Paglia to WMA

Opening Message of
Archbishop Vincenzo Paglia
President of the Pontifical Academy for Life
I would first like to express my gratitude to the World Medical Association,
as well as to the German Medical Association, for welcoming the collaboration of
the Pontifical Academy for Life in hosting this European Region Meeting on end-
of-life questions. The theme of this Meeting, a theme that is meaningful for all of
human society, makes clear why we have chosen the Vatican as the venue for our
scientific consideration of certain difficult issues that the world is struggling with
today. We needed a place where dialogue can flourish far from the passions that
are unleashed in the discussion of issues that are sensitive and controversial, not
only by reason of the pluralism that characterizes today’s world, but also by reason
of the way they are sensationalized in the media. What must be done is to go
beyond initial reactions and emotional considerations and search for the deeper
reasons for the choices we have to make as we pursue doing good. This is one of
the principal tasks that Pope Francis has entrusted to the Pontifical Academy for
Life as it explores the full range of human sensitivity with respect to fundamental
life-related questions. The Academy’s methodology is not based on ideological
conflict and on the dictatorship of public opinion, but on the shared search for a
common ground on which even differing opinions can find points of agreement
about the truth of the human being. Clearly, the question of what choices are to be
made at the end of life falls within the Pope’s mandate to the Academy. We are
truly grateful to him for having sent his greetings to this Meeting and for proposing
guidelines for making the difficult decisions that face us all as death draws near.
As I begin the conversations among us—and then I’ll leave the floor to
Professor Franz Ulrich Montgomery for his introduction—I would like to highlight
some aspects of the theme of our Meeting, starting from the principle that the final
decision with respect to the proportionality of any medical choice belongs to the
patient. This principle is easy to accept in theory but difficult to apply in practice,
and those difficulties increase when the patient is no longer able to make the
necessary decisions. It is in this area that Advance Directives can provide a
treatment team with reliable guidance as to the preferences of the patient.
Naturally, draft Directives they should be gathered with appropriate care. First to
be considered would be the conversations—the dialogue—that should be part of
process that produces the Directives. The Directives are not to be simply a
bureaucratic act, isolated from medical and healthcare concerns and lacking
appropriate accompaniment in an atmosphere of mutual trust.
In these circumstances, the Pope’s call for loving closeness offers us sure
guidance. It is a closeness that is not to be understood as paternalistic, rigid or
opposed to the patient’s right of self-determination. Patient autonomy plays a
central role, as is rightly stated in your Association’s recently revised Declaration
of Geneva. However, we know that autonomy is subject to differing
interpretations and in my opinion it should not be considered as individualistic and
abstract but rather as relational and concrete. On the one hand, life and liberty
always include relationships with others. Neither life nor liberty can ever be
privatized, as if they belonged to an isolated individual who has no ties with
relatives and with a wider circle of persons. On the other hand, freedom is always
conditioned by many internal constraints and external pressures, especially when it
finds itself in—or is headed toward—a situation of suffering and illness, which
makes it more fragile and vulnerable.
We know as well that the word “dignity” can have different meanings: it
can be interpreted from a relational point of view, following that tradition of
European thought of which Immanuel Kant is an outstanding exponent, or else in
an optic that defends the individual from intrusive power structures, thus placing
more emphasis on self-determination than on responsibility. I think it is important
not to break off the dialogue between these two perspectives. And I am convinced
that the most promising path to finding a commonality between them is to
recognize that humans are made for relationships and that mutual recognition and
respect is essential to our life together as humans.
There is one point, however, on which all must agree: we must accompany
and support those who suffer, especially when the moment of death approaches,
and we must never accept what might be called “therapeutic abandonment.” Two
improvements we could make are the following: expressions like “discontinue
treatment “(even worse, “pull the plug”) could be abandoned in favor of terms that
are more able to convey the idea that “care continues”; and sustainable protocols
could be adopted that are not uselessly invasive and that temper care according to
the actual needs of the patient and the current stage of the patient’s illness.
The Pope also noted in his greeting the distinction between discontinuing
disproportionate care and euthanasia, that is, the distinction between accepting
death and causing it intentionally. Now, however, it may seem that such a
distinction does not take into account the case of assisted suicide. In that case, it is
not the physician who intervenes as the prime actor in the shortening of life. He
merely provides the patient with the means, both the instructions and the
substances, to autonomously bring about death. Still, such participation in a series
of actions that the patient proposes to undertake implies a sharing in the intention
of the patient to shorten his or her life (in the traditional terminology of moral
theology, this is called “formal cooperation,” in this case, in an “illicit act”). It is
therefore important to reflect carefully on the questions posed by the phenomenon
of medically assisted suicide because they go far beyond the private sphere,
understood individualistically, and they involve the public sphere—the alliance
between society and the medical profession. How can a person who has been
given the task of protecting health and of working in defense of the fundamental
human right that health care represents shorten life itself? What effect does that
have on the relationship of trust between doctor and patient? And even if such
action were claimed to be justified by a narrow conception of autonomy, would
that not still give rise to a contradiction between theory and practice? In fact, when
we see more and more how vulnerable freedom is in situations of suffering, as is
seen in the difficulty of the concrete practice of informed consent, we come to a
somewhat contradictory situation: the legitimization of decisions that are heavily
influenced by external (social) or internal (psychological) factors, and that are
therefore not really autonomous. We are then faced with a dilemma that, in the
name of autonomy, forces those who are weakest to make choices under conditions
that make autonomy impossible or else reduces the choices available to persons
who can actually choose freely—persons who, in the light of our experience, are in
any case a minority. In these circumstances, would it not be reasonable to give
priority to the protection of those who can’t effectively choose, even if we reduce
the number of choices available to those who can, especially when we consider the
fundamental importance of the value that is at risk, that is, life itself, and the
irreversibility of choosing death? To this we can add that staying alive, certainly
with the provision of proportionate care and with effective accompaniment, always
makes it possible to change (through whatever circumstances) the beliefs that
motivated the request of death.
These questions, and others that could be added. have long been the subject
of debate. Today, however, they are particularly urgent and must be studied in
their implications and causes, according to the best traditions of your Association,
which treats ethical issues with care and prudence commensurate with their novelty
and their complexity. (see WMA, Medical Ethics Manual, 2015 p. 25). I note that
it is precisely for this reason that you have insisted on the unacceptability of any
medical intervention that intentionally causes death.
I am sure that our discussions during these two days will be serious and
deep, as we pursue the best ways to promote health, to defend the human person
and the human person’s fundamental and inalienable rights. In the end, the human
work of care for human material and spiritual vulnerability, in whatever form or
profession that care manifests itself, always lives on the edge of the anti-utilitarian
paradox. But it is the paradox that makes us human.
The men and women we have felt committed to care for from time
immemorial are mortals. And we can’t cure them of their mortality. Yet, nothing
more identifies us, and moves us, than our daily struggle against the painful signs
of weakness that reminds us that we are all mortal. We struggle hard not to let the
gloom of death be what decides the value of life. We struggle not let disease be
what decides the usefulness of our lives, the worth of our persons, the genuineness
of our affections. We accept our mortal condition. We resist the fevered delusion
that we can overcome the mystery of our inevitable passing, with all its painful
contradictions. The care we provide shows our commitment to making acceptance
of death more human while at the same time not becoming death’s accomplice.
We refuse to do the work of death, even if only symbolically. Providing care is an
acceptance of, and will help us to accept, our own insurmountable limits, with the
tenderness of love, with all respect for the person, and with all the power of
dedication of which we are capable. No care, however, is to show any complicity,
not even seeming complicity, with death.
Dear friends, this is the challenge—a very difficult but humane challenge—
that must bring us together. Accompaniment in order to accept the need to live
humanly, and to live the reality of death without losing the love that struggles
against its darkness, is the goal of that “responsible closeness” to which all, as
human beings, are called. The whole community must be involved. We will not
stand by without doing anything while death goes about it task. But neither will
we do the work of death, simply to relieve ourselves of a burden and think we are
acting out of love. That love for life within which we have loved and been loved is
no longer just ours, it belongs to all those with whom it has been shared. And
that’s how it must be, to the end. No one should feel guilty about the burden that
his or her mortal condition lays on the community. We are human, and the human
idea of care is radically opposed to the notion that sickness requires exclusion from
the community, that it is an unpardonable failing. And I must add to that human
idea of care the Gospel message that frees us theologically from our fear of death.
16 November 2017