The article deals with three "medical" options about the end of a man's life. The first two, respectively euthanasia and therapeutic obstinacy, are misunderstandings of human nature and dignity at the end of life and do not accept, in the end, that death is a human fact.
That is why, in this article, a third option is advocated: for the medical service of Palliative Care because comprehensively cares for terminally ill patients, with In order that they may lead a full life, within the context of the terminal illness.

Keywords: euthanasia, therapeutic obstinacy, palliative care

Death is part of human nature and therefore has to happen naturally. Accepting it means that we should prepare properly for the death of other people, but also for ours. Unfortunately it is not so. If one wanted to "avoid" death as a natural occurrence, he would cease to be a person. Even so, there are two ways to “avoid it”: 1) with euthanasia; 2) with therapeutic obstinacy. These two options are misunderstandings of human nature and dignity at the end of life.

Death places us in the reality of what we are constitutively: limited, finite, weak, fragile beings. Disease and death are obvious signs of this vulnerability. In this sense, it is noticed that for every living being it is as natural to be born as to die.

Definition

A definition of euthanasia that could be admitted by all,¹ is one that defines it as: “Conduct (action or omission) intentionally aimed at ending the life of a person who has a serious and irreversible disease, for compassionate reasons (this it is, in order to minimize suffering) and in a medical context ”.

However, it should be noted that those who favor euthanasia do not usually use this term, but refer to it by putting other denominations "euphemistic", such as "dignified death", "help die", "right to die”… The use of all of them is intended to decriminalize euthanasia, justifying it as a way of preventing the physical suffering of people.

Euthanasia and "Right to Die"

Another term that is usually used to refer to euthanasia and want to legalize it is the right of the patient to die with dignity.² The human dignity of the patient would result in the right to freely choose the moment of death itself.

But, in this respect it is necessary to specify:

1. There is no "right to die." If doctors acted forgetting their professional ethical commitment and putting their medical science at the service of obtaining an end contrary to the current legal system, their action would be unlawful, and of course, it would be against medical ethics. There is no right to commit an evil such as requesting that another take your life.
2. What exists is the right to life,³ which is, on the other hand, an inalienable and fundamental right, therefore, prior to a legislative concession, and as such, intrinsic to human dignity that is not based on majority determinations. Precisely, human life is the substrate of rights. The right to life derives directly from the dignity of the person.

If the dignity and the right to life are not recognized to every human being, regardless of their state of health, their usefulness... the attention to incurable and terminal patients, that "collapses" certain health social services and that involves a great investment economic and personal, it would remain in the air.

Euthanasia is justified for the sake of freedom. But one can only speak of the “right to die”, if one starts from a concept of individualistic and solipsist freedom, that is, closed in itself. This conception would erect freedom itself as a source of law and, consequently, individual wishes would be the creators of rights. If a man does not wish to continue living, his will should be respected. From this mistaken conception of freedom the connection of this false “right to die” with the patient's request or request is based.

Suppressing life means destroying the very roots of freedom. Therefore, it is a mistake to think that there is an all-powerful and egocentric individualist freedom beyond all rational limits. Indeed, freedom is only totally free and human if it translates into individual commitment to do good.

This non-existent right,⁴ is also defended for the sake of a false understanding of human autonomy. Remember that this is only possible if you have the budget of being alive and knowing that our life is a life given by and for others.

Precisely, individual and social responsibility consists in taking charge of the weak and fragile human life of those who no longer have the capacity to take care of themselves.

Therefore, autonomy does not mean accepting the decision as valid. Certainly, our society has endorsed human rights as basic pillars in such a way that it must protect citizens so that their actions in the field of these rights can be respected.

However, this protection also extends to protecting the individual even from himself, when he intends to violate his own human rights.⁵ That is why it can be understood that the requirement to treat people respecting their dignity may sometimes mean limiting their decisions that go against their dignity, even if they are carried out autonomously.

If euthanasia were accepted and legalized, where would the autonomy of the doctor, his professional identity and his free decision be? Where would the lex artis of the doctor always be called to sustain life and cure or alleviate pain, and never to give death “not even moved by the pressing requests of anyone” (Hippocratic Oath)?, What place would dialogue and trust between the doctor and the patient occupy, if the particular opinion of the doctor and the lex artis of his profession were subject to the wishes of the sick?

Martínez Otero adds other questions of what would happen if the doctor had to fulfill the wishes of the patient or his relatives.⁶ These questions allow us to glimpse an uncertain horizon for the medical profession and for the doctor-patient relationship.

These questions and statements, which this author asks himself, raise us, among other things, that, if euthanasia is legalized, for the sake of a supposed right to patient autonomy there would only be the same for some citizens, others would lack that right. , that is, the autonomy of the doctor would disappear.

It seems to me that those in favor of euthanasia make an exacerbation of the patient's autonomy, whose only limitation would be, in any case, that of the legal system without mentioning the lex artis of the doctor. This cannot be reduced to a technician who must execute the patient's own wishes or a legal representative of the same. Therefore, if the autonomy of the patient is not properly and correctly understood, the doctor becomes, in euthanic action, the only person responsible for the medical act, relegating the medical staff to a mechanical executor. If the medical commitment to preserve life is weakened, the "doctors" would also be dedicated to causing death, then the very nature of the medicine and the doctor's own identity would undergo a profound transformation. The "doctor" would adopt the role of an amoral technician, who can both end a human life and save it.

If euthanasia were admitted legally, the relationship of trust would be broken, that is, there would be a fear that doctors could make a decision about my life. Thus, euthanasia tragically breaks that relationship, in which the two wills (that of the doctor and that of the patient), through dialogue and respect contribute to the improvement of the patient.

Given these arguments, it can be affirmed that euthanasia is an anti-medical practice, since the end of the health professions is the healing and suppression, as far as possible, of pain, and not causing death. It has already been said above: we are not an island, nor do we live alone. The actions of others affect us and what each of us does is a guideline for others. His life, and therefore also his death, affects everyone.⁷

In short, death is not a right, because it implies the annulment of human life, that is, of being. The right to a "dignified death" is a contradiction, a euphemism of the word euthanasia to foster a supposed right to kill oneself. If there is a right to life, there can be no duty to kill.⁸

Euthanasia and patient request

Euthanasia is also linked to the request or request of the patient.

Those in favor of euthanasia do not usually use the expression "kill with dignity", but use another, which could be labeled as "more acceptable": "help" to those who ask.

Directly link the patient's request to the concept of human dignity. Invoking (the defenders of euthanasia) the term of human dignity expresses the demand for recognition of the right to a dignified death, (non-existent right,⁴ that is defended for the sake of a false understanding of human autonomy, that is, not there is the right to take one's life), which is part of the field of personal privacy.

The euthanasia supporters argue that the decision is in that area and that others must respect it and act according to what one has decided about oneself.

This petition, which those who are against euthanasia call it "requested euthanasia," seems to have become an essential element in its philosophical, political and legal justification.

But when euthanasia is requested and linked to the concept of human dignity, is the dignity of the other essential person (whether or not a healthcare professional) to carry out euthanasia being considered?

Do not forget that you cannot kill another person because they have lost their physical health, or for nothing, even if you ask them to, because, otherwise, it would be inciting to kill, which is the same as implicitly saying that human life is worth living if there are a number of conditions.

You cannot ask another person to "help" us or participate in that death, even with medical "help," because another person is being asked to commit a wrong. Therefore, no one can force anyone to commit evil.

Life, like freedom, is a good of humanity, so they cannot be eliminated even at your own request. No one can ask for death, as no one can voluntarily surrender as a slave.⁹

The purported "permission" of euthanasia avoids the key and central issue of this matter: euthanasia involves killing the terminally ill, the elderly, the quadriplegic ... requested by himself, his relatives, or a patient representative.

In fact, article 28.1 of the Code of Ethics and Medical Deontology of the Spanish Collegiate Medical Organization states that:

“The doctor will never intentionally attempt the death of a patient, either by choice, or when the patient or his relatives request it, or by any other requirement. Euthanasia or "homicide for compassion" is contrary to medical ethics".

On the other hand, many of the people who request to advance their end consider it meaningless to continue living suffering from a serious illness, bedridden all day, or sitting in a wheelchair. Of course, they need others to carry out their intentions.

E. Montero wonders about the true content of the petition. When a patient asks to help him die what he is requesting is that they take away his suffering, give him human warmth, listen to him, accompany him in his last days of life, comfort him and give him more affection.¹⁰

Should euthanasia be admitted at the request of the patient, it would have terrible consequences at the social level,¹¹ Advocating for euthanasia would be a claudication of society.

Then, euthanasia is not a purely private and individual matter. Accepting euthanasia would be unconsciously betting on the failure of society.

In short, a promoted and permitted euthanasia would create distrust of citizens, their families and hospitals.

No one has the right to cause the death of another, to annihilate him so that he ceases to be, even if the "sick" asks for it. And no one (the "sick") can have the right to require another person to commit an evil.

Being against euthanasia does not mean being in favor of prolonging the agony of the patient. Likewise, being in favor of death happening naturally does not mean being against the administration of a medication that mitigates or alleviates pain.

Therapeutic obstinacy consists in the establishment of treatments with the intention of preventing death, even though there is no hope of cure.¹² Basically, it generates unnecessary suffering for the patient.

The doctor, who helps the patient in the trance of his death, has to avoid this form of "over-action" known as therapeutic cruelty or incarnation, therapeutic obstinacy, "dysthanasia" (it comes from the Greek words dis and thanatos that mean etymologically prolong the death), that is, the use of all disproportionate or extraordinary measures to keep life going out at all costs.

If the treatments tried by the doctor are applied, which are ineffective, they will end up being a serious damage in terms of anguish or tension for him or his relatives. In this case, the patient can request the suspension of said treatments with all legitimate legitimacy.¹³

The terminal illness produces those who suffer from it, their family and society from excessive expenses. But this does not mean that it is against therapeutic obstinacy by criteria exclusively of an economic nature. Only a conception of life based on utilitarianism can see these patients not as human beings, but as sources of expenses that do not contribute income; not as patients, but as absurd overload of meaningless work.

Therefore, reflection on therapeutic obstinacy requires setting limits, because two imperatives conflict: the technician (do everything possible) and the ethical one (not everything that can be done must be done). But not doing everything technically possible is very different to conclude that nothing needs to be done. Quite the opposite; Now they begin a series of very specific care that must be given to the patient and his family.

In this context, the limitation of therapeutic effort (LET) is in accordance with professional health ethics.¹⁴ According to the analysis of the individual case of each patient, the limitation of therapeutic effort is a decision that is taken, for a specific case, once we have weighted the clinical information, the personal and social situation and the socioeconomic and health factors.

Therefore, when a treatment qualified by the medical team is suspended as futile or disproportionate and without therapeutic expectations, it does not imply euthanasia, neither active nor passive, but it is a correct bioethical action.

In this regard, article 28.2, the aforementioned Code explicitly states the following:

“In case of incurable and terminal illness, the doctor should limit himself to alleviating physical and moral pain, maintaining as much as possible the quality of a life that is running out, and avoiding undertaking or continuing therapeutic actions without hope, useless or stubborn. He will assist the sick until the end, with the respect that human dignity deserves”.

Therefore, euthanasia and therapeutic obstinacy constitute a medical malpractice and a deontological failure. Neither one extreme nor the other: nor euthanasia understood as the right to die with dignity in a way that implies the duty, on the part of the doctor, to kill “with dignity”, or therapeutic obstinacy, that is, to try to prevent one from dying “when It is your moment.” Both options are not consistent with the deal due to a human being.

However, being against therapeutic obstinacy also does not translate into interrupting the basic care that is due to the patient in similar cases.

Indeed, the will of the patient or his family has a limit: they cannot force the doctor to apply treatments not indicated (such as a contraindicated sedation), but neither can the doctor withdraw food and hydration to the patient when care is being provided, that they are basic.

Definition

The World Health Organization (O.M.S) defined Palliative Care in 2002:

“As the approach that improves the quality of life of patients and family members who face the problems associated with life-threatening diseases, through the prevention and relief of suffering through the early identification and impeccable evaluation and treatment of pain and other physical, psychological and spiritual problems”.

The Palliative Care medical service treats the terminally ill in an integral and individualized way with the objective of providing physical, psychological, social, spiritual and religious well-being (not only the absence of physical illness) and their families.¹⁵

In order to provide comprehensive care of these dimensions, close cooperation of multidisciplinary teams is required, which can include health professionals, social workers, occupational therapists, psychologists, ethics experts, spiritual advisors, lawyers and volunteers.

Under this definition, disease and pain, as an expression of the limitation of human beings, are not purely physical matters. Therefore, a medicine that fights exclusively against physical illness is not enough, but a medicine that treats the disease from human reality in all its integrity is required: this is what the medical area of Palliative Care is dedicated to.

Therefore, among Euthanasia, Therapeutic Obstination and Palliative Care, the latter are the most humane way to die, because they establish principles and values in the health system focused on the needs and demands of the sick and their families.

3.2. Palliative Care: ethical solution according to human dignity

The option more in line with the dignity of the human being, which everyone says they want to safeguard, is in palliative medicine, because this "new" medical area is based on respect for human dignity in care.

This medical service considers the patient as a human being until the moment of death, hence their participation in decision making through a close and sincere relationship with the care team.

But for there to be a real decision-making process, communication with the family is essential, which is a fundamental therapeutic instrument, but it is also essential that there be communication between the members of the health team.

For all these reasons, Palliative Care is the best way to help the patient die, not "helping" him to end it. In a nutshell, palliative medicine is not intended to cause death or delay it, but rather constitutes the assistance option compatible with dying with dignity in a humanized context. To alleviate is to mitigate suffering, reaffirming the importance of life, but accepting that death is a human reality.

The option for Palliative Care is precisely what the doctor can ethically do as a doctor.

Also, doctors and their team have the "opportunity" to present their more human face in front of the patient who lives in a dramatic situation close to death.

Hence, the responsibility of the Palliative Care medical team is greater, never forgetting that they are attending to a human being and not a thing. In order to carry out this responsibility, it is necessary that this medical team, as necessary ethical attitudes, of purely existential admiration before that weakened human being who demands respectful protection and care,¹⁶; and spend time listening to the terminally ill.^17,18

These two attitudes must be present in all the members that make up the health team of Palliative Medicine.

1. Dying is constitutive of human nature. But there are two realities that falsify it: euthanasia and therapeutic obstinacy. Two erroneous options that do not accept the human reality of death (the first advancing it and the other delaying it). From the philosophical and ethical point of view of medicine itself, both are rejected, because they threaten human dignity at the end of life and good clinical practice.
2. It is a mistake to consider euthanasia, as an exclusively individual right, because its social dimension and its impact on the protection of the common good are lost.
3. It is also a mistake to deny the reality of the impending situation of death or to flee from the inevitable, stubbornly seeking every possible intervention, no matter how disproportionate it may be.
4. However, Palliative Care rescues the human in the terminal patient. These respond, fully, to the inevitable human situation of dying, and manifest, at the same time, our humanity.

None.

None.

The authors declare no conflict of interest.

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