human question, but of confronting ideologies and attitudes that contradict God's loving plan for every human being. This commitment is carried out with the power of reason, truth, witness and conviction. A Christian cannot give up trying to have a positive influence in this field: his Christian identity would be negatively affected if he were to let topic pass by without doing his part, as if it were something that could no longer be remedied.
Public life, woven with a multitude of human relationships, always offers some point where one can contribute to the improvement of society by promoting respect for the dignity of every human being and showing the inhumanity of euthanasia. This task acquires a particular relevance in those who have responsibilities in the field of politics, the media, the Education and public and private institutions.
We would like to conclude this document with some considerations offered by Pope Francis on the issues we have discussed. In the speech before the European Parliament on November 25, 2014 he stated, "Too many situations persist in which human beings are treated as objects, whose conception, configuration and usefulness can be programmed, and which can then be discarded when they are no longer useful, because they are weak, sick or elderly. Human beings run the risk of being reduced to mere cogs in a mechanism that treats them as mere consumer goods to be used, so that - unfortunately we often see it - when life is no longer useful to this mechanism it is discarded without so many qualms, as in the case of the sick, the terminally ill, the elderly abandoned and uncared for, or children killed before birth".
And in a speech to the plenary of the Congregation for the Doctrine of the Faith in January 2018 the Pope stated, "Pain, suffering, the meaning of life and death are realities that the contemporary mentality struggles to face with a hope-filled gaze. However, without a reliable hope to help him face pain and death, man cannot live well and maintain a secure outlook on his future. This is one of the services that the Church is called to render to contemporary man because love, which approaches in a concrete way and which finds in the risen Jesus the fullness of the meaning of life, opens new perspectives and new horizons even to those who think they can no longer do so." And finally, in a tweet in June 2019 Pope Francis declared: "Euthanasia and assisted suicide are a defeat for everyone. The response to which we are called is never to abandon those who suffer, never to give up, but to care and love in order to give hope."
Likewise, the October 28, 2019 Joint Declaration of the Abrahamic monotheistic religions on end-of-life issues stated: "We oppose any form of euthanasia - which is the direct, deliberate and intentional act of taking life - as well as medically assisted suicide - which is the direct, deliberate and intentional support of suicide - because they fundamentally contradict the inalienable value of human life and are therefore morally and religiously wrong acts, and should be prohibited without exception."
In the face of the throwaway culture, it is necessary to recreate a culture of life and of meeting, of love and true compassion. Let us remember the words of St. Teresa of Calcutta: "Life is beauty, admire it; life is life, defend it". We want to be sowers of hope for those who feel tired and distressed, especially the seriously ill and their families. We know that "hope does not disappoint, because the love of God has been poured into our hearts" (Rom 5:5). We have recourse to the maternal intercession of the Virgin Mary, Health of the Sick, Comfort of the Afflicted. May she always accompany us in the passionate task of welcoming, protecting and accompanying every human life. With great affection.