The Charter for Health Care Workers: A Synthesis of Hippocratic Ethics and Christian Morality

I have the honor rather than the task of presenting the Charter for Health Care Workers to this international conference. When I thought about the best way of doing this it seemed to me opportune as well as useful to take a broad overall view. With such an approach it would be possible to give a clear presentation of the chief concern which pervades the text, namely that of helping the health care worker to serve human life from its beginning until its natural end. Such service is fully human and specifically Christian. This paper of mine thus seeks, and this is a very important point, to show immediately how the Charter is in very practical terms a synthesis of Hippocratic ethics and Christian morality. In order to achieve this rather ambitious goal I will begin by emphasizing the divine origins of each human life and its destination towards God himself. After this I will describe how the figure of the health care worker is a servant to this life and thus, and above all else, to the Author of this life. Finally, I will trace the path of human existence: generation, life, and death, all of which are central reference points for ethical-pastoral reflection and thought.

1. God: The Alpha and Omega of Human Life

When there was no man who tilled the soil or who brought forth water from the earth to irrigate its surface "the Lord God formed man of dust from the ground, and breathed into his nostrils the breath of life; and man became a living being."1 From this creative act of God the Church derives her teaching that each spiritual soul is created directly by God and is immortal--that is to say, that it does not perish at the moment of its separation from the body at death. Not only this but the Church also teaches that this soul is united once again with the body at the moment of the final resurrection. The life of the human being, of every human being, is not the product of parents or of a laboratory projected and constructed by man. Human life, and the point is not in the least open to discussion, has a divine origin.2 A sentence from the Book of Job is very significant here: "If he (the Lord) should take back his spirit to himself, and gather to himself his breath, all flesh would perish together, and man would return to dust."3 Of no less significance is Ezekiel's comment on the resurrection: "And I shall put my spirit within you, and you shall live."4 Without the "vitalizing breath" of God man would indeed merely fall back into nothing. But if God gives a soul to the body--that is to say, if he gives life--then it is more than right that He, and only He, attributes to Himself the inalienable and inviolable right to manage and order the life of each human being from the moment of conception until natural death. John Paul II does not hesitate for a moment to proclaim, with a certain solemnity, the existence of this divine right: "Human life is sacred because from its very beginning it bears the `creative action of God' and it always remains in a special relationship with the Creator, its only end. Only God is the Lord of life from its beginning until its end: nobody, in any circumstances, can give to himself the right to directly destroy an innocent human being."5 Here we encounter the central feature of Christian morality in relation to the sacredness and the inviolability of human life, of every human life, of the human life of every man. This is why Jehovah, when he revealed the ten commandments of the Covenant, put the commandment "Thou shalt not kill" at the center of this Covenant, a fact which deserves special attention. God makes himself not only judge of each violation of the commandment in defense of life but also and above all else he makes himself the defender of a commandment placed at the very basis of the whole of social coexistence.6 For good reasons, therefore, Christian morality has always proclaimed and defended and still proclaims and defends today the incomparable value of the life of each human person. But Hippocratic ethics, expressed in the ever relevant and contemporary famous oath, have also proclaimed and defended this value of each human life and has done so for over two thousand years. It therefore comes as no surprise that within this permanently valid set of ethics there are to be found four key features, as Cardinal Fiorenzo Angelini has pointed out, and these are: "a profound respect for nature in general; a unifying and integral conception of human life, or rather, of the human being; a close and rigid relationship between personal ethics and professional ethics; and a largely active vision of the practice of the art of medicine."7 For Hippocratic Ethics as for Christian morality, therefore, the life of each human being is a value which cannot be called into question--it must be defended and watched over. In a word, it must be served. If this imperative applies to everybody, it must apply first and foremost and above all else to health care workers. This is what the Charter makes clear, a Charter which (as I have made clear above) I have the honor to present to this great and august assembly present here today.

2. The Figure of the Health Care Worker

The activities of the health care worker are the expression of a deeply human and Christian act of service precisely because such service is not only of a technical character but also and above all else because it involves devotion to, and love for, one's fellow man, one's neighbor. In their care and concern for the lives of other people, health care workers perform an action which involves the prevention, cure and rehabilitation of human health and the stewardship of life, an action which is truly Christian and human. For this reason the primary and emblematic form of such care is to be found in their concerned and committed presence at the side of the sick.8 This is why medical and health care service implies an interpersonal relationship which is very special: it is, indeed, an encounter between trust and conscience. It is a relationship of "trust" on the part of the person in need of treatment and care because he is afflicted by illness and thus by suffering, and of "conscience" on the part of the person who is able to respond to this need through a fusion of care, treatment and healing. For the health care worker the sick person is never or at least should never be a simple clinical case which should be examined "scientifically." He is always a person who is in special need--because he is sick--of sympathy or perhaps of empathy, in the etymological sense of these terms. "Scientific and professional skill are not enough, personal participation in the practical situations of each individual patient is what is needed." That is to say one needs: "readiness to help, attention, understanding, sharing, benevolence, patience and dialogue."9 In order to achieve a better and more precise understanding of this Charter it is very important to observe that this total dedication on the part of the health care worker to serving each sick person finds its truest "objective" basis and its most pressing "subjective" basis--that is to say its most involving basis--in an overall vision and understanding of the sick man himself. Understood at their roots, illness and suffering are in reality phenomena of human life which pose questions which transcend medical science and technology. This is because they touch upon the axiological essence of the existential condition of man on earth. From this point of view the health care worker, if he is a Christian and thus a follower of the Good Samaritan or even if he is not a Christian and thus a follower of the most human "secular" figure of Hippocrates, easily understands that his profession is a mission and thus a vocation. His medical-health care activity is thereby a response to a transcendental call which takes concrete form in the suffering and imploring face of the patient entrusted to his care. His loving care for a sick person, characterized by sympathy and empathy, becomes an act of service which is similar to that related by the parable of the Good Samaritan and also that required by the oath of the Hippocratic physician. This is why profession, vocation and mission meet each other in the figure of each and every health care worker, and in the light of the Christian vision of life and health the health care worker is a minister of that God who in the Holy Scriptures is presented as a "lover of life."10 To serve the life of the sick man becomes, indeed, service to God and also cooperation with God: the gesture of loving welcome of the weak and sick life in order to give health becomes the giving of praise and glory to God.11 It is no surprise, therefore, that the Church "has always seen medicine as an important support of her own redemptive mission in relation to man. Indeed, service to the spirit of man cannot take place fully if it does not place itself at the service of his psycho-physical unity. The Church well knows that physical ills imprison the spirit in the same way as the ills of the spirit enslave the body."12 The figure of the health care worker is, and thus should always increasingly become, a live image of Christ the Good Samaritan. "Doctors, nurses, other workers in the world of health, and volunteers," John Paul II makes clear, "are called upon to be the alive image of Christ and of his Church in love towards the sick and the suffering: witnesses of the `gospel of life.'"13

3. Ethical-Moral Faithfulness and the Sacredness and Inviolability of Life

The profession, mission, and vocation of the health care worker naturally requires a solid training and a constant ethical-religious formation in moral questions in general and in questions relating to bioethics in particular. In the presence of clinical cases which become ever more complicated and intricate in character because of advances in the realm of biotechnology, all health care workers--but especially medical doctors--cannot and must not be left alone to be burdened by responsibilities which can not be borne. This is becomes even more evident if we reflect upon the fact that many of these advances are still at an experimental stage and are of great social relevance when we come to consider matter relating to the whole world of health and health policy.14 We can state with certainty that the true and authentic humanization of medical science and technology is clearly at stake. In other words, it is evident that in the field of medicine we need to bring about that "civilization of love and of life without which the existence of individuals and society loses its most authentically human meaning."15 Such, then, is the principal aim of this Charter: to guarantee the ethical faithfulness of the health care worker so that he can build--both in his choices and in his behavior--that civilization of love and life invoked by the eminent author of the Evangelium Vitae. And it is for this reason that the Charter takes as its reference point for ethical and religious reflection and thought that path of human existence which consists of being created, of living and of dying.16

3.1. Responsibility Towards the Dignity of Human Procreation

The creation of a new human being is an event which is both profoundly human and highly religious. This is because it involves the unitive love of the marriage partners, a reality which is itself an act of cooperation with God the creator. Because of this it is more than evident that health care workers are called upon to help the parents and marriage partners to "procreate with responsibility, to favor the conditions of such procreation, remove obstacles to it, and safeguard it against an invasive `technologicalism' which is not worthy of human procreation."17 In this service true morality rightly distinguishes between the therapeutic manipulation and the alternative manipulation of the human genetic patrimony. "No social or scientific usefulness and no ideological motivation could ever justify intervention on the human genome which is not therapeutic in character, that is to say in itself directed towards the natural development of the human being."18 The reason for this "absolute no" is to be found in the very dignity of human procreation, and this is because the new human being who is born from conjugal union "carries with him a special image and likeness of God himself: in the biology of generation is inscribed the genealogy of the person."19 The conception and generation of a new human being is not the outcome of the laws of biology but constitutes, rather, an event of conjugal cooperation in the continuation of divine creation. Here the Charter makes clear that the procreative cooperation practiced by the marriage partners is not only the criterion behind the anthropological and moral difference between natural and artificial methods of procreation but also constitutes the evaluative criterion in matters relating to artificial procreation. "The dignity of the human person requires that he comes into existence as a gift of God and fruit of the conjugal act which belongs to, and is specific to, the unitive and procreative love of the marriage partners, an act which by its very nature cannot be substituted."20 This is why the appeal to the sense of responsibility of health care workers to promote this Christian and human conception of sexuality is more than right and just. In this way the knowledge required for behavior which is responsible and respectful of the special dignity of human sexuality in general, and the conjugal act in particular, is made accessible to marriage partners and above all to young people.21 Health care workers should in the first place help marriage partners to understand the anthropological and moral difference between natural assistance and artificial substitution in matters relating to procreation. In relation to the last question health care workers should stress the wrongfulness of in vitro fertilization with embryo transfer, whether it is heterologous or homologous in character. Obviously enough, this moral judgment concerns only the methods of fertilization and not the human being in question who must always be welcomed as a gift of God and brought up with great love.22 Service to life performed by health care workers begins, therefore, with the promotion of this very great respect for the originality of the generation of human beings.

3.2. Responsibility Towards Human Health and Life

The marvelous process of a new human life begins under the wise and loving protection of love at the moment of fertilization. Health care workers and in particular gynecologists and obstetricians should "watch with great care over the wonderful and mysterious process of generation which takes place in the maternal womb in order to follow its correct development and promote its happy outcome through the coming into the light of a new creature."23 They must remind themselves first and foremost of the singular dignity of each human life: the dignity of the person created in the image and likeness of God. Health care workers must above all else be aware that each person is a unity of body and soul, and realize that for this reason the person himself in his practical reality becomes achieved through the body. "Each intervention on the human body does not act only upon tissue, organs and their functions, but involves the same person at different levels."24 From this it follows that the body, by being a reality which is a property of the person because it reveals the person in his relationship with God, with other human beings, and with the world, is the basis and source of moral requirements. The body cannot be treated like an object which belongs to somebody, like a thing or an instrument of which we are owners and arbiters. This is the reason why not everything which is technically possible can be considered morally acceptable."25 The intrinsic purpose of the profession of health care workers is the upholding of the right of man to life and to his dignity. Their duty (which flows from this reality) lies, therefore, in the preventive and therapeutic stewarding and promotion of health and the improvement of the lives of people. "Illness and suffering are not experiences which only affect the physical dimension to man but man in his entirety and in his somatic-spiritual unity."26 Diagnosis, treatment and rehabilitation, therefore, not only aim at the well-being and the health of the physical body but also seek the integral well-being of the person in a more general sense. At this point there arises the question of what happens when it is impossible to cure the sick person. In such a case the health care worker is always required to effect and practice all suitable forms of treatment and care but he can also quite rightly interrupt forms of treatment and care which are not suitable or appropriate.27 Here the question of the humanization of pain through the use of analgesics or anesthetics is very important. Even though for the Christian pain has a great penitential and salvific significance, Christian charity itself also calls upon health care workers to alleviate suffering.28 And here in more pressing fashion comes into play the fundamental right of the sick person to pastoral care and to the sacrament of the anointing of the sick. Each and every health care worker is required to create conditions which will enable those who call for religious assistance, whether implicitly or explicitly, to receive such assistance. "Indeed, experience teaches us that man when in need of both preventive and therapeutic help reveals needs which go beyond the confines of the pathology of the body which afflicts him. He expects from the medical doctor not only adequate and suitable care--care which sooner or later will be shown to be insufficient and with obvious fatal consequences--but also the human support of a brother who knows how to ensure that he participates in a vision of life which provides him with a meaning--amongst other things--to the mystery of suffering and death. And where can be found a peace-giving answer to the supreme questions about existence if not in faith?"29

3.3. Care and Assistance Until the Natural Conclusion of Life

When conditions of health deteriorate to an irreversible and terminal level, or rather when man enters into the final stage of his earthly existence, health care workers are called upon to give special care and help to the sick person. "Never should life be celebrated and exalted so much as in nearness to death and at death itself... Behavior towards the terminally sick is the acid test of the sense of justice and charity, of the nobility of soul, of the responsibility and the professional ability, of health care workers, beginning with the doctors themselves."30 This is the moment when dying should be withdrawn from the realm of medicine, concerned as this is in large measure with the biophysical aspect of the illness. At this stage the most important form of care lies in a loving presence which is full of attention and concern, and which instills trust and hope, replacing, thereby, a refusal of death with its acceptance. Powerless as we are when faced with the mystery of death, Christian faith is in such a context the only source of serenity and peace. For this reason, the bearing of witness to faith and hope in Christ by the health care worker is of crucial importance. The creation of a presence of faith and hope is the highest form of humanization and Christianization of dying which doctors and nurses can promote. In the case of the terminally ill the right to life becomes the right to die in all serenity and with the greatest possible human and Christian dignity. This right rules out every form of therapeutic overkill and, to an even greater extent, every attempt to put an end to life.31"Euthanasia upsets the relationship between patient and doctor. With regard to the patient this occurs because the patient enters into a relationship with the doctor which is based upon this latter providing death. With regard to the doctor this occurs because the physician is no longer the guarantor of life--the sick person fears, instead, that the physician will proffer death. The relationship between the doctor and the patient is a relationship based upon trust in life and it must remain as such. Euthanasia is a `crime' in which health care workers who are always and only guarantors of life can never participate."32 The same is true of abortion even if the health of the mother, a child too many, a serious fetal deformation, and a pregnancy caused by sexual violence, all involve very serious questions. Indeed, life is such a primary and fundamental good that it can be placed on an equal footing (in a situation of equality or even of inferiority) with certain very serious disadvantages.33 Here the evident synthesis of Hippocratic ethics and Christian morality cannot be contested -both Hippocratic ethics and Christian morality regard all forms of direct abortion or direct (whether active or passive) euthanasia as illegitimate because one is dealing with an act which destroys a prenatal life and with an act of murder which nobody can justify.34 Hence the difference from the right to die with human and Christian dignity. "This is a real and legitimate right which health care staff are called upon to safeguard by taking care of the dying person and accepting the natural ending of life. There is a radical difference between `putting to death' and `allowing to die': the first is an act which destroys life; the second accepts life until death."35 It is precisely in this acceptance of the end of earthly life that each faithful servant of life watches over this fulfillment of the will of God. He does not for any reason whatsoever consider himself the arbiter of death, in the same way as he does not for any reason consider himself the arbiter of somebody's life.36 Indeed, it is this context, more than at any other time, consoling for the dying person when the health care worker bears witness to the fact that full participation in divine life is the goal to which man on this earth is called to and oriented towards. In such a context, more than at any other time, is it comforting for the terminally ill to experience the sacramental presence of Christ, "Word of life," through the anointing of the sick. "The whole of man receives help through this sacrament to achieve salvation. He feels strengthened by trust in God and gains new strength by which to combat the temptations of evil and the anxieties of death."37 The same is even more true when we consider the Eucharistic encounter, something which is a viaticum of the body and blood of Christ. In the words of Christ it is a pledge of the resurrection: "who ever eats of my flesh and drinks of my blood will have eternal life, and I will raise him up on the last day."

Conclusion

I hope that I have demonstrated what our president, Cardinal Fiorenzo Angelini, wrote in the preface: that none of the complicated and intricate problems and questions raised by the inseparable existing relationship between medicine and morality can, at the present time, be considered a sort of neutral ground in relation to Hippocratic ethics and Christian morality. For this reason, the Charter for Health Care Workers has given rigorous respect to the need to offer an organic and complete synthesis by the Church, beginning with Pius XII, on all matters concerning the upholding, in the field of health policy and care, of the primary and fundamental value of the life of each and every human being from the moment of conception to natural death.38 I would like to conclude with a special reference to the progress and spread of the medicine and surgery of transplants, phenomena which guarantee the treatment and the cure of many sick people who until only recently found themselves in a terminally ill condition. Here we encounter a challenge to love of a totally unprecedented character: loving one's neighbor through the donation of organs so that he can go on living. The removal of organs for homoplastic transplants from live or dead donors can take place, but naturally enough within the limits imposed by human nature.39 In the first case the removal is legitimate as long as the removal does not imply serious and irreversible damage for the donor. In the second case the body of the dead person must be respected as belonging to a human being, even if it no longer has the dignity of an individual and the value bestowed by a person who is still alive. The medical act of transplantation, therefore, makes the act of oblation on the part of the donor possible, a sincere giving of oneself which expresses one's essential human and Christian call to love and communion.40 The intention of the Charter for Health Care Workers is paradigmatic with regard to service to life, that is to say, in relation to responding to the call of Christ: "Vade et fac similiter."

Notes

1. Genesis 2:7; see also 2:5-6.

2. Catechism of the Catholic Church, 366; hereafter CCC.

3. Job 34:14-15.

4. Ezekiel, 37:14.

5. JOHN PAUL II, Evangelium Vitae, 53; hereafter EV.

6. Ibid.

7. FIORENZO ANGELINI, Quel Soffio sulla Creta, (Rome, 1990), pp. 377-378.

8. Pontifical Council for Pastoral Assistance to Health Care Workers, Charter for Health Care Workers (Vatican City, 1995), fourth edition, no. 1; hereafter Charter.

9. Charter, 2.

10.Wisdom 11:26.

11. Cf. Charter, 4.

12. Charter, 5.

13. Quoted in Charter, 5.

14. Cf. Charter, 8.

15. EV, 27, quoted in Charter, 9.

16. Cf. Charter, 10.

17. Charter, 11.

18. JOHN PAUL II, "All'Unione Giuristi Cattolici Italiani," 5 Dec. 1987, in Insegnamenti, X/3 (1987), 1295, quoted in Charter, 13.

19. Charter, 15.

20. Charter, 22.

21. Cf. Charter, 20-23.

22. Cf. Charter, 24.30.

23. Charter, 36.

24. Charter, 40.

25. Cf. Charter, 44.

26. Charter, 53.

27. Cf. Charter, 64-5.

28. Cf. Charter, 68-71.

29. JOHN PAUL II, "To the World Congress of Catholic Doctors," 3 October 1982, in Insegnamenti, V/3, 1982, p. 675, quoted in Charter, note 212.

30. Charter, 115.

31. Cf. Charter, 119; 147-8.

32. Charter, 150.

33. Cf. Charter, 141.

34. Cf. Charter, 139; 147.

35. Charter, 148.

36. Cf. Charter, 114.

37. Cf. Charter, 111.

38. Cf. Charter, p. 5.

39. Cf. Charter, 83.

40. Cf. Charter, 86-91.

(*) The quotations from the Charter for Health Care Workers have been translated from the Italian edition. The English edition (Vatican City: Pontifical Council for Pastoral Assistance to Health Care Workers, 1995) is now available - ED).