Put simply, here are two basic understandings of what it means to be human and a person, which underlie two diametrically opposed views on the discipline and practice of medicine.
The first account recognizes the human as a being with a body, soul and spirit; possessing a unity which is greater than the sum of its parts, a human person, a self-conscious being, a transcendent being. This is consistent with the Hippocratic understanding of the patient, a human being with specific diseases or disorders of the body,2 as distinct from the soul or spirit. Indeed this was the basis from which he developed his views on medicine as a discipline, a profession and an art.
The second account, very prevalent in our time, holds that all that exists is material being, and all epi or meta phenomena in humans, the intellect, moral conscience and free choice are to be accounted for as products of the body, particularly the brain. By definition a person becomes reduced to something less than he is; and with loss of intellect, a very clever animal perhaps, but not a personal subject. The person is objectified. His value is in what he has or possesses; He does not have any intrinsic worth.
One sees human life as a gift, something sacred; the other sees human life as something to be manipulated. Living out these positions is what we mean by the Culture of Life and the Culture of Death; and in the context of medicine, Hippocratic medicine or the 'new' medicine.
From the time of Hippocrates, 400 BC, the Physician's prime duty has been to his patient "I will follow that system of regimen which, according to my ability and judgement, I consider for the benefit of my patients, and abstain from whatever is deleterious or mischievous3 Hippocrates: The physician is personally responsible for his acts and advice to his patient. He recognizes absolute and objective moral norms associated with the practice of his art.4
Today, the Physician has a "social commitment to sustain life and relieve suffering. Where the performance of one duty conflicts with the other the preference of the patient should prevail".5 The physician no longer accepts full responsibility for his patient "but will comply to the wishes of the patient or family or proxy " even against his own best judgement.6 All morality is utilitarian; all truth is relative.
When the World Health Organization (WHO) in 1948 redefined health7 as a state of complete physical, social and mental well-being and not merely the absence of disease. The Medicalization of life was established and complete, with the moral being subsumed under the medical, acts, open to public scrutiny like abortion, become private acts. The result is the therapeutic Society.8
Hippocratic medicine/Culture of Life: "Only the loss of the vital unity of the organism can be taken as the sign of death"9 The human soul, being eternal, can exist without the human body, but the human body cannot exist without the human soul.10
Throughout history, death has been understood as the end of earthly life: and in some way the entrance into eternal life. Death also includes the separation of the soul or principle of life from the body.
The 'new' medicine/Culture of Death: There is no legal definition of death. Basically, you are dead when a doctor says you are dead. Death is the complete end of life. As nothing exists except the material, when the body dies the person ceases to exist. "There is no ethical distinction between withdrawing and withholding life-sustaining treatment, including food and drink"11 This means that under some circumstances the physician may directly kill his patient, whether the patient wants to die or not. In the Netherlands, patients are being killed without their consent by their physicians.12
Hippocratic medicine/Culture of Life: Dying is due to illness or old age. It is associated with physical pain and may be accompanied by suffering, fear and despair. It is part of life. Helping the Dying includes spiritual help, medical help, human and personal help and help with physical pain
The 'new' medicine/Culture of Death: When death is understood as the end of everything, suffering and pain before death have no meaning. When a person is severely handicapped, although alive, their lives have little meaning or value. Hence the growing practice of Euthanasia, Physician assisted suicide, Suicide, and blurring the distinction between killing and letting die.
I will now briefly review the circumstances in which this arises:
Hippocratic medicine/Culture of Life: Life is inherently valuable and sacred, a gift from God. Suicide is directly taking one's own life. It is a very serious offense against God and neighbor. Suicide is associated with Major psychiatric illness which can be successfully treated, with pain which can be successfully treated and with despair, the belief that there is no hope for oneself before God, a spiritual need which can be helped
The 'new' medicine/Culture of Death: When death itself is meaningless, suffering before death makes no sense. Why should a suffering person who is dying, not kill themselves or be helped to do so? After all, your life is your own to be disposed of as you see fit.
Hippocratic medicine/Culture of Life: "The act13 of deliberately ending the life of a patient, with or without the consent of the patient or his family. It is always wrong." _ "The Physician may allow the natural process of death to take its natural course."
The 'new' medicine/Culture of Death: Euthanasia is the administration of a lethal agent by another person to a patient for the purposes of relieving the patient's intolerable and incurable suffering14. Euthanasia is a gentle15 and easy death. Words are used with changed meanings what used to apply to the dog, now applies to grandma. You put her out of her misery. It now means voluntary ways of assisting in another's death.
Hippocratic medicine/Culture of Life: Killing is the direct act (commission or omission) of bringing about another's death. Letting die is foreseeing a person will die, and doing nothing to either prolong or hasten death by direct means. Right and wrong can be objectively known based on Natural Law and revelation. The physician accepts personal responsibility for his conduct in the death of his patient.
The 'new' medicine/Culture of Death: There is no ethical distinction between withdrawing and withholding life-sustaining treatment.16 This includes mechanical ventilation, renal dialysis, chemotherapy, antibiotics and artificial nutrition and hydration. Advance directives supercede physician's informed opinion and are acted on even to killing patient, although it is not called that. The Physician has general responsibility for the patient's death based on current practice, protocol etc. The distinction of killing/letting die is no longer used.
Hippocratic medicine/Culture of life: Food and drink are normative for life. They should never be actively removed - that is direct killing by starvation. Dying patient many be unable to take food and drink - patient may legitimately refuse food or drink. Towards death fluids may flood patient's tissues - make things worse - withdraw.
The 'new' medicine/Culture of Death: Assumed that food and drink are part of treatment This is another way of saying food and drink are extraordinary means of care. Withdrawing food and drink is a legitimate form of "treating" the dying.
Hippocratic medicine/Culture of Life: When ICU's became standard practice in the 1960's, the physician was not recognizing his patient was dying and engaged in heroic surgery or other interventions. Today relatives occasionally get over anxious that all is not being done. Ordinary means include Food and drink, Pain relief, Human contact, Spiritual comfort, usual medication including antibiotics, insulin etc. It may include use of a respirator.
The 'new' medicine/Culture of Death The physician accepts patient is dying. He does not realize medical intervention has changed to care of the dying. He avoids patient, no medical or spiritual interventions offered except death. The distinction between ordinary and extraordinary means has been lost. This leads to
Hippocratic medicine/Culture of Life: The dying should be cared for and their difficulties adequately diagnosed depression, pain, despair etc. Note, most high profile cases of euthanasia are of women with chronic disease such as MS, ALS etc, not dying patients.
The 'new' medicine/Culture of Death: The patient's request to die is accepted at face value, no medical investigation or appropriate referral is sought. The Physician prescribes medication, which should kill the patient although it often does not. The patient takes the medication himself. The physician is in collusion with the patient in their death, a direct killing.
Hippocratic medicine/Culture of Life: The physician/Hospital must DO NO EVIL in following advanced directives. i.e. directly, kill the patient. The patient cannot foresee the future or be expected to understand current procedures or language on what is now called End-of-Life Care.18 In advance directives patients do not ask or believe they are asking to be killed by direct means.
The 'new' medicine/Culture of Death: Advance directives are for the Hospital and Physician not the patient. They are used as the basis for patient's end of life care in hospital/hospice. Do not resuscitate can become direct killing of the patient. The brain stem may be intact in many so-called cases of brain dead.
Hippocratic medicine/Culture of Life: A Persistent Vegetative19 state is a new name for a very old diagnosis. In Chronic, Organic Brain Syndrome20,21 serious brain damage occurs with loss of cognition, loss of perception with the ability to communicate, loss of volition or loss of memory in a patient with an intact brain stem. I/thou relations is not a diagnostic entity in medicine, but a distinction in philosophy. The patient can breathe, support their own circulation. There are many reports of individual patients who, having recovered, tell of being conscious while in this state. Chronic Brain Syndrome takes many forms. The patient is not dying: To the contrary, she is living with a chronic disability.
The 'new' medicine/Culture of Death: Life sustaining treatment is now defined as "any treatment that serves to prolong life without reversing the underlying medical condition".22 This definition redefines all those patients who are chronically ill from receiving ordinary medical care, to life sustaining treatment. Further, without the mental capacities described above, a person is no longer a person, but a lower form of human life and, although living, may be killed directly. This is to redefine what it means to be a human being; a very serious slippery slope to killing others with brain syndromes such as Alzheimer's, Huntington Chorea, Chronic Schizophrenia, Severe Mental Handicap etc. When coupled with Advanced Directives and Withholding food and fluids. This is a common form of euthanasia.
Hippocratic medicine/Culture of Life24: A person's death is a single event involving spirit, soul and body The defense and promotion of the integral good of the human person must be maintained. Informed consent of the donor must be obtained. Physicians who determine death MUST NOT be involved in organ transplants. Vital organs may only be removed after death there must be no commercialization in human organs.
The difficulty is this: Even if the brain stem is dead, if the patient is still breathing and has a heartbeat, even if artificially maintained, he is still alive. We are being asked to believe we can have a living human body without a soul or spirit.25
The 'new' medicine/Culture of Death:26,27 Until recently, Physicians ascertained death after the fact based on heartbeat, breathing, rigor and post mortem lavidity. Then the physician was asked to make a prognosis on when the patient would die. Now the prognostic criteria are used as diagnostic of death itself to diagnose death before the event28. Because of the need for fully perfused organs for transplantation, death is synonymous with death of the brain and brainstem. However, artificial means are used to keep the body alive. Death does not actually take place until the patient has a major organ removed.
Hippocratic medicine/Culture of Life: Pain can always be treated adequately without unconsciousness with two rare exceptions. Thalamic pain and some severe bone pain. Human Suffering must be recognized and helped Direct withdrawal of food and water is always unacceptable.
The 'new' medicine/Culture of Death: With the use of increasing doses of narcotic medication over a period of days the Patient is or becomes unconscious. Food and drink is withdrawn This is becoming a common form of euthanasia.
The cost of Death and Dying is the unstated factor. With a greatly increased elderly population and relatively few to care for them, the cost of staying alive is becoming prohibitive. Let us not forget, contraception and abortion are the two most common medical interventions. The killing is going on because the medical profession agrees to it. The profession is clearly accepting euthanasia, only this time it will be done without any change in the law.
1 Illich, Ivan, 1976. Medical Nemesis, Part II, Random House []
2 Hippocrates of Cos., On Ancient Medicine, Trans Francis Adams, http://classics.mit.edu/Hippocrates/ancimed.mb.txt [Back]
3 Hippocrates of Cos, 400 BC, Translated by Francis Adams, The Oath, http://www.classics.mit.edu [Back]
5 Withholding or withdrawing life-sustaining medical treatment, E2-20 AMA http://www.ama.com [Back]
7 Preamble to the Constitution of the World Health Organization as adopted by the International Health Conference, New York, 19-20 June, 1946; signed on 22 July, 1946 by the representatives of 61 States (Official Records of the World Health Organization, no 2, p100) and entered into force on 7 April; 1948 The Definition has not been amended since 1948. [Back]
8 Reiff, Philip: The Triumph of the Therapeutic, uses of Faith after Freud (1966) Harper Torch Books [Back]
9 Most Rev Elio Sgreccia, Bishop, The Subject in a Vegetative State: a personalist view, http://www.zenitenglish@zenit.org weekly news analysis April 24, 20 [Back]
11 Dr. David Hill, MD, Consultant Anesthetist, Addenbrooks Hospital, Cambridge, England, Interview, Transplants - are the Donors really really dead http://www.cmf.org.uk.pubs/helix/spr99/trans.htm Withholding or withdrawing life-sustaining medical treatment, E2-20 AMA http://www.ama.assn.org [Back]
12 John Keown; Euthanasia in the Netherlands in Euthanasia Examined, ethical, clinical and legal perspectives (1995) Cambridge University Press [Back]
13 World Medical Association Declaration on Euthanasia, Adopted by the 39th World Medical Assembly, Madrid, Spain, October 1978 http://www.wma.net/e/pol.icy/e13.htm [Back]
14 Euthanasia E-2American Medical Association Policy Finder. http://www.ama.assn.org [Back]
15 Oxford English Dictionary, 1975 [Back]
16 Decisions near the end of Life H-140.966, American Medical Association http://www.ama.assn.org/ [Back]
17 John Paul II Address 20 March 2004, to participants in the international congress on "Life-Sustaining Treatments and Vegetative state: Scientific advances and ethical Dilemmas" http://www.vatican.va []
18 Quality End of Life Care, American Medical Association, http://www.ama.assn.org/ [Back]
19 World Medical Association Statement on Persistent Vegetative State, Policy statement adopted by the 41st World Medical Assembly Hong Kong September 1989 http://www.wma.net/e/policy/p11.htm [Back]
20 MyerGross Slater and Roth, Clinical Psychiatry, Tindall & Cassell, London, 1969, Ch VII Alcoholism Drug addictions etc. p 388-442, Ch IX Mental Disorders in Trauma etc. p 485-530. Ch X Aging and Mental Diseases p533-610. Ch XII Mental Subnormality etc. p692-731 [Back]
21 Diagnostic and Statistical Manuel of Mental Disorders, Fourth edition, 1995 American Psychiatric Association, Delirium, Dementia etc. p123, Mental Disorders….Medical Condition etc. p165, Substance, p175, Schizophrenia p273 [Back]
22 Withholding or withdrawing life-sustaining medical treatment E2.20, AMA http://www.ama.assn.org [Back]
23 Most Rev Elio Sgreccia, Bishop, The Subject in a Vegetative State: a personalist view, http://wwwzenitenglish@zenit.org weekly news analysis April 24, 2004 []
24 Pope John Paul II Address to the 18th International Congress of the Transplantation Society, 29 August, 2002 on http://www.vatican.va [Back]
25 Most Rev Elio Sgreccia, Bishop, The Subject in a Vegetative State: a personalist view, http://www.zenitenglish@zenit.org weekly news analysis April 24, 20 [Back]
26 Guidelines for the determination of death: Report of the medical consultants on the diagnosis of death to the President's Commission for the Study of Ethical Problems in Medicine and Biomedical and Behavioral Research, JAMA, 246, 1981 [Back]
27 World Medical Association Declaration on Death, Policy statement adopted by the 22nd World Medical Assembly, Sydney, Australia, August, 1968 and amended by the 35th World Medical Assemble Venice, Italy, October 1983. http://www.wma.net/e/policy/d2.htm [Back]
28 Dr. David Hill, MD, Consultant Anesthetist, Addenbrooks Hospital, Cambridge, England, Interview, Transplants - are the Donors really really dead http://www.cmf.org.uk.pubs/helix/spr99/trans.htm [Back]