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 I.-Ministers of Life
Value of life:
Indisposability
Organ Donation
Pastoral
Care
Painkillers
Telling the |
68. Pain, on the one hand, has of itself a therapeutic function, because "it eases the confluence of the physical and psychic reaction of the person to a bout of illness,"[148] and on the other hand it appeals to medicine for an alleviating and healing therapy. 69. For the Christian, pain has a lofty penitential and salvific meaning. "It is, in fact, a sharing in Christ's Passion and a union with the redeeming sacrifice which he offered in obedience to the Father's will. Therefore, one must not be surprised if some Christians prefer to moderate their use of painkillers, in order to accept voluntarily at least part of their sufferings and thus associate themselves in a conscious way with the sufferings of Christ."[149] Acceptance of pain, motivated and supported by Christian ideals, must not lead to the conclusion that all suffering and all pain must be accepted, and that there should be no effort to alleviate them.[150] On the contrary this is a way of humanizing pain. Christian charity itself requires of health care workers the alleviation of physical suffering. 70. "In the long run pain is an obstacle to the attainment of higher goods and interests."[151] It can produce harmful effects for the psycho-physical integrity of the person. When suffering is too intense, it can diminish or impede the control of the spirit. Therefore it is legitimate, and beyond certain limits of endurance it is also a duty for the health care worker to prevent, alleviate and eliminate pain. It is morally correct and right that the researcher should try "to bring pain under human control."[152] Anesthetics like painkillers, "by directly acting on the more aggressive and disturbing effects of pain, gives the person more control, so that suffering becomes a more human experience."[153] 71. Sometimes the use of analgesic and anaesthesic techniques and medicines involves the suppression or diminution of consciousness and the use of the higher faculties. In so far as the procedures do not aim directly at the loss of consciousness and freedom but at dulling sensitivity to pain, and are limited to the clinical need alone, they are to be considered ethically legitimate.[154] The informed consent of the patient 72. To intervene medically, the health care worker should have the express or tacit consent of the patient. In fact, he "does not have a separate and independent right in relation to the patient. In general, he can act only if the patient explicitly or implicitly (directly or indirectly) authorizes him."[155] Without such authorization he gives himself an arbitrary power.[156] Besides the medical relationship there is a human one: dialogic, non-objective. The patient "is not an anonymous individual" on whom medical expertise is practiced, but "a responsible person, who should be called upon to share in the improvement of his health and in becoming cured. He should be given the opportunity of personally choosing, and not be made to submit to the decisions and choices of others."[157] So that the choice may be made with full awareness and freedom, the patient should be given a precise idea of his illness and the therapeutic possibilities, with the risks, the problems and the consequences that they entail.[158] This means that the patient should be asked for an informed consent. 73. With regard to presumed consent, a distinction must be made between the patient who is in a condition to know and will and one who is not. In the former, consent cannot be presumed: it must be clear and explicit. In the latter case, however, the health care worker can, and in extreme situations must, presume the consent to therapeutic interventions, which from his knowledge and in conscience he thinks should be made. If there is a temporary loss of knowing and willing, the health care worker can act in virtue of the principle of therapeutic trust, that is the original confidence with which the patient entrusted himself to the health care worker. Should there be a permanent loss of knowing and willing, the health care worker can act in virtue of the principle of responsibility for health care, which obliges the health care worker to assume responsibility for the patient's health. 74. With regard to the relatives, they should be informed about ordinary interventions, and involved in the decision making when there is question of extraordinary and optional interventions. 75. A therapeutic action which is apt to be increasingly beneficial to health is for that very reason open to new investigative possibilities. These are the result of a progressive and ongoing activity of research and experimentation, which thus succeeds in arriving at new medical advances. To proceed by way of research and experimentation is a law of every applied science: scientific progress is structurally connected with it. Biomedical sciences and their development are subject to this law also. But they operate in a particular field of application and observation which is the life of the human person. The latter, because of his unique dignity, can be the subject of research and clinical experimentation with the safeguards due to a being with the value of a subject and not an object. For this reason, biomedical sciences do not have the same freedom of investigation as those sciences which deal with things. "The ethical norm, founded on respect for the dignity of the person, should illuminate and discipline both the research stage and the application of the results obtained from it."[159] 76. In the research stage, the ethical norm requires that its aim be to "promote human well-being."[160] Any research contrary to the true good of the person is immoral. To invest energies and resources in it contradicts the human finality of science and its progress.[161] In the experimental stage, that is, testing the findings of research on a person, the good of the person, protected by the ethical norm, demands respect for previous conditions which are essentially linked with consent and risk. 77. First of all, the consent of the patient. He "should be informed about the experimentation, its purpose and possible risks, so that he can give or refuse his consent with full knowledge and freedom. In fact, the doctor has only that power and those rights which the patient himself gives him."[162] This consent can be presumed when it is of benefit to the patient himself, that is, when there is a question of therapeutic experimentation. 78. Secondly, there is the risk factor. Of its nature, every experimentation has risks. Hence, "it cannot be demanded that all danger and all risk be excluded. This is beyond human possibility; it would paralyze all serious scientific research and would quite often be detrimental to the patient.... But there is a level of danger that the moral law cannot allow."[163] A human subject cannot be exposed to the same risk as beings which are not human. There is a threshold beyond which the risk becomes humanly unacceptable. This threshold is indicated by the inviolable good of the person, which forbids him "to endanger his life, his equilibrium. his health, or to aggravate his illness."[164] 79. Experimentation cannot be begun and generalized until every safeguard has been put in place to guarantee the harmlessness of the intervention and to lessen the risk. "The pre-clinical basic phase, carried out carefully, should give the widest documentation and the most secure pharmacological-toxicological guarantees and ensure operational safety."[165] To acquire these assurances, if it be useful and necessary, the testing of new pharmaceutical products or of new techniques should first be done on animals before they are tried on humans. "It is certain that the animal is for the service of man and can therefore be the object of experimentation. However, it should be treated as one of God's creatures, meant to cooperate in man's good but not to be abused."[166] It follows that all experimentation "should be carried out with consideration for the animal, without causing it useless suffering."[167] When these guarantees are in place, in the clinical phase experimentation on the human person must be in accord with the principle of proportionate risk, that is, of due proportion between the advantages and foreseeable risks. Here a distinction must be made between experimentation on a sick person, for therapeutic reasons, and on a healthy person, for scientific and humanitarian reasons. 80. In experimentation on a sick person, due proportion is attained from a comparison of the condition of the sick person and the foreseeable effects of the drugs or the experimental methods. Hence the risk rate which might be proportionate and legitimate for one patient may not be so for another. It is a valid principle—as already said—that "in the absence of other remedies, it is licit to have recourse, with the consent of the patient, to means made available by the most advanced medicine, even if they are still at an experimental stage and are not without some risk. By accepting them the patient might also give an example of generosity for the benefit of humanity."[168] But there must always be "great respect for the patient in the application of new therapy still at the experimental stage...when these are still high-risk procedures."[169] "In desperate cases, when the patient will die if there is no intervention, if there is a medication available, or a method or an operation which, though not excluding all danger, still has some possibility of success, any right-thinking person would concede that the doctor could certainly, with the explicit or tacit consent of the patient, proceed with the application of the treatment."[170] 81. Clinical experimentation can also be practiced on a healthy person, who voluntarily offers himself "to contribute by his initiative to the progress of medicine and, in that way, to the good of the community." In this case, "once his own substantial integrity is safeguarded, the patient can legitimately accept a certain degree of risk."[171] This is legitimized by the human and Christian solidarity which motivates the gesture: "To give of oneself, within the limits marked out by the moral law, can be a witness of highly meritorious charity and a means of such significant spiritual growth that it can compensate for the risk of any insubstantial physical impairment."[172] In any case, it is a duty to always interrupt the experimentation when the results disappoint the expectations. 82. Since the human individual, in the prenatal stage, must be given the dignity of a human person, research and experimentation on human embryos and fetuses is subject to the ethical norms valid for the child already born and for every human subject. Research in particular, that is the observation of a given phenomenon during pregnancy, can be allowed only when "there is moral certainty that there will be no harm either to the life or the integrity of the expected child and the mother, and on condition that the parents have given their consent."[173] Experimentation, on the other hand, is possible only for clearly therapeutic purposes, when no other possible remedy is available. "No finality, even if in itself noble, such as the foreseeing of a usefulness for science, for other human beings or for society, can in any way justify experimentation on live human embryos and fetuses, whether viable or not, in the maternal womb or outside of it. The informed consent, normally required for clinical experimentation on an adult, cannot be given by the parents, who may not dispose either of the physical integrity or the life of the expected child. On the other hand, experimentation on embryos or fetuses has the risk, indeed in most cases the certain foreknowledge, of damaging their physical integrity or even causing their death. To use a human embryo or the fetus as an object or instrument of experimentation is a crime against their dignity as human beings." "The practice of keeping human embryos alive, actually or in vitro, for experimental or commercial reasons," is especially and "altogether contrary to human dignity."[174] Donation and transplanting of organs 83. The progress and spread of transplant medicine and surgery nowadays makes possible treatment and cure for many illnesses which, up to a short time ago, could only lead to death or, at best, a painful and limited existence.[175] This "service to life,"[176] which the donation and transplant of organs represents, shows its moral value and legitimizes medical practice. There are, however, some conditions which must be observed, particularly those regarding donors and the organs donated and implanted. Every organ or human tissue transplant requires an explant which in some way impairs the corporeal integrity of the donor. 84. Autoplastic transplants, in which there is the explant and implant on the same person, are legitimate in virtue of the principle of totality by which it is possible to dispose of a part for the integral good of the organism. 85. Homoplastic transplants, in which the transplant is taken from a person of the same species as the recipient, are legitimized by the principle of solidarity which joins human beings, and by charity which prompts one to give to suffering brothers and sisters.[177] "With the advent of organ transplants, begun with blood transfusions, human persons have found a way to give part of themselves, of their blood and of their bodies, so that others may continue to live. Thanks to science and to professional training and the dedication of doctors and health care workers...new and wonderful challenges are emerging. We are challenged to love our neighbor in new ways; in evangelical terms—to love 'even unto the end' (Jn 13:1), even if within certain limits which cannot be transgressed, limits placed by human nature itself."[178] In homoplastic transplants, organs may be taken either from a living donor or from a corpse. 86. In the first case the removal is legitimate provided it is a question of organs of which the explant would not constitute a serious and irreparable impairment for the donor. "One can donate only what he can deprive himself of without serious danger to his life or personal identity, and for a just and proportionate reason."[179] 87. In the second case we are no longer concerned with a living person but a corpse. This must always be respected as a human corpse, but it no longer has the dignity of a subject and the end value of a living person. "A corpse is no longer, in the proper sense of the term, a subject of rights, because it is deprived of personality, which alone can be the subject of rights." Hence, "to put it to useful purposes, morally blameless and even noble" is a decision "not be condemned but to be positively justified."[180] There must be certainty, however, that it is a corpse, to ensure that the removal of organs does not cause or even hasten death. The removal of organs from a corpse is legitimate when the certain death of the donor has been ascertained. Hence the duty of "taking steps to ensure that a corpse is not considered and treated as such before death has been duly verified."[181] In order that a person be considered a corpse, it is enough that cerebral death of the donor be ascertained, which consists in the "irreversible cessation of all cerebral activity." When total cerebral death is verified with certainty, that is, after the required tests, it is licit to remove organs and also to surrogate organic functions artificially in order to keep the organs alive with a view to a transplant.[182] 88. Ethically, not all organs can be donated. The brain and the gonads may not be transplanted because they ensure the personal and procreative identity respectively. These are organs which embody the characteristic uniqueness of the person, which medicine is bound to protect. 89. There are also heterogeneous transplants, that is, with organs of a different species than that of the recipient. "It cannot be said that every transplant of tissues (biologically possible) between two individuals of different species is morally reprehensible, but it is even less true that every heterogeneous transplant biologically possible is not forbidden and cannot raise objections. A distinction must be made between cases, depending on which tissue or organ is intended for transplant. The transplant of animal sexual glands to humans must be rejected as immoral; but the transplant of the cornea of a non-human organism to a human organism would not create any problem if it were biologically possible and advisable."[183] Among heterogeneous transplants are also included the implanting of artificial organs, the lawfulness of which is conditioned by the beneficial effect for the person and respect for his dignity. 90. The medical intervention in transplants "is inseparable from a human act of donation."[184] In life or in death the person from whom the removal is made should be aware that he is a donor, that is, one who freely consents to the removal. Transplants presuppose a free and conscious previous decision on the part of the donor or of someone who legitimately represents him, normally the closest relatives. "It is a decision to offer, without recompense, part of someone's body for the health and well-being of another person. In this sense, the medical act of transplanting makes possible the act of donation of the donor, that sincere gift of himself which expresses our essential call to love and communion."[185] The possibility, thanks to biomedical progress, of "projecting beyond death their vocation to love" should persuade persons "to offer during life a part of their body, an offer which will become effective only after death." This is "a great act of love, that love which gives life to others."[186] 91. As part of this oblative "economy" of love, the medical act itself of transplanting, of even just blood transfusion, "is not just another intervention." It "cannot be separated from the donor's act of giving, from life-giving love."[187] Here the health care worker "becomes a mediator of something which is particularly meaningful, the gift of self by a person—even after death—so that another might live."[188] 92. Dependency, in medical-health terms, is an addiction to a substance or product—such as drugs, alcohol, narcotics, tobacco—for which the individual feels an uncontrollable need, and the privation of which can cause him psycho-physical disorders. The phenomenon of dependency is escalating in our societies, which is disturbing and, under certain aspects, dramatic. This is related, on the one hand, to the crisis of values and meaning which contemporary society and culture[189] is experiencing and, on the other hand, to the stress and frustrations brought about by the quest for efficiency, by activism and by the high competitiveness and anonymity of social interaction. Doubtless, the evils caused by dependency and their cure are not a matter for medicine alone. But it does have a preventive and therapeutic role. 93. Drugs and drug-dependency are almost always the result of an avoidable evasion of responsibility, an aprioristic contestation of the social structure which is rejected without positive proposals for its reasonable reform, an expression of masochism motivated by the absence of values. One who takes drugs does not understand or has lost the meaning and the value of life, thus putting it at risk until it is lost: many deaths from overdose are voluntary suicides. The drug-user acquires a nihilistic mental state, superficially preferring the void of death to the all of life. 94. From the moral viewpoint "using drugs is always illicit, because it implies an unjustified and irrational refusal to think, will and act as free persons."[190] To say that drugs are illicit is not to condemn the drug-user. That person experiences his condition as "a heavy slavery" from which he needs to be freed.[191] The way to recovery cannot be that of ethical culpability or repressive law, but it must be by way of rehabilitation which, without condoning the possible fault of the person on drugs, promotes liberation from his condition and reintegration. 95. The detoxification of the person addicted to drugs is more than medical treatment. Moreover, medicines are of little or no use. Detoxification is an integrally human process meant to "give a complete and definitive meaning to life,"[192] and thus to restore to the one addicted that "self confidence and salutary self-esteem" which help him to recover the joy of living.[193] In the rehabilitation of a person addicted to drugs it is important "that there be an attempt to get to know the individual and to understand his inner world; to bring him to the discovery or rediscovery of his dignity as a person, to help him to reawaken and develop, as an active subject, those personal resources, which the use of drugs has suppressed, through a confident reactivation of the mechanisms of the will, directed to secure and noble ideals."[194] 96. Using drugs is anti-life. "One cannot speak of 'the freedom to take drugs' nor of 'the right to drugs,' because a human being does not have the right to harm himself and he cannot and must not ever abdicate his personal dignity which is given to him by God,"[195] and even less does he have the right to make others pay for his choice. 97. Unlike taking drugs, alcohol is not in itself illicit: "its moderate use as a drink is not contrary to moral law."[196] Within reasonable limits wine is a nourishment. "It is only the abuse that is reprehensible":[197] alcoholism, which causes dependency, clouds the conscience and, in the chronic stage, produces serious harm to the body and the mind. 98. The alcoholic is a sick person who needs medical assistance together with help on the level of solidarity and psychotherapy. A program of integrally human rehabilitation must be put in place for him,[198] 99. With regard to tobacco also, the ethical unlawfulness is not in its use but in its abuse. At the present time it is established that excessive smoking damages the health and causes dependency. This leads to a progressive lowering of the threshold of abuse. Smoking poses the problem of dissuasion and prevention, which should be done especially through health education and information, even by way of advertisements. 100. Psycho-pharmaceuticals are a special category of medicines used to counter agitation, delirium and hallucinations and to overcome anxiety and depression.[199] 101. To prevent, contain and overcome the risk of dependency and addiction, psycho-pharmaceuticals should be subject to medical control. "Recourse to tranquilizing substances on medical advice in order to alleviate—in well-defined cases—physical and psychological suffering should be governed by very prudent criteria in order to offset dangerous forms of addiction and dependency."[200] It is the task of health authorities, doctors and those responsible for research centers to apply themselves in order to reduce these risks to a minimum through apt measures of prevention and information."[201] 102. Administered for therapeutic purposes and with due respect for the person, psycho-pharmaceuticals are ethically legitimate. The general conditions for lawfulness in remedial intervention applies to these also. In particular, the informed consent of the patient is required and his right to refuse the therapy must be respected, taking into account the ability of the mental patient to make decisions. Also to be respected is the principle of therapeutic proportionality in the choice and administration of these medicines, on the basis of an accurate etiology of the symptoms and the motives for the subject's requesting this medicine.[202] 103. Non-therapeutic use and abuse of psycho-pharmaceuticals is morally illicit if the purpose is to improve normal performance or to procure an artificial and euphoric serenity. This use of psycho-pharmaceuticals is the same as that of any narcotic substance so the ethical verdict already given in the case of drugs is valid also here. 104. There is already ample evidence that all bodily illness has a psychological component, either as a co-efficient or as an after-effect. This is what psychosomatic medicine is concerned with, where the therapeutic value depends on the doctor-patient relationship.[203] Health care workers should seek to relate to the patient in such a way that their humanitarian attitude reinforces their professionalism and their competence is more effective through their ability to understand the patient. A human and loving approach to the patient, required by an integrally human view of illness and strengthened by faith,[204] is the key to this therapeutic effectiveness of the doctor-patient relationship. 105. Psychological disorders and illnesses can be dealt with and treated through psychotherapy. This includes a variety of methods by which someone can help another to be cured or at least to improve. Psychotherapy is essentially a growing process, that is, a path of liberation from childhood problems, or from the past, in any case, which enables the individual to assume his identity, role and responsibilities. 106. Psychotherapy is morally acceptable as a medical treatment.[205] But it must respect the person of the patient, who allows access into his inner world. This respect prohibits the psychotherapist from violating the privacy of the other without his consent and obliges him to work within these limits. "Just as it is unlawful to appropriate the goods of another or invade his corporal integrity without his permission, so it is not permissible to enter the inner world of another person against his wishes, whatever be the techniques and methods employed."[206] The same respect prohibits the influencing or forcing of the patient's will. "The psychologist whose only desire is the good of the patient, will be all the more careful to respect the limits to his action set down by the moral code in that—in a manner of speaking—he holds in his hands the psychological faculties of a person, his ability to act freely, to achieve the noblest ideals which his personal destiny and his social calling imply."[207] 107. From the moral standpoint, logotherapy and counseling are privileged forms of psychotherapy. But they are all acceptable, provided that they are practiced by psychotherapists who are guided by a profound ethical sense. Pastoral care and the Sacrament of Anointing of the Sick 108. Pastoral care of the sick consists in spiritual and religious assistance. This is a fundamental right of the patient and a duty of the Church (cf. Mt 10:8; Lk 9:2, 10:9). Not to assure it, not to support it, to make it discretionary or to impede it is a violation of this right and infidelity to this duty. This is the essential and specific, though not exclusive, task of the health care pastoral worker. Because of the necessary interaction between the physical, psychological and spiritual dimension of the person, and the duty of giving witness to their own faith, all health care workers are bound to create the conditions by which religious assistance is assured to anyone who asks for it, either expressly or implicitly.[208] "In Jesus, the 'Word of life,' God's eternal life is thus proclaimed and given. Thanks to this proclamation and gift, our physical and spiritual life, also in its earthly phase, acquires its full value and meaning, for God's eternal life is in fact the end to which our living in this world is directed and called."[209] 109. Religious assistance implies that there be, within the health care structure, the possibility and the means to carry this out. The health care worker should be totally available to support and accede to the patient's request for religious assistance. Where such assistance, for general or particular reasons, cannot be given by the pastoral worker, it should be given directly—within possible and allowable limits—by the health care worker, respecting the freedom and the religious affiliation of the patient and aware that, in doing so, he does not detract from the rights of health care assistance properly so called. 110. Religious assistance to the sick is part of the wider vision of medical-pastoral assistance, that is, of the presence and activity of the Church which is meant to bring the word and the grace of the Lord to those who suffer and to those who care for them. In the ministry of those—priests, religious and laity—who individually or as communities are engaged in the pastoral care of the sick, the mercy of God lives on, who in Christ has bound to human suffering, and the task of evangelization, sanctification and charity entrusted to the Church by the Lord is carried out in a singular and privileged manner.[210] This means that pastoral care of the sick has a special place in catechesis, in the liturgy and in charity. Respectively, it is a matter of evangelizing illness, helping a person to uncover the redemptive meaning of suffering borne in communion with Christ; of celebrating the sacraments as efficacious signs of the recreative and vitalizing grace of God; of witnessing by means of the "diakonia" (service) and the "koinonia" (communion) to the therapeutic power of charity. 111. In pastoral care of the sick, the love—full of truth and of grace of God comes near to them in a special sacrament meant for them: the Anointing of the Sick.[211] Administered to any Christian who is in a life-threatening condition, this sacrament is a remedy for body and spirit, relief and strength for the patient in his corporeal-spiritual integrity casting light on the mystery of suffering and death and bringing a hope which opens the human present to the future of God. "The whole person receives help from it for his salvation; he feels strengthened in his trust in God and he receives reinforcement against the temptations of the devil and the fear of death."[212] Since it has the efficacy of grace for the sick person, the Anointing of the Sick "is not the sacrament of those only who are at the point of death." Hence "the suitable time to receive it is when one of the faithful, either from illness or old-age, begins to be in danger of death."[213] As with all the sacraments, the Anointing of the Sick should also be preceded by a suitable catechesis so that the recipient, the sick person, is a conscious and responsible subject of the grace of the sacrament, and not an unconscious object of the rite of imminent death.[214] 112. The proper minister of the Anointing of the Sick is the priest only, and he should see that it is conferred "on those of the faithful whose state of health is seriously threatened by old-age or illness." To evaluate the seriousness of the illness it is sufficient "to have a prudent or probable judgment." Celebrating communal Anointing might help to overcome negative prejudices against the Anointing of the Sick, and help to value the meaning of this sacrament and the sense of ecclesial solidarity. Anointing can be repeated if the sick person, having recovered from the illness for which the sacrament was received, should again become ill, or if in the course of the same illness his Condition should worsen. It can be given before surgery if the reason for surgery is "a dangerous illness." Anointing may be conferred on the elderly "because of the notable diminishing of their strength, even if they do not have any serious illness." If the conditions are present, it can also be conferred on children, "provided they have sufficient use of reason." In the case of sick people who are unconscious or deprived of the use of reason, it is to be Conferred "if there is reason to believe that in possession of their faculties they themselves, as believers, would have, at least implicitly, requested holy Anointing." "The sacrament cannot be conferred on a patient who is already dead."[215] "When there is a doubt whether the sick person has attained the use of reason, or whether the person is gravely ill or whether the person is dead, this sacrament is to be conferred."[216] 113. The Eucharist, also, as Viaticum, has a special significance and efficacy for the patient. "Viaticum of the body and blood of Christ strengthens the believer and furnishes him with the pledge of resurrection, as the Lord has said: The one who eats my flesh and drinks my blood has eternal life, and I will raise him up on the last day" (Jn 6:54).[217] For the sick person, the Eucharist is this viaticum of life and hope. "Communion in the form of Viaticum is, in fact, a special sign of participation in the mystery celebrated in the sacrifice of the Mass, the mystery of the death of the Lord and of his passing to the Father."[218] Therefore it is the duty of a Christian to request and receive Viaticum, and the Church has a pastoral responsibility to administer it.[219] The minister of Viaticum is a priest. But he may be substituted by a deacon or an extraordinary minister of the Eucharist.[220]
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