How the concept of dignity is used in the intense and interminable debate around euthanasia.

Intervention by Dr. Gonzalo Herranz Rodríguez, professor of histology and pathological anatomy, Director of the Department of Biomedical Humanities of the University of Navarra, during the International Conference on Bioethics "Bioethics and dignity in a society Plural ", held in Pamplona, from 21 to 23 October 1999, in the Aula Magna of the University of Navarra.

 

Index:

I. Introduction

II. The dominant interpretations of the idea of dignity when talking about the dignity of death

1. The dignity of dying in the pro-life context

The religious tradition
the culture of human rights
the ethical-deontological norms of medicine
the bioethics reflection

2. The universal condemnation of the therapeutic fiercely, attack on the dignity of the dying man

3. Dignity of dying in the pro-euthanasia context

III. The peculiar human dignity in the trance of terminal illness and in the process of dying.

 

I. Introduction

The framework that imposes the general title of these days, bioethics and dignity in a Plural society, obliges us to try euthanasia and dignity of dying from the various and found perspectives that circulate through today's ethically fragmented society. I have been entrusted with the task of referring to how the concept of dignity is used in the intense and interminable debate around euthanasia.

The task is not easy. First, because much has been written on the subject: in the Bioethicsline database (until the end of 1998) there are more than three hundred bibliographical references on euthanasia and dignity. Second, because the word dignity has acquired a special rhetorical force in the debates on euthanasia or medical aid to suicide, and, logically, has been used with the purpose of persuading both those who promote them and those who reject them: what is the dignity of dying has become the main issue facing the conflicting cultures of life and death (1). Third, because the terms euthanasia and dignity of dying are victims themselves of a hard and deliberate polysemy: they mean, in different contexts, different and confusing things (2). Thus, with the abundance of the available material, the lexical confusion and the dialectic polarization are added.

And yet, since the equivocal idea of dying with dignity to the type of behavior (palliative or euthanasia) of the doctor who attends the terminal patient and the dying person is so linked, it is understood that, from the point of view of medical ethics, we are before a capital issue. The medical profession cannot avoid a serious discussion about death and dying in its relations with human dignity.

Since, at the beginning of our meeting, an analysis has been made of the notion of human dignity in the bioethical context, in what follows I will confine myself to dealing with two matters: one is to collect, simplify things to the maximum in two polar positions, the essentials of the interpretations that are made, in today's plural society, of the dignity of dying. The other is to rehearse a personal interpretation of the peculiarity that human dignity acquires in the trance of terminal illness and in the process of dying.

 

II. The dominant interpretations of the idea of dignity when talking about the dignity of death.

The various attitudes that are given today around the relationship between dignity and death of man can be reduced to two polar positions.

The one proclaims the intangible dignity of all human life, even in the trance of dying: all human lives, in all their duration, from conception to natural death, are endowed with an intrinsic, objective dignity, equally possessed by all : that dignity surrounds an aura of immoral nobility and sacredness all the moments of the life of man.

The other asserts that human life is a precious good, endowed with an excellent dignity, which is dealt in unequal measure among human beings , and which, in each individual, suffers fluctuations over time, to the point that it can be extinguished and Disappearing: dignity consists in quality of life, in a founded aspiration for excellence. When quality decays below a critical level, life loses its dignity and ceases to be a highly estimable good. Without dignity, the life of man ceases to be truly human and is made dispensable: that life is no longer life (3). So, anticipating death is the appetizing solution when life loses its dignity.

And yet the pro-life and pro-euthanasia attitudes coincide in a capital point: the condemnation of the therapeutic fiercely that, in addition to being bad medicine, is a serious attack on the dignity of the dying man.

 

1. The dignity of dying in the pro-life context.

As noted earlier, in the ethical tradition of respect for life, human dignity is invariably: it is not diminished by sickness, suffering, malformation or dementia. Moreover, biological or psychic adversity may be the occasion of further finishing: as John Paul II affirms, the great dignity of man is confirmed in a special way in suffering (4). Man does not live in a paradise of friendly ecology. It coexists with the risk and the hardship, in a natural environment, to which it is exposed and in which it is to integrate its vulnerability and its strength, its finiteness and its dignity.

The dignity of dying, in the pro-life context, receives support from the religious tradition, from the culture of human rights, from the professional ethics of medicine, from bioethics reflection.

 

 

The religious tradition

The Biblical-Christian tradition proclaims respect for life, affirms that human dignity is shared equally by all men and ensures that this dignity does not succumb to the passing of the years and is degraded by sickness and the process of dying.

In this tradition, man, every man, is a being of intrinsic value and dignity, a moral, responsible and free agent, who, by being Imago Dei, is absolutely resistant to ontological degradation (5). Consequently, respect for the intangible dignity of all human life also extends to the time of death: all human lives in all its duration from conception to natural death are endowed with an intrinsic, objective dignity, possessed equally by all: that dignity surrounds an aura of sacredness all the moments of man's life.

God, mysteriously, creates us in his image and likeness also when our appearance and biological value are decayed by sickness or malformation. Thus, Yahweh says to Moses (6): "Who has made the mouth of man? And who made you dumb, or deaf, or psychic or blind? Was it not I, the Lord?"

This understanding of man as the image of God, even in spite of his handicaps and shortcomings, granted immense moral superiority and a humanity incomparable to the Mosaic law, when compared with other laws of antiquity. What is distinctive about it is that it is no longer acceptable to mark the weak, poor and blind, widows and orphans, slaves and foreigners as unworthy.

With Christ and his incarnation, humanity is further dignified, for, with the call to adoptive divine sonship, the likeness of Man with God is reinforced. It is not just the image of God: Man is invited to become the son of God, a dignity impossible to overcome, because there is no more nobility, more courage. The recognition of the value of human weakness is, in the biblical tradition, universal, since God does not make sense of persons (7). All the members of the human family, the strong as well as the weak, are of equal value before God: we all possess the same dignity. "There is only one race: the race of the sons of God", said Blessed Jose Maria Escrivá in a synthesis that sums up the anthropology of dignity, a dignity that comes from participating each and every one, without distinction and mysteriously, of the divine filiation (8).

The encyclical Evangelium Vitae highlights, on biblical sources, the dignity of the entire temporal journey of every human life: it speaks to us of the dignity of the still unborn child and the halo of prestige and veneration that surrounds old age. The supreme weakness of Christ on the Cross is not only the full revelation of the Gospel of life, but it is just the moment that reveals his identity as the Son of God and manifests His glory (9).

It is advisable to consider for a moment what this revolutionary novelty meant to the world then, because modern movements in favor of euthanasia incorporate ideas, in a way, Neo-pagans. Ancient medicine was not blind to the dignity of dying. The extreme weakness, irreversible, did not seem then worthy of attention. The doctor left the incurable. In the Hippocratic tradition, the doctor refrained from providing a poison to his patient so that he could put an end to his life. That was all: the doctor had no medicine, neither heroic nor euthanasian, with which to help him. The therapeutic uselessness forced to respect the natural course of the intractable disease. Plato summarizes the attitude of Greek medicine, including the school of Hippocrates, with these words: "Asclepius taught that medicine was for those of a healthy nature who were suffering from a specific disease. He freed them from their evil and ordered them to live normally. But those whose bodies are always in a sickly internal state, never prescribed a regime that could make their life a more prolonged misery. Medicine was not for them: even if they were richer than Midas, they should not be treated (10).

That blindness to weakness as a specifically human attribute continues today to affect people with a rationalist and pragmatic mind, followers of the philosophies of efficiency, power or vitality. They feel before the incapacitating illness or before the proximity of the death an instinctive displeasure: the life, physically or intellectually impoverished, causes them a lot of uneasiness and a reaction of flight. They prefer to ignore it or extinguish it. Nietzsche took that rejection to the extreme. Based on the demands of reason, feeling and instinct, it made the fundamental will to be healthy the fundamental principle of human dignity. It is not difficult to find a Nietzschean fiber in the complex fabric of today's pro-euthanasia mentality. The vital and sure will of the instinct does not incite to respect the patient, to pity the weak one. On the contrary, it impels contempt, even annihilation, because helping the weak is proper to the morality of the slaves.

Human dignity was never, in Pagan antiquity, a universal human attribute. There was certainly among the classics a sense of dignity, but it was the dignity of the excellent, virtuous man, who lived in a position to develop his virtues, his excellencies, human. The Roman concept of Humanitas was used to describe the dignity of a balanced and educated personality, which was exclusively among the most outstanding individuals of the Roman aristocracy. Dignity was not intrinsic, nor was human rights. Large social groups lacked them. Inequality was a natural feature of society. It was accepted as an inevitable reality that there would be slaves or foreigners, destined for hard or degrading work, that could be tortured or consumed in productive work or in diversions. Physical plenitude was an essential element of that aristocratic human dignity: the chronically ill, the crippled or the deformed were held by unworthy and their death was propitiated by the exposure and the abandonment (11).

 

The culture of human rights

It should be noted, however, that the notion of the universal dignity of man, and in particular that of the dying man, is not only religious: He has become part of the law as well. And so, for example, a recommendation from the Parliamentary Assembly of the Council of Europe on the rights of the sick and dying invites Governments to "define precisely and grant all the right of the sick to dignity and integrity" (12). The Parliamentary Assembly has recently reinforced its position at the end of a recent debate (June 1999) on the protection of human rights and the dignity of the terminally ill and the dying (13), by reiterating the absolute prohibition of Active euthanasia and to affirm that "the desire to die of terminal or dying patients does not constitute any legal right to die at the hands of another person". What is more, the respect for life and dignity of man is, according to some, a right that must be fulfilled the more the greater the weakness of the dying. Indeed, the National Committee of Ethics for the Sciences of Life and health, of France, noted, in a statement on the practice of experiments in patients in chronic vegetative state (14), that "patients in a chronic vegetative coma are human beings who have so much more rights to respect due to the human person that they are in a state of great fragility". The concept of the direct proportional relation between weakness and dignity remains there: with greater weakness in the patient, greater respect in the doctor.

 

The ethical-deontological rules of medicine

The ethical precept of not killing the patient is present and wholly preserved in the professional ethics of the physician from the very origin of the Hippocratic oath. A comparative analysis of the standards of medical care for the terminal patient in the codes of ethics and deontology of 39 national medical Associations of Europe and America, showed the profound unity of the common tradition: together with the unanimous condemnation of the Euthanasia and medical assistance to suicide and the firm rejection of therapeutic fiercely, quality palliative care is recommended as a measure provided to the dignity of the dying person. Precisely, many codes invoke the protection of the human dignity of the chronic or terminal patient as a fundamental reason for the diligent treatment of pain or suffering (15).

 

Bioethics reflection

The argument for the inextinguishable dignity of every man and, in particular, the dying person, has been the subject of study since the birth of bioethics. Moreover, it must be recognized that some of the most inspired and profound reflections occurred in the early years of the young discipline.

One of them is due to Paul Ramsey. Distrustful of the possible perverse uses of the phrase "die with dignity", as an ideal and as a right, and disconsolate with the loss of human dignity that is all death, he rebels against the idea that there is an intrinsic dignity in death and death of man, for as much as the finishing of bodily life, as the end of personal life, death is the Enemy: true humanism is linked to the fear of death. Therefore, Ramsey concludes, it is better to accept the indignity of death than to try to dignify it, because we will always take better care of the dying if, in addition to relieving them of pain and suffering, we recognize that death is a duel that no resource within the reach of the man is able to relieve (16).

The answer that Kass (17) gives to Ramsey, both for his analysis of the notion of dignity, and for the rehabilitation of the death-dignity conjunction in his natural and biblical bases, is an essential starting point for understanding the valid meaning of death with dignity. Years later, in 1990, already in times of vigorous propaganda in favor of euthanasia, Kass further developed his ideas to analyze the connection between sanctity of life and dignity of man and reanalyze in his light the ideas of death with dignity that were already swarming then (18). It is necessary to appreciate, by direct reading, the tempered dialectical force of his arguments against the claims of the promoters of euthanasia, when he evaluates the risk of arrogance of modern medical technology, the temptation to end technologically the failure of death aggressively , and the need to adapt to coexisting with the idea of ​​mortality and finitude. It argues vigorously that, in the presence of incurable and terminal illness, there always remains a residue of human fulfillment that, however precarious it may seem, must be taken care of. If we want to oppose the rising tide that, impelled by the pro-euthanasia mentality and the ethics of free choice, threatens to submerge the best hopes of human dignity, we must learn that human finitude is no misfortune and that the dignity of the human man has to be taken care of and cared for until the end.

In more recent times, analysis and deepening of the concept of dying with dignity have not ceased to appear. There are many who try to snatch it from the hands of the promoters of euthanasia who have tried to appropriate its use exclusively.

Between these analyses, it is worth quoting two. Sulmasy (19), after concluding that the essence of human dignity is nothing more and nothing less than the esteem and honor that human beings deserve simply because they are human. To pretend to prolong always and at all costs the purely human biological life is to deny the truth of the human mortality and, therefore, to act against the human dignity. In the same way, to kill a patient, even when he is already dying, comes to say that the life of this man has lost all meaning and value: but that is to act against human dignity, because this does not depend on social lending, freedom or pleasure , but the fact of being a man. Human dignity is not something subjective: no one can increase, diminish or annihilate their own dignity, nor can they do it with the dignity of another. And the same goes for sickness and dying: they can humiliate, diminish self-esteem, shame and even create a feeling of indignity. But these assaults do not end with it, do not diminish: we are disturbed precisely because they put in the rug the problem of whether human life has meaning and value, has dignity.

Sulmasy describes how different in the expression of dignity can be the deaths of patients: from those who face dying with courage, hope and love, to those who do in fear, rebellion, despair or self-loathing. One and the other must be treated with dedication and respect. It is a tremendous task to return to certain patients faith in their own dignity and to make them feel, in the terminal situation, totally lacking at times of aesthetics, that their life continues to have value and dignity. That is a tough test for the doctor and the nurse, but that is to attend to the dying. As Sulmasy says, "there would be no greater assault on human dignity or, ultimately, greater suffering than to say to one of those patients, looking at his face," Yes, you are right. Your life has no meaning and value. I will kill you, if you love "». The dying must know that, for their doctors, they never lose their human dignity and that they continue to possess all their value and esteem: their lives always preserve a measure well filled with meaning and dignity.

Stolberg (20), after reaching the conclusion that the notion of human dignity cannot be supported only in the capacity of rational self-management of the Kantian, nor in the freedom which persuades us that we are not mere things of the existentialist, because it would reach the pessimistic Conclusion that the dying and the comatose would lack human dignity. Indeed, to say that human dignity can diminish or be lost because of sickness and suffering is tantamount to saying that human dignity depends on the ability to control uncontrollable things such as aging, disability or terminal illness. Argues Stolberg, analyzing the relationship between human dignity and equality, that man cannot stop being human, which means that it is part of nature. The idea of considering natural phenomena as degrading or devastating human dignity is based on the false dualism that presents as antagonistic dignity and nature, which converts the natural into an enemy and destroyer of the proper human. This is tantamount to identifying dignity with physiological well-being or even with the psychic integrity that makes possible the full exercise of rationality, autonomy or self-awareness. But those qualities are very differently distributed in those who are going to die, so they cannot be the basis for equal rights and dignity in the trance of death. To restore a truly realistic and indisputable foundation of the radical equality of human dignity, Stolberg goes to the idea of G. Marcel to go and seek in mortality and precariousness of man the standard of the common human condition that establishes the level of equal value and essential equality. From the confrontation with the finiteness that all of us expect, the consciousness of men coincides in the experiences of pain and sorrow, sickness, ageing and death, an experience that brings us together in the construction of common dignity. Stolberg concludes that it is contradictory to argue that these experiences threaten human dignity, understood as equal value.

 

2. The universal condemnation of the therapeutic fiercely, attack on the dignity of the dying man.

It hardly deserves more than a few lines the reference obliged to the ethical condemnation that has received the therapeutic fiercely. The condemnation is universal: It comes from the pro-life instances, as well as from the ranks of the pro-euthanasia. Of the professional organizations of doctors and nurses as well as of the national or international committees of bioethics. The remarkable thing is that all those sentences, come from where they come from, point out that therapeutic obstinacy is an attack on the dignity of dying.

No one doubts today that the therapeutic obstinacy constitutes a mistake, medical and ethical, very difficult to justify. Everyone shares the idea that applying deliberately useless treatments when there is no longer any reasonable hope for recovery, particularly when they cause pain and isolation, breaks the dignity of the dying man.

The bibliography on medical futility is now incomprehensive, as comments on the dramatic death of certain public figures have multiplied, on jurisprudence about particularly complex clinical cases, and on the multitude of Guidelines dictated by different professional bodies.

Suffice to show two testimonies on the connection between dignity in dying and therapeutic moderation, which come from antipodal ethical positions. The Lura et bona declaration, of the Congregation for the Doctrine of the Faith (21), succinctly described it thus: "It is very important today to protect, at the moment of death, the dignity of the human person and the Christian conception of the life against a technicality that runs the risk of becoming abusive. In fact, some speak of "the right to die", an expression that does not designate the right to procure or make oneself procure death at will, but the right to die with serenity, with human and Christian dignity. The medical critic, Richard Taylor, expressed himself with steely hardness about the therapeutic abuse of the intensive care units of the seventies, in these terms: "Rows of physiological preparations, also known as human beings, lie surrounded by a number amazing of mechanical gadgets. Through innumerable tubes, liquids of a thousand colors are injected or drained. Artificial respirators impel gases, dialysis machines grumble, monitors fire their alarms, oxygen bubbles in humidifiers. The unfortunate prisoners of technology, fortunately oblivious to what happens around them, because of drugs or their disease, lie unarmed, while performing the ritual of profanation of their dignity (22).

 

3. Dignity of dying in the pro-euthanasia context

It is not easy to find in the publications of the advocates of euthanasia an articulated and coherent doctrine about the dignity of dying. The search in the glossaries that the pro-euthanasia movements maintain on the Internet is unsuccessful: neither in the extensive glossary of the Scottish Society of Voluntary Euthanasia (23), nor in that of ERGO, the intellectual arm of Exit, the powerful American group that directs Derek Humphry, the Dignity entry is included (24).

The use, by the promoters of euthanasia, of the expression dying with dignity has a more opportunistic and rhetorical than substantive purpose. Although death and death constitute for many men of today an unmentionable taboo, in the dynamics of pro-euthanasia movements they lose their negative meaning or transmute it, when combined with dignity, into a new and acceptable one. And so it turns out that many of the associations that advocate the depenalization of euthanasia and medical aid to suicide have been self-denominated with terms that combine death and dignity (25). And, curiously, the only law in force in the world that authorizes the practice of suicide assisted by the doctor, approved in the state of Oregon, is called, by a manipulative pun, the law of death with dignity (26).

The ideological project that underlies the mentality of death with dignity or the right to a dignified death consists in the acceptance that human dignity is undermined, or even treacherously destroyed, by suffering, weakness, dependence on others and the terminal disease. Therefore, it is necessary to rescue the process of dying from these degrading situations through the use of euthanasia or suicide aided by the doctor.

The decision to avoid the final deterioration of quality of life and to maintain self-control and self-dignity in the last days is favored by the peculiarity of the sources of information about the death of people today. On the one hand, very few have the opportunity to witness a calm death. The death of the relatives, apart from being a phenomenon that each one has occasion to witness very seldom in his life, usually happens today in the hospital, not at home. The lack of interpersonal intimacy that this implies is aggravated by the intense medicalization of the agony. On the other hand, the media crowd us with stories and images of a thousand forms of free, violent or tortured deaths. A collective rejection of death is thus created, for no one would ever want to die of any of these modes. And since we must die, all of us, in principle and instinctively, want to do it with dignity and decently, preserving man's own nobility.

On this background, the pro-euthanasia mindset builds its notion of dying with dignity by assigning moral suffering, physical pain, disability, dependence on others, terminal illness, a negative value, destructive of human dignity. Dignified death is the only solution to put an end to the permanent indignity of living those overburdened lives of negative values, lacking vital value.

We also live in a time when the medical decisions are taken in function of the choice, active and informed, of the patient of the treatments that accepts or rejects. Consequently, the right of the patients to decide, together with the fear of being in a painful and usurping agony of self-control, leads to convert the desire to die with the maximum of comfort and dominion of the circumstances: that is to say, it creates a right to die with dignity (27).

The right to die with dignity is invoked as a right that guarantees the possibility of living and dying with the inherent dignity of a human person, and as a resource to free himself from the agony of living in a state of emotional or psychological misery. The biological decay, not self-asserting and depending on others for the most common actions and functions, are considered, in the mentality of death with dignity, as sufficient reason to claim the right to die in order to prevent human dignity from being Undermined and ruined by extreme invalidity, dependence and suffering.

But, is human dignity really lost when one is very ill, very weakened, or cannot continue to live if it is not with the help of others?

In the end, with the notion of dignity proper to the euthanasian mentality, it is totally alien to the concept of dignity of the pro-life mentality. This has an ontological basis: dignity is intrinsic, universal, inalienable, immune to the influences of fortune or grace, refractory to the process of dying. That, although important, is accidental. Social dignity is a dependent variable of numerous circumstances: the passage of time, the possession of money, influence, physical presence, class or titles; you have, but you can decrease below a critical value until you get lost. It is especially sensitive to social and aesthetic influences.

This submissive character to social and subjective influences is the reason that the dignity of dying remains invoked as a right at a time when the progress of palliative medicine has led to the decline of the notion of euthanasia as the release of Pain Unbearable. The pro-euthanasia movements have been forced, therefore, to leave in the background and as a thing of the past the paradigm of killing for compassion the one who suffers intolerably, to take a new direction: to present the dignity of dying as a right that expresses one's absolute dominion over one's own life, or as a sign of personal propriety. In the new context, the enemy is no longer the advanced disease, which, through pain, suffering or total weakness of cachexia, puts a seal on human dignity: the new enemy is the loss of self-sufficiency, the not being able to live independently of others, having to die abdicating from the social image until then prestigious and aesthetic.

Terminal illness can very harshly hurt social dignity, the image of one before the others. It is not strange, therefore, that, in recent years, pro-euthanasia movements tend to present the claim of the right to die in dignity as the crowning of ethical progress, typical of clairvoyant people and advanced ideas, which form a cultural elite, an emancipated minority of prejudices and superstitions.

Some surveys have shown that there is a close correlation between social class and degree of intellectual self-esteem, on the one hand, and adherence to pro-euthanasia activism by another. In the charter literature and on the Internet pages, the promoters of euthanasia present themselves as the leaven in the mass, as leaders and liberators who will transform society. The arguments and examples displayed by the promoters of euthanasia, which are ordinarily overburdened with strong rhetoric, remain, both in society and in health professions, a minority heritage. From professional instances of medicine, there has been a serious risk of this elitist attitude: that of endangering, through skillful manipulation of sentiments in favor of the euthanasia of a small elite, the palliative care of whole groups of People (elderly, incapable, terminal patients). In the end, the pro-euthanasia mentality aims to compel society to choose between the provoked and painless death, as a pretended means of preserving human dignity, and the care and care of the terminally ill, with the vicissitudes and precariousness of the life which is extinguished (28).

It is therefore not surprising, though comforting, to know that, compared to the general population, adherence to euthanasia is notably inferior (50%), among those affected by functional deficiencies, those who feel a burden to the family or those who see their life as useless. In the United States, support for physician-assisted suicide is markedly lower among the elderly, African Americans, the poor, and those who practice religion (29).

Pro-euthanasia activists repeat to the satiety that the option of dying with dignity is closely linked to the right to choose the time and mode of death itself according to the criteria of a hedonistic ethic. As the allegation in favor of beneficent euthanasia pointed out in a paradigmatic way, when life lacks dignity, beauty, promise and meaning, and death is delayed by endless periods of agony and vital degradation, it cannot be said that this is the Life of a human being, because to tolerate or to accept the unnecessary suffering is immoral (30). Unfortunately, there are few doctors who, by ignorance of the advances in the treatment of pain and palliative care, can become provocateurs or accomplices of the request for euthanasia (31).

The elitist arrogance and the fascination with the death (32) of the pro-euthanasia mentality could, if euthanasia reached legal sanction, depriving many patients of the benefits and dignity of palliative care, a humble but immensely branch human of medicine and nursing. One can only speak of true freedom of choice when palliative medicine is practiced with competition and offered to all who need it.

 

III. The peculiar human dignity in the trance of terminal illness and in the process of dying.

This second part of the article is devoted to presenting some considerations about the specific human dignity of the terminal patient.

The hopelessly ill and the dying are presented as a riddle for relatives and strangers, for doctors and nurses. They are often an enigma, because they impose on us the difficult task of discovering and recognizing, under their decrepit appearance, all the dignity of a human being.

For a look that sees only appearances, terminal illness, so accompanied sometimes by pain, anguish and anxiety, tends to overshadow the dignity of the patient: the hidden, even seems to have destroyed. Because if, in a way, health gives us the ability to reach a certain measure of human fulfillment, being seriously ill limits, in ways and in different degrees, that important dimension of dignity, as nobility, which is the capacity to develop the Project of man every one of us caresses.

It is not difficult for the doctor to cooperate in restoring your patient's health while there is hope of reaching it. But it is very arduous today for many physicians, outside those who are competent in palliative care, to recognize the value of their work when, in the trance of terminal illness and the process of dying, there is no place for that hope. It is difficult to recognize, in the environment of today's medicine, interested in healing results and process costs, that serious, disabling, painful disease and, to a greater degree, terminal illness, may have interest. Dominated by a pathophysiological culture, it costs many physicians to understand that terminal illness does not consist only of molecular or cellular disorders that no longer have an arrangement, but also a human problem in which respect for the dignity of the patient imposes the duty to take care of the dignity of his dying.

The terminal disease is also not limited, above the purely biological, to an experiential journey of certain stages that mark the psychological reactions of the patient to the death foretold and ineluctable, reactions that need understanding, support and accompaniment (33).

The terminal situation constitutes, above all, a threat to the integrity of man, to his personal dignity, which puts the patient and those who care for him to the test. And when this is understood, the results are immediate. One of the great promoters of palliative care, this professional way of respecting the dignity of those who are going to die, said that, in his opinion, one of the strongest arguments against euthanasia is the good use that he had I have seen many patients, and their families, from the final days of their existence, after the pain had been mitigated and before death came. Eliminating, through an act of compassionate death, this dignifying opportunity would amount to depriving the family and society of that unique value and dignity that is concentrated in the final stretch of human life (34).

It should be noted that the role of health professionals is to weigh the value, effectiveness and proportionality of the means available to them, not to judge the value of the lives entrusted to them. And yet, some physicians and nurses, in whom a radical idea of the quality of life has been deeply rooted, believe that there are lives so lacking in quality and dignity, that they are not deserving of medical care and that they are a tributary of compassionate death.

Such an attitude underlies the ethical tradition of health professions, one of whose most fruitful and positive elements, both in the progress of medicine and in society, is to understand that the weak are important, that they fully possess the dignity of every man (35). This idea, it is not difficult to intuit, was present at the beginning of the civilizing process and the birth of Medicine. Being weak was in the deontological tradition a sufficient title to be credited with respect and protection. Even being economically weak ceased to be a mark of discrimination for medical care. The socialization of medicine is one of the historical efforts of greater importance in homage to the human dignity of all. And today, however, that effort seems to be affected by intense ethical fatigue and there is talk openly of reducing the costs, certainly gigantic, of health care. It is talking openly about rationing medical care and stratifying care, not according to its benefit / cost ratio, but according to the socio-economic conditions (age, ability to pay, health status) of patients. This introduces a discrimination that affects the core of the relations between doctors and patients: these are no longer invested with the sole and supreme dignity of man, but can be distinguished in various categories: the weak will be discriminated against.

Medicine runs the risk of becoming an instrument of social engineering. But that is a totally bizarre idea of the ethics of health care. The specific of doctors and nurses is to help, with their knowledge and skills, the sick and weak, human beings who live the crisis of being losing their physical vigor, their mental faculties, their life. Respect for the dignity of man, takes in medicine, a peculiar and specific form: respect for the weakened life. In palliative medicine, respect for life is almost constantly conditioned by the presence of the essential vulnerability, by the extreme fragility of man, by the recognition of the inevitable and the next of death. The ethical respect of doctors and nurses who administer palliative care is respect for declining life. Their job is to take care of people in the extreme degree of weakness.

Res Sacra miser. With this denomination of Christian-stoic origin, recovered by Vogelsanger (36), the special situation of the patient's humanity in the field of stresses of the terminal illness is expressed in a magnificent way. It translates wonderfully the coexistence of the sacred and indeclinably worthy of all human life with the misery caused by disease. When the patient is considered in this light, as something worthy and miserable at the same time, we can recognize his condition, both inviolable and needed. This is the ethical basis of terminal care that is due to every patient, the moral justification of palliative care.

 

Gonzalo Herranz Rodríguez

 

Notes

1.John Paul II. Encyclical Letter Evangelium Vitae, Vatican Editrice Library, Vatican City, 1995.

2. P.R.S. Johnson, An analysis of "dignity", "Theor Med Bioethics", 1998, 19, 337-352.

3. J. Hersch, La vie à son juste prix, "Schweiz med Wschr", 1982, 112 (SUPL 13), 29-30.

4. John Paul II. Apostolic letter Salvifici Dolores, Vatican Editrice Library, Vatican City, 1984.

5. U.K. Ferngren, The Imago Dei and the sanctity of life: The origins of an idea, in R.C. McMillan, H.T. Engelhardt Jr, S.F. Spicker, euthanasia and the newborn, Reidel, Dordrecht, 1987, 23-45.

6. Ex 4, 11.

7. Rom 2, 11.

8. J.M. Escrivá de Balaguer, Surco, Rialp, Madrid, 1986, point 303.

9. John Paul II, encyclical letter Evangelium Vitae, LEV, Vatican City, 1995, points 44, 46, 50 and 51.

10. Plato, the Republic.

11. Ferngren, loc. cit., 34-38.

12. Parliamentary Assembly of the Council of Europe, Recommendation 779 (1976) on the rights of the sick and dying, in recommendations adoptées par le Conseil des Ministres et Assembly parlementaire du Conseil de l'Europe sur les problèmes de bioéthique, Conseil de l'Europe, Direction des affaires juridiques, Strasbourg, 1989, 19-21.

13. C. Dennemeyer, assembly in favour of absolute prohibition on active euthanasia, Council of Europe Press Service. http://www.coe.fr/cp/99/370a (99). htm.

14. Comité Consultatif National d'Éthique pour les Sciences de la Vie et de la Santé, Avis sur les experimentations sur des malades en état végétatif chronique (24 Février 1986), en Avis 1984-1986, Centre de documentation et d'Information d'Éthique des Sciences de la Vie Et de la Santé, Paris, 1986, 17.

15. G. Herranz, medical ethics and terminal life. Euthanasia and palliative medicine in the codes of ethics and medical deontology of Europe and America, in "Med Mor", 1998, 48, 91-118.

16. P. Ramsey, The indignity of ' death with dignity ', in "Hastings Cent Stud", 1974, 2 (2), 47-62.

17. L.R., Averting the eyes or facing the music? On dignity in death, in "Hastings Cent Stud", 1974, 2 (2), 67-80.

18. L.R., Death with dignity and the sanctity of life. Commentary, 1990, 98, 3, 33-43. Reproduced in "Hum Life Rev" 1990, 16, 2, 18-40.

19. D.P. Sulmassy, Death and human dignity, "Linacre Quart", 1994, 61 (4), 27-36.

20. S.D. Stolberg, Human dignity and disease, disability, suffering: A philosophical contribution to the euthanasia and assisted suicide debate, "humane Med", 1995, 11, 144-146.

21. Congregation for the Doctrine of the Faith, Declaration on euthanasia, Spanish Episcopal Conference, secretariat of the Episcopal Commission for the doctrine of the Faith, Madrid, 1981, 145-163.

22. R. Taylor, Medicine out of control: The Anatomy of a malignant technology, Sun Books, Melbourne, 1979.

23. Voluntary euthanasia Society of Scotland. Index and Glossary. In: http://www.euthanasia.org/a_z. html. Visited October 10, 1998.

24. ERGO, euthanasia Research and Guidance Organization. Glossary. Accessible through http://www2.privatei.com/hemlock/geninfo.html.

25. Voluntary euthanasia Society Scotland. http://www.euthanasia.org/wfmap.html. Visited October 8, 1998.

26. R.L. Marker, J.J.M. Smith, words, words, words. Words used in assisted suicide debate. International Anti-Euthanasia Task Force Web Site: http://www.iaetf.org/fctwww.htm.

27. T.E. Quill, Death and Dignity: A case of individualized decision making, "N Engl J Med", 1991, 324, 691-694.

28. A. Rodway, Pro-euthanasia lobby represents the minority view in Britain, "BMJ", 1995, 310, 1466.

29. K. Faber-Langendoen, Death by request. Assisted suicide and the Oncologist, "Cancer", 1998, 82, 35-41.

30. American Humanist Association. Plea for Beneficent euthanasia. 1974. http://www.infidels.org/org/aha/documents/euthanasia.html. Accessed November 11th, 1998.

31. R. Sloan, doctors may be ignorant of treatments for intractable symptoms, "BMJ", 1995, 10, 1466.

32. H. Hendin, seduced by death. Doctors, patients, and assisted suicide, (revised and updated), W.W. Norton, New York, 1998.

33. E. Kübler-Ross, On death and dying. What the dying have to teach doctors, nurses, clergy and their own families, MacMillan, New York, 1969.

34. T.S. West, Good care or bad law?, "J Roy Soc Med", 1979, 72, 461-464.

35. R. Crawshaw, Humanism in medicine. The rudimentary process, "N Engl J Med", 1975, 293, 1320-1322.

36. P. Vogelsanger, Die Würde des Patienten, "Bull Schweiz Akad med Wiss", 1980, 36, 249-58.