Charter For Health Care Workers:
Life

( 1, 2, 3, 4, 5 )

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 being106 gives it that sacred character107 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 apossible 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 , 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. , 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 ofthemselves, 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 culture189 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. of the sick consists in spiritual and religious assistance. This is a fundamental right of the patient and a duty of the Church (cf. Mt 10:8; Lk 9:2, 10:9). Not to assure it, not to support it, to make it discretionary or to impede it is a violation of this right and infidelity to this duty.

This is the essential and specific, though not exclusive, task of the health care pastoral worker. Because of the necessary interaction between the physical, psychological and spiritual dimension of the person, and the duty of giving witness to their own faith, all health care workers are bound to create the conditions by which religious assistance is assured to anyone who asks for it, either expressly or implicitly.208 "In Jesus, the 'Word of life,' God's eternal life is thus proclaimed and given. Thanks to this proclamation and gift, our physical and spiritual life, also in its earthly phase, acquires its full value and meaning, for God's eternal life is in fact the end to which our living in this world is directed and called."209


109. Religious assistance implies that there be, within the health care structure, the possibility and the means to carry this out.

The health care worker should be totally available to support and accede to the patient's request for religious assistance.

Where such assistance, for general or particular reasons, cannot be given by the pastoral worker, it should be given directly — within possible and allowable limits — by the health care worker, respecting the freedom and the religious affiliation of the patient and aware that, in doing so, he does not detract from the rights of health care assistance properly so called.


110. Religious assistance to the sick is part of the wider vision of medical–pastoral assistance, that is, of the presence and activity of the Church which is meant to bring the word and the grace of the Lord to those who suffer and to those who care for them.

In the ministry of those — priests, religious and laity — who individually or as communities are engaged in the pastoral care of the sick, the mercy of God lives on, who in Christ has bound to human suffering, and the task of evangelization, sanctification and charity entrusted to the Church by the Lord is carried out in a singular and privileged manner.210

This means that pastoral care of the sick has a special place in catechesis, in the liturgy and in charity. Respectively, it is a matter of evangelizing illness, helping a person to uncover the redemptive meaning of suffering borne in communion with Christ; of celebrating the sacraments as efficacious signs of the recreative and vitalizing grace of God; of witnessing by means of the "diakonia" (service) and the "koinonia" (communion) to the therapeutic power of charity.


111. In pastoral care of the sick, the love—full of truth and of grace of God comes near to them in a special sacrament meant for them: the Anointing of the Sick.211

Administered to any Christian who is in a life-threatening condition, this sacrament is a remedy for body and spirit, relief and strength for the patient in his corporeal-spiritual integrity casting light on the mystery of suffering and death and bringing a hope which opens the human present to the future of God. "The whole person receives help from it for his salvation; he feels strengthened in his trust in God and he receives reinforcement against the temptations of the devil and the fear of death."212

Since it has the efficacy of grace for the sick person, the Anointing of the Sick "is not the sacrament of those only who are at the point of death." Hence "the suitable time to receive it is when one of the faithful, either from illness or old-age, begins to be in danger of death."213

As with all the sacraments, the Anointing of the Sick should also be preceded by a suitable catechesis so that the recipient, the sick person, is a conscious and responsible subject of the grace of the sacrament, and not an unconscious object of the rite of imminent death.214


112. The proper minister of the Anointing of the Sick is the priest only, and he should see that it is conferred "on those of the faithful whose state of health is seriously threatened by old–age or illness." To evaluate the seriousness of the illness it is sufficient "to have a prudent or probable judgment."

Celebrating communal Anointing might help to overcome negative prejudices against the Anointing of the Sick, and help to value the meaning of this sacrament and the sense of ecclesial solidarity.

Anointing can be repeated if the sick person, having recovered from the illness for which the sacrament was received, should again become ill, or if in the course of the same illness his Condition should worsen.

It can be given before surgery if the reason for surgery is "a dangerous illness."

Anointing may be conferred on the elderly "because of the notable diminishing of their strength, even if they do not have any serious illness."

If the conditions are present, it can also be conferred on children, "provided they have sufficient use of reason."

In the case of sick people who are unconscious or deprived of the use of reason, it is to be Conferred "if there is reason to believe that in possession of their faculties they themselves, as believers, would have, at least implicitly, requested holy Anointing."

"The sacrament cannot be conferred on a patient who is already dead."215

"When there is a doubt whether the sick person has attained the use of reason, or whether the person is gravely ill or whether the person is dead, this sacrament is to be conferred."216


113. The Eucharist, also, as Viaticum, has a special significance and efficacy for the patient. "Viaticum of the body and blood of Christ strengthens the believer and furnishes him with the pledge of resurrection, as the Lord has said: The one who eats my flesh and drinks my blood has eternal life, and I will raise him up on the last day" (Jn 6:54).217

For the sick person, the Eucharist is this viaticum of life and hope. "Communion in the form of Viaticum is, in fact, a special sign of participation in the mystery celebrated in the sacrifice of the Mass, the mystery of the death of the Lord and of his passing to the Father."218

Therefore it is the duty of a Christian to request and receive Viaticum, and the Church has a pastoral responsibility to administer it.219

The minister of Viaticum is a priest. But he may be substituted by a deacon or an extraordinary minister of the Eucharist.220


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