Preface

After long, careful and multi-discipline preparation, the <Charter for Health Care Workers> is now being published at the initiative of the Pontifical Council for Pastoral Assistance to Health Care Workers.

Nothing happens by chance in human affairs, and even chronological coincidence can have symbolic meanings. In fact, the awaited document is being published a few months after the institution (February 11, 1994), by the Holy Father, John Paul II, of the Pontifical Academy for Life, which ideally, operatively and in its statutary finality is closely associated with the tasks of the Office for Pastoral Assistance to Health Care Workers.

And this Office cannot but feel flattered that the Congregation for the Doctrine of the Faith approved and quickly confirmed in its entirety the text of the Charter submitted to it: another reason for its full validity and secure authority, but also a concrete proof of the inter-dicastery cooperation expressly desired in the motu proprio which set up the Pontifical Council for Pastoral Assistance to Health Care Workers.

There are many reasons for recommending a knowledge, the divulgation and the application of the directives contained in this deontological code for those engaged in health care. Its publication fills a lacuna which was strongly felt not only in the Church but also by all those who empathize with the primary task it fulfills of promoting and defending life.

The extraordinary advances of science and technology in the very vast field of health and medicine have produced an independent discipline called bioethics, or ethics of life. This explains why, especially from Pius XII onwards, the magisterium of the Church has intervened with increasing interest, with consistent firmness and ever more explicit directives concerning all the complex problems arising from the indissoluble bond between medicine and morality. None of these problems can be considered neutral at this time in relation to Hippocratic ethics and Christian morality. Hence the requirement, strictly respected in the Charter for Health Care Workers, for an organic and exhaustive synthesis of the Church's position on all that pertains to the affirmation, in the field of health care, of the primary and absolute value of life: of all life and the life of every human being.

Therefore, after an introduction on the figure and essential tasks of health care workers, or better, of the "ministers of life," the Charter gathers its directives around the triple theme of procreation, life and death. And so that?as often happens?doubtful interpretations may not prevail over the objective worth of the contents, in the redaction of the document the interventions of the Supreme Pontiffs and authoritative texts issued by the Offices of the Roman Curia have almost always been quoted directly. These interventions show conclusively that the position of the Church on the fundamental problems of bioethics, while safeguarding the sacred limits imposed by the promotion and defense of life, is highly constructive and open to true progress in science and technology, when this progress is welded to that of civilization.

At the beginning of the Charter the activity of the health care worker is said to be "a form of Christian witness."

Humbly, but also proudly, we can say that this Charter for Health Care Workers is part of the "new evangelization" which, in service to life, especially for those who suffer, has, in imitation of Christ's ministry, its qualifying moment.

The hope then is that this work-tool may become an integral part of the initial and ongoing formation of health care workers, so that their witness may be proof that the Church, in its defense of life, opens its heart and its arms to all people since Christ's message is addressed to all people.

Card. Fiorenzo Angelini President of the Pontifical Council for Pastoral Assistance to Health Care Workers

 

Introduction

 

I. Ministers Of Life

 

1. The work of health care persons is a very valuable <service to life>. It expresses a profoundly human and Christian commitment, undertaken and carried out not only as a technical activity but also as one of dedication to and love of neighbor. It is "a form of Christian witness."(1)"Their profession calls for them to be guardians and servants of human life" (<Evangelium Vitae> 89).

Life is a primary and fundamental good of the human person. Caring for life, then, expresses, first and foremost, a truly human activity in defense of physical life.

It is to this that professional or voluntary health care workers devote their activity. These are doctors, nurses, hospital chaplains, men and women religious, administrators, voluntary care givers for those who suffer, those involved in the diagnosis, treatment and recovery of human health. The principal and symbolic expression of "taking care" is their <vigilant and caring presence at the sickbed>. It is here that medical and nursing activity expresses its lofty human and Christian value.

 

2. Health care activity is based on an interpersonal relationship of a special kind. It is "a meeting between trust and conscience."(2) The "trust" of one who is ill and suffering and hence in need, who entrusts himself to the "conscience" of another who can help him in his need and who comes to his assistance to care for him and cure him. This is the health care worker.(3)

For him "the sick person is never merely a clinical case"?an anonymous individual on whom to apply the fruit of his knowledge?"but always a 'sick person,' towards whom" he shows a sincere attitude of "sympathy," in the ethymological sense of the term."(4)

This requires love: availability, attention, understanding, sharing, benevolence, patience, dialogue. "Scientific and professional expertise" is not enough; what is required is "personal empathy with the concrete situations of each patient."(5)

 

3. To safeguard, recover and better the state of health means serving life in its totality. In fact, "sickness and suffering are phenomena which, when examined in depth, ask questions which go beyond medicine to the essence of the human condition in this world. It is easy to see, therefore, how important in socio-medical service is the presence...of workers who are guided by an holistic human vision of illness and hence can adopt a wholly human approach to the suffering patient."(6)

In this way, the health care worker, if animated by a truly Christian spirit, will more easily become aware of the demanding missionary dimension of his profession: "his entire humanity comes into play" here "and nothing less than complete commitment is required of him."(7)

To speak of mission is to speak of <vocation>:(8) the response to a transcendent call which takes shape in the suffering and appealing countenance of the patient in his care. To care lovingly for a sick person is to fulfill a divine mission, which alone can motivate and sustain the most disinterested, available and faithful commitment, and gives it a priestly value."(9)"When he presents the heart of his redemptive mission, Jesus says: 'I came that they may have life, and have it abundantly' (Jn 10:10).... It is precisely in this 'life' that all the aspects and stages of human life achieve their full significance" (<Evangelium Vitae> 1).

The health care worker is the <good Samaritan> of the parable, who stops beside the wounded person, becoming his "neighbor in charity (cf. Lk 10:29-37).(10)

 

4. This means that health-care is a ministerial instrument of God's outpouring love for the suffering person; and, at the same time, it is an act of love of God, shown in the loving care for the person. For the Christian, it is an actualized continuation of the healing love of Christ, who "went about doing good and healing everyone" (Acts 10:38).(11) And at the same time it is love for Christ: he is the sick person?"I was sick"?who assumes the face of a suffering brother; since he considers as done to himself?"you did it to me"?the loving care of one's brother (cf. Mt 25: 3140).(12)

Profession, vocation and mission meet and, in the Christian vision of life and health, they are mutually integrated. Seen in this light, health care assumes a new and more exalted meaning as "service to life" and "healing ministry."(13)<Minister of life>,(14) the health care worker is "the minister of that God, who in Scripture is presented as 'a lover of life"' (Wis 11:26).(15) To serve life is to serve God in the person: it is to become "a collaborator with God in restoring health to the sick body"(16) and to give praise and glory to God in the loving welcome to life, especially if it be weak and ill.(17)

 

5. The Church, which considers "service to the sick as an integral part of its mission,"(18) assumes it as an expression of its ministry.(19)"The Church...has always seen medicine as an important support for its own redeeming mission to humanity." In fact, "service to man's spirit cannot be fully effective except it be service to his psycho-physical unity. The Church knows well that physical evil imprisons the spirit, just as spiritual evil subjects the body."(20)

It follows that the <therapeutic ministry> of health care workers is a sharing in the pastoral(21) and evangelizing(22) work of the Church. Service to life becomes a ministry of salvation, that is, a message that activates the redeeming love of Christ. "Doctors, nurses, other health care workers, voluntary assistants, are called to be the living image of Christ and of his Church in loving the sick and the suffering:"(23) witnesses of "the gospel of life."(24)

 

6. Service to life is such only if it is <faithful to the moral law>, which expresses exigently its value and its tasks. Besides technico-professional competence, the health care worker has ethical responsibilities. "The ethical law, founded on respect for the dignity of the person and on the rights of the sick, should illuminate and govern both the research phase and the application of the findings."(25) In fidelity to the moral law, the health care worker actuates his fidelity to the human person whose worth is guaranteed by the law, and to God, whose wisdom is expressed by the law.

He draws his behavioral directives from that field of normative ethics which nowadays is called bioethics. Here, with vigilant and careful attention, the magisterium of the Church has intervened, with reference to questions and disputes arising from the biomedical advances and from the changing cultural <ethos>. This bioethical magisterium is for the health care worker, Catholic or otherwise, a source of principles and norms of conduct which enlighten his conscience and direct him?especially in the complexity of modern bio-technical possibilities?in his choices, always respecting life and its dignity.

 

7. The continuous progress of medicine demands of the health care worker a thorough <preparation and ongoing formation> so as to ensure, also by personal studies, the required competence and fitting professional expertise.

Side-by-side with this, they should be given a solid "ethico-religious formation,"(26) which "promotes in them an appreciation of human and Christian values and refines their moral conscience." There is need "to develop in them an authentic faith and a true sense of morality, in a sincere search for a religious relationship with God, in whom all ideals of goodness and truth are based."(27)

"All health care workers should be taught morality and bioethics."(28) To achieve this. those responsible for their formation should endeavor to have chairs and courses in bioethics put in place.

 

8. Health care workers, especially doctors, cannot be left to their own devices and burdened with unbearable responsibilities when faced with ever more complex and problematic clinical cases arising from biotechnical possibilities?many of which are at an experimental stage?open to modern medicine, and from the socio-medical import of certain questions.

To facilitate choices and to keep a check on them, the setting up of <ethical committees> in the principal medical centers should be encouraged. In these commissions, medical competence and evaluation is confronted and integrated with that of other presences at the patient's side, so as to safeguard the latter's dignity and medical responsibility itself.(29)

 

9. The sphere of action of health care workers consists, in general, of what is contained in the terms and concepts of <health> and <medicine> especially.

The term and concept of health embraces all that pertains to prevention, diagnosis, treatment and rehabilitation for greater equilibrium and the physical, psychic and spiritual well-being of the person. The term and concept of medicine, on the other hand, refers to all that concerns health policy, legislation, programming and structures.(30)

The full concept of health reflects directly on that of medicine. In fact, "institutions are very important and indispensable; however, no institution can of itself substitute for the human heart, human compassion, human love, human initiative, when it is a question of helping another in his suffering."(31)

The meeting and the practical synthesis of the demands and duties arising from the concepts of health and medicine are the basis and way for <humanizing> medicine. This must be present both at the personal-professional level?the doctor-patient relationship?and at the socio-policy level so as to safeguard in institutional and technological structures the human-Christian interests in society and the institutional and technological infrastructures. The first but not without the second, since such humanization as well as being a love-charity task is "an obligation of justice."(32)"[This humanization strengthens] the bases of the 'civilization

of life and love,' without which the life of individuals and of society itself loses its most genuinely human quality" (<Evangelium Vitae> 27).

 

10. The present <charter> wants to guarantee the <ethical fidelity> of the health care worker: the choices and behavior enfleshing service to life.

This fidelity is outlined through the stages of human existence: procreation, living, dying, as reference points for ethical-pastoral reflections.

 

11. "In the biblical narrative, the difference between man and other creatures is shown above all by the fact that only the creation of man is presented as the result of a special decision on the part of God, a deliberation to establish <a particular and specific bond with the Creator>: 'Let us make man in our image, after our likeness' (Gen 1:26). The life which God offers to man <is a gift by which God shares something of himself with his creature.>"(33)

"'God himself who said, <it is not good for man to be alone> (Gen 2:18) and <who made man from the beginning male and female> (Mt 19:4), wished to share with man a certain participation in his own creative work. Thus he blessed male and female saying: <Increase and multiply>"'(Gen 1:28). The generation of a new human being is therefore

"an event which is deeply human and full of religious meaning, insofar as it involves both the spouses, who form 'one flesh' (Gen 2:24), and God who makes himself present."(34)

Health care workers lend their service when" ever they help the parents to procreate responsibly, supporting the conditions, removing obstacles and protecting them from invasive techniques unworthy of human procreation.

 

Genetic manipulation

 

12. The ever-widening knowledge of the human genetic patrimony (genome), the individuation and mapping of the activity of the genes, with the possibility of transferring them, modifying them or substituting them, opens up untold prospects to medicine and at the same time creates new and delicate ethical problems.

In moral evaluation a distinction must be made between strictly <therapeutic> manipulation, which aims to cure illnesses caused by genetic or chromosome anomalies (genetic therapy), from manipulation <altering> the human genetic patrimony. A curative intervention, which is also called "genetic surgery," "will be considered desirable in principle. provided its purpose is the real promotion of the personal well-being of the individual, without damaging his integrity or worsening his condition of life."(35)

 

13. On the other hand, interventions which are not directly curative, the purpose of which is "the production of human beings selected according to sex or other predetermined qualities," which change the genotype of the individual and of the human species, "are contrary to the personal dignity of the human being, to his integrity and to his identity. Therefore they can be in no way justified on the pretext that they will produce some beneficial results for humanity in the future,"(36)"no social or scientific usefulness and no ideological purpose could ever justify an intervention on the human genome unless it be therapeutic, that is its finality must be the natural development of the human being."(37)

 

14. In any case, this type of intervention "should not prejudice the beginnings of human life, that is, procreation linked to not only the biological but also the spiritual union of the parents, united in the bond of matrimony."(38)

The negative ethical evaluations outlined here apply to all genetic manipulatory interventions concerned with embryos. On the other hand there are no moral objections to the manipulation of human body cells for curative purposes and the manipulation of animal or vegetable cells for pharmaceutical purposes.

 

Fertility control

 

15. "Without intending to underestimate the other ends of marriage, it must be said that true married love and the whole structure of family life which results from it is directed to disposing the spouses to cooperate valiantly with the love of the Creator and Savior, who through them will increase and enrich his family from day to day."(39)"When a new person is born of the conjugal union of the two, he brings with him into the world a particular image and likeness of God himself: <the genealogy of the person is inscribed in the very biology of generation>. In affirming that the spouses, as parents, cooperate with God the Creator in conceiving and giving birth to a new human being, we are not speaking merely with reference to the laws of biology.... Begetting is the continuation of Creation."(40)

"Those are considered to exercise responsible parenthood who prudently and generously decide to have a large family, or who, for serious reasons and with due respect for the moral law, choose to have no more children for the time being or even for an indeterminate period."(41) In the latter case there is the problem of birth control.

 

16. In evaluating behavior with regard to this control, the moral judgment "does not depend solely on good intentions and on the evaluation of motives; it is determined by objective criteria, criteria drawn from the dignity of the human person and human action."(42) It is a question of the dignity of the man and the woman and of their most intimate relationship. Respect for this dignity shows the truth of their married love.

With regard to the marriage act, this expresses "the indissoluble bond between the two meanings of the act: the unitive meaning and the procreative meaning."(43) In fact, the acts by which the partners fully express themselves and which intensify their union are the same ones that generate life and vice-versa.(44)

Love which uses "body language" to express itself is at once unitive and procreative: "it clearly implies both spousal and parental significance."(45)

This bond is intrinsic to the marriage act: "man may not break it on his own initiative," without denying the dignity proper to the person and "the inner truth of married love."[46]

 

17. Therefore, while it is lawful, for grave reasons, to take advantage of a knowledge of the woman's fertility and forego the use of marriage in the fertile periods, recourse to contraceptive practice is illicit.(47)

Natural methods imply a marriage act which, on the one hand does not result in a new life and which, on the other hand, is still intrinsically life-directed.(48)"It is precisely this respect which makes legitimate, at the service of responsible procreation, the <use of natural methods of regulating fertility>. From the scientific point of view, these methods are becoming more and more accurate and make it possible in practice to make choices in harmony with moral values."(49)

Artificial means contradict "the nature of the man and the woman and of their most intimate relationship."(50) Here sexual union is separated from procreation: the act is deprived of its natural openness to life. "Thus the original import of human sexuality is distorted and falsified, and the two meanings, unitive and procreative, inherent in the very nature of the conjugal act, are artificially separated: in this way the marriage union is betrayed and its fruitfulness is subjected to the caprice of the couple."(51)

This occurs in "every action which, either in anticipation of the conjugal act, or in its accomplishment, or in the development of its natural consequences, proposes, whether as an end or as a means, to render procreation impossible."(52)

 

18. Here, then, is "the difference, both anthropological and moral, between contraception and recourse to the rhythm of the cycle."(53)

"It is not a distinction simply of techniques or methods, where the decisive element would be the artificial or natural character of the procedure. "(54) It is a difference involving "two irreconcilable concepts of the human person and of human sexuality."(55)

The "difference," then, must be recognized and illustrated: "The ultimate reason for every natural method is not just its effectiveness or biological reliability, but its consistency with the Christian vision of sexuality as expressive of married love."(56)"It is frequently asserted that <contraception>, if made safe and available to all, is the most effective remedy against abortion.... When looked at carefully, this objection is clearly unfounded.... Indeed, the pro-abortion culture is especially strong precisely where the Church's teaching on contraception is rejected."(57)

 

19. Rather than directions for use, natural methods are in keeping with the meaning of conjugal love, which gives direction to the life of the couple: "The choice of the natural rhythms involves accepting the cycle of the person, that is the woman, and thereby accepting dialogue, reciprocal respect, shared responsibility and self-control.... In this context...conjugal communion is enriched with those values of tenderness and affection which constitute the inner soul of human sexuality, in its physical dimension also."(58)

 

20. Health care workers can contribute, when opportunities occur in their field, towards an acceptance of this human and Christian concept of sexuality by making available to married people, and even before that to young people, the required information for responsible behavior, respectful of the special dignity of human sexuality.(59)

This is why the Church appeals to their "responsibility" in "effectively helping couples to live their love with respect for the structures and finalities of the conjugal act which expresses that love."(60)

 

Artificial procreation

 

21. The application to humans of biotechnology learned from animal fertilization has made possible various interventions in human procreation, giving rise to serious questions of moral lawfulness. "The various <techniques of artificial reproduction>, which would seem to be at the service of life and which are frequently used with this intention, actually open the door to new threats against life."(61)

The evaluative ethical criterion must take account of the originality of human procreation, which "derives from the originality itself of the human person."(62)"Nature itself dictates that the transmission of human life be a personal and conscious act and, as such, subject to the most holy laws of God: immutable and inviolable laws which must be acknowledged and observed."(63) This personal act is <the intimate union of the love of the spouses who, in giving themselves completely to each other, give life>. It is a single, indivisible act, at once unitive and procreative, conjugal and parental.(64)

This act?"an expression of the reciprocal gift which, in the words of Scripture, brings about a union 'in one flesh"'(65)?is the source of life.

 

22. Humans are not at liberty to be ignorant of and to ignore the meanings and values intrinsic to human life from its very beginning. "And therefore means cannot be used nor laws followed which may be licit in the transmission of animal or vegetable life."(66) The dignity of the human person demands that it come into being as a gift of God and as the fruit of the conjugal act, which is proper and specific to the unitive and procreative love between the spouses, an act which of its very nature is irreplaceable.

Every means and medical intervention, in the field of procreation, must always be by way of assistance and never substitution of the marriage act. In fact, "the doctor is at the service of people and human procreation: he has no authority to do as he wills with them or to make decisions about them. Medical intervention respects the dignity of the persons when it aims at helping the marriage act.... On the contrary, sometimes medical intervention replaces the conjugal act.... In this case, the medical action is not, as it should be, at the service of the marriage union, but it appropriates the procreative function and thus is contrary to the dignity and inalienable rights of the spouses and of the expected child."(67)

 

23. "The use of such artificial means is not necessarily forbidden if their function is merely to facilitate the natural act, or to ensure that a normally performed act reaches its proper end."(68) This is <homologous artificial insemination>, that is, within matrimony with the semen of the partner, when this is obtained through a normal marriage act.

 

24. But homologous FIVET (<Fertilization in vitro with embryo transfer>) is illicit because conception is not the result of a conjugal act?"the fruit of the conjugal act specific to the love between the spouses"(69)?but outside it: in vitro through techniques which determine the conditions and decide the effect.(70) This is not in accord with the logic of "donation," proper to human procreation, but "production" and "dominion," proper to things and effects. In this case the child is not born as a "gift" of love, but as a laboratory "product."(71)

Of itself, FIVET "separates the acts which are destined for human procreation in the conjugal act," an act which is "indissolubly corporeal and spiritual." Fertilization takes place outside the bodies of the spouses. It is not "actually effected nor positively willed as an expression of and fruit of the specific act of conjugal union," but as a "result" of a technical intervention.(72)"[Man] no longer considers life as a splendid gift of God, something 'sacred' entrusted to his responsibility and thus also to his loving care and 'veneration.' Life itself becomes a mere 'thing,' which man claims as his exclusive property, completely subject to his control and manipulation."(73)

 

25. The desire for a child, sincere and intense though it be, by the spouses, does not legitimize recourse to techniques which are contrary to the truth of human procreation and to the dignity of the new human being.(74)

The desire for a child gives no right to have a child. The latter is a person, with the dignity of a "subject." As such, it cannot be desired as an "object." The fact is that the child is a subject of rights: the child has the right to be conceived only with full respect for its personhood.(75)

 

26. Besides these intrinsic reasons of the dignity of the person and its conception, homologous FIVET is also morally inadmissible because of the <circumstances and consequences> of its present-day practice.

In fact, it is effected at the cost of numerous embryonal losses, which are procured abortions. It could also involve congealment, which means suspension of life, of the so-called "spare" embryos, and often even their destruction.(76)

Unacceptable is "post mortem" insemination, that is, with semen, given during his lifetime, by the deceased spouse.

These are aggravating factors in a technical procedure already morally illicit <in itself>, and which remains such even without these factors.(77)

 

27. <Heterologous techniques> are "burdened" with the "ethical negativity" of conception outside of marriage. Recourse to gametes of people other than the spouses is contrary to the unity of marriage and the fidelity of the spouses, and it harms the right of the child to be conceived and born in and from a marriage. "<Procreation> then...expresses a desire, or indeed the intention, to have a child 'at all costs,' and not because it signifies the complete acceptance of the other and therefore an openness to the richness of life which the child represents."(789

These techniques, in fact, ignore the common and unitary vocation of the partners to paternity and maternity?to "become father and mother only through one another"?and they cause "a rupture between genetic parenthood, gestational parenthood and educational responsibility," which, from the family, has repercussions in society.(79)

A further reason for unlawfulness is the commercialization and eugenic selection of the gametes.

 

28. For the same reasons, aggravated by the absence of the marriage bond, artificial insemination of the unmarried and cohabitants is morally unacceptable.(80)

 

29. Equally contrary to the dignity of the woman, to the unity of marriage and to the dignity of the procreation of a human person is "surrogate" motherhood.

To implant in a woman's womb an embryo which is genetically foreign to her or just to fertilize her with the condition that she hand over the newly born child to a client means separating gestation from maternity, reducing it to an incubation which does not respect the dignity and right of the child to be "conceived, borne in the womb, brought to birth and educated by its own parents."(81)

 

30. The verdict of moral unlawfulness obviously concerns the ways by which human fertilization takes place, not the fruit of these techniques, which is always a human being, to be welcomed as a gift of God's goodness and nurtured with love.(82)

 

31. Artificial insemination techniques nowadays could open the way to attempts or projects of fertilization between human and animal gametes, to gestation of human embryos in animal or artificial wombs, of sexless reproduction of human beings through twinning fission, cloning, parthenogenesis.

Such procedures are contrary to the human dignity of the embryo and of procreation, and thus they are to be considered morally reprehensible.(83)

 

32. Medicine directed to the integral good of the person cannot prescind from the ethical principles governing human procreation.

Hence the "urgent appeal" to doctors and researchers to give "an exemplary witness of the respect due to the human embryo and to the dignity of procreation."(84)

 

33. Medical service to life accompanies the life of the person throughout their whole life-span. It is protection, promotion and care of health, that is, of the integrity and psycho-physical well-being of the person, in whom life "is enfleshed."(85)

It is a service based on the dignity of the human person and on the right to life, and it is expressed not only in prevention, treatment and rehabilitation but also in an holistic promotion of the person's health.

 

34. This responsibility commits the health care worker to a service to life extending "from its very beginning to its natural end," that is, "from the moment of conception to death."(86)

 

II. Life

 

Beginning of life and birth

 

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)

 

Right to life

 

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.

 

Prevention

 

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.

 

Sickness

 

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)

 

Diagnosis

 

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.

 

Prenatal diagnosis

 

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)

 

Therapy and rehabilitation

 

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)

 

Analgesia and anesthesia

 

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.

 

Research and experimentation

 

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)

 

Dependency

 

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.

 

Drugs

 

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.

 

Alcoholism

 

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)

 

Smoking

 

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.

 

Psycho-pharmaceuticals

 

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.

 

Psychology and psychotherapy

 

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)

III. Death

 

114. For the health care worker, serving life means assisting it right up to its natural completion.

Life is in God's hands: He is the Lord, He alone decides the final moment. Every faithful servant guards this fulfillment of God's will in the life of every person entrusted to his care. He does not consider himself the arbiter of death, just as and because he does not consider himself the arbiter of anyone's life.

 

Terminal illnesses

 

115. When the state of one's health deteriorates to an irreversible and fatal condition, a person enters into a terminal state of earthly existence. For him life is particularly and progressively precarious and painful. To illness and physical suffering is added the psychological and spiritual drama of detachment which death signifies and implies.

As such, the terminally ill patient is one who needs human and Christian accompaniment, and it is here that doctors and nurses are called on to make their expert and unrenounceable contribution. What is in question is special medical assistance for the dying person, so that also in dying he must know and will as a living human being. "Never more than in the proximity of death and in death itself is life to be celebrated and extolled. This must be fully respected, protected and assisted even in one who is experiencing its natural end.... The attitude to the terminally ill is often the acid test of a sense of justice and charity, of the nobility of mind, of the responsibility and professional ability of health care workers, beginning with doctors."(221)

 

116. Dying is part of life as its ultimate phase. It should be cared for, then, as belonging to it. Hence it calls for the therapeutic responsibility of the health care worker just as much and no less than every other moment in human life.

The dying person should not be dismissed as incurable and abandoned to his own resources and those of the family, but should be re-entrusted to the care of doctors and nurses. These, interacting and integrating with the assistance given by chaplains, social workers, relatives and friends, allow the dying person to accept and live out his death.(222) To help one to die means <to help him to live> intensely the final experience of his life. Where possible and when the one concerned wishes, he should be given the opportunity of spending his last days at home with suitable medical assistance.

 

117. A terminally ill person should be given whatever medical assistance helps to alleviate the pain accompanying death. This would include the so-called palliative or symptomatic treatment.

The most important assistance is "loving presence" at the bedside of the dying person.(223) There is a proper medical-health presence which, though not deceiving him, makes him feel alive, a person among persons, because he is receiving, like every being in need, attention and care. This caring attention gives confidence and hope to the patient and makes him reconciled to death.(224) This is the unique contribution which doctors and nurses, by their being human and Christian?more than by their expertise?can and should make to the dying person, so that rejection becomes acceptance and anguish gives way to hope.

In this way human dying is withdrawn from the phenomenon of "being overly medicalized," in which the terminal phase of life "takes place in crowded and activity-dominated environments, controlled by medical health personnel whose principal concern is the biophysical aspect of the illness." All of this "is being seen increasingly as disrespectful to the complex human state of the suffering person."(225)

 

118. "Before the mystery of death we are powerless; human certainties waver. But it is precisely in the face of such a checkmate that Christian faith...becomes a fount of serenity and peace.... What seems meaningless takes on meaning and worth."(226)

When this "checkmate" takes place in the life of a person, in this decisive hour of his existence, <the witness of the health care worker's faith and hope in Christ> has a determining role. It displays new horizons of meaning, that is, of resurrection and life, to the one who sees the prospects of earthly existence being closed to him.

"Over and above all human consolations, no one can be blind to the enormous help given to the dying and to their families by faith in God and the hope of eternal life."(227) To make faith and hope present is for doctors and nurses the highest form of humanizing death. It is more than alleviating a suffering. It means applying one's skills in order to "make going to God easy for the patient."(228)

 

Death with dignity

 

119. The right to life is specified in the terminally ill person as "a right to die in total serenity, with human and Christian dignity."(229)

This cannot be interpreted as the power to kill oneself or to give this power to others, but to experience dying in a human and Christian way and not flee from it "at any cost." This right is being explicitly expressed by people today in order to safeguard themselves at the point of death against "the use of techniques that run the risk of becoming abusive."(230)

Contemporary medicine, in fact, has at its disposal methods which artificially delay death, without any real benefit to the patient. It is merely keeping one alive or prolonging life for a time, at the cost of further, severe suffering. This is the so-called "therapeutic tyranny," which consists "in the use of methods which are particularly exhausting and painful for the patient, condemning him in fact to an artificially prolonged agony."(231)

This is contrary to the dignity of the dying person and to the moral obligation of accepting death and allowing it at last to take its course. "Death is an inevitable fact of human life":[232] it cannot be uselessly delayed, fleeing from it by every means.(233)

 

120. Aware that he is "neither the lord of life nor the conqueror of death," the health care worker, in evaluating means, "should make appropriate choices, that is, relate to the patient and be guided by his real condition."(234)

Here he will apply the principle?already stated?of "<appropriate medical treatment>," which can be specified thus: "When inevitable death is imminent, despite the means used, it is lawful in conscience to decide to refuse treatment that would only secure a precarious and painful prolongation of life, but without interrupting the normal treatment due to the patient in similar cases. Hence the doctor need have no concern; it is not as if he had failed to assist the person in danger."(235)

The administration of food and liquids, even artificially, is part of the normal treatment always due to the patient when this is not burdensome for him: their undue suspension could be real and properly so-called euthanasia.

 

121. For the doctors and their assistants it is not a question of deciding the life or death of an individual. It is simply a question of being a doctor, that is, of posing the question and then deciding according to one's expertise and one's conscience regarding a respectful care of the living and the dying of the patient entrusted to him. This responsibility does not always and in all cases involve recourse to every means. It might also require the renunciation of certain means to make way for a serene and Christian acceptance of death which is inherent in life. It might also mean respect for the wishes of the patient who refuses the use of such means.(236)

 

The use of painkillers for the terminally ill

 

122. Among the medicines administered to terminally ill patients are painkillers. These, which help to make the course of the illness less dramatic, contribute to the humanization and acceptance of death.(237)

This, however, does not constitute a general norm of behavior.(238)"Heroic behavior" cannot be imposed on everyone.(239) And then, very often, "pain diminishes the moral strength" of the person:(240) sufferings "aggravate the state of weakness and physical exhaustion, impeding the impulse of the spirit and debilitating the moral powers instead of supporting them. The suppression of pain, instead, brings organic and psychic relief making prayer easier and enabling one to give oneself more generously."(241)

"Human and Christian prudence suggests the use for most patients of medicines which alleviate or suppress pain, even if this causes torpor or reduced lucidity. With regard to those who are unable to express their wishes, one can reasonably suppose that they wish to take painkillers and these can be administered according to medical advice."(242)

The use of painkillers with the dying, however, is not without its problems.

 

123. First, their use might have the effect, of not only alleviating pain, but also of <hastening death>.

When "proportionate reasons" so require, "it is permitted to use with moderation narcotics which alleviate suffering, but which also hasten death."(243) In this case "death is not intended or sought in any way, although there is a risk of it for a reasonable cause: what is intended is simply the alleviation of pain in an effective way, using for that purpose those painkillers available to medicine."(244)

 

124. There is also the possibility that painkillers will cause unconsciousness in the dying person. This use must receive special consideration.(245)

"Without serious reasons, the dying person must not be deprived of consciousness."(246) Sometimes the systematic use of narcotics which reduce the consciousness of the patient is a cloak for the frequently unconscious wish of the health care worker to discontinue relating to the dying person. In this case it is not so much the alleviation of the patient's suffering that is sought as the convenience of those in attendance. The dying person is deprived of the possibility of "living his own life," by reducing him to a state of unconsciousness unworthy of a human being.(247) This is why the administration of narcotics for the sole purpose of depriving the dying person of a conscious end is "a truly deplorable practice "(248)

It is a different matter when there is a serious clinical case for the administration of analgesics which suppress consciousness, as when there is violent and unbearable pain. In this case the anesthetic is said to be licit, provided certain conditions are fulfilled: that the dying person has fulfilled or could still fulfill his moral, family and religious obligations.(249)

 

Telling the truth to a dying person

 

125. Telling the truth about the diagnosis and prognosis to the dying person, and more generally to those suffering from an incurable illness, poses a problem of communication.

To inform someone that they are dying is difficult and dramatic, but this is not an exemption from <being truthful>. Communication between a dying person and those in attendance cannot be based on pretense. This is never a human possibility for the dying person and does not contribute to the humanization of dying.

<The person has a right to be informed of their condition>. This right is not lessened where there is a diagnosis and prognosis of a terminal illness, rather, it is heightened.

This information, in fact, is linked to important responsibilities which cannot be delegated to another. There are responsibilities bearing on the treatment to be applied with the informed consent of the patient.

With the approach of death comes the responsibility to fulfill certain duties in one's relationship with the family, settling possible legal matters, resolving obligations to a third party. For a believer the approach of death requires that he be fully aware when he performs certain actions, especially the reconciling encounter with God in the sacrament of Penance.

The person cannot be abandoned to unconsciousness in the decisive "hour" of his life, taking him away from himself and from his final and most important decisions. "Death is too essential a moment for its prospect to be avoided."(250)

 

126. The duty of being truthful with the terminally ill patient demands <discernment and human tact> on the part of medical personnel.

It cannot consist of a detached and indifferent communication of the diagnosis and relevant prognosis. The truth must not remain unspoken, but neither must it be given in all its bare, crude reality. It should be given in line with love and charity, calling all those who assist the patient in various ways to be attuned to this communion.

There is the need to establish a relationship of trust, receptivity and dialogue with the patient, seeking the appropriate time and words. There is a way of speaking that is discerning and respectful of the patient's moods, and it should be in harmony with these. There is a form of conversation wherein questions are tactfully handled and even provoked, so that the patient is gradually brought to an awareness of his condition. If one tries to be present to the patient and sensitive to his lot one will find the words and the replies which make it possible to communicate in truth and in charity: "giving the truth in love" (Eph 4:15).

 

127. "Each case has its own requirements, depending on the sensitivity and ability of each person, of his or her relationship with the patient and the patient's condition; to provide for the patient's possible reactions (rebellion, depression, resignation, etc.), one will prepare oneself to face them calmly and tactfully."(251) It is not the exactness of what is said that is important, but the relationship of solidarity with the patient. It is not simply a matter of giving clinical facts, but of meaningful communication.

In this relationship the prospect of death is not presented as inescapable, and it loses its anguishing power: the patient does not feel isolated and condemned to death. When the truth is presented to him in this way he is not left without hope, because it makes him feel alive in a relationship of sharing and communion. He is not alone with his illness: he feels truly understood, and he is at peace with himself and with others. He is himself as a person. His life, despite everything, has meaning, and dying unfolds with optimistic and transcendent meaning.

 

The moment of death

 

128. The use of resuscitative technology and the need for vital organs for transplant operations pose anew today the problem of diagnosing when death occurs.

Death is seen and experienced by people as a decomposition, a dissolution, a rupture.(252)"It comes when the spiritual principle which governs the unity of the individual is no longer able to exercise its functions on and in the organism and the elements of the latter, left to themselves, dissociate.

Certainly, this destruction does not effect the entire human being. The Christian faith?and not it alone?affirms the continuance, beyond death, of man's spiritual principle." Faith nourishes in the Christian the hope of again finding his personal integrity transfigured and definitively possessed in Christ" (1 Cor 15:22).(253)

This faith filled with hope does not prevent "death [from] being a painful rupture." But "the moment of this rupture is not directly perceptible, and the problem is to identify the signs."(254) To ascertain and interpret these signs is not a matter for faith or morals but for medical science: "it is for the doctor...to give a clear, precise definition of death and of the moment of death."(255)"Scientists, analysts and scholars must continue their research and their studies to determine in the most precise way possible the exact moment and the irrefutable sign of death."(256)

Once this determination has been achieved, in its light the questions and moral conflicts arising from new technologies and new therapeutic possibilities can be resolved. Moral theology, in fact, cannot but acknowledge the biomedical determination as the decisive criterion.

 

129. With regard to this determination, the Pontifical Academy of Sciences has made an authoritative contribution. First with regard to the <biomedical definition of death>: "a person is dead when he has irreversibly lost all ability to integrate and coordinate the physical and mental functions of the body."

Second, with regard to the precise moment of death: "death comes when: a) the spontaneous functions of the heart and breathing have definitively ceased, or b) the irreversible arrest of all brain activity." In reality "brain death is the true criterion of death, although the definitive arrest of cardio-respiratory activity very quickly leads to brain death."(257)

Faith and morals accept these findings of science. However, they demand of health care workers the most accurate use of the various clinical and instrumental methods for a certain diagnosis of death so that a patient is not declared dead and treated as such when in fact he is not dead.

 

Religious assistance for the dying

 

130. The crisis which the approach of death involves prompts the Christian and the Church to be a bearer of the light of truth which faith alone can cast on the mystery of death.

Death is an event which brings one into the life of God, and revelation alone can pronounce a word of truth about it. This truth must be brought in faith to the dying person. The annunciation "full of grace and truth" (Jn 1:14) of the Gospel accompanies the Christian from the beginning to the end of life. The last word of the Gospel is the word of life that conquers death and opens up the greatest hope to the dying person.

 

131. <Death>, then, <must be evangelized>: the Gospel must be announced to the dying person. It is a pastoral duty of the ecclesial community in each one of its members, according to the responsibilities of each. The hospital chaplain has a special obligation here, since he is called to minister to the dying within the broader limits of the pastoral care of the sick.

For him this duty implies not only the role he personally carries out at the side of the dying entrusted to his care, but also the promotion of this pastoral activity, through organizing religious services, forming and sensitizing health care workers and involving relatives and friends.

The announcement of the Gospel to the dying finds especially expressive and effective forms in charity, prayer and the sacraments.

 

132. <Charity> means that giving and receptive presence which establishes with the dying person a communion born of attention, comprehension, concern, patience, sharing and selflessness.

Charity sees in the dying person, as in no other, the face of the suffering and dying Christ calling out for love. Charity to the dying person?this "poor one" who is renouncing all the goods of this world?is a privileged expression of love of God in one's neighbor (cf. Mt 25:31-40).

Loving the dying with Christian charity is helping them to recognize and feel vividly the mysterious presence of God at their side: in the charity of a brother the love of God becomes visible.

 

133. Charity enables the relationship with the dying person to expand in prayer, that is, in communion with God. In this communion one relates to God as the Father who welcomes his children returning to Him.

To help the dying person to pray and to pray with him means opening up to him the horizons of divine life. It means, at the same time, entering into that "communion of saints" in which all the relationships, which death seems to break irreparably, are re-knit in a new way.

 

134. A privileged moment of prayer with the dying person is the celebration of the <sacraments>: the grace-filled signs of God's salvific presence.

Foremost is the sacrament of the <Anointing of the Sick> through which the Holy Spirit, completing in the Christian his assimilation to Christ begun in baptism, makes him participate definitively in the paschal triumph over sickness and death.

<Viaticum> is eucharistic nourishment, the bread of communion with Christ which gives the dying person the strength to face the final and decisive stage of life's journey.

<Penance> is the sacrament of reconciliation: at peace with God, the dying person is at peace with himself and with his neighbor

 

135. In this <faith>, filled with <charity> the powerlessness experienced when faced with the mystery of death is not agonizing and paralyzing. The Christian finds <hope> and in it the possibility, despite everything, to live and not suffer death.

 

The suppression of life

 

136. The inviolability of human life means and implies in the last analysis the unlawfulness of every act which directly suppresses human life. "The inviolability of the right to life of the innocent human being from conception to death is a sign and a requirement of the very inviolability of the person, to whom the Creator has given the gift of life."(258)

God himself "is the vindicator of every innocent life." "He will call man to account for the life of man: each one will have to answer for his brother" (Gen 9:5; cf. Mt 19:18; Rom 13:9). And his commandment is categorical: "Thou shalt not kill" (Ex 20:13): "Do not kill the innocent or the just one because I will not absolve the guilty one" (Ex 23:7).(259)

 

137. This is why "no one can make an attempt on the life of an innocent person without opposing God's love for that person, without violating a fundamental, unrenouncable and inalienable right."(260)

This is a right that one has come <directly> from God (not from others: parents, society, human authority). "Hence there is no one, no human authority, no science, no medical, eugenic, social, economic or moral 'indicator' which can show or give a valid juridical justification for direct, deliberate disposal of an innocent human life, that is, a disposal aimed at its destruction, either as an end or as a means to another end which in itself may not be at all illicit."(261)

In particular "nothing and no one can authorize the killing of an innocent human being, whether it is a fetus or an embryo, a child or an adult, elderly, ill, incurable or dying. Moreover, no one can request this homicidal act for themselves or for another for whom they are responsible, nor can they consent to it explicitly or implicitly. No authority can legitimately impose it or permit it. It is, in fact, a violation of divine law. an insult to the dignity of the human person, a anti-life crime, an attempt on humankind "(262)

 

138. "Ministers of life and never agents of death,"(263) it is for health care workers "to safeguard life, to be watchful over its evolution and development throughout its whole existence, respecting the plan drawn up by the Creator."(264)

This vigilant ministry of safeguarding human life rejects <homicide> as a morally grave act, contrary to the medical mission, and opposes voluntary death, <suicide>, as "unacceptable," dissuading anyone tempted to do so from carrying it out(265)

Among the modalities of the suppression of life, homicide or suicide, there are two?abortion and euthanasia?against which this ministry should be particularly vigilant and in a certain way prophetic, due to the cultural and legislative context which is rather frequently insensitive if not, indeed, favorable to their propagation.

 

Abortion

 

139. The inviolability of the human person from conception prohibits <abortion> as the suppression of prenatal life. This is "a direct violation of the fundamental right to life of the human being"(266) and is "an abominable crime."(267)

There is need to make explicit reference to suppression of life by abortion and its moral gravity because of the ease of recourse to this homicidal practice today and the ethical indifference towards it induced by a hedonistic and utilitarian culture?offspring of theoretical and practical materialism?which has spawned a truly abortionist mentality.

The elimination of the unwanted pregnancy has become a wide-spread phenomenon, financed by taxpayer's money and facilitated by permissive and guaranteed legislation.(268) All of this is the fatal cause for many people to avoid taking responsibility for the expected child and so to banalize a serious sin.(269)

"Unfortunately, this disturbing state of affairs, far from decreasing, is expanding.... At the same time a new cultural climate is developing and taking hold, which gives crimes against life a <new and?if possible?even more sinister character>, giving rise to further grave concern: broad sectors of public opinion justify certain crimes against life in the name of the rights of individual freedom, and on this basis they claim not only exemption from punishment but even authorization by the state, so that these things can be done with total freedom and indeed with the free assistance of health care systems."(270)

 

140. The Church, like every person who holds life dear, cannot become accustomed to this mentality, and she raises her voice in defense of life, especially that of the defenseless and unknown, which embryonic and fetal life is.

She calls health care workers to <professional loyalty>, which does not tolerate any action which suppresses life, despite "the Ask of incomprehension, misunderstanding, and serious discrimination" which this consistency might cause.(271) Fidelity to <medical health> de-legitimizes every intervention, surgical or pharmaceutical, intended to interrupt the pregnancy at any stage.

 

141. It is also true that in certain cases, by refusing an abortion, other important goods?which it is only normal that one would want to safeguard?are put in jeopardy. These could be: danger to the mother's health, the burden of another child, a serious malformation of the fetus, a pregnancy caused by rape.

These problems cannot be ignored or minimized, nor the reasons supporting them. But it must also be affirmed that none of them can objectively give the right to dispose of another's life, even in the initial phase. "Life, in fact, is too fundamental a good for it to be compared with certain disadvantages, even if they be very great."(272)

 

142. Ethical delegitimization applies to all forms of direct abortion, since it is an intrinsically blameworthy act. The use of substances or means which impede the implantation of the fertilized embryo or which cause its premature detachment is also an act of abortion. A doctor who would knowingly prescribe or apply such substances or means would cooperate in the abortion.

If the abortion follows as a foreseen but nor intended or willed but merely tolerated consequence of a therapeutic act essential for the mother's health, this is morally legitimate. The abortion in this case is the indirect result of an act which is not in itself abortive.(273)

 

143. If the health care worker is faced with legislation favorable to abortion he "must refuse politely but firmly."(274)"One can never obey a law that is intrinsically immoral, and this is so in the case of a law which admits, in principle, the lawfulness of abortion."(275)

As a result, doctors and nurses are obliged to be <conscientious objectors>. The great, fundamental value of life makes this obligation a grave moral duty for medical personnel who are encouraged by the law to carry out abortions or to cooperate proximately in direct abortion.

Awareness of the inviolable value of life and of God's law protecting it, is antecedent to all positive human law. When the latter is contrary to God's law, conscience affirms its primary right and the primacy of God's law: "One must obey God rather than men" (Acts 5:29).

"It is not always easy to follow one's conscience in obedience to God's law. It may entail sacrifice and disadvantages, and one can in no way discount this cost; sometimes heroism is called for if one is to be faithful to these demands. Nevertheless, it must be clearly stated that the road of genuine progress for the human person passes through this constant fidelity to a conscience upholding rectitude and truth."(276)

 

144. As well as being a mark of professional loyalty, conscientious objection on the part of the health care worker, for the right reasons, is highly meaningful as a <social condemnation of a legal injustice> against innocent and defenseless life.

 

145. The gravity of the sin of abortion and the ease with which it is carried out, supported by law and the modern mentality, prompts the Church to threaten the penalty of <excommunication> for the Christian who procures it: "One who procures an effective abortion incurs <latae sententiae> excommunication."(277)

The excommunication has an essentially preventative and pedagogical significance. It is a forceful call from the Church, meant to arouse insensitive consciences, to dissuade people from an act which is absolutely incompatible with Gospel demands, and to awaken unreserved fidelity to life. One cannot be in ecclesial communion and at the same time disregard the Gospel of life through the practice of abortion.

The protection and acceptance of the expected child, its preference to all other values, is a decisive and credible witness which the Christian must give no matter what.

 

146. Health care workers have special obligations with regard to aborted fetuses.

An aborted fetus, if it is still alive, should be baptized if at all possible.(278)

A dead aborted fetus must be given the same respect as a human corpse. This means that it cannot be disposed of as just another item of rubbish. If at all possible it should be appropriately interred.

Likewise, the fetus cannot be used for experimentation or transplant if the abortion was caused voluntarily. To do so would be an unworthy instrumentalization of a human life.

 

Euthanasia

 

147. A mentality ever less ready to recognize life as a value in itself, relative to God alone, independent of how it came into being; a concept of the quality of life in terms of efficiency and psychophysical satisfaction, incapable of seeing any meaning in suffering and handicap, and hence to be avoided at any cost and by every means; a vision of death as an absurd end to a life still to be enjoyed, or as a liberation from an existence already considered meaningless; all of this?within a culture which, leaving God aside, makes man responsible to himself alone and to freely established laws of society?is the soil of the euthanasia culture. Where these convictions are disseminated "it could seem logical and 'human' to end one's own life or that of another 'peacefully', when all that is left to it is suffering and serious impairment."(279)

"But this is really absurd and inhuman."(280)<Euthanasia is a homicidal act, which no end can justify>. By euthanasia is meant an action or omission which of its nature or by intention causes death, in order that all suffering may be eliminated. Euthanasia's terms of reference, therefore, are to be found in the intention of the will and in the methods used."(281)

The pity aroused by the pain and suffering of terminally ill persons, abnormal babies, the mentally ill, the elderly, those suffering from incurable diseases, does not authorize any form of direct euthanasia, active or passive. This is not a question of helping a sick person, but rather the intentional killing of a person.

 

148. Medical and paramedical personnel?faithful to the task of "always being at the service of life and assisting it to the end"(282) cannot cooperate in any euthanistic practice even at the request of the one concerned, and much less at the request of the relatives. In fact, the individual does not have the right to euthanasia, because he does not have a right to dispose arbitrarily of his own life. Hence no health care worker can be the executive guardian of a non-existent right.

It is a different matter when there is question of the right, already mentioned, of dying with human and Christian dignity. This is a real and legitimate right which medical personnel are called on to safeguard by caring for the patient and accepting the natural termination of life. There is a radical difference between "death dealing" and "consent to dying": the former is an act suppressing life, the latter means accepting life until death.

 

149. "The pleas of gravely ill persons who sometimes ask for death are not to be understood as implying a true desire for euthanasia; in fact it is almost always a case of an anguished plea for help and love. What a sick person needs, besides medical care, is love, the human and supernatural warmth with which the sick person can and ought to be surrounded by those close to him or her, parents and children, doctors and nurses."(283)

The sick person who feels surrounded by a loving human and Christian presence does not give way to depression and anguish as would be the case if one were left to suffer and die alone and wanting to be done with life. This is why <euthanasia is a defeat> for the one who proposes it, decides it and carries it out. Far from being an act of mercy to the patient, euthanasia is a gesture of individual and social self-pity and an escape from an unbearable situation.

 

150. Euthanasia <upsets the doctor-patient relationship>. On the part of the patient, because he relates to the doctor as one who can assure him of death. On the part of the doctor, because he is no longer the absolute guarantor of life: the sick person will be afraid that the doctor may cause his death. The doctor-patient relationship is a life-trusting one and this is how it should remain.

Euthanasia is a "crime" in which health care workers, who are always and only guardians of life, can in no way cooperate.(284)

For medical science it marks "a backward step of surrender, as well as an insult to the personal dignity of the one who is dying."(285) Its being depicted as a "further harbor of death after abortion" should be understood as a "dramatic appeal" for <effective, unreserved fidelity to life.>(286)