Euthanasia Case Prompts Concerns
Is euthanasia the proper answer?
Compassion and clarity. The greatest compassion is called for when dealing with the case of a person who is suffering and wants to die, such as that of the Italian who recently captured international headlines, Piergiorgio Welby.
On the other hand, the most transparent clarity is required by a case that is political, as Mr. Welby himself desired his own case to be seen.
Silence, meditation and especially prayer are befitting to compassion. Clarity, on the other hand, demands a capacity for analysis and discernment, detached reasoning and especially deep intellectual honesty. It likewise demands that the profound and precious human value of compassion be kept separate from emotionalism, a psychological dynamic as deeply engulfing as it is generally transient and lacking in content.
The public debate, sparked by the letter Piergiorgio Welby sent to President Napolitano [Italian Head of State] on 22 September 2006, asking that he be permitted a "gentle death", was in the news week after week in Italy and worldwide. The discussion mixed different terms and sentiments obviously seeking to alter the deeply and instinctively hostile attitude to euthanasia prevailing in Italy and most places around the world.
It is too early to tell the results and effects of this media campaign. But we can and must say from this very moment that a terrible and moving case has been unduly exploited. Here are some aspects of the problem, which as we will see, are closely interwoven.
The figure, personality, suffering and actual image of Piergiorgio Welby have been exploited, if with his consent and perhaps also on his initiative (but even self-exploitation is always exploitation), to send a false, objectively death-oriented message to the public: that death is the only possible response to terribly invalidating degenerative diseases such as the one that afflicted Mr. Welby, and more generally, all diseases that have reached the terminal stage.
But the true message is exactly the opposite: the right response to all tragic situations of chronic invalidating diseases and illnesses that inevitably lead to death does not consist in the interruption of treatment (of which euthanasia is an extreme form), but in the therapist's warm and compassionate closeness to the patient, understood as a true right that is part of the more general right to health, common to us all.
Palliatives, not sedatives
Palliative medicines, the true pride of medicine in recent times that are required by and can give every sick person the concrete hope of being able to live with his own, even terminal, disease in a dignified manner, are intentionally and unduly confused with practices of strong and irreversible sedation that obviously aim to do away with the sick person rather than alleviate his pain.
The most recent and extraordinary biomedical technologies have been denounced and demonized as true and proper forms of violent and unnatural manipulation of life, which unduly minimize the extraordinary therapeutic effect that has enabled them to save so many human lives, thereby neglecting to recall that manipulation should not be condemned because it is unnatural (if this were the case, even cooking food would have to be condemned), but only if it is incompatible with human good.
The use of artificial respiration equipment on which Mr. Welby depended for survival has been insistently described as aggressive. That it was not aggressive but merely a beneficial form of treatment as a last resort is shown not only by an authoritative opinion expressed by the Superior Health Council, but also in the basic consideration (shared by all bioethicists) that for a treatment to be classified as "aggressive" there must be an objective disproportion between the treatment to which the patient is subjected and the results the doctor desires to achieve by it.
In Mr. Welby's case, the purpose of the mechanical respirator was not to provide him merely with a means of biological survival but to give him the possibility of an authentically and profoundly human survival that would enable him before all else to exercise his admirable role as a true and proper political leader (as members of his party tirelessly recalled).
The erroneous belief has been inculcated in people that one of the fundamental duties of doctors is to help their patients die, carefully forgetting that the Hippocratic Oath — even before a religious vision of life — binds the doctor always and only to fight for life and not to hasten death.
Spin, to legalize euthanasia
The principle of the patient's self-determination has been exalted as if it legitimized any demand the sick person might make of the doctor, even the extreme request for euthanasia.
This principle, however, which is fundamental to a correct attribution of full moral responsibility, acquires a far narrower effect in bioethics, for in order to legitimize any medical act it is generally reduced to the obligation to acquire a patient's fully informed consent should he be in command of his mental faculties.
Reference has been made to the Welby case to stigmatize the absence in our juridical system of a law recognizing the validity of so-called "living wills". (I prefer to call them Directives on Advanced Medical Treatment, following the practice of the Italian National Committee for Bioethics).
It is obvious, however, that even if there were in force in Italy a body of norms on living wills that addressed those situations where the patient has lost the capacity to understand and will, there still would have been no way that this could have been applied to the case of Piergiorgio Welby, who retained all his faculties until the end. So how can this misinformation be explained?
In many cases, one can blame the bioethical incompetence of those who created it; but in other instances, it is possible to discover behind it an unequivocal intent to open a new front in order to legitimize euthanasia for the sick with impaired mental faculties.
Although the Italian National Bioethics Committee views favourably the hypothesis of the legal recognition of Advanced Declarations, it has indicated with extreme precision the rigorous ethical and juridical limits of the validity of such Declarations: it will never be possible to use them to claim illegal services from a doctor (such as euthanasia), nor will they ever be able to bind a doctor to any arbitrary desire which the author of the living will may have formulated and set down in writing.
A doctor obliged to carry out passively the wishes expressed by a sick person in his or her Advanced Declaration would see discounted his scientific and deontological autonomy, a most precious good to which the dignity of the medical profession itself is bound.
If euthanasia in Italy, for example, is in no way recognized as a penal case in point, this is not due to an oversight but rather to the unambiguous decision of our legislators (who, on the other hand, have provided that anyone who kills out of compassion can invoke the common attenuating clause in art. 62 of the Penal Code, that is, of having acted "for reasons of special moral value").
Both the homicide of a consenting person and instigation or accessory to suicide are likewise prohibited but with lighter penalties than those prescribed for voluntary homicide.
To insist on hypothesizing gaps in the law is equivalent to hoping that euthanasia will be depenalized or even legalized: this is a strong claim on which it would certainly be possible to begin a legitimate ethical or political discussion.
However, this is a topic that should be explicitly submitted to public opinion and that cannot be glossed over as a simple request for its integration in an incomplete penal code.
Factors cloud the case
An exaggerated interpretation has been made of a fundamental constitutional principle (art. 32), by which "a specific health-care treatment cannot be obligatory for anyone except by a provision of the law". There is no doubt that on the basis of this principle a sick person can refuse any treatment, even lifesaving therapy, or may at any rate request its suspension.
The value of the principle lies in setting a limit, difficult to exceed, to the recurrent if basically inoffensive temptation of therapeutic paternalism. When health services acquire a public character they inevitably become "administered" bureaucratically and easily succumb to paternalistic treatment.
It is certain that Italian legislators, for example, who made the law did not introduce this norm as a shortcut to euthanasia. From the strictly legal viewpoint, Piergiorgio Welby had the right (after having been properly informed of the consequences of his decisions) to refuse the use of the mechanical respirator for his benefit.
However, from the ethical viewpoint, the doctor can only accept such a request should the situation prove unbearable to the patient in the imminence of death or in similar situations, as the Declaration on Euthanasia states (5, 5:80): "In the imminence of inevitable death despite the means used, it is licit in conscience to take decisions to refuse a treatment that would procure only a precarious and painful prolongation of life without, however, interrupting the normal treatment due to the patient in such cases".
In Welby's case, this situation was not present. But what prevailed was the presentation of the "right to die", which is ethically unacceptable and was not accepted by the Court of Human Rights in Strasbourg (29 April 2002, Diane Pretty vs. United Kingdom case).
As for assistance in normal treatment, this is regulated by medical practice and ethics with the sole aim of alleviating suffering.
Lastly, there was a desire to politicize the Welby case, including an appeal to the Head of State, as if this dramatic case and all the other equally tragic issues surrounding bioethics might truly find their solution through politics.
Such is not the case. Those who believe the contrary show that they understand little of the complexity of bioethics, which places everything on a metapolitical level. In fact, bioethics was brought to the attention of the contemporary world at the moment when politics realized it was inadequate to deal with the issues of health, life and death to which the frenetic development of contemporary medicine has given rise.
What the Welby case really taught us is that bioethics has an anthropological dimension in which are summed up social and coexistential issues that are ethical, religious and symbolic, and cannot be reduced to the logic of social interests for which politics mainly assumes responsibility.
Proof can be found in the systems that legalize voluntary euthanasia in the name of the respect that ought to be shown to patients should they manifest a conscious desire to die; the result is a bureaucratic control on the end of human life, which has slowly been extended to involve the psychologically sick, the elderly who are chronically ill and even (with the so-called Groeningen protocol) newborn babies with disabilities.
We cannot here discuss how far political and financial motives can influence the legal suppression of so many sick people — but we know that they exercise a strong influence!
Here, we state that the compassion we must all feel for Piergiorgio Welby and his suffering must go hand in hand with compassion for many other sick people, extremely frail both physically and psychologically, who have the right to expect from the health-care system and from us words of life and not death, closeness and not abandonment, hope and not macabre despair.
Weekly Edition in English
7 February 2007, page 10
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