Protection of Conscience
Project
Issues in Depth: Ethical
Commentaries
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Protection of Conscience
Project |
CHARTER FOR HEALTH CARE WORKERS
Pontifical Council for Pastoral
Assistance
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Introduction
Value of
life:
Indisposability
Organ
Donation
Pastoral Care
Painkillers
Telling the |
35. "From the time that the ovum is fertilized, a life is begun which is neither that of the father nor of the mother; it is rather the life of a new human being with its own growth. It would never be made human if it were not human already.... Right from the fertilization the adventure of a new life begins, and each of its capacities requires time—a rather lengthy time—to find its place and to be in a position to act."[87] Recent advances in human biology have come to prove that "in the zygote arising from fertilization, the biological identity of a new human individual is already present."[88] It is the individuality proper to an autonomous being, intrinsically determined, developing in gradual continuity. Biological individuality, and therefore the personal nature of the zygote is such from conception. "How can anyone think that even a single moment of this marvelous process of the unfolding of life could be separated from the wise and loving work of the Creator, and left prey to human caprice?"[89] As a result, it is erroneous and mistaken to speak of a pre-embryo, if by this is meant a stage or condition of pre-human life of the conceived human being.[90] 36. Prenatal life is fully human in every phase of its development. Hence health care workers owe it the same respect, the same protection and the same care as that given to a human person. Gynecologists and obstetricians especially "must keep a careful watch over the wonderful and mysterious process of generation taking place in the maternal womb, to ensure its normal development and successful outcome with the birth of the new child."[91] 37. The birth of a child is an important and significant stage in the development begun at conception. It is not a "leap" in quality or a new beginning, but a stage, with no break in continuity, of the same process. Childbirth is the passage from maternal gestation to physiological autonomy of life. Once born, the child can live in physiological independence of the mother and can enter a new relationship with the external world. It may happen, in the case of premature birth, that this independence is not fully reached. In this case health care workers are obliged to assist the newborn child, making available to it all the conditions necessary for attaining this independence. If, despite every effort, the life of the child is at serious risk, health care workers should see to the child's baptism according to the conditions provided by the Church. If an ordinary minister of the sacrament is unavailable—a priest or a deacon—the health care worker has the faculty to confer it.[92] The value of life: unity of body and soul 38. The respect, protection and care proper to human life derives from its singular dignity. "In the whole of visible creation it (human life) has a unique value." "The human being, in fact, is the 'only creature that God has wanted for its own sake. Everything is created for humans. The human being [93] alone, created in the image and likeness of God (cf. Gen 1:26-27) is not and cannot be for any other or others but for God alone, and this is why he exists. The human being alone is a person: he has the dignity of a subject and is of value in himself."[94] 39. Human life is irreducibly both corporeal and spiritual. "By virtue of its substantial union with a spiritual soul, the human body cannot be considered merely an amalgam of tissues, organs and functions, nor can it be measured by the same standards as the body of animals, but it is a constitutive part of the person who by means of it manifests himself and acts."[95] "Every human person, in his unrepeatable uniqueness, is made up not only of spirit but also of a body, so that in the body and through it the person is reached in his concrete reality."[96] 40. Every intervention on the human body "touches not only the tissues, the organs and their functions, but involves also at various levels the person himself."[97] Health-care must never lose sight of "the profound unity of the human being, in the obvious interaction of all his corporal functions, but also in the unity of his corporal, affective, intellectual and spiritual dimensions." One cannot isolate "the technical problem posed by the treatment of a particular illness from the care that should be given to the person of the patient in all his dimensions. It is well to bear this in mind, particularly at a time when medical science is tending towards specialization in every discipline."[98] 41. Revealing the person,[99] the body, in its biological make-up and dynamic, is the foundation and source of moral accountability. What is and what happens biologically is not neutral. On the contrary it has ethical relevance: it is the indicative-imperative for action.[100] The body is a properly personal reality, the sign and place of relations with others, with God and with the world.[101] One cannot prescind from the body and make the psyche the criterion and source of morality: subjective feelings and desires cannot replace or ignore objective corporal conditions. The tendency to give the former pride of place over the latter is the basis for contemporary psychologization of ethics and law, which makes individual wishes (and technical possibilities) the arbiter of the lawfulness of behavior and of interventions on life. The health care worker cannot neglect the corporeal truth of the person and be willing to satisfy desires, whether subjectively expressed or legally codified, at variance with the objective truth of life. Indisposability and inviolability of life 42. "The inviolability of the person, a reflection of the absolute inviolability of God himself, has its first and fundamental expression in the inviolability of human life."[102] "The question: 'What have you done?' (Gen 4:10), which God addresses to Cain after he has killed his brother Abel, interprets the experience of every person: in the depths of his conscience, man is always reminded of the inviolability of life—his own life and that of others—as something which does not belong to him, because it is the property and gift of God the Creator and Father."[103] The body, indivisibly with the spirit, shares in the dignity and human worth of the person: body-subject not body-object, and as such is indisposable and inviolable.[104] The body cannot be treated as a belonging. It cannot be dealt with as a thing or an object of which one is the owner and arbiter. Every abusive intervention on the body is an insult to the dignity of the person and thus to God who is its only and absolute Lord: "The human being is not master of his own life: he receives it in order to use it, he is not the proprietor but the administrator, because God alone is Lord of life."[105] 43. The fact that life belongs to God and not to the human being[106] gives it that sacred character[107] which produces an attitude of profound respect: "a direct consequence of the divine origin of life is its indisposability, its untouchability, that is, its sacredness."[108] Indisposable and untouchable because sacred: it is "a natural sacredness, which every right reason can recognize, even apart from religious faith."[109] Medical health activity is above all a vigilant and protective service to this sacredness: a profession which defends the non-instrumental value of this good "in itself"—that is, not relative to another or others but to God alone—which human life is.[110] "Man's life comes from God; it is his gift, his image and imprint, a sharing in his breath of life. God therefore is the sole Lord of this life: man cannot do with it as he wills."[111] 44. This must be affirmed with particular rigor and received with vigilant awareness at a time of invasive development in biomedical technology, where the risk of abusive manipulation of human life is increasing. The techniques in themselves are not the problem, but rather their presumed ethical neutrality. Not everything which is technically possible can be considered morally admissible. Technical possibilities must be measured against ethical lawfulness, which establishes their human compatibility, that is, their effective employment in the protection of and respect for the dignity of the human person.[112] 45. Science and technology "cannot by themselves give the meaning of human existence and progress. Since they are ordained for the human being from whom they receive their origin and increase, it is from the person and his moral values that they draw direction for their finality and awareness of their limits."[113] This is why science and wisdom should go hand in hand. Science and technology are extremist, that is, they are constantly expanding their frontiers. Wisdom and conscience trace out for them the impassable limits of the human.[114] 46. The divine lordship of life is the foundation and guarantee of the right to life, which is not, however, a power over life.[115] Rather, it is the right to live with human dignity,[116] as well as being guaranteed and protected in this fundamental, primal and unsuppressible good which is the root and condition of every other good-right of the person.[117] "The subject of this right is the human being in every phase of his development, from conception to natural death; and in every condition, either health or sickness, perfection or handicap, wealth or paupery "[118] 47. The right to life poses a two-fold question for the health care worker. First of all, he must not think that he has a right—power over the life he is caring for, something which neither he nor the patient himself has. and therefore cannot be given by the latter.[119] The right of the patient is not one of ownership nor absolute, but it is bound up with and limited by the finality established by nature.[120] "No one...can arbitrarily choose whether to live or die; the absolute master of such a decision is the Creator alone, in whom 'we live and move and have our being"' (Acts 17:28).[121] Here—on the limits themselves of the right of the subject to dispose of his own life—"arises the moral limit of the action of the doctor who acts with the consent of the patient."[122] 48. Secondly, the health care worker effectively guarantees this right: "the intrinsic finality" of his profession "is the affirmation of the right of the human being to his life and his dignity."[123] He fulfills it by assuming the corresponding duty of preventive and therapeutic care of the health,[124] and of the improvement, within the ambit and with the means at his disposal, of the quality of life of the persons and their life environment.[125] "On our journey we are guided and sustained by the law of love: a love which has as its source and model the Son of God made man, who 'by dying gave life to the world."[126] 49. The fundamental and primary right of every human being to life, which is particularized as the right to protection of health, subordinates the trade union rights of health care workers. This means that any just claims of health workers must be processed while safeguarding the right of the patient to due care, because of its indispensability. Hence, if there is a strike, essential and urgent medical-hospital services for the safeguarding of health should be provided for—even by means of appropriate legal measures. 50. Safeguarding health commits the health care worker particularly in the area of prevention. Prevention is better than cure, both because it spares the person the discomfort and suffering from the illness, and because it spares society the costs, and not only economic costs, of treatment. 51. Medical prevention, properly so called, which consists in administering particular medicines, vaccination, screening tests to ascertain predispositions, in prescribing behavior and habits to prevent the occurrence, the spread and the worsening of the illness, essentially belongs to health care workers. This might be for all the members of a society, for groups of people or for individuals. 52. There is also medical prevention in the wider sense of the term, in which the work of the health care worker is but a part of the preventive commitment set in motion by society. This is the type of prevention used in cases of so-called social illnesses, such as drug-dependency, alcoholism, tobacco addiction, AIDS; of the problems of social sectors of individuals such as adolescents, the handicapped, the aged; of risks to health tied up with the conditions and ways of living nowadays, such as in food, the environment, the work-place, sports, urban traffic, the use of transportation means, of machines and domestic electrical appliances. In these cases preventive intervention is the primary and most effective remedy, if not, indeed, the only possible one. But it needs a concerted effort from all sectors of a society. Prevention in this case is more than a medical-health action. It involves a sensitizing of the culture, through a recovery of forgotten values and education in them, to a more sober and integral concept of life, information about risky habits, the formation of a political consensus for supporting laws. The effective and efficacious possibility of prevention is linked not only, nor primarily, to the techniques adopted, but to the reasons behind it and to their being made concrete and made known in that culture. 53. Although it shares in the transcendent value of the person, corporeal life, of its nature, reflects the precariousness of the human condition. This is shown especially in sickness and suffering, which affect the whole person adversely. "Sickness and suffering are not experiences which affect only the physical substance of the human being, but they affect him in his entirety and in his somatic-spiritual unity."[127] Sickness is more than a clinical fact, medically controlled. It is always the condition of a human being, the sick person. It is with this holistic human view of sickness that health care workers should relate to the patient. It means that they have, together with the requisite technical-professional competence, an awareness of values and meanings that make sense of sickness and of their own work, and makes every individual clinical case a human encounter. 54. The Christian knows by faith that sickness and suffering share in the salvific efficacy of the Redeemer's cross. "Christ's redemption and its salvific grace touches the whole person in his human condition and hence also in sickness, suffering and death."[128] "On the Cross, the miracle of the serpent lifted up by Moses in the desert (Jn 3:14-15; cf. Num. 21:8-9) is renewed and brought to full and definitive perfection. Today, too, by looking upon the one who was pierced, every person whose life is threatened encounters the sure hope of finding freedom and redemption."[129] Borne "in close union with the sufferings of Jesus," sickness and suffering assume "an extraordinary spiritual fruitfulness." So that the sick person can say with the Apostle: "I fill up in my body what is wanting to the sufferings of Christ, for the sake of his body which is the Church" (Col 1:24).[130] From this new Christian meaning, the sick person can be helped to develop a triple salutary attitude to the illness: an "awareness" of its reality "without minimizing it or exaggerating it"; "acceptance," "not with a more or less blind resignation" but in the serene knowledge that "the Lord can and wishes to draw good from evil"; "the oblation," "made out of love for the Lord and one's brothers and sisters."[131] 55. In the person of the patient, in any case, the family is always affected. Helping the relatives, and their cooperation with health care workers are a valuable component of health care. The health care worker is called to give the family of the patient—either individually or through membership in appropriate organizations—together with the treatment also enlightenment, counsel, direction and support.[132] 56. Guided by this integrally human and properly Christian view of sickness, the health care worker should seek, first and foremost, to find the illness and analyze it in the patient: this is the diagnosis and related prognosis. A condition for any treatment is the previous and exact individuation of the symptoms and causes of the illness. 57. In this, the health care worker will make his own the questions and anxieties of the patient and he must guard himself from the twofold, opposing pitfalls of "hopeless" and "tenacious" diagnosis. In the first case the patient is forced to go from one specialist or health care service to another, without finding the doctor or diagnostic center capable and willing to treat his illness. Over-specialization and fragmentation of clinical competencies and divisions, while ensuring professional expertise, is damaging to the patient when health services in the place prevent a caring and global approach to his illness. In the second case, instead, one persists until some illness is found at any cost. It may be through ignorance, laziness, for gain, or for rivalry that an illness is diagnosed or problems are treated as medical when, in fact, they are not medical-health in nature. In this case the person is not helped to perceive the exact nature of their problem, thus misleading them about themselves and their responsibilities. 58. The diagnosis does not pose, in general, problems of an ethical order when these excesses are excluded and it is conducted in full respect for the dignity and integrity of the person, particularly with regard to the use of instrumentally invasive techniques. Of itself, its purpose is therapeutic: it is an action to promote health. However, particular problems are posed by predictive diagnosis, because of the possible repercussions at a psychological level and the discriminations it could lead to and to prenatal diagnosis. In the latter case we are dealing with a substantially new possibility which is rapidly developing, and as such merits separate treatment. 59. The ever-expanding knowledge of intrauterine life and the development of instruments giving access to it make it possible nowadays to diagnose prenatal life, thus opening the way for ever more timely and effective therapeutic interventions. Prenatal diagnosis reflects the moral goodness of every diagnostic intervention. At the same time, however, it presents its own ethical problems, connected with the diagnostic risk and the purpose for its request and practice. 60. The risk factor concerns the life and physical integrity of the embryo, and only in part that of the mother, relative to the various diagnostic techniques and the perceptual risk which each presents. Hence, there is need "to evaluate carefully the possible negative consequences which the necessary use of a particular investigative technique can have" and "avoid recourse to diagnostic procedures about which the honest purpose and substantial harmlessness cannot be sufficiently guaranteed." And if a certain amount of risk must be taken, recourse to diagnosis should have reasonable indications, to be ascertained in a diagnostic center.[133] Consequently, "such diagnosis is licit if the methods used, with the consent of the parents who have been adequately instructed, safeguard the life and integrity of the embryo and its mother and does not subject them to disproportionate risks."[134] 61. The objectives of prenatal diagnoses warranting their request and practice should always be of benefit to the child and the mother; their purpose is to make possible therapeutic interventions, to bring assurance and peace to pregnant women who are anxious lest the fetus be deformed and are tempted to have an abortion, to prepare, if the prognosis is an unhappy one, for the welcome of a handicapped child. Prenatal diagnosis "is gravely contrary to the moral law when it contemplates the possibility, depending on the result, of provoking an abortion. A diagnosis revealing the existence of a deformity or an hereditary disease should not be equivalent to a death sentence."[135] Equally unlawful is any directive or program of civil and health authorities or of scientific organizations which support a direct connection between prenatal diagnosis and abortion. The specialist who, in carrying out the diagnosis and communicating the result, would voluntarily contribute to the establishing and support of a connection between prenatal diagnosis and abortion would be guilty of illicit collaboration.[136] 62. After diagnosis comes therapy and rehabilitation: the putting into effect of those curative and medical interventions which lead to the cure and personal and social reintegration of the patient. Therapy is a medical action properly so-called, aimed at combating the causes, manifestations and complications of the illness. Rehabilitation, on the other hand, is an amalgam of medical, physiotherapeutic, psychological measures and functional exercises, aimed at reviving or improving the psychophysical efficiency of people in some way handicapped in their ability to integrate, to relate and to work productively. Therapy and rehabilitation "are aimed not only at the well-being and health of the body, but of the person as such who is stricken by bodily illness."[137] All therapy aimed at the integral well-being of the person is not content with clinical success, but views the rehabilitative action as a restoring of the individual to his full self, through the reactivation or re-appropriation of physical functions weakened by the illness. 63. The patient has a right to any treatment from which he can draw salutary benefit.[138] Responsibility for health care imposes on everyone "the duty of caring for himself and of seeking treatment." Consequently, "those who care for the sick should be very diligent in their work and administer the remedies which they think are necessary or useful."[139] Not only those aimed at a possible cure, but also those which alleviate pain and bring relief in incurable cases. 64. The health care worker who cannot effect a cure must never cease to treat.[140] He is bound to apply all "proportionate" remedies. But there is no obligation to apply "disproportionate" ones. In relation to the conditions of a patient, those remedies must be considered ordinary where there is due proportion between the means used and the end intended. Where this proportion does not exist, the remedies are to be considered extraordinary. To verify and establish whether there is due proportion in a particular case, "the means should be well evaluated by comparing the type of therapy, the degree of difficulty and risk involved, the necessary expenses and the possibility of application, with the result that can be expected, taking into account the conditions of the patient and his physical and moral powers."[141] 65. The principle here proposed of appropriate medical treatment in the remedies can be thus specified and applied: —"In the absence of other remedies, it is lawful to have recourse, with the consent of the patient, to the means made available by the most advanced medicine, even if they are still at an experimental stage and not without some element of risk." —"It is lawful to interrupt the application of such means when the results disappoint the hopes placed in them," because there is no longer due proportion between "the investment of instruments and personnel" and "the foreseeable results" or because "the techniques used subject the patient to suffering and discomfort greater than the benefits to be had." —"It is always lawful to be satisfied with the normal means offered by medicine. No one can be obliged, therefore, to have recourse to a type of remedy which, although already in use, is still not without dangers or is too onerous." This refusal "is not the equivalent of suicide." Rather it might signify "either simple acceptance of the human condition, or the wish to avoid the putting into effect of a remedy disproportionate to the results that can be hoped for, or the desire not to place too great a burden on the family or on society."[142] 66. For the restoration of the person to health, interventions may be required, in the absence of other remedies, which involve the modification, mutilation or removal of organs. Therapeutic manipulation of the organism is legitimized here by the principle of totality,[143] and for this very reason also called the principle of therapeuticity, by virtue of which "each particular organ is subordinated to the whole of the body and should be subjected to it in case of conflict. Consequently, the one who has received the use of the whole organism has the right to sacrifice a particular organ if by keeping it, it or its activity might cause appreciable harm to the whole organism, which cannot be avoided otherwise."[144] 67. Physical life, although on the one hand manifesting the person and sharing his worth, so that it cannot be disposed of as an object, on the other hand it does not exhaust the value of the person nor does it represent the greatest good.[145] This is why part of it can be disposed of legitimately for the well-being of the person. Just as it can be sacrificed or put at risk for a higher good "such as the glory of God, the salvation of souls and service to one's neighbor."[146] "Corporeal life is a fundamental good, a condition here below of all the others; but there are higher values for which it could be legitimate or even necessary to expose oneself to the danger of losing it."[147]
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