End of life care must acknowledge our mortality, Francis reminds physicians

Vatican City, Nov 16, 2017 / 15:05 pm

In a message to medical professionals Thursday, Pope Francis said that when it comes to end-of-life care, treatments should always be based on human dignity and with the patient's best interests in mind.

He also stressed that the various medical options provided must avoid the temptation either to euthanize a patient or to pursue disproportionate treatments which do not serve the integral good of the person.

When it comes to caring for those at the end of their earthly life, "it could be said that the categorical imperative is to never abandon the sick," the Pope said Nov. 16.

The anguish of being faced with our human mortality and the difficult decisions we have to make "may tempt us to step back from the patient," he said, but cautioned that is the stage when we are most called to show love, closeness, and solidarity.

Each person – whether they are a parent, child, sibling, doctor or nurse – must give in their own way, he said, and even though there is not always a guarantee of healing or a cure, "we can and must always care for the living, without ourselves shortening their life, but also without futilely resisting their death."

In this sense, he pointed to the importance of palliative care, "which is proving most important in our culture, as it opposes what makes death most terrifying and unwelcome – pain and loneliness."

Pope Francis offered his words in a message sent to participants in the World Medical Association's Nov. 16-17 European Meeting on End-of-Life Questions, organized in collaboration with the Pontifical Academy for Life.

The Pope said "greater wisdom" is needed today when it comes to end-of-life care, "because of the temptation to insist on treatments that have powerful effects on the body, yet at times do not serve the integral good of the person."

The increase in the "therapeutic capabilities of medical science" have made it possible to eliminate various diseases, improve health and prolong a person's life, he said, noting that while these are certainly positive developments, there is now also the danger "to extend life by means that were inconceivable in the past."

"Surgery and other medical interventions have become ever more effective, but they are not always beneficial: they can sustain, or even replace, failing vital functions, but that is not the same as promoting health."

Referencing a speech given by Venerable Pius XII to anaesthesiologists and intensive care specialists in 1957, Francis said that "there is no obligation to have recourse in all circumstances to every possible remedy" for an illness, and that in specific cases, "it is permissible to refrain from their use."

"Consequently, it is morally licit to decide not to adopt therapeutic measures, or to discontinue them, when their use does not meet that ethical and humanistic standard that would later be called 'due proportion in the use of remedies,'" referencing the Congregation for the Doctrine of the Faith's 1980 Declaration on Euthanasia.

The key element of this criterion, according to the CDF, is that it considers "the result that can be expected, taking into account the state of the sick person and his or her physical and moral resources."

This "makes possible a decision that is morally qualified as withdrawal of 'overzealous treatment'," the Pope said.

"Such a decision responsibly acknowledges the limitations of our mortality, once it becomes clear that opposition to it is futile." He quoted the Catechism in saying that "here one does not will to cause death; one's inability to impede it is merely accepted."

"This difference of perspective restores humanity to the accompaniment of the dying, while not attempting to justify the suppression of the living," he said.

"It is clear that not adopting, or else suspending, disproportionate measures, means avoiding overzealous treatment; from an ethical standpoint, it is completely different from euthanasia, which is always wrong, in that the intent of euthanasia is to end life and cause death."

When it comes to concrete clinical situations, Pope Francis noted that various factors come into play that are not always easy to evaluate, and to determine whether a medical intervention is proportionate or not, "the mechanical application of a general rule is not sufficient."

"There needs to be a careful discernment of the moral object, the attending circumstances, and the intentions of those involved."

Francis emphasized that when caring for any given patient, decisions must be made in light of human dignity. "In this process, the patient has the primary role," he added.

"The patient, first and foremost, has the right, obviously in dialogue with medical professionals, to evaluate a proposed treatment and to judge its actual proportionality in his or her concrete case, and necessarily refusing it if such proportionality is judged lacking. That evaluation is not easy to make in today's medical context, where the doctor-patient relationship has become increasingly fragmented and medical care involves any number of technological and organizational aspects.

Compounding this difficulty, the Pope said, is the "growing gap" in healthcare opportunities, which he said is due to "the combination of technical and scientific capability and economic interests."

What this means, then, is that sophisticated and costly treatments are increasingly available to "ever more limited and privileged segments" of the population. This then raises questions regarding sustainable healthcare delivery and "a systemic tendency toward growing inequality in health care."

This tendency, Francis said, "is clearly visible" on a global level, especially when comparing different continents. However, he noted this is also seen within wealthier countries, where access to healthcare "risks being more dependent on individuals' economic resources than on their actual need for treatment."

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In this context, as it relates to both clinical practice and medical culture in general, "the supreme commandment of responsible closeness must be kept uppermost in mind," he said.

Given the complexity of issues surrounding end-of-life care and the moral and ethical questions they raise, the Pope said democratic societies must address them "calmly, seriously and thoughtfully," in a way open to finding agreeable solutions whenever possible, including on the legal level.

"On the one hand, there is a need to take into account differing world views, ethical convictions and religious affiliations, in a climate of openness and dialogue. On the other hand, the state cannot renounce its duty to protect all those involved, defending the fundamental equality whereby everyone is recognized under law as a human being living with others in society."

Special attention must be paid to the vulnerable, who need help when it comes to defending their own interests, he said, noting that if this "core of values essential to coexistence" is weakened, then "the possibility of agreeing on that recognition of the other which is the condition for all dialogue and the very life of society will also be lost."

Healthcare legislation must adopt this "broad vision and a comprehensive view" of what will most effectively promote the common good in each concrete case, he said, and closed by offering his prayer for the discussion.

"I also trust that you will find the most appropriate ways of addressing these delicate issues with a view to the good of all those whom you meet and those with whom you work in your demanding profession."