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DOLENTIUM HOMINUM N. 48 — Year XVI — No. 3, 2001 JOURNAL OF THE PONTIFICAL COUNCIL FOR HEALTH PASTORAL CARE

ARCHBISHOP JAVIER LOZANO BARRAG N, Editor-in-Chief CORRESPONDENTS BISHOP JOS L. REDRADO, O.H., Executive Editor REV.FELICE RUFFINI, M.I., Associate Editor REV. MATEO BAUTISTA, Argentina MONSIGNOR J. JAMES CASSIDY, U.S.A. REV.RUDE DELGADO, Spain REV.RAMON FERRERO, Mozambique EDITORIAL BOARD REV.BENOIT GOUDOTE, Ivory Coast PROFESSOR SALVINO LEONE, Italy REV.JORGE PALENCIA, Mexico REV. CIRO BENEDETTINI REV. GEORGE PEREIRA, India DR. LILIANA BOLIS MRS.AN VERLINDE, Belgium SR.AURELIA CUADRON PROFESSOR ROBERT WALLEY, Canada REV. GIOVANNI DERCOLE, F.D.P. DR. MAYA EL-HACHEM REV. GIANFRANCO GRIECO REV. BONIFACIO HONINGS MONSIGNOR JES S IRIGOYEN EDITORIAL STAFF REV.JOSEPH JOBLIN REV.VITO MAGNO, R.C.I. DR. COLETTE CHALON DR. DINA NEROZZI-FRAJESE DR. ANTONELLA FARINA DR. FRANCO PLACIDI DR. MATTHEW FFORDE REV.LUCIANO SANDRIN REV.BERNARD GRASSER, M.I. MONSIGNOR ITALO TADDEI DR.GUILLERMO QWISTGAARD

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Contents

4 Prayer THE INTERNATIONAL MEETING John Paul II OF CATHOLIC OBSTETRICIANS AND GYNAECOLOGIST 4 Pontifical Appointments ROME, 17-20 JUNE 2001

TOPICS 64 Address of Presentation Dr. Gian Luigi Gigli 6 The Perception of Pain 65 Doctors Protest in the Buddhist World Conscience Discrimination Prof. Elena De Rossi Filibeck John Paul II 10 Evangelisation in the World 67 The International Meeting of of Mental Health: Catholic Gynaecologists and Foundations and Guidelines for Action Obstetricians: The History of an Event Rev. José Antonio Pagola Dr. Gian Luigi Gigli 2 17 The Anthropology and Ethics of Dying 69 Protecting Human Life Prof. José Garcia Ferez in a Changing World: the Responsibility of 20 Dying in our Society: Catholic Obstetricians Philosophical and Ethical Aspects H.E. Msgr. Javier Lozano Barragán Dr. Franco Davide Pilotto 74 A Question of Conscience Prof. Robert Walley TESTIMONY 78 The Importance of the Catholic Obstetrician-Gynaecologist for the 44 Problems of Health in Burkina Faso Presence of the Church in the World Rev. Renato Di Menna, M.I. of Health and Health Care Dr. Gian Luigi Gigli 49 The Blessed Luigi Tezza: Founder of the Daughters 81 The Year 2001: of San Camillo The Activity of the Pontifical Council Rev. Angelo Brusco, M.I. for Health Pastoral Care Msgr. Krzysztof Nykiel 55 Pastoral Care in Health The Archdiocese of Managua, Nicaragua 60 The World Day of the Sick ‘Praying in Illness’, 11 February 2002: Guidelines for Pastoral Care in Health Ð Spain The Department for Pastoral Care in Health Ð Spain

The illustrations in this edition are taken from the book: ‘Omaggio a San Marco, Tesori dall’Europa’ edited by Hermann Fillitz, Giovanni Morello Electa

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Prayer to Mary Most Holy ÇHealth of the SickÈ

O Virgin Mary, ÇHealth of the sickÈ, you who accompanied Jesus on the way to Calvary and remained near the cross on which your Son died, participating intimately in his suffering, take our suffering and unite them with His, so that the seeds sown during the Jubilee continue to produce abundant fruits in the coming years. Most tender Mother, we turn to you with confidence. Obtain from your Son the strength to return soon, completely restored, to our duties, 4 so that we be useful to our neighbour through our work.

Meanwhile stay with us at the moment of trial and help us to repeat everyday with you our yes, sure that God will bring out from every evil a greater goodness. Immaculate Virgin, may the fruits of the Jubilee Year be for us and for our dear ones a pledge of renewed vigour in Christian life, so that in the contemplation of the Face of the Risen Christ we will find the abundance of the mercy of God and the joy of a more complete union with the brethren, the beginning of the joy without end in heaven. Amen.

Vatican City, February 11, 2001.

Pontifical Appointments

The Holy Father has confirmed, for another quinquenium, His Excellency Msgr. Javier Lozano Barragán President of the Pontifical Council for Health Pastoral Care

The Holy Father has confirmed, for another quinquenium, His Excellency Msgr. José Luis Redrado Marchite, O.H. Secretary of the same Pontifical Council

The Holy Father has confirmed Reverend Father Felice Ruffini, M.I. Under-Secretary of the same Pontifical Council, until the age of 70.

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Topics

The Perception of Pain in the Buddhist World

Evangelisation in the World of Mental Health: Foundations and Guidelines for Action

The Anthropology and Ethics of Dying

Dying in our Society: Philosophical and Ethical Aspects

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The Perception of Pain in the Buddhist World

In order to introduce the sub- teracted with it and tried to find cient times it was not possible ject of our meeting I would like different answers to it. But to alter the natural path taken to make an observation which these answers are always by men but in the contemporary is perhaps obvious but which is sought through a vision of pain world this is no longer the case. nonetheless also essential: in which sees it as a time of trial I would like to make it ab- the generally accepted meaning and judgement which involves solutely clear that I do not in of the term,”pain” is something the entire meaning of personal any way wish to diminish the which is experienced at various existence. great benevolent effects of the levels by all human beings The literature on this subject high scientific levels which without any distinction. The is very great. Here it is suffi- have been attained by Western perception of pain and individ- cient, for the purposes of under- medicine. Instead, I want to ual and collective responses to standing the questions and is- identify the reasons why many it, on the other hand, vary from sues which are being addressed, people now ask themselves person to person and from peo- to cite, for example, the opin- about the actual real value of an ple to people. Indeed, it is be- ions of the philosopher Salva- answer to pain which is based cause of this fact that reference tore Natoli. In the opinion of exclusively on a faith in techno- is rightly made to an anthropol- this authority there are in essen- logical and scientific means and 6 ogy of pain. Employing the re- tial terms two great cultural instruments. flections of philosophers on this forms through which the West It is in this sense no accident term, I would say that pain is has interpreted suffering Ð on that I have been invited to that which is most specific, in- the one hand the tradition of the speak here today, and my pres- dividual and non-transferable in Greek world which was charac- ence is certainly not the out- the lives of men. At the same terised by the meaning of come of the fact that Buddhism time, however, because it in- tragedy from which there or Tibet have become fashion- volves an experience which in- sprang the vision of the hero able. It is because, rather, that in evitable leads the person who who challenged pain; and on the people who are more sensitive suffers to ask himself why he other the Judeo-Christian tradi- towards, and concerned with, and not others is afflicted by tion which affirms that man the questions and issues con- such pain, pain itself becomes a must resist pain and await sal- nected with pain there is a subject of thought and attention vation. In the contemporary growing interest in possible al- and leads the person who suf- world, observes Natoli, these ternatives which can interact fers from it to speak about his ideal visions have been replaced with modern technology and own pain and thereby to escape by faith in technology and sci- methods to help those who suf- the prison of loneliness to ence. The approach which sees fer and are in pain, something which pain Ð because of its in- technical instruments as offer- which is matched by increased trinsic nature Ð has condemned ing the solution to pain and interest in the cultural world him. Within testimony to pain which concentrates solely on from which these alternatives the individual and collective the sick part of the suffering come. meaning of suffering are bound person is an approach which is In speaking about the percep- up in an inseparable way. This typical of Western society, and tion of pain within the Buddhist is because the person who this occurs as that society be- world I am compelled to en- speaks about his own pain comes ever more distant from gage in a clarification which speaks about it in a world in its religious roots. brings out with greater preci- which mental and oral cate- In this way pain tends to be sion what is actually meant by gories already exist, and these removed and to be withdrawn the phrase “Buddhist world”. categories, it should be ob- from sight and handed over to Buddhism is a religion which served, are designed to be un- professionals. At times it is has experienced twenty-five derstood by other people. The even denied. The context within centuries of history and which universal dimension is present which science and technology began in India roughly speaking in every individual experience operate is based upon the idea in the fifth century before of pain and allows the individ- of dominating and eliminating Christ. It then spread throughout ual who suffers to communicate pain. Thanks to the opportuni- Asia and changed its shape and that pain in a scenario which al- ties offered by modern thera- form according to its geographi- ready exists. These are scenar- peutic techniques, science and cal location. These changes ios of meaning which make technology have the ability to were possible because Bud- suffering more bearable and cross the threshold of pain and dhism did not preach theologi- tolerable because within them thus to decide the levels of per- cal principles but proposed in- pain is justified and understood. ception of suffering. Following stead the superiority of practice This is true for all men, to the utmost the idea of control over theory and left people whether they are children of over pain there is even the idea from different cultures and tra- Western culture or Eastern cul- that in the future the world will ditions to encounter each other tures. Throughout history be pain-free Ð in this way tech- at the level of experience. It mankind has been tested by the nology will be able to give us will suffice for my purposes in experience of pain and has in- what God has denied us. In an- this paper to dwell upon the

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core of the oldest preaching of individual’s life in line with cultural world which identifies the historical Buddha which is certain sound moral principles its vision of faith and life “more made up of the so called “Four (the person should not kill, or less” with the principles Noble Truths”. These are the steal, lie, or commit adultery, which I have just outlined basis of the various schools and etc.). I would like to observe above. Buddhism, therefore, currents of Buddhism. An here that Buddhism has also sees the whole of human exis- analysis of these “Four Noble been defined as being an ethical tence as being inseparably Truths” enables us to under- philosophy. bound up with pain. In a similar stand immediately how pain is In Buddhist thought, it approach, illness, old age and seen in this religion as being should be observed, the distinc- death are accepted as being in- central to existence. The order tion between pain and pains is escapable in the same way as in which the Buddha (who is al- very important. Pain is immedi- pain is inescapable. This, how- so called the “physician of all ately perceivable and experi- ever, does not in the least mean peoples”) lists his truths re- enced by everybody, even that because of an awareness of minds us of the diagnostic though it is limited to certain the inevitability of such events schema of ancient Indian medi- events such as illness, old age, that there are not attempts to cine, and this of course is not a death and the more subtle and engage in healing or cures or question of mere chance. This universal suffering caused by that death is not feared. Indeed, branch of medicine believed all possible changes. throughout the Eastern world that it was first necessary to If a person follows the path medicine is seen as one of the identify the malady and its indicated by the Noble Eight- most important of all branches symptoms, then to discover fold Path in his behaviour Ð of learning, together with as- whether it could be cured, and which is seen by the Buddhists trology, grammar and logic. However, it should be stressed that the therapeutic ap- 7 proach and the way that the in- dividual should prepare for death are heavily based upon a religious view of life. Indeed, medicine is not seen as a disci- pline with its own cultural au- tonomy but as part of the vast conceptual system produced by the teaching propagated by Buddha. The central reference point is the concept of the world under- stood as being both mental and physical at the same time. Life, it is believed, is not something attached to individuals alone but is a global phenomenon which links all living forms in a unique project which in its ulti- finally to prescribe the treat- as being physical, vocal and mate essence is mental Ð the na- ment which was required to mental in character (that is to ture of the mind is the nature of heal the patient. say a person behaves well or all things. It is above all else the Taking this approach as a badly with his body, his speech Tibetan point of view in rela- model, in the Buddhist way of and his mind) Ð then he will not tion to pain and its possible thinking the malady is akin to be moved by the three negative remedies that will be examined existential pain and suffering. impulses of hatred, greed and here Ð in full awareness that the The first noble truth asserts that ignorance and will not be re- subject of this paper will not be everything is pain. The second sponsible for negative conse- deviated from by choosing such noble truth discerns in desire quences. On the contrary, he an emphasis Ð because the Ti- and in attachment to existence will generate compassion for all betan medical tradition is an in- the real cause of the malady. living creatures and this feeling tegral part of Tibetan Bud- The third noble truth sees the produces in those who experi- dhism. The knowledge derived suppression or the ending of de- ence it a great desire to achieve from Indian and Chinese medi- sire as the cure for the maladies salvation or illumination. For cine also forms a part of that of existence. Lastly, with refer- Buddhists, our acts follow us in tradition. ence to the prescription which this world and the world to Furthermore, I think it is im- is needed to obtain healing, the come, and for this reason the portant to remember that after fourth noble virtue points to the great goal is to escape a convul- the Arab conquest of Persia the path which leads to the ending sive way of living, stop mov- distant influence of Greek med- of desire and thus to the elimi- ing, and enjoy the peace of lib- icine could be felt in Tibet dur- nation of pain and suffering. eration Ð liberation from the cy- ing the period of the monarchy, This path involves a detailed cle of birth and death in order to that is to say from the seventh ascetic practice termed “Noble achieve Nirvana, an indescrib- to the ninth centuries after Eightfold Path” whose initial able state of being. Christ. Historical sources refer and fundamental base is the When I refer to the Buddhist to a Ga le nos at the court of the regulation and ordering of the world I mean the whole of that Tibetan king as well as a Chi-

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nese physician and an Indian medical practitioner. The name is a clear reference to Galenus of Pergamos who lived in the second century after Christ. It is not impossible to argue that a Persian doctor belonging to the Greek school Ð and thus named Galenus accordingly Ð came to live in Lhasa during that period. Tibetan medicine approaches the patient with reference to the whole of his person whose physical, emotional and spiritu- al aspects are thought to be in- separably unified in the individ- ual being. Furthermore, man is seen as an organic part of the biological and cosmic universe and subject to all the immutable and unchanging laws of nature Ð in this way the microcosm of ments and as a result reflective amining his tongue and his an individual is an exact copy of their properties. Thus wind is urine. When it comes to treat- of the macrocosm of the uni- an expression of the element of ment there is no one treatment 8 verse. It is believed that a hu- air which has characteristics which is exclusively organic in man being is the product of the such as lightness, mobility and character. The therapy involves temporal conjunction of five or- so forth; bile is an expression of providing the patient with the ders of phenomena which are in the element of fire which has prescription of a suitable diet, a state of constant mutation, characteristics such as warmth, advice regarding behaviour and and more specifically the body, fluidity etc; and phlegm is an activity, the application of med- sensations, perceptions, impuls- expression of the elements of icines and external medical es and consciousness. The con- fire and water and has such treatment. It is interesting to ob- sciousness is the beginning characteristics as heaviness, serve that prior to any form of which arranges all sensorial in- slowness, softness and so forth. therapy or cure a suitable reli- formation and is therefore the Through their cohesive rela- gious rite has to be engaged in. seat of discorsive thought. Sus- tionship or otherwise the hu- There is a vast literature on this tained by a subconscious which mours regulate and condition subject in which all those Ti- is conditioned by past experi- the health of the organism and betan texts which are called ences, this consciousness influence the seven constituents “long life rituals” and “prayers trasmigrates from one existence and the three secretional func- and rites for the maintenance of to another when, at the moment tions. good health” should be placed. of death, the elements which Tibetan medicine first of all Quite beyond what may seem make up the individual’s body treats the mental attitudes and to us to be religious magic, it disintegrate. In all its aspects Ð approach of the patient and his should be grasped that preven- from the most important to the relationship to the three hu- tion is the first aim of Tibetan smallest Ð the body, in substan- mours of the body. This is be- medicine. tial terms, is thought to be noth- cause mental and physical The basic substances of Ti- ing else than a complex and di- health are said to depend upon betan medicine (there are 2,294 versified aggregate of the five the state of harmony and bal- in number) are herbs, precious elements which go to make up ance of the five elements which stones, minerals, and plant and the whole universe: earth, wa- in turn can be disturbed by ex- animal juices and secretions. ter, fire, wind and space. ternal or internal causes such as The medicines which are pre- In order to express this con- thoughts or bad actions. The Ti- pared with these substances are cept in more precise terms, it betans believe that when ha- then prescribed as decoctions, should be stressed that for Ti- tred, greed or ignorance come powders, pills, syrups, mineral betans the body functions to disturb the three humours oils and ashes. The Tibetan thanks to the present of seven (namely wind, bile and phlegm) medical texts contain explana- component elements Ð the nu- illness breaks out. For this rea- tions by which to combat 1,616 tritive essence, blood, flesh, son, Tibetan medicine has been illneses and indicate and de- adipose tissue, bone, marrow defined Ð and with very good scribe over a thousand forms of and regenerative fluid; of three cause Ð as one of the oldest medical treatment. The provi- secretional functions: faeces, wholistic and psychosomatic sion of medicines is seen as a sweat and urine; and three forms of medicine that we light method, whereas such so-called humours: wind, bile know about and which is still techniques as bleeding, cutting, and phlegm. The humours are being practised during the con- moxibustion and the use of seen as being both physical Ð as temporary age. golden needles are considered the breath of breathing, bile ac- Diagnosis is based first of all to be a strong forms of medical cumulated in the gall bladder, upon the information which is treatment. and mucous secretions in the gathered from asking the pa- There is also the so-called vi- stomach Ð and as something tient about his symptoms and olent method which involves produced by the cosmic ele- from taking his pulse and ex- small surgical operations where

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foreign bodies are removed; the separates the Tibetan Buddhist meet the same destiny. From cauterisation of abscesses; and world and the West is that con- another point of view I would the destruction of seriously stituted by approaches to death. venture to observe how the damaged tissues. This is a result not only of the Christian message in the field According to people who belief in the samsaric cycle but of assistance to the sick has have lived in the medical centre primarily because of the atti- been able to generate sublime of Dharamsala in India, the res- tude of Tibetans towards death. examples of humanity and that idence of the Dalai Lama and Over time in Tibet what we this too is endangered by mar- many Tibetan refugees, the Ti- might call a real and authentic ginalisation in the contempo- betans believe that ability to ars moriendi has developed. In rary world. I would like to con- bear pain and have these surgi- the West the Bar do thos grol or clude this paper by referring to cal operations without recourse the Tibetan “Book of the Dead” what Cristrina Campo writes in to anaesthetics is a virtue. How- is well known. This is a text the preface to the work Nato in ever, it would be reductive not which the Tibetan tradition at- Tibet by Chogyan Trungpa to refer to this aspect of Tibetan tributes to the eighth century of where she attributes to the dis- Buddhism which finds its high- our era. The tradition of the title appearance of the vertical di- est point in meditation Ð some- means: “self-liberation through mension of thought the respon- thing which provokes so much hearing during the intermediate sibility for so many evils of our fascination in the West. period”. The intermediate peri- contemporary culture. I am referring here in particu- od is the time which Tibetans lar to Tantrism by which I mean experience between physical Professor ELENA DE ROSSI that whole set of instructions death and subsequent rebirth FILIBECK, and methods concerning spiri- and which can be compared to Professor of Tibetan Studies, tual concentration which bring those pre-death experiences “La Sapienza” University of Rome. out to the full the possibilities which in the West are currently 9 of the human mind and which the subjects of scientific re- are also of great importance for search. The person who dies Paper presented at the conference or- that part of the medical ap- conserves a conscious principle ganised by the “S.Pietro” Hospital in proach which is most mental upon which the lama who helps Rome on the subject of “Chronic, Ma- and spiritual. Through the him can act by reciting a text. lign and Benign Pain”, Rome, 16 March Tantric meditative technique Through this reading Ð if the 1998. there is generated, for example, dying person has been suitably what the Tibetans call gTum prepared during life Ð the indi- mo, that is to say the practice of vidual can be guided towards a psychic warmth which is also freeing knowledge which en- able to raise body temperatures ables him to achieve a suitable Bibliography thereby making survival possi- rebirth, if not even complete ble for those who know how to liberation from the existential G.L.MASARAKI, Tibet, Magia e Medi- cina (Istituto Riter, Milan, 1989). engage in this practice even in cycle. To conclude this section SOGYAL RINPOCHE, Il Libro Tibetano extreme conditions. There is al- of my paper I would like to re- del Vivere e del Morire (Ubaldini ed. so the practice which the Ti- fer to what the fourteenth Dalai Rome, 1994). S.NATOLI, L’Esperienza del Dolore. betans call bCud len which in- Lama of Tibet has written on Le Forme del Patire nella Cultural Oc- volves being able to live with- the subject of death: “medita- cidentale (Feltrinelli ed., Rome, 1987). out food for a certain period by tion on death and imperma- VAIDYA BHAGAWAN DASH, Ency- eating only pills made of pow- nence should be inspired by clopaedia of Tibetan Medicine (Delhi, 1994, 3 vols.). dered minerals or flower petals. great pleasure. It is very impor- VAIDYA BHAGAWAN DASH, Materia Thanks to Tantric meditation it tant to be aware and conscious Medica of Tibetan Medicine (Delhi, is also possible to produce the of death: if a person has been 1994). GYURME DORJE, YURI PARFIONOVIC so-called “seeds of blessing” preparing for it for a long time and FERDINAND MEYER, Antica Medici- which are perhaps similar to he will not be upset by its ar- na Tibetana (Zanfi ed. Modena, 1994), those substances which for us rival, but if a person avoids the Italian version edited by Antonella are the endorphines and which question of death and tries to Comba. NAMKI NORBU, Il Libro Tibetano dei provide spontaneous protection forget about it then he will be Morti. Magia e Religioni (New Comp- against both mental and physi- caught unprepared and he will ton, ed., Rome, 1983). cal forms of pain and suffering. be frightened when the moment TENZIN GYATSO ZIV DALAI LAMA, La Perfetta Felicità (Studio Tesi ed., It is also possible through of death arrives”. 1995), Italian translation by Federica meditation techniques to be Those listening to my paper Meret from Path to Bliss: a Practical able to see what the Tibetans will not have failed to notice Guide to Stages of Meditation (Ithaca, calls the “Clear Light”. By this that from certain points of view 1991). W.Y.EVANS-WENTS, Lo Yoga Ti- phrase is meant the most so- the Christian and the Buddhist betano e le Dottrinbe Segrete (Ubaldini phisticated level of the mind visions of life, death and pain Ð ed. Rome, 1973). which becomes manifest only although profoundly different Ð YESHI DONDEN-JEMPA KELSANG, Il Tanta della Medicina Tibetana (Ubaldi- when all the large organs and have a number of points of con- ni ed., Rome, 1980). members of the body have halt- tact. It is not inappropriate to CHOGYM TRUNGPA, Nato in Tibet ed their active functions. This is refer to the serious danger (collana documenti di cultura moderna, thought to be a condition which which is now before us that the Borla ed., Turin, 1970). E. DE ROSSI FILIBECK, Catalogue of is normally reached at the mo- religious, cultural and medical the Tucci Tibetan Fund in the Library of ment of death but which can al- traditions of the world will be- ISMEO (Rome, 1994, vol. 1). so be induced intentionally with come extinct, and that the Ti- M.PIANTELLI, ‘Il Buddhismo Indiano’ in G.Filoramo (ed.), Storia delle Reli- the technique of meditation. betan people themselves in this gioni. Religioni dell’India e del- The greatest distance which tragic hour of their history will l’Estremo Oriente (Laterza ed., 1996).

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Evangelisation in the World of Mental Health: Foundations and Guidelines for Action

For the followers of Christ, sessed by devils’ according to tion he communicated his words his work is the model of inspira- the mentality of the epoch). to him, he gave him faith. The tion and the decisive criterion The situation of the sick per- possessed man was not only for determining the character of son was tragic. He was the vic- healed he was a ‘saved’ man. He evangelising action and captur- tim of an ‘unclean spirit’, that is was a disciple of Jesus. ing the spirit which should ani- to say he was distant from the Lastly, Jesus integrated him mate it. Only in the light of his Holy God, without God; ‘he ran once again into society. He work can we establish the bases amongst the rocks’ in a condi- broke him away from the loneli- for evangelisation in the world tion of total and wild loneliness. ness of the mountains and the of mental health and suggest ‘This man made his dwelling tombs where he had previously certain guidelines for action. among the tombs’, and he was lived out his existence. He re- excluded from the world of the leased him from his isolation living. ‘He had been bound with and his segregation and brought I. The Work of Christ in the fetters and chains often before’ him back to life, to home, and to World of Mental Infirmity by a society which only thought living with others. ‘Go home to about defending itself against thy friends, he said, and tell 10 Jesus proclaimed and offered him. He was a sick man who them all that the Lord has done the salvation of God, not in any could not be redeemed, ‘nobody for thee, and what great mercy kind of way but by generating had the strength to control him’. he shewed thee’ (Mk 5:19). And health and by doing good in the He lived ‘crying aloud’ phrases he went to the Decapolis and world of illness and suffering. that nobody could understand proclaimed ‘what Jesus had Jesus made himself present and he was unable to communi- done for him’ (Mk 5:20). That where life seemed to be most cate with anybody. ‘He cut him- man was transformed into the deteriorated, tormented, and self with stones’ and was the Gospel, into the Good News of worn out, and only beginning victim of his own violence. God. In him was manifested the with a liberating and beneficial Jesus met him and the sick man ‘mercy’ of God for human be- action for these men and for cried out to him in a loud voice: ings. these women did he preach that ‘why dost thou meddle with me, God was the Saviour, the Friend Jesus, Son of the Most High 2. Jesus draws near to the of life and the ultimate happi- God?’. What did Jesus, the Son world of mental infirmity ness of every human being. of God, have to do with this To move to a practical level, I dark and painful world of men- This is the first thing that we will point out four aspects of the tal illness? The evangelists de- should observe. Jesus drew near work of Jesus in the world of scribe the work of Jesus in great to sick people but at a more mental infirmity: 1) ‘making detail. Jesus asked the possessed practical level he drew near to room’. Jesus welcomed these man his name; he wanted to the mentally-ill. In the long list sick people and made room for help him to recover his own of sick people whom Jesus took them in his life; 2) ‘saving the identity: ‘What is thy name?’ care of, reference is constantly lost’. Jesus strove to save those The sick man answered: ‘My made to those kinds of sick peo- who seemed to be lost; 3) ‘de- name is Legion; there are many ple who in that epoch were fending the weak’. Jesus de- of us’. He was a divided man, a thought to be possessed by Sa- fended the abject, the victims of man internally fragmented by tan and bad spirits. Jesus healed evil; 4) ‘communicating with his illness. Inside him there was the sick but also expelled the excluded’. Jesus included a confused world of division demons. He went through the sick people excluded by so- and of pain. Jesus then said to Galilee ‘preaching the gospel of ciety in his life with others. him: ‘Leave this man, unclean the kingdom, and curing every spirit’. Make way for the Spirit kind of disease and infirmity 1. The healing of the mentally of God, make room for reconcil- among the people... they ill man from Gerasanes iation, for peace, for inner liber- brought to him all those who ation, for the growth of this per- were in affliction, distressed Before studying the work of son. with pain and sickness of every Jesus, we will dwell upon a Luke describes the transfor- sort, the possessed, the lunatics, well-known episode – ‘the heal- mation of this sick person very the palsied; and he healed them’ ing of the possessed man of well. When people arrived they (Mt 4:23-24; Cf. Mk 1:34 and Gerasanes’ which appears in the found the man ‘sitting... at Je- Lk 6:18-19). synoptic tradition (see Mk sus’ feet’. Those who had wit- In order to understand this ac- 5:1-20; Mt 8:28-34; Lk 8:26-39). nessed the event told them ‘how tion of Jesus correctly, we must We have before us a surprising the possessed man had been de- remember how mental illness scene in which is demonstrated livered’. Jesus placed in that life was viewed by the society of the in clear brush-strokes the evan- a new equilibrium, he released time. In the Semitic mentality, gelising action of Jesus in the the man from an infrahuman every sick person was a person mysterious and tormented world state, and provided him with a who had been abandoned by the of mental illness (of those ‘pos- new quality of life. But in addi- Spirit of God Ð that vital breath

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Son of man has come to search out and to save what is lost’ (Lk 19:10). Jesus, the friend of life, drew near to the world of the sick in order to save what was lost, deteriorated health, and worn-out life. He was the hope of the lost. It is for this reason that we en- counter Christ amongst those who are mentally-ill, amongst the alienated, amongst those who have been corrupted, who have lost the meaning of their lives and their identity, amongst those who are possessed by evil, those condemned to insecurity and fear, amongst those who ex- perience their own affliction as something which cannot be remedied. Of those who study ‘the movement towards the low’ which is characteristic of Christ, C.H. Dodd observes the ‘un- precedented interest for the lost’ 11 and L. Boff emphasises that Christ directs his preference to- wards the ‘non-men’. If Christ drew near to mentally-ill people it was simply because he was moved by his very deep love for these lost beings and by his pas- sionate intent to release them from the disintegrating power of with which God sustains every whom one had to defend oneself evil. The first Christian commu- person. For this reason, the sick and from whom one had to flee. nity had this memory ‘about Je- person was always a person In this socio-religious con- sus of Nazareth, how God threatened in his or her own be- text, Jesus ‘makes room’ in his anointed him with the Holy ing, a person who was walking own life for these men and these Spirit and with power, so that he towards death, who was falling women who have no place in went about doing good, and cur- into an oblivion without God. society and, it would appear, not ing all those who were under the For this reason, the sick Jew even in the heart of God. This is devil’s tyranny, with God at his lived out his or her own illness the fundamental fact. The sick side’ (Acts 10:38). Such was Je- as an experience of powerless- person was the prototype of the sus: full of the Spirit of God he ness and abandonment, and ‘abandoned person’. Jesus wel- went about freeing and healing what was truly terrible, of aban- comed and made room for these those oppressed with evil and by donment by God. After a certain sick people who lived in the inner division (‘devil’ = ‘he who fashion, every illness was a pun- world but without the world be- separates’). ishment or a curse of God, and a ing for them a home, for those I would like to observe that in sick person was a person who had nowhere to go, for sick the gospels the possessed (the ‘wounded by Jehovah’. people who were rejected, who mentally infirm, epileptics etc.) The situation of the mentally- did not know to whom to turn, are never described as sinners, ill person was even more tragic. who clashed every day with the as morally bad men, but as the Such a person was so emptied of raised barriers of those who defenceless victims of evil. For the Spirit of God, so abandoned, were healthy, who were safe. Je- this reason, the struggle of Jesus that his or her person was invad- sus showed them that they were was not against the sin of these ed by Satan and malign spirits. not alone and that they were not men but against the evil which Satan was evil by definition, the abandoned. tormented them and destroyed personification of everything them. that destroyed the salvific plans 3. Jesus saves the lost life Jesus freed them from loneli- of God, he who destroyed hu- of the mentally-ill ness and isolation. He liberated man beings and tormented them from inner confusion, them. The Jews spoke about Sa- Saving what is lost is another from division, and from alien- tan when they referred to a per- aspect of Jesus, indeed almost ation. He freed them from the son subjected to an inexplicable an obsession. Jesus spoke in his torment of illness, from fear of and mysterious affliction which parables about ‘lost sheep’, God. He infused ‘peace’ into generated fear and was threaten- about the ‘prodigal son’, and their lives, ‘shalom’, that is to ing. For this reason, the mental- about the ‘lost coin’ (Lk 15). He say blessing, grace, well-being, ly-ill person was an individual felt that he was sent to the ‘lost security, and trust in the future. abandoned by God and pos- sheep of the house of Israel’ (Mt This is what Jesus placed in sessed by evil, someone against 15:24) and proclaimed that ‘the every sick person: ‘go in peace

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and be rid of thy affliction’ (Mk can enter into a strong man’s Spirit (Lk: finger) of God, then 5:34). Jesus, full of God, trans- house and plunder his goods, it must be that the kingdom of mitted life, health and blessing without first making the strong God has already appeared to the mentally-ill: ‘the Son of man his prisoner’ (Mk 3:27). Je- among you’ (Mt 12:28). God was revealed to us, it was sus committed all his authority Through his healing and hu- so that he might undo what the and strength to free these sick manising action, Jesus was a devil had done’ (1 Jn 3:8). people from their affliction: ‘he sign that God had not aban- has authority to lay his com- doned these sick people. They 4. Jesus defends the weak mands even on the unclean spir- were not lost and abandoned. sick person its, and they obey him!’ (Mk God was near to them. In defini- 1:27). tive terms, the God of good and There is another fundamental not of evil, the God of the cre- aspect to Jesus: he always de- 5. Jesus integrates sick people ation, of health, of life, not the fended the weak, the defence- into society God of destruction, of illness, less, and those who could not and of death. The ultimate pur- assert themselves. Jesus spoke In Israel, the mentally-ill per- pose of the healing action of Je- often about ‘the little ones’, of son was the prototype of the ex- sus was to show that even in this those who were not great in any- cluded person. Possessed by Sa- dark and painful world of men- thing, of those who did not have tan, he or she was considered tal infirmity God reigns as a the power or the strength to de- impure. Such a person did not friend of human beings. fend themselves. ‘See to it that belong to the holy community, you do not treat one of these lit- to the people of God. He or she tle ones with contempt’ (Mt did not know the law and he did 18:10). ‘So too it is not your not carry it out. He or she could 12 heavenly Father’s pleasure that not enter the Temple. Such a one of these little ones should be person was excluded from soci- lost’ (Mt 18:14). ‘Believe me, ety, condemned to live in soli- when you did it to one of the tary places distant from inhabit- least of my brethren here, you ed cities and was stigmatised did it to me’ (Mt 25:40). both socially and in religious For this reason, we see Jesus terms. defending the mentally-ill, who The gospels repeatedly ob- did not have any prestige or serve the efforts made by Jesus power, who were without an im- to reintegrate sick people into age and without an identity, who society. Thus he proclaimed to were poor not only at the level the healed paralytic: ‘Rise up, of possession but also poor in take up your bed and go home’ the poverty of being, poor in (Mk 2:11). The same thing hap- terms of a conscious and affec- pened with the possessed man tive life, and without the power of Gerasanes. Jesus made him to present coherent views, being leave the loneliness of the as they are isolated and divided mountains, made him break by affliction. with loneliness and segregation, II. Major Guidelines Jesus defended these people and led him back to life. for Action against that society which ex- The sick person expressed his cluded them and condemned wish to stay with Jesus but The work of Jesus enables us them to live in solitary and Christ wanted him to go home. to discern and outline certain ba- far-off places; he defended them He had suffered enough being sic guidelines for evangelising against laws and taboos which distant from his kin. He had to action in the world of mental despised them as being impure. go home and proclaim that the health. He was not afraid to touch them Lord had had mercy on him. and to free them from impurity The return to a normal life was 1. Drawing near to the and from contempt. He was so seen as a grace of God. ‘Go mentally-ill person committed to their defence that home to thy friends, he said, and soon he, too, was identified with tell them all that the Lord has The first such form of action, the possessed: ‘He is possessed done for thee, and what great without doubt, is to stimulate by Beelzebub; it is through the mercy he shewed thee’ (Mk within the Church a greater sen- prince of devils that he casts the 5:19-20). sitivity and a change of mentali- devils out’ (Mk 3:22). He was ty which draws us close to the seen as being mad and pos- 6. The proclaiming world of the mentally-ill person sessed: ‘He is possessed by an of the salvation of God and his or her family. unclean spirit’ (Mk 3:30). But Jesus also defended these The work of Jesus in the 1.1. Unknown and feared men and these women from the world of the mentally-ill was Today, Christian communities power of evil. He saw these sick not one medical action amongst are making a very significant ef- people as the victims of some- many other such medical ac- fort in the world of the most in thing that was ‘strong’ and had tions. Curative activity was not need and least helped sick peo- entered them and enslaved being engaged in. Jesus gave ple. However, with the excep- them. He felt that he was this work a deeper and evange- tion of the generous dedication ‘stronger’ and could liberate lising meaning. ‘if when I cast of certain religious Orders and them from affliction. ‘No one out devils, I do it through the Congregations and certain sen-

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sitised groups, the mentally-ill of our limits, together with a health (psychiatric hospitals, and those people who are most radical love for these human be- psychiatric units in general hos- absent from the evangelising ings, would allow us to draw pitals, mental health centres, concern of the Church and of near to them in a more welcom- etc.); achieve a greater knowl- Christian communities. ing and understanding way. edge of the sick people who be- There can be no doubt that At the same time, it is easy to long to our own Christian com- there has been a growth in sensi- see the mentally-ill man or munity; and secure closer con- tivity towards those who suffer woman as a person who is inca- tacts with the families who suf- from depression, from senile de- pable of any real communica- fer with a loved sick person mentia, and towards alcoholics tion and personal growth. What amongst them, etc. This is a and drug-addicts who are afflict- can be true in some of the differ- matter, in definitive terms, of ed in their personalities, but we ent varieties or stages of mental ‘making room’ for the mentally- cannot observe, at least to the illness, extended in erroneous ill person in the heart of the same extent, a change of ap- fashion to every sick person and Church and within the Christian proach towards, and a greater to all the fields of human experi- community. nearness to, mentally-ill people. ence, becomes transformed into They are the people who are an obstacle to a more human 1.4. The need for training most in need, but they are also and constructive drawing near. A healthy drawing near to the the most unknown and the most The approach of Jesus, which world of mental infirmity re- feared. Between this world of amounted to ‘seeking out and quires a minimum of rigour and suffering, of darkness, of loneli- saving those who are lost’, competence; making the rela- ness, and of destruction, and the life of Christian communities, there seems to be raised a kind of invisible wall which prevents 13 people from drawing near to the mentally-ill and from under- standing their pain and suffering, and this is something which ob- structs evangelical communica- tion, the gospel-based presence.

1.2. Overcoming negative connotations At the root of this distancing of the mentally-ill a series of negative connotations are at work which must be addressed in a more positive and Christian way. In the first place, and this is something which has been true should give life to a very differ- tionship more healthy and bene- ever since time begun, there is ent approach. ficial for the sick person; know- the image of what is dangerous Lastly, to all this is to be ing how to keep the right dis- which is associated with mental added the general idea that men- tance; developing a style of pos- infirmity, and this is something tal illness cannot be cured, that itive communication; and which rapidly leads to the isola- one can do little or nothing co-operating in a therapy of sup- tion and the shutting away of the about it. Quite apart from what port for the mentally-ill person. sick person in order to defend the experts and specialists may All this requires training. society against the threat that he say and can do in individual cas- Good will is not enough. With or she represents. A more rigor- es, it should be remembered that the best of intentions one can in- ous knowledge and a spirit near- when one cannot treat one can terfere in, or obstruct, therapeu- er to Jesus should lead Christian and one must accompany, alle- tic work. Those working in pas- communities to adopt a more re- viate, defend, and love. toral care for mentally-ill people alistic and differentiated posi- must acquire a specific mini- tion and an approach which in- 1.3. Giving an impulse mum training in order to know volves greater welcoming. to drawing near the possible reactions and atti- Secondly, the most important Animating the Church in a tudes of the sick person, and the expressions of mental infirmity process of drawing near to the most suitable way by which to are behavioural disturbances. world of the mentally-ill in- secure a positive relationship And it is specifically these volves various aspects. I will with him or her. Hence the need changes in behaviour, which are now list some of them. First of for close and effective co-opera- deviant from what is considered all, we should look anew at the tion between psychiatrists and ‘normal’, that create insecurity role that mentally-ill people experts in mental health and and impede us, or make it diffi- have in the memory and the groups and people who ap- cult for us, to draw near to the concerns of Christian communi- proach the mentally-ill person painful reality of mentally-ill ties; promote a campaign of sen- with a different and non-spe- people, given that we seek to de- sitisation and of change in ap- cialised perspective made up of fend our ‘normality’. A healthy proach in relation to the mental- human and Christian friendship. awareness of our weaknesses ly-ill; effect a more real drawing This co-operation or ‘alliance’ at and a more realistic acceptance near to the world of mental the service of the sick person, in

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should be promoted. Without life. It is placing a freely-given denying the relevance of these love that illuminates this life, actions in every case, and re- which at times is so dark and specting the skill and expertise impenetrable. It is placing peace of experts in psychiatric help, and grace where there is only an the evangelising approach bears excess of affliction. in mind above all else that there Naturally enough, blessing is is before us a poor and suffering not an isolated gesture. It needs human being who needs love to be maintained. Indeed, the and blessing. Without denying sick person needs constant proof the paths of psychiatric help or that he or she is accepted and psychological wisdom, indeed loved. He or she needs benevo- these are to be included, there lent words and gestures, com- exists a pathway by which to munication, company, care, wel- reach the broken life of the men- come and tranquillity. The sick tally-ill person: active compas- person needs to know in one sion, patient love, and commu- way or another that whatever he nication which transmits bless- or she does and says there will which each person maintains his ing. always be grace and mercy for or her own identity and respon- him or her, that there will al- sibility, would constitute, in my 2.2. Imposing the blessing ways be somebody who will opinion, one of the most posi- of God take care of him or her and try to tive signs of real interest in To bless (from the Latin achieve his or her good. achieving overall care for the ‘benedicere’) means literally ‘to 14 mentally-ill person. speak well’, to say good things 2.3. The style of blessing As regards Christians, whether to someone and above all else to Blessing requires its own medical doctors or medical staff, speak about our love, to express style of implementation. First of who work in the field of psychia- to him or her our good will. Ac- all, as a support for all the care try, in addition to everything that cording to the French psychoan- and attention towards the sick they can teach us, and they can alyst Françoise Dolto, ‘to bless’ person, freely-given love is re- teach us a great deal, it should be is to do good. It is like saying: ‘I quired. This love cannot be said that they also have the right want your good. I will think of based upon mutual giving, and to find us at their side in relation you, I will not want anything cannot require such a thing. to other believers in order to but good for you’. This is what Those who take care of these search together for the evangelis- is really important: the certainty sick people and live with them ing meaning of their work and to that a human being will receive by blessing do not act out of illuminate the problems that a blessing (Concilium, 198, personal interests, or for reasons mental health raises for a Christ- March 1985, 254). This is a of fear or because of apprehen- ian vision of existence. matter, therefore, of being to- sion. Those who bless do not gether with mentally-ill person have fear. They only have love 2. Introducing the blessing in an approach marked by bless- for the search for the good of the of God ing, which means leaving be- person who is blessed. hind the stigma of being badly This love is made up of total It is not enough to be present born, of being badly made, of respect for the sick person, not in the world of mental infirmity. being cursed; of addressing because of his or her human ma- We should ask ourselves what with benevolence those who turity or his or her natural digni- this presence should be and seem to be marked only by a ty, but simply because he or she what should be adopted to make curse; and of treating with love is a person, an image of the liv- it evangelising, like the presence those who seem to be marked ing God, the loved son or of Jesus. by affliction. daughter of the Father. Those It involves ‘blessing in the who bless are concerned with 2.1. Towards an evangelising name of God’. Communicating the deep mystery of which every approach with gestures, words and ap- human being is a bearer, and this Drawing near to the mentally- proaches the love of God who is even more the case with this ill person can have different em- does not abandon these broken kind of sick person, who is at phases. If the mentally person and stigmatised lives. Telling times without inner freedom and generates distrust and fear be- the mentally-ill person that he or has been transformed into some- cause of the fact that he or she is she is blessed, that God is aware thing that is foreign and dark for dangerous, an approach involv- of him or her, sees him or her, himself or herself. ing caution and care should be and loves him or her infinitely. Those who bless act by listen- developed. If one wants to com- Giving back to him or her the ing with compassion to the suf- bat his or her deviant behaviour, certainty that he or she is a being fering of the sick person, to this measures of a corrective charac- loved by God with fathomless life which has been transformed ter should be developed which and freely-given love. into torment. Those who love are directed towards reducing For this reason, to bless is to this sick person seek to grasp and attenuating the illness. If ensure that the sick person is en- the overall message of this sick one is trying to retrieve the veloped in love, even though he person, what he or she wants to healthy aspects of the sick per- or she is not able to understand tell us (although what he or she son and to provide an impulse to this fact in a conscious way. It is says is not coherent), what he or his or her growth and develop- placing a silent love which is she wants, and what he or she ment, therapeutic treatment recognised only by God in this needs.

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At the same time, drawing stitutionalisation of psychiatry’ tact, about sick people whose re- near to the mentally-ill, as is the if we want to reinsert and inte- ligiosity is an obsession, and case in drawing near to every grate these sick people into soci- about sick people whose reli- being who is deeply in need, ety. A complete work of sensiti- gious behaviour is deviant or makes us humble. A certain re- sation and a complete change in extinct. Reliance must be placed sult or spectacular results are not mentality are required in order on those who strive to help men- possible. We cannot extirpate to alter the existing social ap- tally-ill people and restore their the affliction at its roots. We proach to mentally-ill people. health. They should be co-oper- cannot save. Those who bless in We need to welcome and to be ated with in order to act in the the name of God work with hu- near to these sick people with- safest and most beneficial way mility and patience beginning out marginalising them; to sup- for the sick person. But it should with faith and hope in God, the port their families and offer never be forgotten that from the only definitive saviour of man. them the necessary resources action of Jesus there stands out a and help as the first means by general criterion: there should 3. Defending the mentally-ill which to obtain such integra- be an overcoming of everything person tion; and to take care of mental- that involves marginalisation, ly-ill people who are homeless isolation, distancing, and pro- Evangelising work in the and drift from one place to an- hibiting, and a promotion, in- world of the mentally-ill can other. stead, of everything that in- find concrete expression in the Christian communities and volves living with, drawing near task of defending the mentally- workers in pastoral care in to, welcoming, and integrating. ill person by giving him or her a health here have a major task to From the perspective of the more human and dignified place carry out at the level of sensiti- believer, what matters in all this within the Church and society. sation, help for families, co-op- is to remove obstacles and eration with the associations humbly help so that in these 15 3.1. The defence of rights made up of the family relatives people, too, there takes place a A Church faithful to the spirit of mentally-ill people, etc. meeting of the mystery of God of Jesus, and some Christian There can be no doubt that one with the mystery of man. This is communities rooted in his work, of the best ways by which to the thing which is of primary must know how to defend the contribute to the social integra- and decisive importance. As re- dignity and the primary impor- tion of mentally-ill people is to gards all the approaches that one tance of the sick person against make room for them in Christ- can have in relation to the fact everything connected with ne- ian communities, to restore to that the mentally-ill person is a glect, marginalisation, abuse, or them their ‘right as members of subject of religious life, and in insensitivity. the community’, and to open to concrete terms a subject capable This means in practical terms them the doors of the parishes, of receiving the sacraments, I defending the right of the sick inviting them to take part in the will merely read the words of person to suitable health care; life of the community and facili- the priest and psychiatrist, Mari- the right to the best possible tating their presence at celebra- ano Galve, with whom I identify quality of life; the right to indi- tions, meetings or activities, totally: ‘I am amazed when I vidualised forms of treatment; from which, indeed, there is no hear that the sacraments are de- the right to overall care and con- reason for them to be excluded. nied because ‘the subject is ab- cern for his or her various fami- sent’. And I will say why this is ly, social, and religious needs; 3.3. Religious care the case... In psychiatry the sub- and the right to see his or her One of the areas where the ject is here, in front of us, obses- ethical and religious values re- Church can best demonstrate sively in front of us, with a reali- spected. her evangelical and evangelis- ty that one cannot mask or de- This is not a matter of defend- ing countenance towards these scribe, in a cruel and shameless ing the sick person in theoretical sick people is through religious way. It is certainly the case that terms, from outside, but rather welcome. There can be no doubt in most instances, when he or is of co-operating in everything that the situations vary. Experts she is not a reluctant and un- that could involve an improve- speak about sick people whose reachable, unintelligible and ment in prevention, in treat- religious life is practically in fleeting, subject, he or she is a ment, in rehabilitation, in over- bad, empty and distorted sub- all care, and in the social inte- ject. He or she is an ambiguous, gration of these sick people. The rambling and destroyed subject. role of voluntary workers has But there is a subject, and an been decisive in many European evangelical subject... ‘I did not countries in obtaining improve- come to heal the healthy but the ments that would not have been sick... I came to find who was possible without this kind of lost’’ (in ‘Objectivos y activi- co-operation. dades del quehacer pastoral en psichiatria’, November 1986). 3.2. Social integration Here three fields deserve a Gospel-based action which is more detailed analysis. 1) The rooted in Jesus involves the pro- sacrament of reconciliation as a motion of communion with place of welcoming and these sick people, who are, in- peace-making, a place for bless- deed, discriminated against and ing and grace, a propitious field marginalised in many ways. It is for the deep restoration of the not enough to defend the ‘de-in- person (self-esteem, friendship

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with God); 2) the celebration of Certain difficulties are born of First of all, the families must the Eucharist with its various as- an economic character, prob- be known about, drawn near to, pects: the welcoming and partic- lems at work and to do with ad- and their problems listened to. ipation of sick people as mem- ministration, consultations with The measures and the channels bers of the assembly; action of medical doctors etc. to be near to them and to accom- thanks to God who is a friend; Dr. V. Beramendi very effec- pany them to solve their various listening to the Good News of tively describes the powerless- problems or at least to alleviate Jesus; drawing near to commu- ness or fear which often arise their situations must be sought nicate with Christ; receiving the because of these family dynam- out. blessing of God; 3) prayer with ics: 1) fear about admitting the The forms and the kinds of the sick and for the sick; helping person to hospital (the sick per- help are many in number. There to find the right prayer, accom- son will ruin the family, he or are no recipes. In each case the panying in prayer, invoking and she has to be hidden away, what needs which must be met must thanking God together. Listen- will happen?); 2) fear during the be identified. It may be neces- ing together to his Word. hospitalisation (fear that he or sary to liberate these families she will not be treated, fear from isolation and provide them 4. Supporting the family about the discharge from hospi- with security; they should be in- tal, about the reactions of the formed about their rights and Reference is made to reinser- sick person, visits that are not defended in practical terms; tion and the social rehabilitation wanted, etc.; 3) fear after the they must be helped to look af- of mentally-ill people, but this is discharge (the risks of living ter the sick person and in the difficult if families are not sup- with the person, fear about the carrying out of various tasks; ported to a greater extent, and unpredictable consequences of and they should be put in con- the family is the first and princi- the behaviour of the sick person, tact with the associations of 16 ple sphere of reference, in gen- fear that he or she has not been family relatives of mentally-ill eral, for reintegration. Families subjected to effective care and people. need greater resources and treatment, etc.). I would also like to draw your greater support in order for them In this situation there are fam- attention to homeless mentally- to be an effective support in the ilies which look after their sick ill people, whose number is con- rehabilitation of the sick person. member well, with love, pa- stantly increasing and who need tience, competence, and by therapeutic support and to be 4.1. The situation of families co-operating in a positive way followed from close at hand. There can be no doubt that the with the medical doctors. But The special help of Caritas is situations of families vary a there are also families where the not enough Ð more specialised great deal, just as in the same sick person is an insupportable action is required. way there are major variations burden; who are not able to deal I would like to conclude with in the approaches towards the with him or her, and whose the testimony of the Marxist Lu- sick family relative adopted by members are negatively affected cio Lombardo Radice who de- the other family members. But it and in turn foster a deterioration scribes one of the most charac- is nonetheless possible to point in the condition of the sick per- teristic aspects of Christianity in out certain rather common as- son. the following way: ‘From a pects. Christian point of view it is im- Many families feel that they 4.2. Support for families portant to dedicate oneself to a are alone and that they have lit- Christian communities must human creature, look after him tle support in facing up to the be very near to these families. or her and love him or her, how- problems that arise because of This is in turn one of the most ever much our dedication may the illness of one of their mem- important fields of action for the not be productive. For the Chris- bers (a parent, a son, etc.). parish communities. tian it is important to give all his At the same time, families of- or her time with joy and happi- ten feel that they are marked out ness to the incurably ill person in relation to other members of and to give it ‘freely’; for the society. There is a fear of what Christian it is important to ac- ‘people will say’ and an attempt company with love and patience is made to hide the illness be- the elderly person, who is al- cause it is something which is ready ‘useless’ and on his or her dishonourable for all the mem- way to death; it is important to bers of the family. take care of the ‘last’ human be- A feeling of guilt can also ings, the most unhappy and im- arise. The illness can be an perfect, including those in hereditary phenomenon; there whom it is almost impossible to can be recriminations about not discern human traits’ (I Marxisti having perceived it earlier or e la Causa di Gesù, 26-27). about not having taken care of it in a serious way etc. Rev. JOSÉ ANTONIO PAGOLA In some cases a fear of the Diocese of St. Sebastian sick person can arise on the Spain grounds that he or she is danger- ous or because of the problems that he or she creates in the fam- ily environment and in the more general environment.

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The Anthropology and Ethics of Dying

I. Human Death and Dying

a. The human being faced with death

It is clear that man is a mor- tal being. This is a natural fact that we can do nothing about, although some people, for ex- ample Walt Disney, prefer to be frozen at -190E in the hope that after a few decades or a century medical science will be able to bring them back to life. Heidegger said that man is a 17 being-for-death and that not only does he die but he knows that he will die. Some adages which figure on certain ancient sundials such as ‘tempus fugit’ (‘time flies’) or ‘carpe diem’ which provokes fear in us: of principally because he or she (‘seize the day’) or ‘memento loneliness, of pain, of a lack of has an irreversible clinical mori’ (‘remember that you will satisfaction with a life which state, that is to say that there is die’) remind us that sooner or has been badly led and which no therapeutic action which can later we will have to die, that cannot be lived again in a dif- avoid the progressive organic just as we have come into this ferent way, a sense of guilt deterioration that will lead to world so also we will have to about having behaved badly to- death. Of the criteria which can leave it. Quevedo was right wards somebody, and so forth. be employed to diagnose the when he said that ‘man is a be- Death is something which is syndrome of a terminal illness, ing who lives between the cra- uncomfortable, we are afraid to the following can be listed: dle and the funeral shroud’. think about it, we think that it is a. An incurable illness with a something for other people and progressive development. b. Death and illness not for us. However, it is an in- b. The prediction of survival in contemporary culture evitable reality, something of under a month (or six which is natural to the exis- months at the most). Speaking about death and ill- tence of all living beings. There c. The proved ineffectiveness ness is not something that is is in addition something curi- of treatment. liked by anyone, as though they ous and ambivalent in the ap- d. The loss of hope of recov- were subjects which were taboo proach of many human beings ery. and not to be raised. However, to death: on the one hand there today we will speak specifically is a wish to know, and on the about illness and about death. other hand the fear of knowing, II. Living Dying The world of illness is a diffi- that is to say, there is the fear of cult world but a compelling one. knowing but there is also the Plato said to his disciples: It is difficult because it is a world fear of the unknown. ‘practice your death’, ‘practice in which we move on the thresh- dying’. Every day we experi- old of dualisms (hope/hopeless- c. The terminally-ill person ence small deaths, small sig- ness, meaning/meaningless- nals (for example the death of a ness), but compelling because Today it is estimated that the person dear to us, the loss of we enter into the very depths of reason why 87% of the people our usual work, emotional frac- the human being. In the world who die in the world, principal- ture or separation, etc.) to the of death something rather the ly in the most industrialised point that one can speak about same takes place. Death is al- countries, is to be attributed to daily dying, on the one hand, ways something which takes us chronic or terminal illnesses. and final dying, on the other. by surprise. It is premature, we However, and despite that fact We can say a great deal about do not know when it will ar- that at a medical level there is final dying, but almost nothing rive, and this is the specific rea- not a unanimity of criteria by about death, except what some son for the anxiety it provokes. which to define a patient as be- people derive from parapsy- Death, for this reason, imposes ing ‘terminal’, we can say that chology and others from faith. itself on us, does with us as it a terminal situation is one in Unamuno said that he was not will. And it is also a reality which a person reaches the end worried about dying but that he

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perienced from near to hand mism and hope (for example, (for example the death of some- the sick person who gives up one because of a road accident, and becomes depressed lives the terminal illness of a family out his or her own illness in a relative or when one feels be- worse way than the person who cause one is of an advanced age adopts the opposite approach). that little time is left before one Do not close oneself up in leaves this world). pain. If the sick person closes We should also say that himself or herself in his or her death is a good teacher regard- own pain he or she becomes ing life. When you look at even more depressed. In the death face to face, life becomes face of the risk of becoming transformed into a unique ex- darkened by his or her own suf- perience. In this sense we can fering, the sick person must say that death can give mean- struggle to break the circle ing to life. Death turns us to which imprisons him or her. life, it reminds us that our time A meaning to pain should be is limited, destined to end, and looked for. The sick person that we should thus take advan- should be helped to find a felt anxiety about ‘not existing’, tage of it. Hence the impor- meaning to his or her suffering about ceasing to exist forever, tance of enjoying our lives. and this helps him or her to and hence his yearning for im- We should say here that it is face up to and experience his or mortality, his strong desire not more important to live the time her illness in a healthier way. 18 to disappear forever. that we have than to want to But the problem is not as Viko- With all this we must accept live as long as possible (quality tor Frankl said to suffer, but to human finiteness and approach is more important than quanti- suffer without meaning. Per- death as something which is in- ty). A person can die at the age haps it will not be easy to evitable. However, if one has to of thirty and have lived a great search for this meaning, and choose between the absurdity deal or die at the age of ninety even less easy to find it, but an of not believing in anything and never experienced the im- attempt is worthwhile. and believing in something, I portant things of life. For this think that the second is prefer- reason we should aspire to c. Care for the dying able because nothing springs what Neruda said at his death: from the absurd whereas some- ‘I confess that I have lived’. The ultimate demonstration thing valuable springs from be- of respect and affection in rela- lief - mystery. b. Facing up to suffering tion to the dying person is ‘to be with him’, to share his mo- a. Spirituality Suffering is another in- ments, to allow him to show and transcendence evitable human reality. I will himself as he is and to die in his now attempt to list some ways own way (and not in our way). In all ages and cultures hu- by which we can live out suf- But it should be realised that man beings have needed to be- fering in a healthy way: the dying person has two funda- lieve in something that goes be- Suffering should be eliminat- mental needs: first, the need to yond daily life. Hence cults, fu- ed as much as possible. The feel the nearness of someone at neral rites, etc. Every man has first thing that we should do the moment of death (although asked himself, asks himself, with suffering is to remove it there are those who say that and will ask himself about the where this is possible. This is those who belong to Latin cul- meaning of life and also about even more the case if we are ture prefer to die alone and the meaning of death. In addi- dealing with senseless suffer- curled up), and second, the tion, as they grow older people ing. need to be able to draw up a fi- adhere more closely to their Bear inevitable suffering. In nal summary of his death. What own ‘beliefs’ and ask them- life there is a kind of suffering elements constitute this care? selves about whether another which in itself is inevitable: ill- life exists. During adulthood, ness, old age, misfortune, the Elements: or to express it more effectively loss of dear ones, etc. These Communication with the dy- during the maturity of old age, moments bring out the dark ing person: verbal: providing a rebirth of spirituality takes and painful side of life. This him or her with serenity and place. suffering can be alleviated or showing affection; non-verbal: This spirituality is nothing attenuated but it cannot be re- expressions of the body and else but a search for the mean- moved because it is a part of looks. As the Spanish saying ing of one’s own existence, a existence itself. has it: ‘a gesture is worth more way of connecting our ‘higher Face up to suffering with re- than a thousand words’. self’ to our ‘inner self’, or to alism. In the face of suffering Silence: staying at his or her what some people call God. rather than making fine speech- side in silence can be a valu- Spirituality can be an impulse es or producing theories it is able experience. towards this transcendence but necessary to act against it. Touch: physical touch is im- in many cases it is nothing else Rather than a passive approach portant for newly-born chil- than mere help and mere conso- or resignation, one should dren, for mental and emotional lation at difficult moments, adopt a realistic attitude - it development, and also for above all else when death is ex- should be fought through opti- those who are at the ends of

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their lives. Experience teaches die what is commonly believed ues to exist. The same author us that almost everybody to be a natural death, or old also states that when they are reaches out for other people’s age. A bad death is said to be to on the threshold of death peo- hands and this is because a ca- die suffering or from a death ple see a bright light and that ress is the most direct way of which was not sought for. within it there are their loved sharing love. There are many authorities ones who have died. They have Hope: they should always who have studied the subject an expression which seems to have the hope that they will get and they have provided a series want to welcome the person better, live a little longer, or en- of more or less personal criteria who has left life. In the face of counter a calm death. on the question. But despite this description, it should be this variety of approaches it is borne in mind that faith is not d. The experience of mourning possible to summarise what for in any way science-fiction. many people are the fundamen- Death is a part of our exis- Mourning is the natural reac- tal rights required for a digni- tence. There are people who tion of a human being in re- fied death. mask death, who paint it over, sponse to the death of a loved or who hide it, and there are one. This reaction can be a long The right to know that one is others who accept it as it is. But journey, made up of two days, about to die (the right to know to accept dying one must ‘ac- or of two years, or even of the the truth). climatise oneself’, to under- rest of a person’s life. It is use- The right to express one’s stand what will happen to us, ful to point out what could be own faith (respect for the per- and this should be done begin- the principal stages through son’s values and creed). ning with faith, hope and love, which a person undergoing The right to be conscious (to the ingredients which not only mourning usually passes: die in a state of consciousness make it easier to accept this re- 19 with one’s eyes open), even ality but in definite terms fill it Stages of Mourning: though there are those who pre- with meaning and personal ful- Shock: (distress): a feeling of fer to know nothing and to die filment. But what should we incredulity: ‘it can’t be true’, ‘I in tranquillity. believe? What should we hope don’t believe it’, ‘it can’t be The right not to suffer with- for? What should we love? happening to me’. out good reason or needlessly. These are three verbs which Stage of anger: aggression, The right to die ‘naturally’, call on and worry all those who anxiety, confusion, self-rebuke, without an extension of one’s want to face up to this subject etc. (loneliness and isolation life or it being shortened. personally. The before and the are engendered). The right to die in human after... will be strongly impreg- Stage of hopelessness: aware- contact with the people near to nated with meaning if these ness is gained of the fact that one (human warmth). three categories are taken into the deceased person will not account. The ‘before’ because come back (deep sadness and b. Preparing to die: it bears upon the daily life of uncontrolled weeping). believing, hoping, loving the person in all his or her di- Stage of reorganisation: mensions (functional-biologi- putting the pieces back together It is difficult to day ‘adieu’ cal, psychological, social and and the adoption of new life but we must learn to separate spiritual), and the ‘after’ be- models without the deceased ourselves from our loved ones. cause a priori one does not person (social life is taken up For the Swiss doctor, E. know anything and the person again). Kubler-Ross, who is resident in is moving inevitably towards the European Union, to die the final moment. Mourning for somebody is means to abandon one’s physi- This integration of the here also an act of love. Sharing and cal body, in the way that a but- and now, and of the there and helping a person during his or terfly leaves its silk chrysalid. then, passes, as has already her mourning is fundamental to One is dealing here with pass- been observed, through believ- ensure that he or she accepts ing to a new state of conscious- ing, hoping and loving. To have and takes in the fact that the ness in which the spirit contin- faith in the fact that death is not person will no longer be pre- the end of everything, to hope sent physically with him or her, that something good will come even though spiritually that out of all this, and to love be- person will be present (of cause this is the most important course not like Patrick Swayze thing there is in life. Further- in the film ‘Ghost’) and inside more, when the final adieu is his or her heart. spoken, love is really the only thing that remains.

III. Towards JOSÉ GARCIA FEREZ, a Dignified Death Assistant Professor at the Faculty of Theology of the Pontifical a. Ethical considerations University ‘Comillas’, Secretary of the Chair of Bioethics and Master in Bioethics A popular idea exists about of the same university, what is a good death and what Professor of Bioethics is a bad death. A good death is at the Centre for the Humanisation said to be one without pain, to of Health.

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Dying in our Society: Philosophical and Ethical Aspects

1. Dying in History figuration of dying into histori- cal living (that is to say living is Death is not only a biological dying, and dying is living) or fact: it is also a cultural event into an eschatological dimen- which is experienced and trans- sion. In every historical age mitted within the context of the man has never feared death as collective imagination, in addi- an event but he has feared the tion to being a political ques- process of dying both at the tion, because it gives rise to the physical level (he fears pain, action of the state in a democra- suffering) and at a psychologi- tic and pluralistic society in cal and social level (a sense of which different ideas encounter the removal of family affec- and come into conflict with tions, economic goods, etc). 20 each other at the level of law. Such fears are removed at a hu- But the question of death, both man level by man and concen- at the level of definition and at trated into death as an event, that claimed at a personal level not least because this existential as being a right on commission, limit has always been increas- finds its meaning in that philo- ingly modified and planned by sophical question which seeks modern technology (for exam- to understand the complexity of ration for a new way of living ple the development of medical the human condition, the mean- within a metaphysical horizon: resuscitation). ing of its existing and its dying spatial-temporal life was a Philip Ariès2 has identified in the ambiguity specific to a carpe diem for and in relation four ways of living the event of society where values and to spiritual life. Here the An- dying to be found in human his- anti-values intertwine and are glo-Saxons distinguish dying as tory, and they may be listed as in contrast with one another in a process from death as an follows: dramatic fashion, such as the event. Physical human life is 1. The tamed death of man of meaning of the potentiality of characterised by a teleologism, the medieval age. Man is aware the object, technological effi- death, and by a locus epistemo- of his finiteness and his destiny ciency, scientific progress and logicus as a point of ontological in the form of death, indeed he destructiveness, necrophilia, reflection, that is to say of being experiences it as a natural event the planning and the decreeing that is realised through living. connected to the chronological of life, and its own and other Indeed, death is the characteris- age of each and every person ends.1 tic element of this human reali- according to a series of seasons Death is an incomprehsible sation, in addition to being tran- of life: there is the age of birth and indefinable event for con- scendental opening. In fact, (spring), of psycho-physical temporary man, above all else both in the psychological do- vigour (summer), of senile de- in the light of the aspired to om- main, and in the philosophical cay (autumn), and then the end nipotence of biomedical tech- domain death is the impenetra- of the terrestrial journey (win- nology. During the medieval ble destiny of mankind: it is the ter). Aware of this cyclical na- period, in fact, it was suggested end of a terrestrial biography ture of life, man awaited death to health care workers, to fami- but also the potential expres- with tranquility, supported and ly relatives, and to the dying sion of metaphysical freedom. surrounded by his family rela- person himself or herself, that According to positive law, tives and acquaintances. This an unbridled rush to forms of death involves the loss of every was a tamed death in the sense treatment in order to regain right and duty but not the, albeit that it was not experienced in a physical health was something unconscious, right to have blind way, but at the same time to be avoided. The idea was one’s own corpse respected. death was not an irrelevant ex- rather that the dying person Furthermore, it can become a istential event. should be prepared to enter moment of the highest expres- 2. The death of oneself or consciously into the spiritual sion of the freedom of the giv- one’s own death: the man of the dimension. In other terms, ing of oneself to other people, period which runs from the death was the epiphenomenon as happens in the case of organ twelfth to the seventeenth cen- of an existential process, or bet- donation. With physical death turies discovered that death was ter, a process of gradual dying. the very process of perception a self-limitation in relation to Dying was a vera ars vivendi in and experience comes to an his own great ideals and plans. the sense that every moment of end, at least in the positivistic This awareness of oneself took life had to be lived in an overall sense of acceptance, whereas in place because the process of the way in its fullness and in prepa- fact death constitutes the trans- socialisation of death itself de-

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clined. Man was left alone with came a personal fact where the institutions of the welfare his cold rationality, at times even every social and participa- state and anaesthetised by the without the support of faith, tory demonstration was relegat- advances of medical science, and discovered his existential ed to the so-called ‘rites’ of the the expression of a process of limits. He perceived that the funeral parlour. The very the control of emotions and af- move was personal and could process of dying was increas- fections which is characteristic not be transformed by reason it- ingly less taken part in, with the of the contemporary stage in self. The seventeenth century dying person being entrusted to which civilisation now finds it- was the age of rationalism, of suitable institutions such as self: ‘so removal, the atmos- scientific discoveries, of trust in hospices, residences for termi- phere of ill-being that often to- progress, which, however, was nally-ill people, and homes for day surrounds the final mo- powerless to distance opposed the elderly. ments of life, are certainly not a natural forces Ð eros and These four approaches to help for people. Death conceals thanatos, life and death. When death have now been joined by no mystery, opens no door Ð it this last came to prevail it left a new tendency: is the end of the human crea- the subject in a state of despera- 5. The return of death, a de- ture. What remains is what has tion and fear. Fear above all velopment that is expressed at been given to other people and else of being buried alive Ð the two levels: what remains in their memo- rite of ‘conclamatio’ was evi- a) Speculative interest. Inter- ries. The ethics of homo dence of this, a rite which in- est in death involves different clausus, of the man who feels volved, in conformity with the speculative domains (the histor- that he is alone, will decay instructions expressed in the ical, the anthropological, the rapidly if we cease to remove person’s will, the corpse being psychological, the sociological, death and accept it instead as an 6 addressed three times before etc.) as a thanatological reac- integral part of life’. 21 being actually buried. tion to the removal of the denial b) Existential curiosity. Cer- 3. The death of the other per- or the ideologisation of death. tain phenomena typical of our son: in the eighteenth century, The historiographical analysis time form a part of the tendency at the height of the Romantic of P. Ariès, mentioned above, is which involves the removal and regime, death was experienced marked by an interest in the ex- the denial of death. We are in as the loss of another person, perience of dying and death as a the presence of an increasingly and took the form of a reified personal, social and eschatolog- posed question about what hap- character of social reflexes. ical phenomenological event. pens after death: visits to clair- Those who surrounded the dead This historian has transposed voyants, to mediums, paraphsy- person wept and exorcised the reflections of American au- chology magazines, religious death with religious practices thorities on the subject onto the movements which preach rein- (prayers, invocations) because European context, and has em- carnation, pre-death studies, their affective and relational phasised the approach of con- and all the rest. A. Moody Jnr.’s possessions were being re- structing a taboo in relation to studies in this area on ‘ideal’ or moved. This was a form of so- death which is characteristic of ‘ideal’ pre-death experiences cialisation of death as a reaction our age. The same conclusions are well known.7 His research is to the personal diminishment of are reached by the two histori- interesting and indicative of the those who were linked; it was a ans, J. McManners3 and M. new interest in the event of kind of intolerance in relation Vovelle.4 In the sphere of psy- death, although its results are to separation. chology, in Italy for example, F. debatable from both a scientific 4. The prohibited death of the Campione organised a universi- and a philosophical point of twentieth century: this was typ- ty centre in Bologna concerned view. It is the case that a patient ical of the positivistic age and with studies on death and relat- who is subject to pain and un- of the scientific discoveries of ed questions and issues (for ex- bearable suffering can tem- experimental medicine and ample mourning, suicide and porarily alter his or her percep- biotechnology, elements that euthanasia), an initiative which were able to make precise diag- gave rise to the Revista di Tana- noses which at times involved tologia (Zeta). This author the prediction of death and had seeks to rediscover death by a notable prognostic value. combating the thanatological Foreseen death worries people, inversion characteristic of mod- frightens them, and as a result it ern man, who strives to remove was better not to talk about it, to and deny death by rationalistic keep it hidden or at least to con- paths, betraying dying as a way ceal it not only from the sick of living: death is a human real- person but at times also from ity, which despite the difficul- his or her closest family rela- ties encountered in understand- tives. In the light of medicine, ing it, belongs to existence and death became a synonym for being in the world. In the defeat, which was hidden be- sphere of sociology, N. Elias,5 hind a white sheet, a waiting beginning with the tandem room prior to removal, where it ‘ageing/death’ which is typical did not frighten other people, of our industrialised society, and in that loneliness and isola- observes how death has be- tion what had happened was al- come a personal fact, a solitary most not noticed. Death be- event even though protected by

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tive and consciousness faculties nomic well-being, of the dis- propose a invitation to learn as regards external messages coveries of cosmetic surgery how to die, nor does he suggest and that during the internal and cosmetic systems are able elements that can console us processes of elaboration this to mask every final reality. Our about death, rather he generates can lead to errors in the process cultural world has given way to in the reader those reflections of decodification. In these cas- uncertainty and artifice rather which lead him or her to a more es, we are not in the presence of than engaging in a positive ap- authentic life, that make him or people who are dead in the preciation of the naturalness her understand that death can bio-functional sense of the and certainty of the vital human be a real and unique teacher. term, we are dealing here with processes. The very language of His methodological approach clinical deaths, which are very dramatic encounter with death constitutes authentic maieutics similar to other physiological or has been subjected to a taboo, by which to learn to live, to un- pathological situations of the and increasingly in obituaries derstand within the horizon of psyche such as dreaming, the noun ‘death’ is avoided and death the real meaning of life schizophrenia, hysteria and replaced by sweeter phrases and responsibility towards one- suggestion. What the ‘dead pa- such ‘has gone to rest’, ‘has self and other people. This is tients’ of Moody are referring gone on’, ‘has left us’, and ‘has the ‘thought of death’ which en- to as reality is in fact the experi- disappeared’ Ð we have before sures that man lives an exis- ences of dying, that is to say in- us a tendency to preach the tence which has the characteris- stances which anticipate death, death of death. Philosophers, in tics of seriousness and not those but not real death itself. Thus different fashion, have been of vacuous fatuousness. He ar- the results published by this au- less concerned about linguistic gues that ‘the seriousness of thor are extreme situations of taboos and have dedicated a death does not deceive because 22 experiences of dying which do great deal of space to the ques- it is not death which is serious not in the least provide or offer tion of death, its understanding but the thought of death. If, information about the life be- and justification, in their ratio- therefore, you, my dear listener, yond our own. In fact, this re- nal speculations. In particular, adhere to this thought and in newal of interest constitutes an- they have been concerned with thinking it do not concern your- other negative aspect of re- self with anything else than moval, that is to say speaking thinking about yourself, thanks about death with a view to ex- to yourself this approach with- orcising it rather than experi- out authority will become encing it in one’s own con- something serious. To think sciousness as a natural fact of ourselves dead in the first per- human existence. son is seriousness, to be the wit- Our society, instead, needs nesses of the death of another euristics of death and dying, person is a state of mind’.9 and it is precisely this biologi- Kierkegaard argues that cal and biographical event and death is seriousness, not so process that allows us to under- much because of the external stand the meaning of living, the fact of the death of somebody value of life, of illness, and of else but rather because ‘it can suffering: as a tendency of be- teach us that seriousness is in ing towards overall self-realisa- the internal, in thought; it can tion, towards making one’s own the argument advanced by Mar- teach us that to look with action responsible, as well as tin Heidegger according to melancholy or indifference to- one’s own choices and their which ‘living-for-death’ is the wards what is external is an il- consequences not only for one- authentic meaning of existence, lusion... the seriousness of self but for each and every per- but also that proposed by Soren death is different from the seri- son. Cicero liked to argue that Kierkegaard (1813-1855). ousness of life, which so easily ‘tota philosophorum vita com- The works in which Kierke- draws us into a deception’10 memoratio mortis est’, that is to gaard dwells upon these ques- through such elements as states say death should become a mo- tions and issues are many in of mind, feelings of piety, or ment of reflection and of number, and go from ‘The Con- memories, which vanish and awareness about the limits to cept of Anxiety’ to ‘Diary’, and make us forget about the seri- one’s own human condition, to on to the ‘Three Discourses for ousness of death and do not af- one’s own actions, and, in addi- Imaginary Occasions’, which fect our lives, save where they tion, a rediscovery of the value he published in April 1845. immerse it and hide it in the de- of life. This philosopher sees in the personalism of daily routine. modern world a widespread su- Death, Kierkegaard affirms, is Philosophical Thanatology perficiality and widespread in- the teacher of seriousness and it and the Consciousness differentism in relation to the is the thought of death that of Contemporary Man meaning of life, Christian val- points out ‘the right direction in ues, and he perceives in death life and the right goal towards In our secularised society (indeed, in the thought of which to direct our journey. No there is no longer any space to death) that propulsive element bow allows us to be directed so reflect upon and speak about that can shake man out of his much, no bow is able to impart death. This is because the worldly torpor of daily life. In so much power to the arrow, as worldly culture of external his work ‘Next to a Tomb’,8 this much as the thought of death, beauty, of physical and eco- philosopher does not seek to which calls on the living, as

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long as it is seriousness which they live death, in an analogous entity possess a primary posi- bends it’.11 The thought of death way to the harsh criticisms that tion as regards the approach to must not distract man and lead Kiekegaard levels at Christiani- the question of being?’16 The him to engage in the sensual ty. He makes a net distinction privileged entity by which to pleasures and lose himself in between ‘knowing what Chris- understand the meaning of be- daily routine, just as it must tianity is’ (which is the easiest ing is man, who is able to pose motivate him to involve himself thing) and ‘being Christians’ to himself the question of be- in life without wasting the time (which is the most difficult ing, and this is because he has a that is available. Death for thing). For that matter, in his special relationship with being. those people who live seriously work ‘The Concept of Anxi- For this reason, man is the en- is not a narcotic that inhibits, ety’,15 Kierkegaard had already trance door to being, as long as but a ‘source of energy unlike defined death as planning to- our knowledge of man is er- any other, which makes us wards Transcendence, towards ror-free. This philosopher, in awake like no other’.12 ‘the Other’ who constitutes the his anthropological analysis, Education in life, for that end of possibility (of vague- identifies certain fundamental matter, must be based upon the ness, of uncertainties). Death is elements in man which are typi- existential reality and serious- the price to be paid for sin, and cal of his being, and these he ness specific to the thought of is the encounter of the individ- calls ‘existential’.17 They are as death, employing the limited ual with time and eternity. The follows: and finite instruments specific anxiety of death has as its end Being-in-the-world. Here to uncertainty that are offered transcendence itself. Heidegger means by world the by human and historical contin- For Martin Heidegger, as I set of interests, of concerns, of gencies. Kiekegaard main- have already observed, life has affections, of wishes, of forms tained that ‘the serious man is meaning only if it is finalised to of knowledge in which man is 23 the man who is educated out of death. In his work ‘Being and immersed. Man is always in- uncertainty to seriousness be- Time’, Heidegger considers the serted into situations, and is cause of certainty... the pupil phenomenology of man. Being thus called by this thinker ‘Da- worries, in fact who does not never reveals itself directly, in sein’, being, that is to say the worry cannot learn about this or condition of ‘situationness’ in that subject with all his or her which man finds himself every soul, and in reality, also, the day. certainty of death is a subject to Existence. Man in his situa- be worried about. The pupil tionness is not a static state but who worries about it turns to is projected towards the future, the teacher of seriousness, and that is to say he is open to be- as a result death is not some- coming something else. Every thing that is frightening, al- action is finalised to what man though it remains frightening wants tomorrow. Thus exis- for the imagination’. Death, fi- tence is the possibilities of be- nally, is the most certain thing, ing of man, it is man outside of but at the same time it is the on- himself Ð such is the essence or ly thing about which there is nature of man. nothing certain; indeed, no man Temporality. Man is an exis- knows the exact moment when tent being because he is bound he will meet death. ‘The cer- an immediate way, but through existentially to time. It is the tainty of death determines once the being of an entity (a man, a temporality of being that gener- and for all that the pupil enters dog, a home, etc.). We can un- ates time and not, vice versa, seriousness but the uncertainty derstand the nature of being by time which renders being tem- of death is his daily supervi- beginning with the being of a poral. Man is not stranded in sor... Seriousness thus becomes particular entity, and in remov- being but in his real being he al- living every day as though it ing from it what does not be- ready finds himself beyond was the last, and at the same long to it the being is unlocked himself, projected into his fu- time as though it was the first, from itself. ‘But we give the ture possibilities. In this sense of a long life’.13 name of ‘entity’ to many things man is existent because the ex- Kirkegaard’s criticism of and with different meanings. pressions of situationness pre- those who tend to explain, and An entity is everything that we sent with the luggage of past after a fashion also to justify, speak about, what we speak experiences are projected into death is also of great relevance about, what we behave towards the future Ð man is future. In here: ‘as regards death, one in one way or another. An entity bringing about these possibili- should not rush to acquire an is also what we are and how we ties, man, therefore, begins opinion about it. The uncertain- are. Being is found in what is, from a situation of fact into ty of death is constantly and in in being in that way, in reality, which he is at the present time all seriousness freely verified if in mere presence, in subsis- inserted, and in this sense he the person who has an opinion tence, in validity, in Being, in has been: the past presents itself really has this opinion, or if his ‘there is’. In which entity as a static contingency of the or her life is an expression of should the meaning of being be present of man who projects re- it’.14 In other words, this grasped? From what entity does alisable possibilities into the fu- philosopher distinguishes be- the opening of being take its ture. Temporality, therefore, tween what death is in the opin- steps? Is the point of departure unites existence (the possibility ion of intellectuals, and how immaterial or does a specific of future), actually being (the

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present), and being deceased struction of a meaning to life ety because of the ‘possible nul- (past), and this constitutes the can make it authentic, can open lity of the possibilities of man three elements of what goes to out its possibilities, removing it and the whole form of man’. make up the structural totality from the day by day character Man cannot withdraw from of man. of the situation and from vague- such a possibility without a de- To each of these three tempo- ness. nial of the character of his be- ral states there corresponds Man is an existential pro-ject, ing. Death for man means the three ways in which man the actuation of possibility. If achievement of the Totality of knows: Being-here wants to acquire its his life. Death is possibility it- Ð past, through feeling; authenticity it must take on its self in relation to which the au- Ð present, through taking; most specific possibility Ð thenticity of human existence is Ð future, through understand- death. The man who directs his defined. Authentic existence is ing. existence towards death has an existence that is anticipated in Between Being-in-the world authentic life. Death, for Hei- death, that takes on death as the (first existential) and Existence degger as well, is a personal fact most specific possibility of liv- (second existential) there exists Ð my life and my death belong ing. For Heidegger, being-here a clivus of contrasts with possi- to me because they are the ulti- cannot be seen as a totality be- ble forms of conditioning in the mate possibilities of existence. cause it is influenced by a po- Death is the objective of one’s tentiality whose practicability own existence. Man in his ‘be- belongs to the very way of be- ing-in-the-world’, in his ing of human existence. This ‘being-here’, in his being becomes ‘authentic’ only if it ‘thrown’ into the world, in his keeps its gaze fixed on the death 24 ‘being in a situation’, is search- which looms up upon it, on its ing for the ‘Being’ hidden be- own finiteness. Authentic exis- hind the daily ‘care’ employed tence requires, therefore, the in the use of things. Man thus planning and the foreshadowing moves towards truth as a revela- of death. Human life becomes tion of what is hidden. In this totality through death, which search man finds anew the au- limits it, informs it, and pre- thenticity of ‘being-here’ if he serves it from being made un- directs his planning to death, the natural and disfigured.19 Ac- implicit end of which does not cording to Heidegger, death is mean a ‘being-at-the end’ of be- no longer, as it is in the Catholic ing-here but being ‘for the tradition, the beginning of a dis- end’.18 Before specifying Being- course about the life beyond here as being for death, Heideg- this one, but becomes an oppor- ger restates that it is in the death tunity for a discourse about life, of another person, who is near and at a precise level an oppor- expression of being. Gazing on to me, that there is realised the tunity to characterise life in Being-in-the-world leads man to first stage of understanding of terms of its rooted finiteness. stop in the past, whereas in po- the central phenomenon of ex- In this radically secular ap- larising himself in existence isting, the move from the im- proach, Heidegger rejects sui- everything is projected into the personal ‘one dies’ to dying as cide and sees it as flight from future. According to which con- such. But for Heidegger ‘no- commitment and planning. ditioning tendency prevails in body can take on the dying on There can be no doubt that Hei- the life of a man (the meaning another person’; we are near to degger’s idea of death is in es- that he wishes to give to his the other person who dies but it sential terms individualistic in life), he will either live a is he or she who dies. character. However, it over- non-authentic or authentic life. In ‘Being and Time’ Heideg- comes anxiety not through di- Heidegger sees as constituting a ger argues that death is a ‘possi- alectical artifices but through non-authentic life that life which bility’, indeed it is the extreme exit from chatter, from the allows itself to be administered possibility, the possibility of ab- non-authentic, and from the ar- by situationness, by ‘chatter’, by solute possibility, which is an tificialness of technological so- being-in-the-world, by being integral part of the constitution ciety. concerned with things and of the ‘being-here’ of man. The The alternative to the empty anonymous mass relationships. authentic Being-here foreshad- results of Heidegger is the pro- The non-authenticity of life is ows in an emotional sense its posal of Christian philosophy, dominated by anonymous mass ultimate possibility in becom- which does not confine itself to relationships which level the ex- ing a ‘being for death’. a mere inquiry into death, but pression of life itself and the as- Just as in Kierkegaard the se- through reason, through the piration to knowing. Whereas, riousness of the thought of paths of faith, it offers direc- in fact, authentic life is deter- death can bring about anxiety, tions to man that free him from mined by the subject gradually, even though this must not inhib- noetic anxieties and improve in line with an active definite it the person from constructing the quality of his existing. The plan, feeling the responsibility a responsible, aware and ful- faith proposed by philosophers of an incessant appeal of the fu- filled life, so for Heidegger man is not oblivion in theological ture, the only place for the reali- becomes aware of his ultimate expressions but an opening up sation of his possibilities. possibility of death and this is to truth that transcends the mere The aware planning and con- something that causes him anxi- request for truth of reason.

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Gabriel Marcel has ex- substantiality or in the qualita- tion, of the taking of organs for pressed with extreme clarity tive substantialism of his or her the purposes of transplantation, the philosophical correctness of function as consciousness? bestowing thereby a false tran- immortality by identifying in Does the basic anthropology to quillity on the consciences of love and loyalty between two define the life of a person refer health care workers to the effect human beings the sign of onto- to the principle of the sacred- that the person declared dead logical resistance to death and a ness of life or to the utilitarian really is dead. propensity to engage in the principle of the quality of life? b) Cortical death. This defin- lasting. ‘The spirit of truth also Obviously enough, the utilitari- ition, although it is based upon has another name, which is still an reference has the advantage empirical data, has a quintes- more revealing Ð it is the spirit of seeing as being dead, and sentially philosophical charac- of loyalty, and I am increasing- thus to be eliminated, every ter, and is advanced first and ly convinced that what this subject who not only has lost foremost by scholars such as spirit requires from us is an ex- his or her reason (a person in a Veatch, Engelhardt, and Defan- plicit rejection, a precise de- state of coma; a demented el- ti. These authorities see the nial, of death... To love a being derly person) but also a person death of a person as the disap- means saying: you will not die! who possesses this function on- pearance of the higher cerebral For me this... is an absolute ly at a potential level (the em- functions, such as the activity statement’.20 bryo, anencephalic people, the of consciousness, and the ratio- To believe that there is a handicapped). Given that man nal functions such as thought, world beyond the uncertain fu- is a fusion of matter (the body) social ‘relationality’ and its ex- ture of this world is a risk, but and form (relational soul), that pression through language. to refuse this risk would pre- is to say that the physical di- Cortical death involves an in- pare the way for a road that mension is linked with and sup- ability to engage in personal 25 leads to the void and to a total ports the psychic dimension, in acts and thus the person is said loss of self. Death is no longer the event of death when the to no longer exist. Naturally, an enigma but a mystery, a truth body ceases to exist as such, the these acts are the expression of greater than us but a truth physical activities also disap- the activity of the person, that is which is not completely un- pear. This definition of death to say they constitute the per- known to us, a truth that is safeguards the psycho-physical sonality, and are not constitu- grafted into the heart of life, definition of man, and the mea- tive of the person himself or which is destined for eternity. suring of the physical datum of herself. This definition of death Specifically when face to face death is determining in defining is very dangerous because it with the death of another per- death as an integrated system.22 runs the risk of a person being son, faith can raise questions Three definitions of death declared dead when in fact he about the capacity to think prevail in the bioethical field, or she is not really dead. philosophically, ‘Faith does not and they are as follows:23 c) Cerebral death. The prin- fear the great questions of rea- a) Cerebral death, initially ciple of the unification and inte- son; it only fears the small described as depassé coma in gration of the human organism questions, cultivated under the the famous publication of the is said to be found in the brain wounding dictatorship of banal- Harvard Committee (1968).24 in an overall sense. Thus death ity. And it is great questions, in- Subsequently, the debate be- stead, that at this point we so came more lively and scholars desperately need, even at the such as the German philoso- cost of finding on the outlying pher Hans Jonas defined death ring of faith, inhabited by rea- employing a cardiological crite- son, only small answers. It is in rion, seeing the death of the or- fact the great questions, in the ganism as the death of a whole, final analysis, that render the that is to say not only the necro- small answers great as well’.21 sis of the encephalus but the disappearance of the Bichat tri- ad, i.e., the cardiac, respiratory 2. Death: A and cerebral function. Here it is Neuro-philosophical argued that: Question Ð in cerebral death what goes is not these functions but their The definition of death is a capacity for spontaneous ex- subject that does not only in- pression, thus a disappearance volve neuro-physiological sci- of a whole does not take place; entific knowledge but also rais- Ð the classic Cartesian defini- es philosophical questions. It is tion is proposed again here, a a subject that involves to the distinction centring around the full bioethical reflection: what body-brain, res extensa Ð res is to be identified not only with is man, or, better, what is a per- cogitans dichotomy, rather than the death of the cortex (respon- son? When does a man die? the identity of the whole organ- sible for the higher functions What are the parameters to be ism being recognised; such as the activity of con- used to define the person and as Ð the definition of cerebral sciousness) or of the brainstem a result his or her non-person of death does not belong to a (responsible for the homeostat- the corpse? Should the person philosophical interpretation but ic, cardio-respiratory, metabol- be looked for in ontological rather to a utilitarian orienta- ic, etc. functions)25 but of all

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the brain. The concept of death deems a person to be dead moting thereby arguments based upon the death of the when cerebral death (state of which support the pro-euthana- brainstem is a metaphysical death) has been ascertained: the sia movements. Thus cerebral concept (the capacity for inte- brain is the principle of the uni- death should be distinguished gration), lying beneath the cor- fication and integration of the from irreversible coma because responding principle according human organism, and this is to in the latter clinical situation to which everything is more be found in the brain in an over- neurons still exist which contin- than the sum of its constituent all sense. To avoid the manipu- ue to function, and thus the sub- parts (for this reason death is lation and abuse of bodies in ject is not in fact dead. In the not the ceasing of an activity or special states of life, and in an case of cerebral death, instead, of a function of the human attempt to establish rules re- all the cells of the brain have body but the ending of a per- garding scientific data with re- been destroyed. son, that is to say the loss of spect to the existing confusion Parallel with the concept of that element that confers unity between cerebral death, cardiac encephalic death, some criteria on the organism, i.e. the ner- death, comas, and the persistent by which to ascertain such vous system).26 The medical vegetative state, law n. 578 of death have been drawn up. judgement, instead, seeks to 29 December 1993 Ð entitled These criteria have been incor- verify the absence of the vital ‘norms for the ascertaining and porated into sets of legislation functions, that is to say the de- the certifying of death’ Ð de- in order to govern this very im- cease of the person. This defin- fines death, in article 1, as ‘the portant area. ition was accepted in Italy by irreversible ceasing of all the The concrete diagnostic ways the Comitato Nazionale per la cerebral functions’ caused by by which to document the irre- Bioetica (the National Com- primary irreversible damage to versible ceasing of the en- 26 mittee for Bioethics) of 1991, the brain and at a secondary cephalic functions were laid which defined death as the to- level by cardio-circulatory ar- down in specific fashion in the tal and irreversible loss of the rest and the lack of a flow of decree which implemented the ability of the organism to au- blood to the encephalus with law of 14 April 1994. tonomously maintain its own the consequent arrest of all its In the case of cardiac arrest functional unity, something to activities: a person is dead an assessment made through be identified in the brain, when his brain is dead. the use of an electrocardiogram brought about by ‘organic C. Manni makes clear that for at least twenty minutes is cerebral damage that cannot be death is not an instantaneous sufficient. After this period, in repaired, where artificial sup- event but a developmental fact, we can be certain that the port has taken place in time to process which can also precede anoxia has produced irre- prevent or treat anoxic cardiac by a great deal the complete versible and total alterations at arrest’. necrosis of the organism. It is the level of the central nervous the moment at which there is system. Criteria for the Determining recorded the irreversible loss of In subjects affected by en- of Death the integration and co-ordina- cephalic lesions who have un- tion of the physical and mental dergone attempts at resuscita- Whereas the definition of the functions of the body, a mo- tion, the certain diagnosis of death of a person is a matter for ment generally defined with the death requires the simultane- philosophy, the determining of term ‘brain death’, and a mo- ous and protracted registering the ending of the unity of the ment suitable for the removal of for at least six hours of certain integrated complex of a person organs for the purposes of specific clinical-instrumental is a matter for medicine. Car- transplantation. In order to signs. These have been listed rasco De Paul maintains that avoid misunderstandings con- by the National Committee for ‘the moment of death cannot be nected with this term, it is more Bioethics as the following: a the object of a diagnosis be- exact to speak about ‘encephal- state of coma which does not cause it is neither evident nor ic death’, that is to say that con- respond to external stimuli; ari- verifiable. As a result, the asyn- dition when cell necrosis is ex- flessia tendinea of the skeletral chrony between the dramatic tended to the whole of the muscles linked to the cranial instant of the separation of the brain. Other forms of brain nerves and thus the absence of soul (understood as the moment death, such as that of the brain- brainstem reflexes (photomo- of separation of the rational stem (the criterion employed in torial reflexes, of the corneas, form or integrating and inte- the United Kingdom for the di- oculoencephalic or oculovesti- grated form of rationality) from agnosis of death on a neurologi- bolary reflexes, of the pharynx the body, and the moment at cal basis) or of the cortex, are and the trachea); muscular which the event of decease is completely equivocal and gen- atony; the absence of cerebral manifested (the state of disinte- erate dangerous forms of ab- electric activity measured gration), must be maintained. stentionism in relation to peo- through EEG registration, and Technological advance may be ple who are still alive.28 This the absence of spontaneous able to reduce the space of time clarifying observation can breathing. which divides the two episodes, come into conflict with those Conditions which could lead but it is improbable that it will currents of thought that wish to to error must be excluded disappear entirely. To diagnose describe physical death as the (artificial hypothermia, sub- death means to verify not the loss of some, albeit important, stances which depress the cen- detachment of the soul but the capacities of the patient, such as tral nervous system, endocrinal absence of signs of organised takes place with the death of the pathologies...). In children un- life’.27 Our legislation in Italy brainstem or the cortex, pro- der the age of five, twelve

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hours of observation are re- affirmations of science into the function of relating and quired; in children under the metaphysical realities, on the adapting to the environment of age of a year twenty-four hours other in a realistic gnoseology the person (temperature, blood of observation are required. the understanding of the human pressure, metabolic activity), At the present time sophisti- composition cannot depart from on the other, the diagnosis of cated machine examinations are the supports offered by the em- death, according to Italian law, able to confirm the accuracy of pirical sciences. From a strictly involves the demonstration of the diagnosis of cerebral death practical point of view, we can, irreversible damage to the in an even shorter period, however, adopt the observa- whole of the encephalus, which demonstrating in an unequivo- tions made on this subject by has to be so damaged as to cal way the absence of cerebral the ‘Charter for Health Care eliminate every doubt about the circulation and thus that the Workers’: faith and morals ac- possibility of life. The diagno- blood cannot reach the cerebral cept these findings of science. sis of death is carried out by the parenchyma. First, there is However, they demand of medical doctor treating the cerebral angiography: in nor- health care workers the most case, who generally is a resusci- mal conditions the blood flow accurate use of the various clin- tation specialist, and involves is equivalent to 50ml/100 gr. of ical instrumental methods for a an etiopathogenetic definition tissue/min, and when this level certain diagnosis of death so of the damage, that is to say an exact diagnosis of the malady which has caused cerebral death. Once the diagnosis of death has been carried out, the resuscitation doctor tells the health authorities that there is a 27 potential donor so that the med- ical committee engaged in the ascertaining of death can be ap- pointed. These health care spe- cialists have to be employees of a public structure and must not be members of the team re- sponsible for the removal of or- gans or the team responsible for the transplant. They are: a legal doctor or a doctor of the health care authority or a anato- mopathologist, that is to say someone who knows about the legal rules that apply to trans- plants. In addition, an anaes- thetist doctor, a neuropys- iopathologist or a neurologist or a neurosurgeon has to be pre- sent who is able to correctly read the print-out of an elec- troencephalograph. The length of the period of observation in order to ascertain death is six hours in the case of adults and children above the age of five, twelve hours for children be- tween the age of one and five, and as much as twenty-four goes down to 15ml/100gr of tis- that a patient is not declared hours for children under the age sue/min we are in the presence dead and treated as such when of twelve months. The simulta- of the death of the whole of the in fact he is not dead.29 neous presence of a state of un- cerebral population. Then there Given that from a physiologi- consciousness, an absence of is the Doppler flowmeter, cere- cal point of view the en- reflexes on the part of the trunk, bral scintigraphy with Tecnezio cephalus carries out two impor- and cerebral electric silence as 99m, and the SPECT (comput- tant activities: the working out demonstrated by an EEG, at the erised tomography with the of the contents of conscious- beginning, the middle and the emission of individual pho- ness (the cortical area), that is end of the period of observa- tons). to say awareness of one’s own tion, allows the certification of The precise relationship be- being and existing in relation to the presence of death. The med- tween the death of the organ- the surrounding (physical, rela- ical committee appointed to as- ism, encephalic death, and the tional) environment on the one certain death must, after the rel- death of a person is very far hand; and homeostatic (the en- evant period of observation, from being clear in all respects. cephalic trunk) activity, which confirm the diagnosis of death If on the one hand one should in addition to regulating the formulated by the medical doc- clearly avoid transforming the state of being awake also has tor who has treated the case,

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and whatever the case will en- mulations are not in competi- cant way the availability of, and gage in its activities from the tion with one another Ð the access to, transplants because beginning of the observation: death of the cerebral trunk, in patients (including those suffer- the principle of shared respon- fact, also involves the loss of ing from anencephalia) declared sibility and the need for una- consciousness and cognition. to be dead on the basis of the nimity will allow the drawing neo-cortical definition can be up of a statement as regards Ontological and Biological conserved biologically for years clinical and legal death. Thus, Interpretations rather than a few hours or days death is identified with the as is the case with total cerebral death not only of the cortex (re- Awareness of the philosophi- death. This is said to offer the sponsible for the higher func- cal problems implied in the def- possibility of parts of bodies or tions such as the activity of inition of cerebral death has led the bodies of neo-cortically consciousness) or of the brain- to discussion about the criteria dead people being donated and stem (responsible for the home- to be employed to determine conserved for the purposes of ostatic, cardio-respiratory, neta- the loss of personality, and to research over the long term in bolic, etc. functions) but of the certain people proposing the organ banks, or for other pur- whole of the brain. This defini- loss of personality, or of per- poses such as pharmacological tion conforms to that estab- sonal identity, as a valid para- tests or the production of bio- lished by the National Commit- meter for determining death. logical compounds.31 The sup- tee for Bioethics of 1991, The definitions which refer to porters of these ontological the- which defined death as the total the loss of personality have ses have even sought to de- and irreversible loss of the abil- been described as ontological scribe the minimum qualities ity of the organism to au- definitions30 and placed in op- that are necessary in terms of 28 tonomously maintain its own position to the biological defin- psychological faculties to de- functional unity as identifiable itions expressed in formulations fine the personality of the sub- in the brain, brought about by which refer to the brain as a ject. The loss of the higher cere- ‘irreparable organic cerebral whole or to the cerebral trunk. bral functions implies the loss damage, where artificial sup- The supporters of the definition of the continuity of the psychic port took place in time to pre- and determination of death processes, and thus a redefini- vent or treat anoxic cardiac ar- based upon ontological criteria tion of cerebral death must rest’. refer to the loss of the higher stress the loss of personal iden- tity. The ontological definitions attribute no importance to the persistence of other functions such as spontaneous breathing or the heart beat. The neurolo- gists and philosophers who sup- port the thesis of cerebral death refer to the higher or lower parts of the brain, which are responsi- ble, respectively, for the cogni- tive and integrating functions. The ontological definitions for the most part concentrate on the former whereas the biological definitions address themselves to the latter. Amongst neurosci- entists there is agreement on the fact that such ‘higher cerebral’ functions such as consciousness or cognition cannot be mediated rigorously by the cerebral cor- tex but it is probable that they 3. Problems in the Definition cerebral functions of subjects in constitute the result of complex of Death a persistent vegetative state and inter-relations between the cere- various forms of anencephalia. bral trunk and the cortex. The We will now take into con- At times in this context am- higher brain controls movement sideration certain attempts to biguous and out of place syn- and language. Its action in- achieve redefinitions of death onyms such as ‘neo-cortical volves the contents of con- that are based upon ontological death’ or ‘pallic syndrome’ are sciousness (covering in a broad foundations, that is to say in employed. In 1988 Smith ar- sense the sum total of the cogni- terms of the loss of personality gued in favour of the ontologi- tive and affective endowment of or personal identity, following cal definition of death and de- the individual). The contents of the loss of the neuropsychologi- scribed the benefits of such a consciousness must be distinct cal structures responsible for definition in the obtaining of from the capacity for conscious- consciousness and cognition. organs for the purposes of ness, which is determined by The ontological formulations transplantation. the structures of the cerebral here are unsatisfactory at a the- The criterion of neo-cortical trunk. The higher parts of the oretical level, and indeed the death is said to have the advan- cerebral trunk activate the cere- ontological and biological for- tage of increasing in a signifi- bral hemispheres and are re-

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sponsible for the generation of is when death is said to take variations in quality of life are the faculties of psychological place, not because of moral or expressed in forms of being consciousness. Despite the fact biological reasons but as a re- alive and with a continual func- that the capacity for conscious- sult of what are mere ontologi- tion of the cerebral trunk there ness (a function of the cerebral cal factors. It should be ob- can be observable and record- trunk) does not correspond to served that there is nothing in able, although not intentional, the contents of consciousness (a the reference to ontological fac- reactions. function of the higher brain), tors that can invalidate the for- the pre-condition of this latter is mulation of death which centres fundamental. If the function of around the cerebral trunk. the cerebral trunk did not exist, The concept of death which there would not be an affective centres around the cerebral life, a cognitive life, thought ac- trunk necessarily involves the tivities or feelings and social in- loss of all the cognitive func- teraction. tions and is compatible with the Gervais maintains that the criteria of personality specific ‘permanent absence of con- to the ontological definition: sciousness’ is the ‘yardstick of with the death of the cerebral death in man’,32 that is to say trunk there is neither the capac- she defines death on the basis ity for nor the contents of con- of the ceasing of the neo-corti- sciousness. The divergences be- cal functions, even including tween the ontological and the newly-born victims of anen- biological formulations lie in cephalia and patients in a per- the status of the residual func- 29 sistent vegetative state. This au- tions, when, that is to say, the thor has in mind neo-cortical damage is limited to the higher death (a neuropathological con- regions and most of the cerebral cept) and the persistent vegeta- trunk is, instead, still intact. The tive state (a clinical concept), diversity between the two for- even though the first concept is mulations has been acutely de- The Vagueness of the Concept never defined in a clear way. In- scribed by A. Earl Walker.34 of Personal Identity deed, the parameters corre- Some people have affirmed sponding to the concept of that a person with a complete The arguments adopted to neo-cortical death require a flat lack of intentional reactivity, define death in terms of person- electroencephalogram, whilst but who is still able to breath al identity often perceive an the patients in a persistent vege- and to maintain certain spinal ‘essence’, whose loss brings tative state who meet this re- reflexes or reflexes of the cere- about the loss of identity. The quirement are few in number. bral trunk, should be consid- personality is seen as the mani- Neo-cortical death is a very rare ered in legal terms to be dead. festation of the specific poten- variant of the persistent vegeta- Yet, these individuals, who veg- tialities of the person and thus tive state given that a large ma- etate without showing any sign the personality is a category or jority of these kinds of patients of recognition of or response to predication, even though not have not been subjected to hy- the environment, obviously do the most important one, of the poxic or ischemic injuries of not possess a dead brain. It is personal but not unique sub- such gravity as to produce a flat mere conjecture that the level stance. The arguments regard- electroencephalogram. This of functional activity mediated ing personal identity are dis- writer criticises the formulation by the cerebral trunk and the tinctly vague, and with respect centred around the encephalic spinal chord is sufficient for the to cerebral death have generat- trunk because it is from the out- capacity to recognise and react ed undoubted confusions be- set based upon biological con- to the environment on the part tween the death of a person and siderations. of the individual. Anencephalic the death of the body of a per- The formulation which cen- babies, who are born without son. tres around the cerebral trunk brain matter above the cerebral Personal identity, that is to has also been criticised by other trunk, are able to move, to say personality, is a quality near supporters of the ontological makes certain movements with to others such as the spirit, position. Green and Walker33 ar- their arms and legs which ap- courage, the will, the heart and gue that psychological continu- pear to be intentional, and to re- the soul, all of which are attrib- ity, brought about by the func- act with elaborated motor re- uted to a human being because tioning of the higher brain, is sponses. However, the life with of social conventions and not needed for the maintenance of which these babies are en- with reference to the physical personal identity. Thus for these dowed for a short period is of a structure of a subject. It is pre- authors the continuity of per- completely different quality cisely because the personality is sonal identity is the defining from that of the life of adult hu- connected with the complex of parameter of life in man. For man beings, although the ques- relationships and legal and po- this reason, death is said to be tion remains whether it is very litical approaches expressed in the loss of the psychic function. different from that of a normal social life that there is disagree- The loss of the capacity to en- newly-born child. ment about the determination of gage in psychic activity, when The existence of differences the moment at which a being cerebral death deprives the in quality of life does not per- can become a person or cease to body of its psychological traits, mit the redefinition of death: be a person. Catholic theolo-

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gians identify the origins of along similar lines to the giving tions. It is simply assumed that personal identity in conception up of the soul Ð what is left are all that counts is the interrup- because it is potentially present, ‘mortal remains’. Now, nobody tion of psychic continuity. whereas some philosophers lo- will want to deny that the cere- Some societies attribute to cate its emergence in a much bral aspect is decisive in defin- psychic continuity more impor- later stage of development in ing the human quality of the life tance than others. In addition, childhood. In the view of Kush- of the organism that is man. also that which constitutes the ner,35 the personality is acquired This was the meaning of my loss of psychic continuity pre- and develops only gradually position when I laid stress on sents itself as being culturally during the course of the devel- the fact that the irreversible and relative. The importance given opment of the foetus and the complete loss of the cerebral to psychic continuity (the ca- child. The process of becoming functions should not authorise pacity to take initiatives) is the a person is long and even at us to delay the death of the rest result of the cultural context be- birth the newly-born child has of the organism, the loss of longed to, and as such has a only some characteristic traits which is the natural conse- spatial-temporal relativity. If of the adult personality, such as quence of that loss. But to deny this last was raised to the status desires, wants, frustrations and that the extra-cerebral body is of an exclusive criterion, a feelings. Time is needed for the an essential component of the medical doctor who practices in development of the more com- identity of the person is no less a multi-cultural social context, plex faculties during the course exaggerated in the case of the something that is common in of the interaction of the child brain than it was in the case of today’s society, would find with his or her psycho-socio-re- the conscious soul. The body is himself face to face with almost lational environment. solely the body of this brain, insurmountable problems at the 30 and of no other. What is subject moment he decided whether to to the central control of the proceed with resuscitation or brain, the corporeal organism, not. But even if he were able to is so characteristic of my per- determine, with a satisfactory son, it is ‘mine’, it is unique for level of precision, that personal my identity (one thinks of fin- identity had been lost, that ‘X is gerprints), that it cannot be ex- no longer with us’, this would changed, like, indeed, the same still not be a good reason to for- brain which controls it (which mulate a diagnosis of death. It is in its turn controlled). My would mean at the most that ‘X identity is the identity of the is no longer with us in the sense whole organism, even though that he is no longer what we the highest functions of my per- knew him as’. son lie in the brain. For this rea- The definition of death cen- son, although the body of a sub- tred around personal identity ject in a state of coma still encounters difficulties in ex- breathes, has a pulse, and func- treme cases such as anen- In a criticism of the report of tions, albeit with the help of cephalics or those people af- the Harvard Committee (the Ad technology, it must be seen as fected by grave dementia. The Hoc Committee of Harvard that which remains of the sub- similarities between a persistent Medical School, 1968), Hans ject, and as such it still has the vegetative state and grave de- Jonas36 identified in the docu- right to that inviolability that mentia are much closer than ment a reproposal of the the laws of God and men have those between the loss of the brain-body dualism where irre- accorded to such subjects. This function of the cerebral trunk versible coma is adopted as a inviolability means that it can- and a persistent vegetative concept of death. But the obser- not be used as a mere instru- state. There are in addition clin- vations made by Jonas are even ment or tool. ical objections to a diagnosis of more effective if they are ap- One of the most evident death where there is an ongoing plied to some of the contempo- anomalies in concepts of life functioning of the cerebral rary theories about personal which centre around the person trunk. It is still not clear if frag- identity. is that their supporters do not ments of consciousness or of It seems to me that behind consider the distinction be- awareness can be mediated by the proposed definition of tween the absence of responses the sub-cortical structures. In death, quite independently of to the environment specific to particular, it is difficult to its evident pragmatic motiva- the death of the cerebral trunk demonstrate the total absence tion, a curious return of the old and cases where the damage is of sensitivity when there is a soul-body dualism is con- limited to the higher parts of the lasting functionality of the cere- cealed. This has now appeared person’s brain. Most of the ver- bral trunk. as a dualism of the brain and sions centred around the person Whilst it is relatively simply the body. In a similar fashion to refer to the mere absence of ex- to diagnose the death of the its predecessor, it argues that perience, to the lack of con- cerebral trunk, the same may the real human person is made sciousness and of cognitive ca- not be said for death conceived up of (or represented by) the pacities. But it is not clear in terms of the loss of the high- brain, of which the rest of the whether in determining death er functions. The diagnosis of a body is a mere instrument. For this loss of psychic reactivity to persistent vegetative state can this reason, when the brain dies the environment has a greater present certain difficulties, and something occurs which is importance than other depriva- the problem of the diagnosis of

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the absence of self-awareness non-retrieval of cognition and cerebral trunk constitutes the should not be underestimated. other intellectual functions can- death of the person. The sup- Differently from clinical tests not be determined with even a porters of this thesis argue that for the death of the cerebral low level of certainty, some- once the criteria for the death of trunk, which is an unmistakable thing, instead, which can only the cerebral trunk have been phenomenon, the tests for be achieved much later on in met, there are no further ethical self-awareness can have differ- the development of the condi- obligations of the kind that ent results. Some patients in a tion of these kinds of patient. should be applied to a person persistent vegetative state show An unbridgeable disagree- who is still alive. a considerable number of or- ment does not exist between the The second position holds ganised behavioural responses ontological formulation of the view that the death of the in reaction to sudden or harmful death as advanced by Gervais cerebral trunk constitutes the stimuli. Nearly all of them reac- and the formulation centred death of the person but not nec- quire the cycles of sleep/being around the cerebral trunk, in the essarily the death of the body, awake: they display facial ex- sense that both place emphasis which could go on ‘living’ with pressions denoting interest and on the irreversible loss of con- the help of sophisticated med- some even display emotional sciousness. But differently from ical technology. in this sense, a fluctuations with occasional Gervais, the supporters of the diagnosis of the death of the tears or smiles of an infantile formulation centred around the cerebral trunk does not deter- kind in response to non-oral cerebral trunk place equal stress mine death but merely indicates stimuli. Some move their eye- on the loss of the moneostatic that the individual belongs to a lids regularly in the face of a vi- capacities, such as breathing category of beings whose death sual threat, open or close their eyes in reaction to sudden nois- 31 es, or display reflexes involving groping or sucking. For the health care workers looking after these patients, and the family relatives of these patients, these behaviour- al expressions are indicative of the continuation of life and suggest that residual levels of self-awareness cannot be ex- cluded with certainty. The clin- ical-instrumental parameters to establish the irreversible loss of consciousness require more accurate definitions. Despite the fact that the cases of recov- ery from persistent vegetative states are rare, the residual pos- sibilities following damage confined to the higher regions of the brain require clinical re- and the heart beat, that is to say is permitted. This position search and philosophical re- of all the organismic functions. should be rejected because the flection for us to be able to is- The thesis of Gervais38 on hu- death of the cerebral trunk sue a diagnosis of irreversible man death, as a state of ‘perma- meets all the necessary and suf- absence of self-awareness. nent unconsciousness’, implies ficient conditions for there to be Stanley37 has affirmed that the inclusion among the list of a diagnosis of death. ‘there is at the moment no sim- dead people of those subjects in The third position puts the ple test which is valid at a prac- persistent vegetative states and death of the cerebral trunk and tical level for the persistent anencepahlics as well. a persistent vegetative state on vegetative state’ but ‘there is the same level, and as a result certainty about the non-re- The Problems of Neo-Cortical no ethical problems present versibility of the death of the Death themselves with regard to the cerebral trunk, a certainty classification of the two condi- which, instead, is lacking in the If we want to assess the re- tions of death in question. The case of decortexation’. spective merits of the formula- proponents of this view argue The prognosis of the death of tion of death centred around the that the capacity for moral ac- the cerebral trunk and of a per- cerebral trunk and that centred tion is linked to the integrity sistent vegetative state, respec- around the higher brain, and and the continuity of personal tively, have similarities only their consequences in terms of identity, which in turn depends during the initial period. The the removal of organs for the on the biological substratum re- death of the cerebral trunk can purposes of transplantation, we sponsible for the maintenance be brought about with absolute have to take into consideration of the cognitive functions. For precision within a few hours or three ethical and philosophical this reason, a corpse and a pa- a few days at the most. But in positions. tient in a persistent vegetative the case of a persistent vegeta- The first position advances state are not capable of relevant tive state the prognosis of the the thesis that the death of the moral actions. Furthermore, it

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should be observed that the in- in both cases are based upon the the ‘ethically interesting’ sense ability to begin a morally sig- loss of meaning and the ability of that term. Once this decision nificant action, or even to react to appreciate life Ð the loss of has been taken we no longer or to be aware of such action, is personality Ð then once it is af- have before us a person who is not a reason to exclude a sub- firmed that these criteria have a patient to be treated but a ject from belonging to the been met, it is of little impor- body in which our ex-patient is moral community or to deny tance what description is ap- no longer interested. This is a the right to morally significant plied to the set of actions (or social utilitarian disengaged ap- omissions) that lead to the ex- proach...’ tinction of the residual life Gillet is clearly working functions. In these cases, in within a Cartesian dualistic fact, the crucial border is said to conceptual framework in seeing be crossed at that moment at the loss of certain structures which life is said to have lost its connected with consciousness meaning. as constituting the criteria for Rachels41 argues that it is the definition of death, or rather necessary to make a net distinc- of the non-meaning of living. tion between being alive in a bi- But the exact description of the ological sense and having a life structures involved and the size in the social and moral sense of of the damage which has to be the term. In his opinion, being undergone are not easy to for- alive in a biological sense is in mulate. Furthermore, why such relative terms not very impor- primary ethical importance 32 tant. Life, in contrary fashion, is should be given to conscious- meaningful because of ‘its aspi- ness is not clear. Although con- rations, decisions, activity, pro- nected with ethically significant jects and human relationships’. interactions, such as intentional Once life has been lost, in these behaviour and responsibility, it terms, being alive (such as a pa- does not constitute the totality attention. In the view of tient afflicted by Alzheimer’s of what has ethical importance. Gillett39, the ability to express disease) is of little moral impor- Indeed, one may observe that and develop personality de- tance. The approach adopted by the person who is weak and pends in a crucial way on the in Rachels is of a clear euthanasia- without help generates in others tact functioning of the brain inspired and eugenic stamp. It a need for respect and help. (and in particular those areas of raises certain doubts: what do In his observations, Lamb the brain which are most grave- we mean by meaningful, and observes that there are many ly damaged because of cases of meaningful for whom? Accord- social contexts in which one trauma or anoxic ischemia) ing to what social rules? Mean- could invoke the criterion that which allows the individual to ing is such because it refers to a meets the concept of ‘no longer interact with other people and fundamental essence Ð life. The being alive in an ethically inter- with the surrounding world in a meaning of life cannot be a rea- esting sense’, but one cannot rich and complex way. Once son for engaging in a personal reach a level of precision and this crucial condition has disap- or social assessment, it should certainty such as to justify the peared, we are justified in merely be appreciated for its es- employment of these criteria in thinking that his body can no sentialness. But against this the- situations in which it is a matter longer be considered as the lo- sis it should be emphasised that of deciding whether to autho- cation of that activity we call the criteria which meet the bio- rise the suspension of treatment the expression of personal iden- logical concept (the death of the or the removal of organs for the tity. If the brain has stopped cerebral trunk) are precise and purposes of transplantation. To working and there is no possi- objective, whereas the criteria extend the definition of death to bility that it will return to a lev- for having life are vague and the point of including decortex- el of working which can sustain subject to a variety of social ation (or the loss of personality such activity, then his or her and personal interpretations. In- in this sense) compels us to ad- freedom as a person endowed deed, Gillett defines being alive dress ourselves to a large num- with a body has been destroyed. in an ‘ethically interesting’ ber of implications that are con- This involves the upholding sense. trary to current clinical practice of the right to euthanasia, and Gillet42 on this point makes and to widespread public atti- the extension of the definition the following observation: tudes, including the implication of death to persistent vegetative ‘When the body of a person has according to which all those pa- states and all the other cases fallen into a state where he or tients who are in a persistent where it is believed that the she is not able to sustain any- vegetative state are indistin- conditions for an ethically rele- thing beyond his or her life as a guishable in an ethical sense vant life do not exist. Lamb40 person, we are completely right from corpses. The affective and argues that whereas there is a in saying that his or her soul has cognitive components of con- clear distinction between the separated from the body, what- sciousness can be essential for a criteria for euthanasia and the ever our metaphysical beliefs meaningful and pleasurable life proposal of criteria for the diag- and convictions may be... With- but they are not necessary and nosis of death, there is a sense out ‘getting mixed up’ in defini- sufficient conditions for a diag- in which this distinction can tions of death, we can affirm nosis of death. lose its relevance. If the criteria that this person is not alive in To summarise: the idea of

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cerebral death is very far from such as being self-aware or re- they are capable of death as being universally accepted, al- sponsible. This discrimination death’.45 though it is the subject of many between human beings in terms Ramon thus concludes that definitions and diverse criteria of their performance, although ‘every material substantial enti- regarding its ascertainment. We one is dealing here with expres- ty, because it is composed of may remember above all, be- sions of typically human per- primary matter and substantial cause of the influence that it has formance, is unacceptable. form, is subject to corruption, had, the Report of the Ad Hoc The position which requires that is to say to substantial mu- Committee of the Harvard the irreversible loss of all the tation: separation of the sub- Medical School of 1968 and ‘A encephalic structures seems to stantial form (of a rational na- Proposed Uniform of Death be more persuasive and is in ture) from the primary matter. Act’ of the President’s Com- harmony with an overall vision The material causes modify the mission of 1981. of man as a psycho-physical accidental properties beyond The English neurological unity in which physical and the limit, making them incom- school argues, in fact, that for mental functions are distinct patible with the substantial there to be cerebral death, the but interconnected expressions form through new substantial death of the encephalic trunk is of the person. For this reason, it forms. Man is man because of sufficient. However, in coma would be preferable to translate the human substantial form: the produced by primary injury to the English expression ‘brain spiritual soul; a corpse is not a the trunk, there is often the per- death’ into Italian not with man because it is informed by sistence of visual potential flut- ‘morte cerebrale’ (‘cerebral another substantial (non-ratio- tering and spontaneous cortical death’) but with ‘morte en- nal) form which is not the sub- electrical activity Ð the absence cephalica’ (‘encephalic death’), stantial (non-rational) form of of the working of the rest of the with a precise reference to all man; the substantial form has 33 encephalus is the result of the the encephalic structures and separated from the primary lack of input from the trunk not only to the brain alone. matter. Death is the crisis of the and not of an intrinsic func- substantial union that consti- tional deficit. Concluding Observations: tutes each and every man, and it In a rare pathological situa- the Personalist Position is painful because the body is tion, the ‘locked-in syndrome’, co-natured with the spirit’.46 there is a partial injury to the The human person is a fusion Death is thus a substantial trunk, and the person, although of matter and form,44 and thus ongoing event, that is to say a he or she is not able to commu- should be seen in his or her ma- substantial mutation that limits nicate with the external world, terial component (a biological two states: the preceding and remains to a certain extent con- being) and in his or her spiritual the subsequent substantial enti- scious and in truth is like a pris- form (or relational-rational ty. This is why death cannot be oner, locked in himself or her- form or a being being). Man defined as the process of dying self. lives this condition of incarnat- or the state of a corpse, but The death of the encephalic ed existence Ð man is incarnat- trunk alone is therefore insuffi- ed spirit. cient for a declaration to be Death cannot be described made to the effect that the solely in terms of the organis- whole of the organism is dead. mic decomposition of living Other authorities, above all matter, but above all else it Americans, identify cerebral should be described in terms of death with cortical death, even the destruction of human exis- in the presence of integral or tence, that is to say the eclipse working cerebral trunk struc- of every expression of personal tures. In this clinical condition, presence in this world. named ‘persistent vegetative Death is human precisely be- state’, or apallic coma or coma cause of its spiritual-formal vigil, there remain active the character, otherwise it would be capacities for the (central) a process of material corrup- homeostatic regulation of the tion. Only in man is there a organism, as well as the capaci- mortal being: in every other en- ty to carry out the life functions tity because of the lack of a ra- in an integrated way, including tional form it is destined to per- autonomous breathing: there is ish (a plant, an animal). Hei- not, therefore, the total and irre- degger argues that ‘men are versible loss of the functional mortal. They are mortal be- rather as an instantaneous event unity of the organism.43 Stress cause they can die, To die where the material causes mod- should also be laid on the fact means to be capable of death as ify the accidental properties that this state is not always irre- death. Only man dies. Animals making the substantial union versible and that there are cases perish. They do not possess impossible and bringing about of a partial recovery of relation- death because death is neither the rise of a new entity with al life. The underlying idea of ahead of them nor behind them. new substantial forms. The hu- this position is that the individ- Death is the casket of nothing... man body is not a material ob- ual is a person only if he or she The mortals are now called jectivisation connected to a can carry out certain functions mortal not because their terres- spiritual form but a ‘subjectual’ held to be characteristic of man, trial life finishes but because body, that is to say a body hav-

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favoured divergent forms of so- cial behaviour, from the re- moval of the problem to scien- tistic reductionism which does not respect the spiritual or non-biological component of man, and on to ideological and pseudo-religious expressions which conceal this reality, tak- ing advantage of the weakness of the mental states of their ad- herents. These attitudes, which are spread far and wide by the mass media, have helped to dis- seminate states of uncertainty and insecurity as regards the methods and instruments by which to ascertain death, ele- ments which are reflected in a low level of organ donation and the upholding of the right to eu- thanasia. The alteration in the paradigm of reference for the 34 meaning and experience of death can be encountered at Ð indeed, is to be attributed to Ð ing a psychic character which spirit in the world. For this rea- three levels, which may be list- links it to the world in a particu- son, to ascertain and certify ed as follows:47 lar relationship specific to hu- death from this point of view 1. The socio-cultural level. man subjectivity. Indeed, the means to affirm this irreversible Here we encounter the affirma- subjectual function of the body and total separation of the spiri- tion of rational-secularism and through its form expresses the tual form from biological mat- the suppression of the eschato- existential and human condi- ter, and as a result patients in a logical dimension specific to tion. Death destroys not only state of coma or in a persistent Christian faith. Death as a mo- the biological component (the vegetative state, where they ment of moving on from one body) but also the formal com- continue to conserve their hu- life to another comes to be ex- ponent, that is to say its person- man form (or human substan- perienced as something which al and relational existence. The tiality), cannot be placed on this concludes life. The worldly em- body is the ‘subjectuality’ of same level. The corporeal di- pirical daily experience has im- the rational dimension, that is to mension is not only responsible posed itself as the sole ontolog- say the mediation of any ex- for being in this world with its ical horizon of man Ð there is pression and realisation of man personal form but it is subject no hope that transcendence ex- in the world. From these to being-for-death because ma- ists. premises one understands the terial causes determine that lim- 2. The availability of life. dramatic nature of death, be- it of incompatibility with the Life used to have a sacred char- cause it represents the dramatic substantial form and thus the acter which saw man as the end of human existence, be- disappearance/appearance of a steward of the life entrusted to cause it is detachment-separa- new substantial entity Ð the him, and God was the only Be- tion from the human world dead corpse. ing who could govern life. The (=body), from its psychic form. denial of God, individualism The dramatic nature of the sep- with its denial of every form of aration of the form from the 4. Ethical-Philosophical social relation, and dominating body, however, opens up a hori- Problems Connected subjectivism, have all fostered zon of immortality; at a phe- with the End of Life an experiential solipsism with a nomenological level the ratio- consequent upholding of per- nality is inserted into the tem- We have already emphasised sonal rights rather than the so- porality of history and becomes how in contemporary society cial rights characteristic of a immortal; at a theological level the meaning of the event of state based upon the rule of law. the eschatological dimension death has changed, not only at 3. The ontological horizon. emerges from transfiguration the level of experience but also Man as a being in the world and the resurrection. Thus the at the level of epistemological ‘being here’ is aware of his human soul (the human sub- argument. This is due to the finiteness and his mortality of stance) has the characteristic of change in the paradigm within ‘being-for-death’. This aware- immortality. The goals of which death is interpreted and ness is the authentic experience thanatology are not those of as- the difficulties associated with specific to the human being but sessing whether the body is the definition of death in the le- it is absent in every other living dead but whether the whole of gal-medical sphere (cardiac being. Man is aware of his the man is dead, that is to say death, cerebral death, cortical death and sees it not only as a the human being in his or her death). Cultural contexts and biological transformation but as integrity or unitive tendency as epistemological models have human death. Authenticity is

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taken on as a norm correspond- reason, the same meanings of right to euthanasia. ing to this human awareness. euthanasia, of illness/health, in The wish to put an end to a Authenticity is awareness of the changing their interpretive para- life or to meet the request to specific limitation of man who digm, appear to man in forms end a life which is seen as not does not have any other mean- that are incisive in effect and in being worthy of being lived in ings than those which are in- forms that are increasingly less the eyes of contemporary utili- trinsic to him. As a result, death scandalous than was the case in tarianism, cannot be accepted is the possible experiential limit the past. either as a right or as psycho- of man, beyond which there ex- logical pietism. ists an emptiness of possible What Kind of Meaning A right is human because it meaning and sense. It is an for Euthanasia? belongs to being, and this, be- elimination of meaning and of cause of the ontological para- the symbolic realities which The original etymological digm of being-for another, con- have so far been valid, such as meaning of ‘euthanasia’, from stitutes the co-existentiality that death as moving on, the life be- the ancient Greek eu-thànatos, alone can render a choice legiti- yond, eternity. In this axiologi- good death, has had different mate. Whereas in the sphere of a cal horizon a good death cannot contents and meanings over re- relationship based upon a con- find space because the attribute cent years. tract between the doctor and the of sense is always referred to Today, thanks to the innova- sick person the principle of something that has a temporal tions of medical technology, it self-determination can justify and spatial dimension, that is to is possible both to artificially the request for euthanasia, in the say that which has a certain con- prolong the life of a terminal- sphere of the therapeutic al- tinuity of meaning. With death ly-ill patient (disproportionately liance the constitutive sharing of time and space no longer exist, intense treatment) and to pro- the experiences of being cannot 35 and thus its only reference is the cure death before its due time aspire to provide responses to non-being specific to elimina- (euthanasia). such a request. This is true both tion, non-authenticity. Thus the Euthanasia, in fact, involves for procured euthanasia and for non-sense of the expressions re- deliberately bringing about assisted suicide, and even more garding a good/bad death, which death in a direct or indirect way, for those conditions in which are not authentic according to that is to say ending the life of a the health care workers believe the approach of the secularist, person through an action which that the life of their patient is and which cannot leave any involves commission or omis- not worthy of being lived ac- space to the dignity of dying. sion cording to the utilitarian para- Obviously enough, the attri- Ð out of compassion; digm Ð the intrinsic thelos of bution of dignity to an action Ð in order to reduce suffer- nature and co-existentiality re- implies an ethical reference that ing; quire being, side by side with includes responsibility, capacity, Ð in order to comply to the psycho-assistance and pain-re- and awareness in relation to wishes of the sick person. ducing forms of care. Post-mod- stewardship. The consequence Western culture emphasises ern secularism, which seeks to of this argument could not be the right to self-determination evaluate life from the point of anything else than of a clear util- on the part of the patient, as view of efficiency and in terms itarian character, as indeed are well as the right of the health of the dignity of the being that is their secondary affirmations: care worker, and especially the experienced, that is to say stew- prenatal life, the life of the men- medical doctor, to respect the arded in a responsible way, has tally handicapped etc. are not principle of benefit, and thus influenced the very concept of considered worthwhile. For this goes so far as to uphold the health care. This care must be

THE VOCABULARY OF THE GOOD DEATH

Active, direct or positive euthanasia The health care worker intervenes directly to procure the death of a patient

Passive or negative or indirect euthanasia This involves refraining from measures which could keep a patient alive

Voluntary euthanasia The euthanasia repeatedly asked for by the patient

Non-voluntary euthanasia The patient is unable to make a request for euthanasia because he or she has been rendered incapable

Involuntary euthanasia A health care measure designed to suppress life despite the express dissent of the patient

Dystanasia Refraining from health care measures to prolong life which do not respect the dignity of the patient

Physician assisted suicide The suppression of the life of a patient as a direct consequence of a suicidal act by the patient, but advised and/or assisted by a health care worker

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directed towards defending the it closes that social-relational sponsibility, if not of a religious quality of the different cate- dimension that began on the kind, then certainly of a gories by which life is expressed day of his or her conception; socio-juridical character. In- more than towards defending whereas to accept the relational deed, there is an imperative that life itself as a fundamental val- dimension means to limit one- man should commit himself to ue. The quality of life means a self but at the same time to maintaining and respecting this life interpreted according to the achieve real autonomy Ð free- relational net for the being-well parameter of well-being con- dom. For that matter the condi- of mankind, that is to say he sciously chosen by the subject tion of freedom would not exist should defend life as a sharing himself or herself. A conscious if not to the extent to which a of experiences. choice requires the health care subject interacts with other peo- The Civil Code of Italy itself staff to respect the wish of the ple. This is freedom which is in article 5 envisages and pro- sick person, and in this they constructed and fulfilling.49 In hibits any medical activity that should avoid all forms of pater- addition, our life is not some- can bring about a permanent nalism. thing to be disposed of; it is en- disability, that is to say that can Every form of treatment trusted to us so that it is fulfilled alter human life in terms of its must be accompanied by the in- in the corporeal experience of integrity and dignity. The same formed consent of the patient each and every man. The hu- principle of doing good cannot but his or her wishes cannot man sciences (anthropology, so- be interpreted as doing to others eliminate the rights of the med- ciology) have always seen man what they ask us to do Ð in the ical doctor who must always as a good not only in himself case in hand procuring death or engage in therapeutic action but in a relational perspective. helping somebody to die. The and not mere technological ap- principle of doing good intrinsi- 36 plications directed towards the cally obliges the health care mere extension of the biologi- worker to do good to his or her cal functions or their premature patient, in the sense of procur- ending. The informed consent ing him or her benefits in de- of the patient and the healing fence of his or her life and his objectives of medical action or her dignity whatever his or must also guide health care her existential state might be. workers in the case of a patient The Italian Constitution itself is who has lost his or her mental pro-life when it upholds as a faculties (because of age or ill- fundamental right the defence ness). The loss of mental facul- and the dignity of human life. ties must not be adopted as a Indeed, article 2 ‘recognises criterion for procuring the death and guarantees the inviolable of the patient Ð the ethical and rights of man both as an indi- deontological principle of do- vidual and in the social forma- ing good to a sick person as a Social power, political-eco- tions in which he develops his sharing of experiences must in- nomic prestige, are the qualities personality...’; in article 3 ‘all volve a rejection of every initia- of cohesion and co-operation citizens have equal social digni- tive in favour of the practice of between the members of a ty and are equal before the law, euthanasia. group. Catholic theology itself without distinction of sex, race, Lecaldano48 stresses that has always proclaimed this language, religion, political ‘each person is completely re- two-dimensional opening: man, opinions, and personal and so- sponsible for his or her life, and man-God. With the advent of cial conditions. The Republic only that person can be directly extreme subjectivism man has has the task of removing those responsible for it, for his or her transformed the experiential obstacles... that... hinder the full own life. For each human being horizon into what is merely an growth and development of the the following principle is valid: existential solipsism. Human human person...’; in article 27 my life is totally mine and I am existence, that is to say we read that ‘penal responsibil- the only person who is directly being-in-the-world involves a ity is personal... punishments responsible for it’. going beyond oneself in order cannot involve forms of treat- This freedom connected with to open oneself to another per- ment that are contrary to the the autonomy of being able to son-in-himself. This premise meaning of humanity... the take one’s own life is totally justifies the approach of rejec- death penalty is not allowed...’; baseless because freedom is the tion of every form of self-dam- and article 32 proclaims: ‘the realisation of an existential age, in the extreme intentional Republic defends health as a state and not its suppression. cases of ending one’s own life, fundamental right of the indi- By death we do not express our as takes place in the case of sui- vidual... Nobody can be forced own freedom, indeed we deny cide. The pre-modern cultural to undergo a certain form of it, in the sense that death ends tradition always proclaimed health care treatment unless by every right. The meaning of au- that life cannot be disposed of a special legal provision. The tarky and of autonomy are often at will and thus also condemned law in no case can violate the confused. Autarky involves be- its planned termination. This limits imposed by respect for ing responsible for oneself in a was in line with the non-solip- the human person’. total way, and thus an individ- sistic character of human exis- The professional codes of ual never has to answer for tence. Human existing, that is conduct of health care workers, what he does Ð this amounts to to say its openness to the per- continuing the well-known eth- authentic social suicide in that son-amongst-us, involves re- ical imperative of Hippocrates

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EUTHANASIA IN THE WORLD

CALIFORNIA (1976) The decriminalisation of euthanasia; recognition by the Natural Death Act and Living Wills (biological testaments). THE SWISS CANTON OF ZURICH Passing of a law on euthanasia STATE OF WASHINGTON After the Cruzan case, the Patient Self Determination Act was passed, which, however, was rejected by a referendum in 1991. HOLLAND (1993 The decriminalisation of euthanasia. In 2001 euthanasia practiced by a medical doctor after being requested to do so was legalised, thereby freeing the health care worker from criminal responsibility. The request of the patient must be voluntary, well thought through, lucid, repeated, and long-lasting; his or her suffering must be unbearable and lacking in any prospects of improvement. The personal medical doctor of the patient must examine the question with a colleague, and then report the action to a special committee of experts which will then assess whether the procedures envisaged by the law have been followed. NORTHERN TERRITORIES, The legalisation of euthanasia, where it was seen as a right sub AUSTRALIA conditione; this law, however was abrogated by a Federal law of 1997. THE SUPREME COURT, A sentence of this court excluded the inclusion within the USA, 1997 Constitution of the right to choose the form and the time of one s own death. It was up to each individual State to legislate on 37 euthanasia and assisted suicide. Oregon authorised assisted suicide in the same year: lethal drugs are prescribed by the medical doctor but not administered by him or her. JAPAN Euthanasia is allowed in the presence of four circumstances: when the patient is suffering from physically unbearable pain; when death is inevitable and imminent; when all measures possible have been taken to reduce pain; and when the patient has expressly given his or her consent. ITALY There is no law which decriminalises or legalises euthanasia. In 1984 Fontana MP introduced a Bill on the dignity of life and the regulation of passive euthanasia , which so far has not been acted upon. The only elements which regulate the question are to be found in articles 579 and 580 of the Penal Code and the professional code of practice. FRANCE On 3 March 2000 the French National Ethical Committee, for the first time, referred to the exception of euthanasia , that is to say a possible decriminalisation of this act in certain cases. For the Committee, the idea of an exception in the case of euthanasia was able to sanction the sound beliefs of people, taking away the veil of hypocrisy and the hidden that conceals certain contemporary practices . The existing religious confessions, with the exception of the Protestants, have expressed opinions contrary to this position. The French Catholic Church does not adhere to the idea of an exception in the case of euthanasia, a legally recognised exception would rapidly lead to the progressive loss of a principle which is still in legal terms held to be fundamental . Despite the fact that euthanasia is illegal, the Penal Code makes a distinction between active euthanasia (the direct procuring of death is murder) and passive euthanasia (the absence of therapeutic action). GERMANY In 1998 the Court of Appeal of Frankfurt established that in principle euthanasia can be authorised only if it conforms to the wishes of the patient. It must, however, be approved by a committee of tutors. GREAT BRITAIN Euthanasia is illegal but in certain cases the judicial system has authorised the shortening of the lives of patients kept alive by artificial means. For the first time, in 1996, the death of a patient was authorised . DENMARK An incurably ill person can halt his or her medical treatment. Since 1992 Danes can make a medical testament which medical doctors have to respect. SWITZERLAND Assisting a suicide is a transgression of the law which is not punished. In extreme cases the medical doctor can turn off the machines sustaining the breathing of the patient. CHINA In 1998 the government authorised hospitals to practice euthanasia on patients in a terminal stage of an incurable illness.50

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– ‘I will not provide any lethal means must be created for a moral suffering, man tends to drug even if asked to do so’ Ð sweet and easy death... when adopt desperate approaches: obliges those adhering to these life has lost all dignity, mean- a) of rejection (taking refuge codes to refrain from any form ing, and prospects for the fu- in pleasure, in escape, and of euthanasia. The 1998 profes- ture’. Melina51 defines this forms of evasion); sional code of conduct for med- statement as being ‘the rhetoric b) of fatalistic endurance ical doctors, whereas it restates of death’, which can be (abandoning forms of treatment in article 14 that ‘the medical arranged into rhetoric on death, and care); doctor must refrain from per- the subject of a formal and c) of fighting against suffer- sisting in forms of treatment empty analysis, or a typical per- ing by using every medical suasive argument, specific to technical possibility that is Platonic rhetoric, so that death available; can be presented in such a way d) of giving value to things, that we are convinced that we as an instrument of personal should accept it, not by involv- growth, by which to understand ing us intellectually or philo- the meaning of life, and aware sophically but by working on acceptance of a personal bio- the emotions of the moment. graphical event. This is an attempt to tame The different ways of ap- death, but first and foremost it proaching suffering, the process should be made clear that death of dying, and the event of is a fact and not a right: man death, depend upon the follow- has the right to steward and de- ing points of reference: 38 fend the life that has been given Ð Those of an anthropologi- to him; death does not belong to cal character. The meaning at- man and cannot be in man, but tributed to the human person, is something which prevails the concept and the definition when you are least thinking of life and illness (illness as a about it. punishment, death as a misfor- which cannot be expected to The old Latin motto of the tune and malediction), and the produce benefits for the health litany ‘A subitanea et im- cultural inheritance of the sub- of the patient and/or an im- provvisa morte, libera nos, ject involved (death as a heroic provement in his or her quality Domine’, on the other hand, action, or death as the failure of of life’, goes on in article 36 to makes clear to us the meaning man). emphasise that ‘the medical of dying with dignity, and as a Ð Those of a psychological doctor, even if requested to do result the value and the mean- character. (The cognitive-psy- so by the patient, must neither ing of ‘the right to a good chological approach): the tragic carry out nor favour forms of death’, that is to say a death character of separation from a treatment intended to bring where one is serene with one- loved one generates feelings of about his or her death’. The self, with other people, and if fear of the unknown, the emer- 1999 professional code of con- one is a believer, with God, al- gence of reactive mechanisms duct for nurses is very categori- leviated of one’s pain and suf- of denial and projection (my cal when it affirms in article fering. relative is not in such a bad 417 that ‘the nurse shall not In this approach are to be condition as that person there take part in forms of treatment found all the documents of the and that person there is older, or intended to bring about the Church’s Magisterium: Iura e my relative has not been given death of the person who is be- bona (1980), the recent encycli- a certain treatment). Death as a ing cared for, whether the re- cal Evangelium vitae (1995), mysterious and painful event is quest comes from the person and the Charter for Health experienced as something that concerned, his or her family rel- Care Workers (1995). This last disturbs, with the generation of atives, or others’. reaffirms that a health care an incapacity for realistic ac- worker has the task of ‘always ceptance and thus its working Moral Aspects of Euthanasia being at the service of life and out (mourning). assisting it to the end’ (n. 148) Ð Those of a theological The ‘Manifesto on Euthana- and that in practicing or allow- character. Catholic theology, in sia’ (The Humanist, July 1974) ing euthanasia ‘he is no longer particular, sees death as a pas- was signed by important scien- the absolute guarantor of life: sage-birth towards a better life tists and winners of the Nobel the sick person will be afraid and a moment when the divine prize, including Jack Monod. that the doctor will cause his comes to be encountered. This last figure, convinced that death’. For scientific research As a result, the patient who the universe and man himself and medicine in particular, eu- suffers or is in the final stage of emerged by chance and by ne- thanasia is ‘a backward step of his or her illness should be pro- cessity, argues that man is the surrender, as well as an insult to vided with moments of support, arbiter of himself, and is alone the personal dignity of the one of welcoming, as regards suf- in this world without any ethi- who is dying’ (n. 150). fering and death, because cal or normative reference Contemporary man sees pain health, illness, and death are point. For this reason, man ‘has and suffering as a mysterious constituent elements of human the right to die with dignity... he and difficult reality which has finiteness, that is to say they are is free to rationally decide to be accepted and lived out. parts of our lives. They have to about his own destiny... the Faced with physical, mental or be known about and under-

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stood, accepted and welcomed, terised by flight into denial or and experts in health care poli- indeed they should be made isolation. For example, the sick cies should adopt three kinds of more human through a caring person goes from one medical approaches, which may be de- and helpful human presence on doctor to another in the vain scribed as follows: the part of both the family rela- search for somebody who can a) having the wish to uphold tives and the health care work- provide him or her with a more the right to euthanasia should ers who should try through their favourable diagnosis; not be seen as such. Indeed, the forms of therapeutic helping Ð a second moment charac- motivations behind the requests service (pain reducing treat- terised by rage which is ex- for euthanasia are to be located ment) to reduce that patient’s pressed to everyone, and by the in the desire of patients to be suffering (the presence of the question: ‘why has this hap- listened to; they are cries for family relatives and the health pened of all people to me?’; help. A wish cannot be convert- care workers becomes listening Ð a third moment charac- ed into a right leading to a pub- and therapy), something that is terised by ‘coming to terms’, lic legitimation of the actions essential to make death as pain- that is to say by a negotiation and instruments adopted to up- less and as natural as possible. with destiny or with God; hold that right. Such a tendency Thus a less isolated event and Ð a fourth moment charac- is encouraged by the permissive an event that involves the terised by depression, where approach of political power, co-presence and the co-partici- rage is replaced by a feeling of which manipulates the mass pation of the family relatives, a loss and of separation; media in a search for public pastor of souls if the patient is a Ð lastly, if the sick person has support and is ready to sanction believer, and health profession- the good fortune to find some- certain personal needs under- als (medical doctors and nurs- body who helps him or her, it is pinned by the social emotional- es), in a welcoming environ- possible for him or her to ism specific to certain social 39 ment in the patient’s own home achieve the acceptance of situations such as suffering, or suitable structures (e.g., a death. fear of the unknown and of the hospital or a hospice). Thus for Kubler-Ross, acute mystery which accompanies worry about death cannot be death, rather than becoming a Suffering and the Request overcome, but man is able to promoter of norms to defend for Euthanasia give meaning to this experi- such values as those of life. In- ence.52 On this point it is inter- stead, the right to die in a digni- Illness involves suffering and esting to note the study de- fied way is legitimate, where is a challenge for the person, scribed by Tambone and carried this is understood as a natural changing his or her existential out by the Campus Biomedical human process that leads to the experience: affection, work, so- University on the relationship end of human existence. The cial relations, all of which ex- between illness and death and wish to die cannot be seen as a press inner trial. The first the request for euthanasia.53 All right Ð we have a right in rela- change, when the illness ap- the requests for euthanasia tion to things or ideas, or we pears, regards the status of the turned out to be rooted in the have the right to profess a faith, patient Ð from a healthy person state of health of the patient, no but we do not have a right in re- he or she becomes pushed to- patient asked for euthanasia out lation to an event to do with an wards adaptation to a new con- of a mere wish to die Ð euthana- entity which cannot be disposed dition that leads him or her to sia was seen as a solution to the of, namely our life. face up to internal problems of patient’s suffering. In particu- b) The acceptance of eu- a psychological and spiritual lar, a request for euthanasia was thanasia would constitute a ca- kind as well as external prob- connected to three factors: pitulation as regards the pur- lems relating to behaviour. physical pain, a state of depres- poses of medicine, which, if it With the arrival of the illness sion, and fear of being a burden cannot actually heal should at the subject turns himself or her- on the patient’s family, all of least seek to take care of a sick self inwards onto his or her own which contributed to bringing person. Death neither prevents body, he or she must listen to it, about total pain, These factors not treats illness but eliminates control it, and understand the mean that health care workers the person, and this represents messages that it sends to him or the de-ranking of the asserted her. omnipotence of medicine. In the face of suffering the Spagnolo is right when he person structures (or destruc- writes: ‘the essence of the med- tures) himself or herself in a se- ical profession is to treat, to ries of chrono-biological reac- give life, not to distribute tive stages, based upon mecha- death... death... may never be nisms of self-defence which defined as a medical action’.54 characterise each such stage. c) A request for euthanasia, For Kubler-Ross, the draw- on the other hand, is a chal- ing near of the final exitus is lenge to the whole of humanity characterised by an evolution- to respond to the call for help in ary series of emotional reac- the context of unbearable pain, tions, which do not always fol- isolation, the indifference of low one another and which other people, to unawareness need not necessarily take place. about the limits to treatment They are as follows: and care which can degenerate Ð a first moment charac- into forms of euthanasia and

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therapeutic overkill. We have to nence is not presently possible rat, natura sanat’. Medical ac- know how to address not only and that therefore measures of tion comes up against its limita- physical and mental needs, help in terms of forms of care tions precisely when the patient through suitable pain-killing and treatment should never be is in a terminal state and has to treatment, but also the spiritual interrupted. On this point, the give way to the intrinsic teleol- needs of the patient, fostering Pontifical Academy of Sci- ogy of the nature of being. any kind of opening up to the ences58,59 made a distinction be- From the point of view of the transcendent on the part of the tween treatment and care in the relationship between the med- sick person.55 following terms: ical doctor and the patient Ð by treatment is understood based upon the alliance of two Persistent Vegetative States any medical action (chemother- actors, neither of the two can apy, radiotherapy) or surgical predominate over the other, but The persistent vegetative measures, of various level of because of the constitutive and state (PVS)56 is what primarily technical complexity and eco- directive principle of human raises the question of euthana- nomic and human costs, which nature, the medical doctor can- sia and therapeutic overkill. are available and appropriate not take initiatives to shorten or This condition arises after a for the treatment of a given uselessly lengthen the life of very serious traumatic injury or clinical case, directed towards the patient, who by now has a vascular accident within the the healing, the improvement or come to the end of his or her brain. After a stage of coma of the stabilisation of the psy- existence. But by the same varying levels of length, the pa- cho-physical conditions of a pa- principle of human co-existen- tient enters into a clinical state characterised by a complete ab- 40 sence of the functions of the cerebral hemispheres (the cor- tex responsible for the function of psychological conscious- ness), although the encephalic trunk (which controls the respi- ratory, cardiac, and thermoreg- ulatory functions) remains in- tact. This situation can be tran- sitory (up to thirty days) and in- volve a return to a state of con- sciousness. When thirty days have passed a persistent vegeta- tive state is referred to. Such a state can be the anti-chamber to a late regaining of conscious- ness, with a return, usually in- complete, of functions, or, dif- ferently, a definitive sliding of the patient into a persistent veg- tient: in the case of persistent tiality, a patient cannot uphold etative state, which is practical- coma there is agreement that his or her right to euthanasia or ly irreversible when the PVS special forms of treatment to therapeutic overkill Ð there lasts more than eight months af- should not be engaged in; prevails, instead, the duty to de- ter a traumatic injury or more Ð by care is meant every form fend this co-existentiality upon than three months after a of medical, psychological and which society is based. Medi- non-traumatic injury. A patient helping action directed towards cine itself takes on its therapeu- in a persistent vegetative state maintaining the psycho-physi- tic character at the moment in breathes, swallows, reacts to cal conditions of the patient in which it procures salus for the light and pain, and has a the best possible state until sick person according to the sleep/being awake rhythm, death. Amongst forms of care law of nature. In relation to an even though he or she is in a we list hydration, alimentation, incurable illness, medicine of- state of complete unconscious- the sedation of pain and the pre- fers its skills and expertise, and ness. Thus we are dealing here vention of the formation of its limitations may not be de- with an individual who is alive sores, all of which should be fined as defeats but as a recog- and not yet dead. In this clinical implemented.60 The Magisteri- nition of its constituent limits. situation, whereas there is um of the Church expressed it- From this point of view are to agreement that special forms of self along these lines in 1981 be seen proportional forms of treatment should not be en- when it defined the minimum assistance and pain-killing gaged in, there remains dis- obligatory measures that have treatment. These health care agreements about the forms of to be employed,61 namely, for services, although they do not care which should be provided example, hydration, and em- lead to healing, reduce suffer- in this state in order to ensure phasised the strict obligation to ing and at a symbolic level re- survival and a certain level of proceed at any cost with the im- alise that being with others decorum and respect for the pa- plementation of such measures. through being next to someone, tient. Faggioni57 argues that an Hippocratic medicine, which thereby overcoming the solip- absolute irreversibility between is often forgotten by health care sistic climate frequently to be simple persistence and perma- workers, argued ‘medicus cu- found in the terminally-ill pa-

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tient and bringing about the As regards disproportionate 9 Ibid., p. 41. 10 Ibid., pp. 38-40. constituent co-existentiality of forms of care and treatment, 11 Ibid., p. 53. being. In this way death be- this is described at length in 12 Ibid., p. 52. comes co-sharing, that is to say section 120 of the ‘Charter for 13 Ibid., pp. 70-1. a relational human experience. Health Care Workers’ of the 14 Ibid., p. 76. 15 S. KIERKEGAARD, In concetto di an- The above quoted ‘Declara- Pontifical Council for Pastoral goscia (Florence, 1966), p. 9. tion on Euthanasia, Iura et Assistance to Health Care 16 M. HEIDEGGER, Essere e tempo Bona’ of 1980,62 argued that Workers, which has already (Longanesi & C., Milan, 1976), p. 22. 17 In the philosopy of Heidegger the ‘near to an inevitable death, de- been quoted. The Charter reads idea of existence defines the singular ex- spite the means employed, it is as follows: ‘Aware that he is istence of man who exists being outside licit at the level of conscience “neither the lord of life nor the in being. The existentives explore this essence (that is to say the ways in which to take the decision to abandon conqueror of death”, the health man decides regarding the alternative forms of treatment that would care worker, in evaluating possibilities of existence) and the exis- procure only a precarious and means, “should make appropri- tentials (the structures that define exis- painful prolonging of life, with- ate choices, that is, relate to the tence itself, such as the affective situa- tion, understanding, anxiety), hence the out, however, interrupting the patient and be guided by his re- distinction relating to the ontical Ð the normal forms of care due to the al condition”.64 Here he will ap- concrete, the contentistic, and the exis- patient in such cases. For this ply the principle Ð already stat- tentive: structural, formal, and existen- tial. For this reason, existence can be un- reason the medical doctor ed – of “appropriate medical derstood as factness or factual dataness, should not worry too much, as treatment”, which can be speci- as exterior ontic phenomenality: the en- though it were the case that he fied this: “When inevitable tity is of itself being and exists because it appears; it expresses itself in a deter- or she had not provided assis- death is imminent, despite the mined way according to its determined- tance to a person in danger’. means used, it is lawful in con- ness and concreteness. 18 The ‘Charter for Health Care science to decide to refuse M. HEIDEGGER, Essere e tempo 41 Workers’ of the Pontifical treatment that would only se- (Longanesi & C., Milan, 1976), pp. 45-53. Council for Pastoral Assistance cure a precarious and painful 19 In his book ‘Il concetto di tempo’ to Health Care Workers, in arti- prolongation of life, but with- (Adelphi, Milan, 1998), M. Heidegger cle 120, emphasises that ‘the out interrupting the normal stresses that ‘in my existing, in fact, I am always ‘still on a journey’. It is always administration of foods and liq- treatment due to the patient in something that has not yet reached its uids, even artificially, is part of similar case. Hence the doctor end... Before this end it is never properly the normal treatment always need have no concern; it is not that which can be; and if it is, then it is so no longer... The end of my being due to the patient when this is as if he had failed to assist the here, my death, is not something be- not burdensome for him: their person in danger”.65 The admin- cause of which at a certain moment a undue suspension could be real istration of food and liquids, constant process suddenly stops, but a possibility in which the being here and properly so-called euthana- even artificially, is part of the nonetheless knows: it is the extreme sia’. normal treatment always due to possibility of oneself, that can be accept- The supporters of quality of the patient when this is not bur- ed and made one’s own as imminent. life63 as a parameter for good densome for him: their undue Being-here has in itself the possibility to encounter its own death as the extreme sense and law in the treatment suspension could be real and possibility of itself. This extreme possi- of sick people criticise the de- properly so-called euthanasia’. bility of being has the characteristic of fenders of the ethics of the sa- being imminent as certainty, and this certainty in turn is characterised by a credness of life, because these Dr. FRANCO DAVIDE complete vagueness... What is to have latter are said to see in the re- PILOTTO, cognisance of one’s own death? It is is jection of therapeutic overkill Medical Director precursor of being-here which goes to its the adoption of quality of life as Az. USL Region 15 Veneto, no-longer as extreme possibility of be- Graduate in Philosophy ing oneself that is imminent in its cer- a discriminating element in the tainty and complete vagueness. and Diploma in Theology, Being-here as human life is primarily a therapeutic operation. But the Contract Professor in Bioethics, error of their logic of interpreta- possible-being, it is the being of the pos- the Faculty of Medicine and Surgery, sibility of no-longer, certain and yet un- tion is to be found in seeing the the University of Padua and Verona. determined... This forerunning is noth- sacredness of life from a mate- ing else but the unique and authentic fu- rialistic point of view. In reality, ture of one’s own being here’, pp. 48-9. 20 G. MARCEL, Homo viator (Rome, the supporters of the sacredness 1967), p. 170. of life see the life of the human 21 L. ALICI, ‘Filosofia della morte’, in subject as a transcendental val- Notes AA.VV, La dignità degli ultimi giorni ue that is expressed in daily life (Cinisello Balsamo, 1998), p. 92. 1 E. FROMM, Anatomia della destrut- 22 I. CARRASCO DE PAULA, ‘Morte in virtue of the co-constituent tività umana (Italian edition, Milan, cerebrale: aspetto etico-filosofici’, Med- existentiality of every man, 1975). icina e Morale, 5, 1993, p. 892. whereas the biological compo- 2 P. ARIéS, Storia della morte in occi- 23 P. CATTORINI, Sotto scacci, Bioetica dente (BUR, Milan, 1998). di fine vita, Liviana Medicina (Naples, nent of man is an empirical cat- 3 J. MCMANNERS, Morte e illuminis- 1993). egory of life itself. Understood mo. Il senso della morte nella Francia 24 The Harvard Committee also sets in these terms, the value of life del XVIII secolo (Il Mulino, Bologna, out the criteria for the identification of 1984). the presence of death: an absence of re- is distinct from a mere biologi- 4 M. VOVELLE, La morte e l’occi- ceptivity and responsiveness; an absence cal perception, indeed it rises dente. Dal 1300 ai giorni nostri (Lat- of spontaneous movements; apnea, an above it and confers a horizon erza, Bari, 1986). absence of reflexes (of the brain and the 5 N. ELIAS, La solitudine del morente limbs), and a flat EEG (Ad Hoc Com- of meaning upon it, and in rela- (Il Mulino intersezioni, Bologna, 1999). mittee of the Harvard Medical School, tion to the terminally-ill person 6 Ibid., p. 82. ‘A Definition of Irreversible Como’, JA- it authorises the moral con- 7 R.A. MOODY, La vita oltre la vita. MA, 6, 1968, pp. 337-338. science of the health care work- Studi e rivelazioni sul fenomeno della 25 On this point the nosographic entity sopravivenza (Mondadori, Milan, 1977). of hedematose troancoencephaltis is er to abandon disproportionate 8 S. KIERKEGAARD, Accanto ad una recognised, something which in certain forms of care and treatment. tomba (Il Melangolo, Genoa, 1999). cases can be reversed through medical

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treatment. This confirms the soundness cannot even exist in a state of distinc- the observations that follow often derive of the adoption of the criterion of total tion. In the organic body we find our- from the accurate analysis carried out by cerebral death as a parameter to declare selves faced not with chemical compo- F. D’AGOSTINO, Bioetica (Giappichelli that a human organism has met with nents or partial organisations but with a Editore, Turin, 1996), to which the read- death. living organism which does not subsist er is directed for a deeper consideration 26 F. D’AGOSTINO, ‘Morte’, in F. except during the integrated union of the of the question. COMPAGNONI (ed.), Etica della vita (San various elements and partial organisa- 48 E. LECALDANO, ‘Questioni etiche Paolo, Cinisello Balsamo, Milan, 1996). tions. This allows us to speak about an sui confini della vita’, in A. Di Meo and 27 I. CARRASCO DE PAULA, op. cit., p. internal teleology of the human body in C. Mancina (eds.), Bioetica (Laterza, 894. the sense that every simple or organised Rome-Bari, 1986). 28 G. PERICO, ‘La nuova legge sull’ac- part is organised with the end in view of 49 A. THÉVENOT, La bioetica (Querini- certamento di morte’, Aggionamenti So- survival or well-being, to the constancy ana, Brescia, 1990). ciali, 4, 1994, 405-416. in time of this body. The organising 50 Data taken from L’Ancora June 29 Pontifical Council for Pastoral As- principle (morphé, entelécheia, of Aris- 2001. sistance to Health Care Workers, Char- totle) is that called the soul in man, and 51 L. MELINA, Bioetica (Piemme, ter for Health Care Workers , n. 129. which in this sense has a prevalence in Casale Monferrato, 1998). 30 K.G. GERVAIS, Redefining Death terms of ends in relation to the body, but 52 F. PILOTTO, ‘Come affrontare la (New Haven, Yale University Press, this is certainly not spatial or temporal. sofferenza umana: problemi psicologi- 1987). The human body (Leib) is the result of ci’, Impegno Ospedaliero, XXII, July 31 D.R. SMITH, ‘Legal Issues Leading the action of the soul in relation to this 2001, 3-8. to the Notion of Neocortical Death’, in matter; this maintains many aspects of 53 V. TAMBONE, Problemi di bioetica R.M. ZANER (ed.), Death: Beyond materiality, of corporeity (Korper), but e deontologia medica (Società Editrice Whole Brain Criteria (Dordrecht, Kluw- what this has at the level of living, of hu- Universo, Rome, 2000). er, 1988), p. 129. man living, is the effects of two sets of 54 A. SPAGNOLO, ‘Perché non condivi- 32 K.G. GERVAIS, Redefining Death co-causes, which, separated, are think- do l’eutanasia’, Le Scienze, 88, 1996, pp. (New Haven, Yale University Press, able and thus can be described and de- 52-3. 1987), p. 11. 33. M.B. GREEN and D. fined only with great difficulty... The 55 M. PORTIGLIATTI BARBOS, ‘Eutana- WIKLER, ‘Brain Death and Personal very fact that a human organism renews sia’, Professione, 88, 1996, 40-44. Identity’, in M. COHEN, T. NAGEL and T. itself constantly through metabolism and 56 C. DEFANTI, ‘Stato vegetativo per- SCANLON (eds.), Medicine and Moral its chemical/physical components and sistente e morte clinicale’, Le Scienze, Philosophy (New Jersey, Princeton Uni- renews most of its own cells without this 88, 1996, 40-44. 57. M. FAGGIONI, ‘Stato 42 versity Press, 1981). meaning that one is dealing with a new vegetativo persistente e morte corticale’, 34 A.E. WALKER, D.M. FEENY and body, is a sign that it is the psyché that Studia Moralia, XXXVI/2, 1998, D.A. HOVDA, ‘The Electrocephalo- produces and maintains its own body. 523-552. graphic Characteristics of the Rhomben- This last is the same... in that it is united 58 Pontificia Academia Scientiarum, cephalectomized Cat’, Electroen- to and organised by the same soul, C. Chagas (ed.), Working Group on the cephalography and Clinical Neurophys- which is human and personally individ- Artificial Prolongation of Life: the De- iology, 57, 1984, 158-165. ual... The soul can thus become a term to termination of the Exact Moment of 35 T. KUSHNER, ‘Having a Life versus indicate that aspect of the Death (Vatican City, 1985), translated Being Alive’, Journal of Medical Ethics, human-living-substance to which to at- into Italian by M. Morgante: L’eutana- 10, 1984, 5-8. tribute the causality of the activity of the sia è un crimine (Editrice elle de ci, Leu- 36 H. JONAS, Della fede antica all’uo- subject: abstract knowledge and volition mann, Turin, 1986), pp. 46-7. mo tecnologico (Il Mulino, Bologna, of objects that are not immediate can be 59 In 1950 Pius XII, in the area of the 1991), p. 218. attributed to it. The physical body, in- provision of health care services to the 37 J.M. STANLEY, ‘More Fiddling with stead, can be a term to be attributed to terminally ill, in referring only to means, the Definition of Death’, Journal of extension, and thus to the possibility of made a distinction between: ordinary Medical Ethics, 13, 1987, p. 22. being seen, first through the sense, but (obligatory) means Ð hydration, alimen- 38 K.G. GERVAIS, Redefining Death subsequently known also in an intellec- tation, and hygienic care; and extraordi- (New Haven, Yale University Press, tual way’, see F. Compagnoni (ed.), Eti- nary (facultative) means Ð surgical oper- 1987), p. 175. ca della vita (San Paolo, Cinisello Bal- ations, chemotherapy and radiotherapy, 39 G.R. GILLETT, ‘Why Let People samo, Milan, 1996), pp. 33-56. Thus which help to increase pain, risks and Die?’, Journal of Medical Ethics, 12, death should be understood in its totality excessive costs. Today we prefer to 1986, p. 84. as an integrated system, as indeed it is make a distinction between proportion- 40 D. LAMB, I confini della vita. Morte seen in different sets of legislations: the ate means and disproportionate means, cerebrale ed etica dei trapianti (Il Muli- death of the body-nervous system. taking into consideration not only the no, Bologna, 1987). 45 M. HEIDEGGER, ‘La Cosa’, in Saggi means but also the clinical state of the 41 J. RACHELS, La fine della vita (Son- e discorsi (Mursia, Milan, 1976), p. 119. patient and the real benefits that can re- da, Milan, 1989), pp. 11-12. 46 R.L. LUCAS, Antropologia e proble- ally accrue to the patient. In the case of 42 G.R. GILLETT, ‘Why Let People mi etici (San Paolo, Cinisello Balsamo, patients in a persistent vegetative state, Die?’, Journal of Medical Ethics, 12, Milan, 2001), pp. 147-8. hydration, alimentation and personal hy- 1986, p. 85. 47 The metholodological approach of giene are proportionate ordinary forms 43 On the persistent vegetative state of care intended to avoid an early death, and in particular the dramatic case of leaving the basic illness to follow its nat- Nancy Cruzan, which divided American ural course. public opinion at the end of the 1980s, 60 S. LEONE, Il malato terminale (San see C. Manni, ‘Sindrome appallica’, in Paolo, 1996). S. Leone and S. Privitera, Dizionario di 61 Pontificio Consiglio “Cor Unum”, Bioetica (Acireale-Bologna, 1994), pp. Alcune questioni etiche relative ai 904-907; A. Puca, ‘Il caso di Nancy malati gravi e ai morenti, 27 maggio Beth Cruzan’, Medicina e Morale, 42, 1981 (Edizioni Dehoniane, Bologna, 1992, pp. 911-931. 1982), p. 19. 44 According to Aristotelian doctrine, 62 Congregazione per la Dottrina della the soul (or substantial form) is the form Fede, Dichiarazione sull’eutanasia, 5 of the body, and it is inseparable and in- maggio 1980, chap. 4 (Edizioni Dehoni- conceivable without its relationship to ane, Bologna, 1982), p. 11. the body. For that matter, Boethius de- 63 M. MORI, ‘Il filosofo e l’etica della fines as a person every individual sub- vita’, in A. DI MEO and C. MANCINA stance of a relational nature, as a result (eds.), Bioetica (Laterza, Bari, 1989), p. of which relational nature does not only 95. involve what is functionally or empiri- 64 Cf. GIOVANNI PAOLO II, ‘A due cally ascertainable but what can be ar- gruppi di lavoro promossi dalla Pontificia gued rationally within a conception of Accademia delle Scienze, 21 ott. 1985’, being and its levels of perfection. F. in Insegnamenti, VIII/2, 1985, n. 5. Compagnoni, on this point, retrieves the 65 Congregazione per la Dottrina della ileomorphic theory and proposes a phe- Fede, ‘Dichiarazione sull’eutanasia, 5 nomenological reading: ‘Considered in maggio 1980’, in AAS, 72, 1980, 551. its manifestation, the body of man can- Cf. Evangelium Vitae, 65. not be defined in opposition to the soul. What man experiences in the living hu- man body is the operative unity of its components which do not subsist and

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Testimony

Problems of Health in Burkina Faso

The Blessed Luigi Tezza: Founder of the Daughters of San Camillo

Nicaragua: Pastoral Care in Health

Spain: The Department for Pastoral Care in Health

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Problems of Health in Burkina Faso

I have known Burkina Faso am mistaken when I state that terial hypertension which af- since 1974. I was there until they apply to the continent of flicts from 10% to 15% of all 1980 in my capacity as provin- Africa in a special way. The the African populations. cial superior of the Camillian Fourth Conference of the Min- I cannot but speak also of the religious and subsequently I isters of Health of the Organisa- presence of the disease of the lived there as a resident from tion for African Unity (OAU), century Ð AIDS. According to 1981 to December 1996. I lived which took place in Swaziland the statistics distributed by the there as a priest but I directed at the beginning of 1991, de- Ninth International Conference my attention to the problems scribed in a vigorous way on AIDS which took place in and the needs of the country and ‘African hypermortality’. In all Kampala (Uganda), this afflic- the populations that live in it. developing countries, the con- tion is in a phase of growth in In my discussion of this sub- ference observed, infectious the Sub-Saharan countries. ject I will confine myself to and parasite-borne illnesses Today in the Sub-Saharan speaking about four aspects of were at the root of most of pre- countries there are eleven mil- health and health care in Burki- mature deaths Ð it was the lion people infected with the na Faso. First of all, I will pro- shared opinion of the members AIDS virus out of an overall 44 vide different kinds of informa- of the conference that in Africa population of 560 million in- tion in order to define the health the quota of such deaths ac- habitants, and of these eleven care context of Burkina Faso. counts without doubt for a half million, seven million have Secondly, I will describe the in- of the total of all deaths. full-blown AIDS. This figure fluences of the local area and of In addition to infectious and constitutes 60% of all cases in environmental deterioration on parasite-borne illnesses and the the world. In 1984 two million the illnesses to be found in the return of malaria, emphasis cases were registered, nearly all country. Lastly, I will speak should also be laid on the return of which had been transmitted about the prevention and treat- of cholera, which in addition to by heterosexual pathways. The ment of illness and the econom- being present in Latin America most afflicted people are the ic difficulties which have to be also affects certain countries in young generation. The great overcome in order to imple- Africa. Attention should also be difference in the incidence of ment an overall and systematic drawn to dracunculiasis or this scourge between rural and plan to combat illness. guinea worm infection which urban areas is tending to dimin- afflicts about twenty countries ish because of the increasing in Africa. movement of people. The in- 1. Some Information To this picture other diseases crease in the incidence of this in Order to Define should be added which have the malady has meant an overbur- the Health Care Context reputation of being modern or dening of hospital admissions. of Burkina Faso imported from the North of the Indeed, in some cities AIDS planet. I am referring here to tu- victims occupy one half of the At the beginning of the berculosis, polio, meningitis, hospital beds that are available. 1990s the World Health Organ- tetanus, pertussis, diptheria, and Three groups of countries isation (WHO) laid stress upon measles. Some of these mal- can be identified in which the the following worrying features adies are no longer a serious HIV infection is especially of the health care situation pre- problem in European countries strong. They are responsible for sent at that time in the world: but in the continent of Africa 90% of the cases of people in the return of malaria and more they are still fatal in their im- Africa who are seropositive. generally the re-emergence of pact (for example, meningitis The first group is that made up various tropical diseases which and measles). It is often said of the countries of central and it was thought had been elimi- that Africans do not suffer from eastern Africa (Uganda, nated; the endemic blindness of heart disease because they are Ethiopia, Rwanda and Zaire). adults and children in many not subject to the stress pro- These are countries where the rural areas of developing coun- duced by European lifestyles. infection has been known about tries; the absence of a world- However, this is a mistaken be- since the 1970s and where 30% wide pharmaceutical policy lief. Unfortunately, heart dis- of the cases are to be found. and a demographic situation ease is present in Africa and al- The second group is that made lacking in a responsible ap- so has a future. In addition, to up of countries located in the proach marked by the two con- cases of cardiopathic illness west of the continent (the Ivory tradictory aspects of the ageing due above all else to underde- Coast, Burkina Faso, Ghana of the North of the planet and velopment, such as those in- and Togo). In these countries the spontaneous growth of the volving the heart valves and about 15% of seropositive South. muscles, there are also to be Africans are to be found. The It is a common view that found illnesses attributed to de- countries of southern Africa these aspects are still a matter velopment, such as angina pec- (Botswana, Malawi, South for worry. They concern the toris and heart attacks. Refer- Africa, Tanzania, Zambia and whole world but I do not think I ence should also be made to ar- Zimbabwe) have about 40% of

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those who are seropositive in basis of about thirty factors regular, is for the most part Africa. which traditionally have been made up of starches. There is a An important point of refer- indexes of health. As regards consequent shortage of protein, ence by which to establish the my paper, that is to say in order and this makes the inhabitants state of health of a people is the to understand the health care susceptible to endemic dis- ‘life expectancy’ index, that is context of Burkina Faso, I think eases. to say the average life-span that what I have already out- In the tropical zone, with its which is to be encountered lined above is sufficient for this alternating seasons, the spread within a people. The following purpose. I can now go on to ad- of insect-borne diseases is caused by the poor quality of the water. During the dry sea- son the water holes become rare and the water becomes stag- nant, becoming thereby centres of disease. During the rainy season the grass grows and favours the movement of the in- sects which carry diseases. There is then a re-emergence of malaria and other kinds of in- fections: bilharziasis, river blindness, and cholera nostras. In the arid or semi-arid zone the same phenomena of the 45 zone of alternating seasons are produced. However in different fashion this zone is charac- terised by a dry season, which is longer in duration and more severe, and by a shorter period of rains with years of drought. If years of drought follow each data are of relevance in relation dress the second of the ques- other, the low harvest produces to this point: in 1994, in the in- tions listed above, that of the re- malnutrition in terms of protein dustrialised countries, life ex- lationship between the local and calories which in turn im- pectancy was 77 years; in Latin area, environmental deteriora- poverishes the human organism America it was 68; in the Ori- tion, and illness. and increases vulnerability to ental countries and the Pacific it the various local diseases, and was 66; in North Africa and the 2. The Local Area, in particular those which in- Middle East it was 64; in Environmental volve cell-based mediation Sub-Saharan Africa it was 51; Deterioration and Illness such as measles, gastroenteritis, but in Burkina Faso it was 47. tuberculosis and leprosy. In this The differences in infant mor- Under this second heading I zone, furthermore, the rapid tality are even more marked: intend to bring out certain changes in temperature are re- whereas in the industrialised causal relationships between sponsible for numerous afflic- countries there were seven such the local area and illness. Ac- tions of the respiratory tract and deaths for every thousand chil- cording to information provid- the sand-carrying winds are an dren born alive, the figure was ed by the World Health Organi- aggravating factor as regards 38 in Latin America, 84 in sation, 80% of world illness is conjunctivitis and trachoma. South Asia, and 107 in Africa caused by a lack of suitable wa- The environmental situation of and the South of the Sahara. As ter and by poor environmental Burkina Faso shares the charac- regards infant mortality rates in conditions which conduce to teristics of these last two zones, Burkina Faso, the situation was ill-health. I will now provide and this is especially true of the better than in other Sub-Saha- relevant information about the centre and the north of the ran countries Ð 89 deaths for local area, water, and illness, country. every thousand live births. This and about environmental deteri- There are those who main- improved situation is also the oration and health. tain that dirty water can contain case when children under the the germs of over twenty infec- age of five are taken into ac- a)The local area, water, tious diseases. In discussing count. Whereas in Sub-Saharan and illness this subject I will confine my- countries the incidence of such self to one example, that of di- mortality taken overall is 177 to In the equatorial and tropical arrhoea illnesses. every thousand, in Burkina Fa- zone the warm and damp cli- Diarrhoea illnesses, such as so the figure is 169 for every mate favours the breeding of amoebic or bacillary dysentery, thousand. certain species of insects and or forms of gastroenteritis, are The experts on the causes of the outbreak of diseases of above all very common illness- illness and the condition of which they are the carriers Ð ty- es which afflict children in health of the various peoples of panosomiasis, malaria, and yel- these countries. Every year, be- the world have carried out re- low fever. In the same zone the cause of the lack of clean water, search and comparisons on the production of food, although these illnesses cause the death

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of about six million children and effected irrigation. which reference has been previ- under the age of five. In the arid Of the causes which have just ously made in this paper. or semi-arid zones, the heavy been adumbrated, deforestation concentration of people around merits special attention. It aris- rare water holes increases the es from the industrial exploita- 3. The Prevention and risks of diarrhoea diseases. In- tion of wood for export purpos- Treatment of Illness deed, these water holes are used es, from the energy needs of the for all purposes. urban and rural populations, When in 1958 Dr. Carrol It is within this context that and from clearance measures to Berohorst left the United States it is necessary to locate the produce new cultivable land. of America to go and treat the health care situation of Burki- But it also involves unpre- Indians of Guatemala, he based na Faso. Despite the attempts dictable changes in the ecosys- himself upon the simple princi- made at the level of hygiene tem at a local, regional, and ple that ‘illnesses are defeated and the treatment of illness, in planetary level. by treating illnesses’. But some Burkina Faso the dominant With regard to the special ef- fifteen years later he expressed factor in bringing about pre- fects of deforestation, we may his disappointment and ob- mature deaths remains the observe that the changes which served that sick people, once prevalence of infectious and this phenomenon brings about they had been treated and got parasite-borne diseases con- in the forest ecology in turn al- better, returned to their condi- nected with unhealthy environ- ter the behaviour of the carriers tion of poverty and their illness. ments and dirty water. I am re- of diseases. The new people It was, therefore, necessary to ferring here to diarrhoea ill- who come to the cleared land adopt a wider approach and to nesses, amoebic dysentery and bring with them new diseases. realise that health requires peo- 46 intestinal parasites. To this These diseases easily infect the ple to live in an environmental should be added the epidemics non-immunised local inhabi- context which is favourable to of measles, meningitis and tants and vice versa the local in- their health. malaria (16.42% of all deaths habitants transmit their diseases Today, in order to ensure that are attributed to malaria). To to the newly arrived people. An an environment is favourable to these causes we should today example of an outbreak of yel- people’s health, the following add the deaths brought about conditions are considered to be by AIDS. Previously in this pa- of primary importance: educa- per I observed that Burkina Fa- tion in health care, and in par- so belongs to a group of coun- ticular such education in rela- tries where 15% of seroposi- tion to women; access to drink- tive Africans live. ing water and the drainage of After these observations one the local area; and the spread of can say that the fight against the ‘primary forms of health care great epidemics or the epi- and treatment’. To these prima- demics which threaten the ry conditions should be added Sub-Saharan countries begins food hygiene and a sense of re- with knowledge about the rela- sponsibility in demographic tionships between man, the en- matters, or rather in matters re- vironment and illness. The lating to population density. study of these ‘medical ecolo- I referred to health care edu- gies’ allows us to understand cation, and in particular to such the differences that occur as re- education in relation to women, gards the prevalence of an en- to begin with. The fact is that it demic disease and to study its is women who reproduce soci- prevention and the ways of low fever caused by deforesta- ety in a biological and cultural fighting it, through changes in tion was the epidemic which af- sense. They are mothers and at environmental conditions as flicted Nigeria in 1986-7. the same time the educators well. Twelve thousand people died and nurses of their families. If and it is estimated that at least they receive a good health care b)Environmental fifty thousand people were af- education, they improve in a deterioration and health fected. positive way the health care be- In conclusion, I may observe haviour of all their family. Ex- Environmental deterioration that deterioration in the local perience shows that the health is a phenomenon which directly area has a direct effect on care education of mothers is a affects Burkina Faso. Indeed, health when it provokes the ap- decisive element in the health Burkina Faso is a country pearance of a new pathogenic of the child Ð as the health care which belongs to the Sahel and factor. It has an indirect effect education of mothers increases, is thus a country threatened by when, in bringing about a re- there is an inevitable reduction desertification. The principal duction of the availability of in the incidence rate of infant causes thought to be behind de- food, an extension of work mortality, and this to whatever sertification are: the over-ex- time, or the scarcity of essential socio-economic condition their ploitation of cultivated land, the goods such as drinking water or family belongs. free-ranging pasturing of live- building materials, there is as a A condition of similar prima- stock, unplanned deforestation, result the debilitation of people ry importance in the defeat of and the erosion caused by tor- who are thereby made more illnesses is the drainage of the rential rains or badly organised susceptible to all the diseases to local area and access to drink-

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ing water. Over a hundred pa- lowering of the birth rate (1960: centres. At the level of preven- pers on this subject (Esrey, 49; 1994: 47). Even stranger is tion, as was observed above, 1991) demonstrate that the the fact that not even female in- the experts on the subject argue drainage of the environment struction has affected in a sig- that health care education, ac- has often reduced the level of nificant way the lowering of the cess to drinking water, the infant mortality caused by diar- birth rate. And that is not all: drainage of the local territory rhoea illnesses by 50%. Some- the present-day growth rate of and the environment, and gen- times this percentage level, in the African populations is one eralised vaccinations are all of conjunction with the presence of the highest in the world and primary importance. All this of other positive conditions, has at the same time the levels of brings out how Africans have a reached a figure of 80%. In the population density are some of good knowledge of their health same way, improved water sup- the lowest. care situation and how are plies in the countryside has giv- This means that one cannot aware of the remedies that are en rise to a reduction in cases of address African demography by needed to improve it. infestation by Guinea worm in- confining oneself to the ques- How, then, can one explain fection. In Nigeria, for exam- tion of the birth rate Ð one has that ‘life expectancy’ is still ple, 640 thousand cases of this to ask oneself if Africa is suffi- roundabout fifty years of age? infection were reported in ciently populated. Indeed, pop- In other words, how can one 1989. In 1991, after an im- ulation density affects develop- explain that the African popula- provement in water supplies to- ment. Without a minimum of tions are still weak? We have a gether with treatment of the density, especially in relation to proverb which provides an an- malady and efforts at health agriculture, no innovating pres- swer: ‘health does not have a care education, only 282 thou- sure is produced. price but it has a cost’. And un- sand cases of this illness were fortunately this cost of health is 47 reported. higher than the economic re- The concept of ‘primary 4. Health Care Planning sources of the country I am here forms of health care and treat- and Economic Limitations discussing; as is the case, in- ment’ was defined in Alma-Ata deed, with all the other coun- (Russia) during an international The observations made so far tries south of the Sahara. Cer- conference in which 134 States in this paper provide us at the tain facts bring this out. For ex- belonging to the World Health same time with a framework ample, malaria is still a serious Organisation took part. ‘Prima- and pointers for what should be problem for health in Burkina ry forms of health care and done to improve the health care Faso. It is the cause of 40% of treatment’ involve two cate- situation in Burkina Faso both the fevers of those who visit the gories of measures and initia- at the level of care and treat- dispensaries. Some examples of tives: activity concerning eco- ment and as regards prevention. research into malaria in this nomic and social development, At the level of care and treat- country reveal that the cases of such as the promotion of better ment, matters were made clear malaria fell by 15% between environmental, food, and hy- with precision by the declara- 1973 and 1981. However, in giene conditions, and the tions of Alma-Ata and Bamako. that latter year it rose again in a spread of scientifically valid These declarations urged the relevant way. The same exam- health care services which are spread of ‘primary forms of ples of research tell us that a socially accessible to all the health care and treatment’ and typical case of malaria, taking families of the community. In the diffusion of essential medi- into account direct and indirect this context, the declaration of cines and drugs bearing labels Alma-Ata urged the encourage- indicating their real origins. I ment of the promotion of the would like to add that in Burki- participation of the inhabitants na Faso health care reorganisa- of villages both through the tion is underway through a de- promotion of health care educa- centralisation which seeks to tion and through the employ- directly involve citizens in the ment of locally available health defence and promotion of their care auxiliaries. health. This reorganisation en- On the same occasion gener- visages the creation of health alised campaigns of vaccination care regions organised into were set in motion to combat health care districts. A health the most common diseases of care district is made up of a cer- the countries of Sub-Saharan tain number of dispensaries and Africa. health care centres which refer I will terminate my discus- to a medical centre, described sion of this subject with an ob- as being ‘improved’, and which servation on the problem of de- are provided with multi-clinics, mography. wards, maternity wards, SMI In relation to this question, wards, a pharmaceutical room, Africa has strange particulari- and a structure for surgery for expenses, costs the output of ties. Differently from other con- the most urgent cases. This ‘im- twelve working days. If one tinents, there is no evident cor- proved’ medical centre is usual- considers that the average relation between the lowering ly located in a place which is monthly wage in Burkina Faso of the level of infant mortality easy to reach for the outlying does not reach 200,000 Italian (1960: 183; 1994: 89) and the dispensaries and health care lire, and that the inhabitants

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with a wage do not constitute even a fifth of the population, one already has sufficient infor- mation to gain an idea of the economic difficulties which every citizen of Burkina Faso encounters in protecting and promoting his or her own health. I will not examine the cost of other illnesses because assess- ments and evaluations in this field remain imprecise. Howev- er, I would add a general as- sessment which I made in 1993 and which I believe is still valid in terms of its overall contents when considered in relation to the new context. In the mean- time, it may be observed, the inhabitants of Burkina Faso ground. It should also be added prevails a planetary manage- have increased in number and that nothing and nobody is en- ment of the health care systems the local currency has under- couraging this country to see under the auspices of the World 48 gone a major devaluation. these problems as really being Bank. According to this man- My assessment referred to the of primary importance. In agement, criteria of profit will budget for 1991. The national searching to achieve its own be increasingly adopted. The budget of that year in Burkina economic independence, Burki- policy of multilateral givers Faso was 176 milliard, 535 mil- na Faso is forced to direct itself will give way to co-operators lion local francs. At the time the more towards productive activi- who are held to be safe and population was about nine mil- ties. Indeed, banks provide trustworthy. Soon a non-gov- lion. If we posit a medical pre- funds only in relation to an abil- ernmental organisation’, con- scription for every inhabitant of ity to repay them and with the cludes Hours, ‘will be given five thousand local francs, the guarantee that the loans will be the health care management of sum required to pay for medi- used in the ways that the banks entire districts and this will not cines alone would amount today themselves indicate. fail to provoke changes in the to 45 milliard francs. This sum This is a difficult situation in approach of associations which is a fourth of the total expendi- relation to which the hard work are concerned with health care ture of the country and half the and the creativity of the inhabi- development’. total health budget for 1991. It tants of Burkina Faso can But Christians cannot and is clear that we are very distant achieve little without effective must not share this mentality not only from the sums needed and important support from the which sacrifices the rights of to carry out an overall project of solidarity of their sister peoples. the human person to that which drainage but also from the costs The industrialised countries is useful for that which is use- of daily medicines. This situa- should become aware of the ful. The Pope reminds them that tion in Burkina Faso also ap- fact that the problems of the ‘there is something due to man plies to the other Sub-Saharan drainage of the local area, ac- because he is man, because of countries. Indeed, an analysis of cess for all to drinking water his dignity and likeness to God, the budgets of the African and a halt to deforestation re- independently of his presence States brings out the lack of quire the commitment of all the or otherwise on the market, of funds which African govern- inhabitants of the earth and not what he owns, and thus can sell, ments allocate to health. The re- only of Africans. If they do not and of the means of purchase he port of the World Bank of 1985 decide to follow in a deter- has available. This something provided the following structure mined fashion the path of an must never be disappointed but of the total public expenditure authentic and solidarity-in- requires rather respect and soli- of nineteen African countries: spired sharing, the state of darity (the social expression of health of the African continent love) which is the sole adequate Health Care Services 5.6% will remain weak and vulnera- approach to the person.’ ‘The Collective Services ble. But one must not forget poor’, continues the Pope in his and Social Security 4.7% that this situation and the caus- encyclical Centesimus Annus, Education 16% es that it generates, for example ‘ask for the right... to make Defence 11.4% desertification, can have nega- good use of their capacity for Economic and tive consequences for the whole work, thus creating a world that Other Services 62.3% of our planet. is more just and prosperous for I would like to finish this pa- all. The advancement of the It is clear that the difficulties per with two quotations: one by poor constitutes a great oppor- which Burkina Faso has to face a member of the laity and one tunity for the moral, cultural up to in dealing with its health by the Pope. Bernard Hours, and also economic growth of all care situation are very real. It is the former President of the humanity’. not only that its financial re- World Bank, complained that sources are really short on the ‘in the world economy there Rev. RENATO DI MENNA, M.I.

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The Blessed Luigi Tezza: Founder of the Daughters of San Camillo

On 4 November John Paul II good fortune to receive his The Leadership raised to the honour of the al- training in a context where reli- of the Camillian Order tars the Camillian priest Luigi gious life had returned to the Tezza, founder of the Daugh- original spirit of the founder, In 1889 Luigi Tezza was ters of San Camillo. Joined to San Camillo, with the observa- elected Vicar, Procurator and the glorious series of man and tion of perfect community life General Counsellor of the woman who, down the cen- and the exercise of the ministry Camillian Order. This role en- turies, have achieved holiness in hospitals. abled him to exercise a positive through the excercise of mercy He was ordained a priest in influence in ensuring that the towards the sick, the new 1864 and spent the first years of reform of religious life which blessed presents himself to the his ministry as a presbyter in had already been carried out in People of God as an original Verona and Rome, where he Verona and France could be ex- interpreter of the charism of was involved in the training of tended to the whole of the Insti- charity towards those people candidates for the consecrated tute. Thus it was that the perfect who suffer in the body and the and priestly life. community life was approved spirit. by the General Chapter of 1898 49 Born in Conegliano (Terviso) In France: and looking after sick people in on 1 November 1842, Luigi Loyalty and Creativity hospitals also regained vigour Tezza died in Lima on 26 Sep- throughout the Order. tember 1923. His existence was He was sent to France in During his period in Rome, a long, eventful and authentic 1871 and contributed in a de- which lasted until 1898, he pilgrimage in favour of mission. termining fashion to the devel- united his responsibilities as In fact, he spent forty-two years opment of that foundation, Vicar General with intense pas- of eighty-two years of his life in which had been begun two toral activity and founded the Italy, nineteen in France, and years earlier. During his man- Congregation of the Daughters twenty-three in Peru. His activi- date as Provincial Superior, the of San Camillo. ties within the Order of the French Camillian province of Ministers of the Infirm (Camil- the diocese of Autun was ex- Hospitals: My Real lians) took many forms: Luigi tended to Lyons, Lille, Cannes, Heaven on Earth Tezza was an educator, a com- Théoule-sur-Mer, and Tournai munity leader, the founder of a (Belgium). Father Tezza was asked to religious Institute, a minister of Geographical development live in the Hospital of San merciful love towards the sick, was matched by creativity and Camillo in Laterano, where he the director of souls, and the re- breadth of vision in pastoral also engaged, part-time, in the former of religious life. choices. Faithful to the Camil- ministry of the chaplain. The lian charism, Luigi Tezza did Camillians had assumed re- In Verona and Rome: not hesitate to take decisions sponsibility for spiritual assis- The Ministry of Training which were distant from the tance in the hospital in 1836,2 letter of tradition but which re- and had exercised that ministry At the age of fifteen, Luigi mained faithful, however, to its in an exemplary way. Tezza entered the Camillian spirit. He agreed with the opin- In this hospital Luigi Tezza seminary of Verona and had the ion of one of his mentors to the was able to exercise the specif- effect that ‘from San Camillo ic charism of the Order with we can and must derive chari- continuity. During the previous ty, but the means by which to years, in fact, it had not been exercise it in our circumstances possible for him to consecrate require that we acquire such much time to this ministry de- means from the special spirit voted to the sick because of his with which the Lord may wish tasks and responsibilities at the to fill our hearts in order to level of training and in the gov- meet present needs’.1 A signifi- ernment of the Order. cant example of such discern- The spirit and the method- ment of the signs of times was ological directions which guid- the decision that was taken to ed spiritual accompanying of create and manage their own the sick at that time can be de- socio-health care structures. rived from a number of manu- This approach, which was con- als written by Camillian reli- trary to the tradition of the In- gious. One of these, ‘Practica stitute and the will of San Visitandi Infirmos’, published Camillo, was to have conse- in 1630 by Father Giacomo quences throughout the Camil- Mancini Ð who had known San lian Order. Camillo personally and who

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passed on his spirit in this vol- to be continued by the priest gi Tezza transmitted the Camil- ume Ð not only constituted a himself or by other people. lian charism of merciful charity synthesis of the theory and the The vision of Mancini, in towards the sick and others, practice of the Camillian Order which assistance to the sick who enriched it and broadened of that time, but had also re- person is called to be a ministry it. Indeed, from the ‘fertile and mained a ‘firm reference point of consolation directed to the blessed trunk’ of the Camillian for subsequent writings on as- whole person, with a view to Order there came forth, engag- sistance to the sick’.3 Indeed, his or her salvation, certainly ing later in its own independent other Camillian authors of the found a positive echo in the growth and development, the seventeenth century, whose spirit of Luigi Tezza, both be- shoot of a new religious family. work had an influence on pas- cause of his personality and be- The close link between the toral action until the beginning cause of the upbringing that he Camillian Order and the Con- of the twentieth century, clearly had received. His encounter gregation of the Daughters of followed on from Mancini. with sick people was enriched San Camillo did not mean, In the book by Mancini, next by that sensitivity and emotion- however, that Luigi Tezza and to the many indications sug- al warmth that gave colour and Giuditta Vannini engaged in a gested by the author, which by contents to his relationship with simple transposition of the that time had been superseded, people he held dear. charism of San Camillo, mov- there were a very large number of original and innovative ele- ments. In very appropriate fashion, Mancini laid stress upon the 50 need for a specific preparation and grounding for the exercise of spiritual assistance to people who are sick. This was, in fact, a ministry that required a good preparation and grounding not only at the theological-moral level but also at the level of ac- tual practice. The sick people of San Gio- ing it, so to speak, from one In- If the stress upon the sacra- vanni gradually became the stitute to another. mental dimension which is pre- beneficiaries of his pastoral It is certainly the case that the sent in the work is relevant, this charity, which was infused charism of San Camillo was the does not take space away either with affection. When asked great reserve of spiritual energy from a need to have knowledge why during the early morning on which the two founders drew about the person and his or her he opened the window and took generously for inspiration and needs or from a consideration in deep breaths, he answered to achieve a special approach by of the interpersonal and dialog- that he wanted to fill his chest which to experience the Lord. ical approaches of the priest. with the scent of charity which But, just as a river comes from a The author invited the pastoral came up to him from the win- lake and goes down its own and worker to arm himself with dows of the courtyard below. original paths, so the Camillian prudence and gentleness, and to This action was an echo of San charism, assimilated by Tezza commit himself to establishing Camillo who, when passing and Vannini, took on original a good relationship with the near to the Hospital of the Holy characteristics thanks to the in- sick person before proposing Spirit, stopped to smell its fluence of a large number of prayer and the sacraments to scent. In a letter written some factors of a personal, historical him or her. The tone of voice years later, Luigi Tezza ex- and cultural character. and the style of conversation pressed his regret at ‘having If we limited emphasis to one are also of importance. left that hospital, my real heav- of the features of this originali- In order to accompany the en on earth’. ty, we could say that through sick person, preaching or high- the Institute founded by Luigi ly complicated theological The Daughters of San Camillo Tezza the Camillian charism speeches were, the author ar- was lived out in a female way, gued, not required: what was However, the project in with all that this implied at the called for were suggestions which Luigi Tezza invested level of significance and mean- marked by a gentle and peace- most of his energies during his ing.4 ful tone. The creation of an ap- period of stay in Rome and Indeed, San Camillo, when propriate atmosphere with mu- which over time was to gain he invited his religious to serve sic and songs chosen for the most visibility was the founda- sick people with the heart of a purpose, as well as the repeti- tion of the Congregation of the mother, had already perceived tion of biblical phrases centred Daughters of San Camillo. that care for the sick had to around the love of the Lord, Cultivated for many years, draw upon those qualities and could also contribute to the ef- this initiative was set in motion approaches which are typical of fectiveness of the pastoral after a meeting between Giudit- the female genius Ð receptive- worker’s activity. ta Vannini (‘Giuseppina’ after ness, readiness to help, tender- The pastoral relationship did her profession), a young woman ness, welcome, the ability to not stop at the celebration of in search of her own vocation. listen, intuition, sensitivity in the sacraments. Indeed, it had Together with Giuseppina, Lui- understanding situations, the

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ability to take on other people’s sign, and an instrument, that is Camillain charism, they had problems, and a propensity to to say, of the love of God for dedicated themselves with offer help... the whole man and all men, great ardour to service to the One rule that San Camillo with special attention for the gravely sick and the dying, and drew up is highly significant in least, for the sick, and for sin- were also involved at an acade- this sense: ‘First of all every- ners’.5 mic level in the local city uni- one must ask thanks of the Is it not the case that the versity. Unfortunately, the Lord so that he can give mater- Church needs to develop in an painful political events of the nal affection to his neighbour, increasingly intense and mean- South American continent and because we wish with the ingful way the Marian dimen- the separation from Rome, ef- grace of God to serve all the sion, made up of ‘silent near- fected by the Spanish monar- sick with that affection that a ness in pain’, of greatness that chy, did not fail to give rise to loving mother gave to her only becomes welcome and service numerous crises and to a cer- infirm son’. towards the poor, the weak, the tain decline in religious obser- In the Congregation founded victims of illness and death? vance. by Luigi Tezza this aspect of The endeavour of consecrat- When in 1897 the Peruvian the Camillian charism was ed women is one of the most foundation once again united deepened and broadened. He suitable endeavours by which with Rome, there was the need asked his daughters to en- to respond to this need. ‘The for the presence and action of counter their Spouse in the sick Daughter of San Camillo, in somebody who could point out person Ð is the sick person not fact, represents the Mother the steps to be taken for a return an icon of Christ? Ð and to Church who welcomes the af- to a style of life more conso- serve him with the heart of a flicted and the weak and en- nant with religious require- mother. velopes them with expressions ments. Father Tezza was cho- 51 Some phrases from the of concern, who tries with sen for this mission. Mulieris Dignitatem of John every care to help those in great In carrying out this task he Paul II allow us to understand need, and in them serves Christ drew productively upon the the profound nature and the himself. In this way she con- rich gifts of his personality contemporary relevance of the tributes ‘to the good and the which his long experience in message of Luigi Tezza. If promotion of the whole human training and government had ‘God entrusts every man to us family, whose joys and hopes, refined, and he happily har- all and to each one of use’, ob- sadness and anxieties find echo monised sweetness and firm- serves the Pope, ‘this entrusting in her heart’.6 ness, understanding and oppo- concerns in a special way Through the presence and sition. The project of reform women Ð precisely because of work of his beloved Daughters, had a happy outcome, and their femininity Ð and it decides the charism of Luigi Rezza, and brought back the Camillian in a particular way their voca- of his co-founder Giuseppina community to its early spirit. tion’ (n. 30). This applies above Vannini (proclaimed ‘Blessed’ Tezza’s project of reform, in all in a socio-cultural context in in 1995), have reached seven- fact, was not only directed to which the successes of science teen countries in four conti- those inside the community. He and technology favour uneven nents. also sought to reconquer the progress and thus can also in- Facing up to the challenges moral prestige that the commu- volve a gradual disappearance of the world of health and suf- nity had previously enjoyed of sensitivity towards man, to- fering through a variety of min- amongst the population. wards what is essentially hu- istries, following in the foot- Fortified and encouraged by man. In this sense, the Pope steps of their founders, the his experience in Italy and continues, our days in particu- Daughters of San Camillo now France, Luigi Tezza thus com- lar require the expression of provide an effective contribu- mitted himself to strengthening that ‘genius’ of women which tion to evangelisation through the already praiseworthy ser- ensures sensitivity for man in the path of compassionate char- vice that was provided by the every circumstance: because of ity, and are a constant appeal to religious through helping sick the fact that he is a man! (ibid.) the presence of Christ in those people in private homes, and he In bringing into being a new who suffer. also promoted such service ex- religious Institute, Luigi Tezza ercised in hospitals. He had re- offered the Church a strong call The Mission to Lima alised, in fact, that in no place to make her concern for people more than Lima was ‘our min- in whom Christ continues to After his mandate as General istry so well understood and ap- live, over time, his passion, Counsellor had terminated, in preciated’. more alive and sensitive. 1898 Luigi Tezza went back to Observing the vast field of This is what John Paul II ex- France. This was a brief stay work in the world of suffering pressed in an enlightened because two years later he and health, he drew up an am- speech to the Daughters of San would be called to go to Peru as bitious plan which involved the Camillo: ‘Your charism of ser- a general visitor of the Camil- creation of a chaplaincy which vice to the sick which distin- lian community in Lima. was able to deal with the pas- guishes you within the Church, In the Peruvian capital the toral needs of the five hospitals also because of your fourth Camillians had been present for and the hospices of the city. vow, is a gift and a task that more than two centuries and This would have allowed a re- places you at the heart of the had produced a history charac- newal of the prestige of the Or- life and the mission of the terised by good and bad as- der in Lima. The idea won the Church, which is a sacrament, a pects. Always faithful to the approval of the ecclesiastical

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authorities and the dispatch in providing assistance in the Ital- Lastly, there were also affini- 1902 of six brothers of the Or- ian hospital and in a prison. ties with the holy Bishop of der from Europe made this ini- From the records of baptisms Geneva. In both there was the tiative practicable. his presence is also borne wit- conviction that the effective- The request to have Camil- ness to in the Dos de Mayo ness of the grace of God, trans- lians as spiritual assistants in hospital. mitted through the sacrament of the hospitals did not have to This ministry in health care reconciliation and spiritual ac- wait long Ð the military hospital institutions was joined by visits companying, depended, albeit in 1901; the French and Italian to private homes. From the reg- in a non-decisive way, on the hospitals in 1902; in 1903 the ister of visits for the years human qualities of the confes- Dos de Mayo with 600 beds; in 1908-1914, it is clear that he sor or spiritual director. Accep- 1905 S. Anna with 500 beds; met 1,192 sick people in pri- tance, respect, understanding and in 1904 the ‘Refugio degli vate homes. At times he even and compassion, in fact, be- Incurabili’ with 200 beds. From visited eleven sick people a day come transformed into a vehi- the ‘Casa della Buenamuerte’, in different parts of the city. cle of the compassionate love Camillian charity reached the He did not hesitate to go into of the Lord, making that love principal places of pain in order the so-called callejones, which more believable in the eyes of to bring relief to them and guar- were the common habitat for the penitent. antee spiritual accompanying. most of the population. These Assistance in the hospitals were blocks of habitations In the Local Church was accompanied by assistance around a shared corridor at the in private homes. San Camillo end of which there was a single At the level of the local called this sphere of the min- source of water and a single Church as well, the action of 52 istry the mare magnum, the vast lavatory for all the families Luigi Tezza was of notable pro- field of action. In Europe the who lived there. Very often, in portions. The prestige acquired Camillians were called the ‘fa- these places afflicted by pover- with the ecclesiastical authori- thers of dying well’. The name ty, there abounded alcoholism, ties is borne witness to by the given to the home in Lima Ð ignorance, promiscuity, and series of important appoint- ‘the convent of the good death’ fights. The sizeable donations ments he received: member of Ð emphasised the importance he received from his penitents the Council of Administration given to providing assistance to usually ended up by being giv- of the diocese in 1902; Consul- the dying, above all in their en to these abandoned families, tor of the Provincial Council of homes. This was apostolic becoming food, clothes and Lima in 1909; member of the work which was very demand- medicines. Council of Vigilance of the dio- ing given the limited number of cese in 1910; and lastly, Theo- religious available. The parish Spiritual Director logical Consultor of the Bish- priests themselves willingly left ops’ Assembly in 1919, when this ministry to the Camillians, He flanked assistance to sick he was about to reach the age of and for this reason the calls on people with an intense activity eighty. their services were large in of accompanying people number and indeed came from through the sacrament of recon- Crossing the Bar ‘the four corners of the city’. ciliation and spiritual direction. Luigi Tezza did not confine Side by side with confessions The itinerary of the life of himself to strengthening spiritu- in the church of the convent Luigi Tezza finished on 26 Sep- al assistance to the sick people and in the hospitals, which oc- tember 1923. He breathed his of the city by promoting an in- cupied him for many hours, he last in a gentle manner after a telligent and effective project discharged the task of confes- long illness. that involved many health care sor in many female religious in- The death of Luigi Tezza had institutions and an innumerable stitutes and colleges. Archbish- a resonance throughout the city quantity of homes to be reached. op Msgr. Tovar made him spiri- of Lima. Even though he lived He was also directly concerned tual father of the candidates to in the isolation of infirmity, the with service to the sick and the priesthood at the ‘Conciliar number of people attending his showed that he was at home in di S. Toribio’ seminary. funeral was above all expecta- this kind of apostolate, even Many religious and members tions. Religious and civil au- though it was not the ministry of the laity looked to him for thorities were present, as well which he most practiced. spiritual direction. He was as representatives of all the reli- For 1901 we already have helped in the carrying out of gious institutes. evidence of his ministry in an this ministry both by his per- The passing away of Luigi emergency hospital in the city sonal qualities and his training Tezza was an opportunity to which took in smallpox and at the level of doctrine. His give public expression to ac- yellow fever victims. He went sweet and affable character, knowledgement of his person there every day and put into linked to the soundness of his and of the holiness of his life. practice the fourth vow by principles and the prudence of One of the most recurrent which he was committed to his advice, earned him the es- phrases to emerge was one serving sick people even when teem and the trust of people. which proclaimed that he was this endangered his life. His For many witnesses at the the ‘apostle of Lima’. Those charity transformed that aban- process of Lima, the figure and who had known him best, as a doned place into a ‘hidden gar- the way of interacting of Luigi counsellor or spiritual director, den’ where he could find relief. Tezza were like those of San did not hesitate to exalt his ho- Later on he was active in Francesco di Sales. liness. The belief that Tezza

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had reached the perfection of managed to unify his life thanks bear fruit. This is a recurrent charity gradually spread in pub- to a golden thread of rich spiri- theme of his letters. A theme lic opinion as well, and this was tuality. learnt when he was young and something which was to resist which always remained keen- the passage of time. Only for the Crucified Christ ly-felt in his conscience. Suffering not only unites a On a Journey The background against person to Jesus but also be- After Death as well which should be depicted the comes a source of approaches whole of his spiritual life was of compassion, understanding The mortal remains of Luigi abandonment to the Lord and and participation in the suffer- Tezza were transported from to his will. Against such a back- ing of other people, transform- the cemetery of Lima to that of ground emerges the Cross, by ing the person into a Good Buenos Aires, to the chapel of which Christ implemented the Samaritan. From this point of the community of the Daugh- plan of salvation wanted by the view, the wounded person be- ters of San Camillo of that city. Father. The Cross occupied an comes also a healer. The convoy which left the capi- important area of space in the In Luigi Tezza, as well, were tal city of Peru reached Buenos spiritual life of Luigi Tezza, as there to be found the fruits of a Aires on 24 January 1947, and it had done in the spiritual life successful integration of his was received with civil and of San Camillo. The founder of suffering, and thus he can right- military honours. the Camillian Order established ly be defined as being a wound- On 15 December 1999 the the fundamental objective of its ed healer, that is to say a person coffin was moved again, from existence in wanting to live able to transform the personal Buenos Aires to Grottaferrata ‘only for the crucified Christ’. experience of pain into a source (Rome), to the General House What links the human person of healing for other people. And 53 of the Daughters of San Camil- to the cross is suffering in all its this integration of his own lo, where the mortal remains of multiple expressions. In the ex- wounds should be seen as one the Blessed Giuseppina already perience of pain, Luigi Tezza of the important factors which lay. saw one of the leading roads by helps us to explain his sensitivi- This nearness was an evoca- which to unite himself to Christ ty towards suffering people. tive symbol of that love which and imitate him in his love.7 was both humanly rich and In this as well he placed him- A ‘Heart’Burning with Love spiritually deep and which unit- self in the tradition of his ed these two people in the im- founder. Contact with Francis- In uniting himself to the cru- plementation of a shared pro- canism had indicated to Camil- cified Christ, Tezza encoun- ject: service to suffering man, lo the road of adaptation to tered the source of love, sym- the icon of Christ. Christ through a life of peni- bolised by the image of the tence, as a result of which heart. The devotion to the heart The Golden Thread: forms of personal suffering Ð of Jesus, which became strong- Spirituality not only those involved in the ly felt and practiced during the death of oneself but also those nineteenth century, thus be- The life of the Blessed Tezza of a physical kind Ð constitute came an important element in was eventful and marked by an effective means by which to the experience and expression dramatic vicissitudes. In Verona imitate the suffering Jesus. of his spirituality. (1866), Rome (1870), and Camillo would never abandon He immediately realised that France (1880), he experienced this pathway. Indeed, he went this devotion found a positive the dramatic moments of the ever more deeply into it. resonance in his spirit. Indeed, suppression of the religious In- Following the example of the well anchored in solid theologi- stitutes. Later on, in Rome, un- founder, Luigi Tezza constantly cal bases, it also appealed to the just accusations separated him linked the negative aspects of dimension of emotions which from the Daughters of San his life to the cross Ð mourning, was so well developed in his Camillo. Furthermore, the work moments of depression, con- personality. activity engaged in was so in- flicts both outside and inside The Heart of Jesus became tense as to generate dispersion. the community Ð in the belief the place where he wanted to Amidst this whirlwind of ex- that united to the suffering of live and to grow, finding refuge periences and work Luigi Tezza Christ they would not fail to and consolation at moments of

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difficulty, and where there took prayer and fostered by a is to be found the most valuable place the encounter with other healthy ascesis, led Luigi Tezza aspect of his spiritual legacy. people and in particular his to turn towards his neighbour If because of his life choice, daughters. His love for them, with generous love. The min- Tezza speaks in particular to indeed, ‘has as its sole source’ istry accomplished by him was consecrated people, his mes- the Heart of Jesus, and ‘its only thus to be seen as a meaningful sage nonetheless is equally ef- nourishment in his inex- expression of his spirituality. fective for all Christians and haustible love’.8 In serving the sick, in spiritu- men of good will, especially in Although there are many ally accompanying the brothers relation to those of them who ways which allow us to enter of his Order and the people are involved in the world of the heart of Jesus, that favoured who turned to him, he achieved suffering and health. by Tezza was the Eucharist. an experience made up of God. From his life witness, in fact, Through this sacrament the In this he found a high mentor come simple and deep mes- riches of the love of God are in San Camillo, for whom ser- sages which find positive transmitted to the human crea- vice given to the sick was trans- echoes in the heart and the spir- ture, and transform that crea- formed into an act of worship it of those who in live in con- ture. of God. In the vision of faith of tact with suffering and work in this saint, the sick person be- favour of the promotion of Supernatural Love came a sacrament of the pres- health. ence of Christ. In him, Camillo These are invitations to keep Devotion to the Heart of Je- saw the wounds of his crucified one’s humanity alive and sus enabled Tezza to develop, Lord reopened and causing warm, to love life and to re- albeit in a fragmentary way, a pain. spect the human person who is 54 rich spirituality of interpersonal This mystical dimension of made fragile by illness, to find relationships and friendships, service to the sick made Tezza in the generous giving of one- something that linked him to a contemplative in action. self the reward for one’s own the great figures of saints of the action. past, amongst whom Francesco ‘Point out Holiness’ To become aware that there de Sales. ‘In the adorable heart is only one answer to the love of the Divine Master’, he wrote At the beginning of the third of God: love. to his Daughters, ‘may there be millennium, the invitation of our constant gathering place John Paul II to plan the pres- Rev. ANGELO BRUSCO, M.I. where now we can taste before- ence and action of the Church Centro Camilliano di Formazione, hand a very sweet taste of the in the world ‘in relation to holi- Verona. love which beatifies and where ness’11 comes forth as coura- I am and I will be for ever’.9 geous and forceful. Luigi Tezza perceived that An ideal of perfection to when lived in the Heart of Je- which all of us are called, holi- sus, interpersonal relationships ness does not involve an excep- and friendship are infused with tional style of life but the abili- supernatural love or agape, ty to live out one’s own ordi- which does not destroy emo- nary life by placing intensely tional reality but purifies it and within it the gospel values of Notes makes it sublime. justice, peace, reconciliation, Seen in this light, the quali- and love. 1 APL, 280/274 2 Cf. M. VANTI, Cento anni dei ties which characterised Tezza Together with other blessed CC.RR. Ministri degli Infermi nell’Ar- in his interpersonal relation- figures and saints, Luigi Tezza, ciospedale del SS. Salvatore a S. Gio- ships acquire a totally special by his life and his witness, of- vanni in Laterano, 1836-1936 (Rome, 1936). significance. The exhortation of fers a ‘high standard of ordi- 3 E. SAPORI, ‘L’opera “Practica visi- Christ: ‘Learn from me for I am nary Christian living’.12 Herein tandi infirmos” del Padre Mancini Gia- meek and humble of heart’ was como M:I Ð Una proposta di pastorale sanitaria nell’Italia del seicento’, in the transforming force of his Camillianum 22 (2000), p. 311. character and his way of living 4 Cf. C. PETRETTO, ‘Il femminile del his relationships with other carisma camilliano’, in La vita con- sacrata nel mondo della salute, gesto e people. annuncio del vangelo della misericordia Brotherhood, as experienced (Quaderni del “Camillianum”, n. 4, by the sisters in their communi- Rome, 1992). ties, must also drink at the 5 Gli insegnamenti di Giovanni Paolo II, Vol. XLII, 1 (1990), 1991, p. 815. spring of love of Christ: ‘Be a 6 R. PESCE, ‘Le Figlie di San Camil- single heart and a single soul in lo’, in A. BRUSCO and F. ALVAREZ, La the Most Sacred Heart of Jesus. spiritualità camilliana, itinerari e prospettive (Camilliane, Turin, 2001), p. In this union you will always 422. find in abundance consolation, 7 Cf. G. TERENGHI, La croce di Cristo strength, and courage’.10 nell’experienza spirituale di San Camil- lo de Lellis (Camillianum, Rome, 1996). 8 AFSC, 1A 087. A Contemplative in Action 9 AFSC, 1A 082. 10 AFSC, 1A 064. 11 Novo millennio ineunte, Apostolic Union with the Lord, mediat- Letter at the Close of the Great Jubilee of ed through a deep devotion to the Year 2000, n. 30. the Virgin, achieved through 12 Ibid., n. 31.

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Pastoral Care in Health

By ‘pastoral care in health’ structure involving forms of we mean the evangelising ac- social development). tion of the whole of the people The home is the family unit of God, committed to promot- in which the people of ing, taking care of, defending Nicaragua organise themselves and celebrating life, thereby in order to meet their moral, making the liberating and spiritual and material needs. salvific mission of Jesus Christ 31% of the heads of families present amongst us. are women and it is they who In order to carry out this take the main decisions regard- mission, in the Archdiocese of ing the home. The average Managua there are two com- family size is 5.5. mittees which work in a specif- Not all homes have hygienic ic way in the field of health and and sanitary services. 64% health care. The first is the have access to drinking water Archdiocesan Committee for through the public system but 55 Social Promotion (COPESA), about a quarter of dwelling which has health programmes, places do not possess accept- programmes for community able sewage systems. operators, for midwives and In recent years, the mortality obstetricians, for medical care, rate of children under the age of the population of the coun- for the donation of drugs and of five has diminished by 60%. try, find themselves below the medicines, and the provision of Despite this fact, in the rural ar- threshold of poverty. aid to people who have fallen eas 32% of children born alive Public policies implemented victim to natural disasters etc. die because of infectious-con- during the 1990s had as their The second is the Commit- tagious diseases. Prenatal and objective a reduction in public tee for Pastoral Care of the birth care is provided by pro- expenditure in order to dimin- Sick and in Hospitals, which fessional staff and personnel ish the budget deficit. In these has a pastoral programme for only in 60% of the cases of ex- conditions, the participation of the years 2001-2003. pectant women. social organisations in the so- In the first part of this paper The most common illnesses cial field gave priority above we will dwell upon the work to afflict children are acute res- all else to basic education in carried out by the Committee piratory infections, diarrhea, various formal and informal for Social Promotion from malnutrition, and skin infec- expressions, the control of dis- 1996 to 2001. In the second tions. These illnesses are one of eases, preventive health, and part we will describe the pas- the priorities of the Ministry of nutrition. The goal of the social toral programme for 2001-2003 Health. infrastructure dealing with of the Committee for Pastoral The average level of illitera- housing, water, improvement Care of the Sick and in Hospi- cy in that part of the population of the marginal urban and rural tals. which is over ten years of age areas, and the network of social is 24.6% and this figure reach- protection, has been to reduce es 24.8% in the rural popula- human poverty and to provide I. REPORT ON THE tion, and this is a factor strong- temporary assistance centred WORK CARRIED OUT ly associated with the principal around extreme poverty. IN 1996-2001 causes of illness and death. The Archdiocesan Commit- Illiteracy or inadequate edu- tee of Social Promotion has as General Aspects cation are factors which affect its purpose the promotion of the levels of mortality and ill- social work and kindred initia- Nicaragua is located in Cen- ness at a general level. This is tives within the archdiocese of tral America. Its population is because they bear upon the per- Managua in order to strengthen estimated to be made up ception of illness, the effective- self-help and to fight against 4,806,700 inhabitants and is ness of measures of treatment, poverty. for the most part made up of early recognition of complica- Amongst the specific objec- children (45% of the popula- tions, the understanding of in- tives of this committee we may tion is under the age of fif- structions, and the ability to list the following: teen). read instructions and sugges- Ð to improve the standard of 59% of the national territory tions. life of those sectors which are consists principally of urban According to the indices of most in need; settlements (localities which poverty, 48% of the population Ð to promote and organise have over a thousand inhabi- of Nicaragua are poor and a communities so that they are tants and some kind of infra- part of these, equivalent to 17% able to take part in a responsi-

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ble way in their own growth Ministry of Health, and by duced in the communities and development; working directly in activity in- where they live. Ð to train leaders for the volving the promotion of largest possible number of health, the control of diseases Medical Care and the communities; transmitted by vectors, and pri- Donation of Drugs and Ð to promote health through mary health care. Medicines to Parish Clinics the training of community op- Some of these community erators and nurses, the provi- operators, thanks to the work Medical care is provided by sion of medical care, and the that they carry out voluntarily, fifty-six parish clinics, most of giving of drugs and medicines have been able to increase their which are administered by to parish clinics and clinics in own personal growth and priests, members of female re- rural areas; thereby have contributed yet ligious orders, parish commit- Ð to promote the socio-eco- further to the good of the com- tees or church movements. nomic development of poor munity. Each of these clinics has labo- communities through social ratory services, dentistry, med- projects designed to benefit The Training of Midwives ical care, and specialised treat- majorities and implemented and Obstetricians ment. All activity in these under the guidance of commu- spheres is carried out by med- nity-based organisations. In the rural areas midwives ical doctors who work volun- and obstetricians help in 65% tarily or for payments made to The Health Programme of births and thus constitute an them by some of the patients. important group in the field of These payments amount to one This programme revolves health and health care because American dollar. 56 around three principal axes of women in the fertile age turn to Medical care is provided, activity: training, medical care, them for prenatal care, help drugs and medicines are sup- and the donation of drugs and during childbirth, and the treat- plied, educational conversa- medicines. ment of their newly-born chil- tions are held, and food com- dren. 80% of these midwives or plements are distributed to peo- The Training of Community obstetricians are over sixty-five ple suffering from malnutrition, Operators years of age and practice natur- to elderly people, and princi- al medicine. pally to children. After an analysis of the so- Given their importance with- In some cases, programmes cial situation of our country, in the community, three groups involving clinical support are training emerged as a priority have been formed in the differ- implemented for people afflict- activity of the programme. It is ent departments of the archdio- ed by chronic illnesses such as directed towards the inhabi- cese - Managua, Masaya, and asthma, arthritis, arterial hyper- tants of the rural and semi-rural Carazo. They deal with the tension, and diabetes. In these communities of the archdio- provision of materials which educational programmes peo- cese. In recent years 3,500 are periodically substituted to ple are divided according to the health care workers have been help during childbirth, provide illnesses involved, and they re- trained and these people have lessons on the growth and de- ceive basic information about followed lessons on preventive velopment of the embryo, nor- their afflictions and about how health, infectious-contagious mal pregnancy, illnesses dur- to live with and avoid compli- illnesses, how to prevent them ing pregnancy and signs of cations. and provide first aid before risk, care during childbirth and These programmes include people seek help from a health care for the newly-born child, educational material, conversa- care centre, vaccinations, the promotion of maternal tions, alternative forms of nu- health and the environment, breastfeeding alone, the impor- trition, medical consultation, primary forms of treatment, tance of vaccination, and drugs and medicines, and labo- natural methods for responsible changing attitudes and customs ratory tests. fatherhood, care for children, which endangers the health of and nutrition (alternative forms the mother and the child. In- The Donation of Drugs of diet and food supply). dices of reference have been and Medicines These lessons have been giv- established with the health en by the medical staff and per- units, they have taken part in We receive drugs and medi- sonnel of COPROSA, of the analyses of the deaths of moth- cines from Americares, an Ministry of Health, and of the ers and of children in the field American non-profit making Red Cross of Nicaragua. of health care they are con- foundation whose principal ac- In order to obtain the certifi- cerned with, and they have also tivity involves the donation of cate of being a community op- participated in initiatives di- drugs and medicines to a hun- erator it is necessary to follow a rected at prevention. dred and thirty countries in the course of 165 hours, at the end Visits are organised with world. In addition to drugs and of which there are written ex- midwives and obstetricians to medicines, this organisation al- ams and practical tests at the the homes of women who have so supplies us with material nearest health units. pregnancies at risk and who do which has to be substituted pe- This initiative has been a not want to take advantage of riodically and food supple- success because this group of the health service. In this way, ments. people offer their work in pre- the mortality rates of mothers We also receive help from vention days organised by the and children have been re- Action Medeor, a German or-

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ganisation that gives drugs and sations (Caritas) have been suffering. In this encounter medicines and materials which asked to supply help to build man becomes the way of the have to be substituted periodi- decent homes, for reafforesta- Church, and this is one of the cally. This was done, for exam- tion, for medical care, for edu- most important ways’ (Salvifici ple, at the time of the hurricane cation in relation to the envi- Doloris, 3). The man who suf- Mitch and the Masaya earth- ronment, and for courses of fers is the way of the Church quake of July 2000. technical training (sewing, because above all else he is the beauty care, carpentry). way of Christ himself, the The Aid and Help Provided The mechanism employed to Good Samaritan, who ‘did not by COPROSA to the Victims build such homes has been the pass by’ but had compassion of Natural Disasters participation of the local com- and ‘drawing near saw his munity in the form of manual wounds’ (Lk 10:32-39) and In the middle of 1998 CO- labour. took care of him. PROSA organised discussion At a national level, CO- It is a matter of urgency and laboratories in the parishes PROSA has provided help necessity that the inheritance along the shores of Lake Man- through the provision of drugs that the Church has received agua. The subjects addressed and medicines, clothes and from Christ, ‘physician of the were civil defence and organi- food supplies to the principal body and the spirit’, is increas- sation in cases of natural disas- departments hit by natural dis- ingly appreciated and enriched ter, among others. As a result, asters: Chinandega, Matagalpa, through a return to, and the when the hurricane Mitch Leon, Esteli, Boaco, Chontales, implementation of, decisive struck the country the local Jinotega and the Atlantic coast. diocesan pastoral action for population was able to co-ordi- and with sick people and those nate the evacuation and thereby who suffer, both when they are 57 avoid the loss of human life. in hospitals and when they are At the archdiocesan level, in their beds at home, through the places struck were the pastoral care for people who coasts of Managua, Mateare, are sick at a parish level. Tipitapa, and San Francisco del In this renewed pastoral ac- Carnicero, Asentamiento Hu- tion one of the fundamental ob- mano Nueva Vida implement- jectives is ‘to look upon the ed its overall programmes of sick person, the bearer of a sustainable human growth and handicap, or the suffering indi- development. vidual, not simply as an object Medical care and drugs and of the Church’s love and ser- medicines were directly pro- vice, but as an active and re- vided to the people who had sponsible participant in the been afflicted by the disaster work of evangelisation and sal- and this took place during the vation’(CL, 54). six months that followed the To be a diocesan Church, in hurricane. Amongst these peo- addition to being a gift of God, ple were found individuals af- is also a beautiful task to per- flicted by illnesses such as mal- form. For this reason, our adies of the respiratory tract, II. THE PASTORAL Church must be a constant ser- diarrhoea, skin diseases (fungi, PLAN FOR 2001-2003 vant of the Kingdom of God, impetigo), nervous disorders proclaiming that Kingdom and etc. Food, drugs and medicines, Introduction making it present in our reality, and clothes were distributed to responding to what is most ur- 3,340 families. Man is called to joy, but he gent, suitable and effective at Courses of preventive medi- has a daily experience of very any given moment as a salvific cine were given, during which many forms of suffering and response of God to harsh reali- subjects were dealt with such pain. The Church shares in the ty, in favour of men and as the prevention of transmissi- suffering of her sick brothers women loved by Him, and es- ble diseases, how to deal with and sisters, and invites her chil- pecially those who suffer in the garbage, education as regards dren to join their illness to the body and the spirit. the environment, reafforesta- redemptive passion of Christ. The Church proclaims and tion, sexually transmitted dis- The Church counts on you to offers salvation through preach- eases, and education in natural teach the whole world what ing and sacramental life, but al- methods of family planning. love is. ‘We will do everything so through the invisible effec- Groups of community work- we can so that you may find tiveness of her pain. For this ers were organised in each of your rightful place in the reason, as mother and teacher, the localities which had been Church and in society’ (Christi- she is not extraneous to the suf- struck, and at the present time fideles Laici, 53). fering of her children: ‘the joys these act with the nearest health The Church, which ‘was and the hopes, the sadness and units in matters relating to vac- born from the mystery of the the worries of men are also the cinations, hygiene, and the redemption on the cross of joys and the hopes, the sadness transfer of sick patients to Christ, is called to search for and the worries of the Church’ health centres. her encounter with man in a (Gaudium et Spes, 1.). Various international organi- particular way on the way of Pastoral care for sick people

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and pastoral care carried out in tals, in lunatic asylums, and in their situation as sharing in the hospitals is one of the forms leper colonies. suffering of Christ, in commu- taken by the presence of the Parishes, the places of en- nion with all those who suffer Church in her preferential op- counter where Christians live for a variety of causes. tion in favour of the poor. His out their communion and over- Ð The establishment of a cal- Holiness John Paul II has said come the limitations of their endar of visits to sick people by that hospitals are privileged small communities, and where sectors in which are set down places to know and love Jesus through the Eucharist the prac- the hour and the day of these in the pain and the meekness of tice of the simple charity of visits. every person. good and brotherly works with Ð The organisation of ‘mis- In our archdiocesan synod feelings and in daily life is sionary pastoral care for sick pastoral care for the sick and in taught, are called to bear wit- people’ in relation to sick peo- hospitals has as its general ob- ness to love for sick people. ple and the entrusting to them jective: For this reason, pastoral care of specific tasks of intercession Ð to evangelise the hospital for the sick at a parish level has through prayer in ordinary or world of the archdiocese in the as its general objective: extraordinary activities carried light of the Gospel, co-operat- Ð to support in an emotional out in parishes or through the ing in the formation of con- and effective sense members of various functions of the life of sciences in the experience of the laity in parishes to live out the Church. faith and human promotion Christian solidarity with those Ð The organisation of pas- with a view to forming Christ- people who experience particu- toral care involving comfort ian communities. lar situations of suffering and and consolation which can The specific objectives of especially the sick. reach all the members of the 58 this pastoral care are: The specific objective is: parish who experience situa- Ð to proclaim the message of Ð to promote programmes il- tions of suffering: invalids, the Gospel in hospitals and to luminated by the Magisterium abandoned elderly people, and the sick people in them, placing of the social teaching of the families worried about the ill- emphasis on the love of God Church in order to sensitise and ness or the death of a loved for sick people; educate members of the active one. Ð to foster and co-ordinate laity and other groups of the visits to sick people in hospitals parishes in relation to an c) The Training at the parish and archdiocesan awareness of the need for sup- of Pastoral Teams levels; port and solidarity towards sick Composed of Sick People people admitted to hospitals. Ð The training of active members of the laity both at the Practical Lines of Action parish level and at the level of the different areas; the organi- a)The Promotion sation of meetings of these pas- and Consolidation toral parish teams through of Pastoral Care training in catechesis, the study for the Sick in Parishes of Church documents, the or- Ð the organisation of teams ganisation of pastoral care, hu- who will visit all the sick peo- manitarian initiatives, retreats, ple in the local parish. To this and assemblies. end, pastoral care for sick peo- Ð The training of extraordi- ple in the parishes will encour- nary ministers of the Eucharist, age and promote teams of pas- catechism, and the celebration toral care for the various dis- of the word directed in particu- tricts into which our archdio- lar towards sick people. cese is organised; Ð The accompanying of the Ð the drawing up of a map by sick in their loneliness so that areas and sectors of homes they feel the peace, the comfort which have sick people so that and the love of God through Ð to reach the heart of sick they can be easily identified by the emotional and charitable people both in parishes and in the local priest, by pastoral solidarity provided by the hospitals through the Eucharist, workers, and by ministers of parish community. the centre of our faith and ac- the Eucharist. Ð The promotion and foster- tions in the life of every sick ing of the participation of the person. b)The Planning of a Strategy laity in the hospital pastoral of Care for the Sick care of the archdiocese (organ- The Work Plan for Ð The classification of sick ised by areas). Pastoral Care of the Sick people on the basis of their ill- and in Hospitals nesses and their basic needs. Specific Tasks Ð The promotion of the at the Parish Level Hospital pastoral care must Catholic faith and conversion Ð The co-ordination of activ- be animated by suitable people through the word of God so ity with other pastoral min- who have the vocation and the that through prayer and the istries: the parish clinic, minis- due grounding and training to sacraments sick people can im- ters of the Eucharist, pastoral provide these services in hospi- prove their health or accept care for families, youth com-

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munities, and social pastoral Today in our hospitals there are dar of visits to hospitals, by care. large numbers of the lay faith- area, establishing the day and Ð The maintenance of con- ful, men and women, who the hour of each visit so that tacts with the parish priest for make Jesus, the Good Samari- priests and members of the the administration of the sacra- tan, be present in the sick and laity can dedicate time to meet- ment of reconciliation, the those who suffer, revealing and ing sick people. anointing of the sick, the Eu- communicating the love of care Ð The organisation of pas- charist for those who ask for it and comfort of Jesus Christ. toral care for the sick and in and those who need it. hospitals by small groups of Ð The evangelisation in addi- The General Objective members of the laity who have tion to the sick person of his or the specific task of interceding her family so that they, too, feel To bring the Gospel into the with prayer for all the sick peo- the special presence and various hospitals of our arch- ple of the hospitals and the strength of God in the most dif- diocese so that in the light of parishes. ficult situations of life and the Gospel is expressed the death. love of Christ and the Church c) The Training of Teams Ð The co-ordination of vari- for sick people, as well as of Members of the Laity ous activities with sick people: Christian solidarity towards all to Visit Hospitals the celebration of the world day those men and women who Ð Accompanying the minis- of the sick of 11 February, the suffer in body and in spirit. ters of the Eucharist through celebration of the Eucharist permanent training on the role with sick people in the parish- Specific Objectives that they play in their work es, and various celebrations with sick people when bringing that are directed towards pas- Ð To proclaim in hospitals them the Eucharist. 59 toral care for sick people. the message of the love and Ð The training of members of Ð The acquisition of basic hope of Jesus to those who suf- the laity who visit sick people knowledge about illnesses and fer. through meetings organised diseases so as to be able to take Ð To foster and co-ordinate along the lines of the pastoral the necessary precautions in re- pastoral work together with areas so that they play a pre- lation to our sick brethren with- priests and active members of ponderant role in the lives of out falling into a condition of the laity. sick people. apathy or indifference. Ð Working with the medical Ð To help sick people, where Practical Lines of Action and hospital staff through con- this is possible: the creation in ferences, retreats, seminars, parishes of a specific day for a)The promotion of sermons, and the Eucharist. the celebration of the Eu- Pastoral Care for Sick charist, and a day of charity for People in Hospitals Specific Tasks sick people so as to help them Ð The organisation of reli- Ð The co-ordination of pas- in relation to any basic needs gious activities within hospi- toral activity to the benefit of that they may have. tals: weekly visits, care for the sick people with other min- sick person through confession, istries of the diocese: the apos- Pastoral Care in Hospitals the anointing of the sick, and tolate of the sick, the ministries the celebration of the Eucharist of preaching, the pastoral care The Church has good news in every hospital. of families, pastoral care for to ring out within the world of Ð The organisation of small young people, and social pas- hospitals, which are ‘places of teams of lay people to visit sick toral care. suffering’, above all in a hedo- people in hospitals together Ð To provide assiduous assis- nistic society which has lost the with priests, to encourage tance to sick people through the meaning of human suffering them, and to be near to them. administration of the sacrament and censures all talk about this Ð The involvement of the lay of reconciliation, the Eucharist, hard reality of life. ‘The procla- faithful of the parishes near to and the anointing of the sick for mation of this good news gains hospitals as a part of the com- those who need this last sacra- credibility when it is not simply mitment with the Lord to the ment. voiced in words, but passes in- apostolate for the sick of their Ð The acquisition of basic to a testimony of life, both in parishes. knowledge about illnesses so the case of all those who lov- that the necessary precautions ingly care for the sick, the b)The Planning of a Strategy can be taken during visits to handicapped and the suffering, of Care for the Sick sick people in hospitals. as well as the suffering them- Ð The promotion of the faith Ð The provision of help to selves who are increasingly of the Church and the conver- sick people or hospitals in rela- made more conscious and re- sion of sick people through the tion to basic needs such as py- sponsible of their place and proclaiming of the word of jamas, drugs and medicines, task within and on behalf of the God so that with prayer and the food, etc. Church’ (CL, 54). sacraments they can improve We urgently need well-or- their state of health or find the The Archdiocese of Managua, ganised pastoral care in hospi- strength to know how to accept Nicaragua. tals. This has already begun to suffering as a moment of en- bear fruit in the lives of those counter with the Lord. who work in such institutions. Ð The drawing up of a calen-

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The World Day of the Sick ‘Praying in Illness’, 11 February 2002: Guidelines for Pastoral Care in Health - Spain

Why Have We Chosen ties as well. This is a time lived variety of factors. The world of this Subject? out in another way. At times, a health and health care and ill- time of grace, of encounter with ness is a good case study of 1. Illness is one of the ‘funda- one’s own truth and that truth of these influences. For many peo- mental events of existence (Do- He in whom we live, we move ple, prayer has stopped being lentium Hominum, 2), a com- and we exist. ‘interesting’ because it is no plex experience that is in con- 5. God did not want to aban- longer ‘useful’; for others, trast with the wish to live, that don man in the face of suffer- prayer continues to be a private demonstrates human fragility ing and illness. Holy Scripture and very personal question. and caducity, that leads those tells us about great people of Prayer should be evangelised who experience it into a world prayer who during their lives and purified so that it accompa- full of questions, a world which experienced moving through nies, stimulates and opens up is different and foreign. ‘deserts’. In Jesus, our pain be- paths for the thirst for God, for 60 2. All of us can fall ill. For comes attentuated and our the strong wish for fullness and this reason, we must be aware hopelessness becomes trans- salvation which lives, at times of this reality and live with the formed into the Good News. unknown, in the hearts of many prospect of illness in mind, The glorious cross of Jesus people. knowing that illness invokes Christ marked the victory of freedom and meaning, that it God over pain, over illness, and can be experienced as an oppor- over death. tunity and a challenge or as 6. The history of salvation negativity, and that it can also and of Christian spirituality, be ignored or denied, as though yesterday and today, presents us it never knocked at out door. with men and women who, in 3. In experiencing illness, in the realism of their lives, have the same way, it is possible that become aware of their own be- the person discovers in a more ing, allowing God to be the radical way his or her own root- God of their lives. In hidden ed loneliness and limitations, teaching, in the experiences of the specific condition of being adversity, God revealed his face unique and irrepeatable, and and his plan of salvation to thus the challenge of our re- them. They did not ask to be sponsibility towards illness. In saved from suffering and ill- this situation, which often im- ness, but to be saved in them, 9. Praying today in the world plies a break with ordinary life thereby finding grace in misfor- of illness has a particular im- and a certain uprooting, ques- tune. portance within the evangelis- tions of every kind are often 7. Praying in illness has been ing mission of the Church. Her asked: some of these involve a constant feature of the faith immense salvific, health-giving searching for reason; others ask proclaimed and celebrated by and therapeutic richness is ex- for an answer; yet others look the Church. It has always been pressed specifically in charity to the past; others, in contrary present at the moment of ill- and prayer, in witness and cele- fashion, look to the future. It is ness. Thus, a liturgical tradition bration. Sick people and their probably the case that in all of the Church at the margins of families, the professionals of these questions there is reflect- this existential situation is un- health care and voluntary work- ed the original and privileged thinkable, and around this situa- ers, pastoral agents and the condition of man: a being, that tion a whole spirituality has Christian community, are all is to say, who is open to tran- been developed and lived out called to discover once again Ð scendence, and at the same time with emphasis being placed on and despite everything Ð that who is woven into fragility, the various dimensions and the God of Life is a God who who is both poor and capable of forms of prayer. For many be- heals and saves, who leads man fullness. lievers this time has been, de- to his fullness, and that a time 4. A period of illness, spite everything, an opportunity of illness is also a time of salva- whether chronic or acute, of to renew weakened faith and tion. varying degrees of gravity, is a once again accept the ecclesial 10. The campaign of the time of worry, of shadows, and offer of salvation. World Day of the Sick should of hope, in which everything is 8. Praying in illness certainly be experienced, therefore, as subjected to trial. In living out raises new challenges of every an opportunity for grace to en- illness, man experiences his kind, but it is no accident that sure that pastoral care in limits and often new opportuni- prayer is influenced by a whole health renews the faith of all

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its members in the salvific and health care institutions. have an approach of faith, health-giving effectiveness of Ð Voluntary workers (both which is simple and responsible prayer, and at the same time men and women) and voluntary and never in conflict with rea- strengthens their capacity to work groups/associations. son: ‘Faith and reason are like accompany people in prayer Ð Health care staff and per- two wings on which the human during illness. sonnel in general. spirit rises to the contemplation Ð Faculties of theology and of truth’” Objectives Institutes of pastoral care. Ð The training centres for fu- The Mystery of Suffering and 1. To reflect, beginning with ture Christian professionals. Illness Must be Illuminated different perspectives, on the Ð Society in general. Taking Faith as a Point meaning, the value and the Ð Communities dedicated to of Departure questions and issues of prayer the contemplative life. in illness. In his first encyclical (Re- 2. To gather together and Activities at a National Level demptor Hominis), the Holy analyse the various experiences Father observed that Jesus of prayer in illness, seeing it in 1. To dedicate the central part Christ reveals to man what is the light of the great people of of the National Days of Pastoral specific to man, and that the prayer of the Bible and Christ- Care in Health (Madrid, Sep- whole of the life of Christ has a ian spirituality. tember 2001) to the subject pedagogic value for us because 3. To illuminate and moti- ‘prayer in health’, in line with it teaches us to address our- vate, in the Light of the Gospel, the principal contents of these selves to every situation taking of the liturgical practice of the ‘Guidelines’. the Gospel as our point of de- Church and of the experience of 2. To organise round table parture. 61 belief, the therapeutic and conferences or other kinds of A constant element in the life health-giving dimension of the initiatives (of the Church or of men and women of all ages life of prayer of the believer other institutions) within the has been and will continue to be and the Church. mass media where experts on the cross. Always present, sewn 4. To analyse and look again the subject will be present. into our earthly, finite and mor- at liturgical and sacramental 3. To publish a monographic tal existence. How should we pastoral activity in the world of edition on the subject in the face up to this reality? Where health and illness, paying spe- journal Labor Hospitalaria. should we learn to ‘deal with cial attention to its intrinsic di- the cross’? For those people mension of prayer. who are inserted into the Mys- 5. To offer those means suit- Praying in Illness tery of Christ and for all our able to fostering growth in the other brothers and sisters called life of the Spirit and to help and The Department of Pastoral one day to be so, the answer is to accompany other people to Care in Health has reflected on the Crucified One. The Cross of ‘pray in illness’. the subject of prayer in illness Jesus illuminates the mystery of with the diocesan delegates, the illness and the suffering of The Materials this subject being the central all men. of the Campaign theme of the World Day of the Sick in Spain. The deliberations Prayer: Embracing Ð Pamphlets and slogans re- were opened by the Bishop re- the Cross of Christ lating to ‘prayer in illness’. sponsible for pastoral care in Ð Prayers in printed form. health, H.E. Msgr. Rafael Pal- Trusting prayer is a privi- Ð The Message of the Bish- mento, with the following short leged means by which to nour- ops of the Episcopal Commis- speech: ish the faith that we profess. We sion for Pastoral Care. ‘“Why do we suffer? What pray to establish ties of union Ð Materials for education in do we suffer for? Does the fact with the Lord, an affective and the faith and subjects dealing that people suffer have a mean- effective union. Through prayer with training. ing?”, the Pope asked in 1979 we enter more deeply into the Ð A guide for the liturgy of during his visit to Mexico, next Mystery of Christ, he who the day. to the Virgin of Guadalupe. And through the Spirit of the Father Ð The book ‘Prayer in Ill- he answered in a loud voice: and the Son gives to us the gift ness’. “pain is a mystery, at times not of faith. Prayer draws us closer Ð The monographic edition penetrable by reason. It is a part to the three divine Persons: to of Labor Hospitalaria on the of the mystery of the human the Father, to the Son, and to subject. person, and it becomes clarified the Holy Spirit. Indeed, we only in Jesus Christ...” unite ourselves to God through Those for Whom In fact there are many ques- love, and this love helps us to such Materials are Intended tions, which on so many occa- align ourselves to the full with sions we direct to the Lord, to the mystery of Christ, and in Ð The sick. which we must offer answers. particular with the mystery of Ð The Christian community And clear answers, because the Cross. To pray, therefore, and teams working in pastoral pain is a mystery. It would means to embrace the cross. It care in health. cease to be such if we under- means to learn to take it on Ð Religious congregations. stood it and could explain it. In one’s shoulders and to walk Ð Health care and socio- the face of mystery we must with strength at the side of

DOLENTIUM HOMINUM N. 48-2001 gg

Christ, the path of Calvary, that Often there are men and pain, ‘I feel an immense joy’, is to say the hill of salvation, of women afflicted by different ill- wrote the Blessed Rafael, a the source of life. nesses who turn to the Messiah Trappist monk, ‘that I can suf- The Blessed Manuel Gonza- to find a remedy for their mal- fer for Jesus, of a kind I never lez, the Bishop of the Eucharist, adies. At other times intermedi- imagined’. without anything or anybody, aries act to ask the Master to prayed as follows during his heal a loved one. And we al- Praying in Illnesses moments of adversity and trial: ways find the Lord who comes of the Soul as well to meet our needs: moved, at Take up your Cross times, by a cry for help, and at In these moments as well we others looking ‘de officio’ for need support, the help of anoth- Take it up...it is pain, illness, those who need him. Jesus al- er person, and the healing that humiliating contempt, an omis- ways serves the sick person. St. has been asked for. ‘Could we sion, a slander, an absence, a Augustine assures us: ‘the heal ourselves’, asks St. Augus- bad interpretation of my inten- Lord, too, serves his sick ser- tine. And he answers: ‘We are tions, an example of ingrati- vants so that he can have ser- capable of wounding ourselves, tude. vants who serve him; he serves but who of us is able to heal the Jesus, my nature has been sick people until they are wounds that have been inflict- shaken; but your presence in healed. Our Lord serves the ed?...Nobody can heal merely me and the certainty that you sick’ (Sermon 265 F, 1). by wanting to do so. Let your will not burden me with more In the Gospel according to soul be pious, be faithfully than you have decided give me St. Matthew (15:21-28), we Christian, and do not be un- courage in order to answer in find a paradigm for beseeching grateful with grace. Acknowl- 62 peace: I will accept it. prayer in illness. A Chanaanite edge the physician. The sick In the hours of this day which woman drew near to Jesus to person can never cure himself’ are lengthened by the cross, ask him to act on behalf of her (Sermon, 170, 7). when my lips open up to utter a sick daughter. Hers was a fine Praying for and helping the cry of lament, a protest, I will lesson. She insisted without be- healthy and the sick, for believ- remember the voice which says coming discouraged. And the ers who want to be consistent to me: take it up, and from the Lord, who appeared not to have and coherent, is the firm sup- hands that will offer it to me; listened, acted. Here we are port upon which the objectives and peace, and at times joy, will taught, and such is the com- of pastoral care in health rest, go on being the companions of mentary of St. Augustine, ‘to and these objectives have re- my cross. move upwards beginning with cently been formulated in the Heart of my Jesus, I want to humility... She cried out with following terms: receive your crosses with joy anxiety to obtain a beneficial Ð to illuminate the mystery of and peace, because I know that action, and called with force; he illness and suffering taking they are made to measure by dissimulated, not to deny mer- faith as a point of departure; the good hands of God my Fa- cy, but to stimulate the wish, Ð to evangelise the world of ther. and not only to increase the the culture of health and health Say to my soul: I am health1 wish, but to recommend humil- care; ity. She cried, therefore to the Ð to accompany the sick; Lord who did not listen but in- Ð to celebrate the sacraments stead planned in silence what of infirmity. he was going to do’ (Sermon Yes, brothers, trusting and 77,1). persevering prayer while we are alive. ‘I already knew from the Not Only Supplication Gospel’, and here we return but also Worship, the Action again to St. Augustine, ‘how the of Grace and Praise Chanaanite through her perse- verance achieved (for her own St. Ignatius di Loyola, in the daughter) what she could not meditation ‘Principle and Foun- obtain by asking for it only dation’ of his Exercises, ob- once...More than the health of a serves: ‘man is created to daughter we are dealing here praise, revere and serve God with the immortality of life. It is our Lord, and through this save this that we should ask right up his soul’(23). The goal of every to the end, so that we can live man, whether healthy or sick, is without end where there is no thus to praise God. asking but exultation’ (Sermon, In Illness and Pain, The poverty which in human 7 B,1). Beseeching Prayers terms is involved in illness is The Department for without any doubt a form of Pastoral Care in Health, All those people who see wealth that joins us to God. Spain themselves as poor and in need This is what we see in the saints have to stretch out their hands. and in so many people who live Note Jesus himself says this in a with real joy in their pain, when 1 F. C. CHAVES, Orar con el Obispo strong fashion in the gospels: there is a motivation which de la Eucaristia (Burgos, 1998), pp. “Ask and you will be given...” gives meaning to illness and 162-3.

DOLENTIUM HOMINUM N. 48-2001 The future of Obstetrics and Gynaecology

The International Meeting of Catholic Obstetricians and Gynaecologists Organised by the World Federation of Associations of Catholic Doctors (FIAMC) and MaterCare International (MCI)

Rome, 17-20 June 2001

DOLENTIUM HOMINUM N. 48-2001 Address of Presentation

Holy Father, those specialists who intend to ed the legislators to acknowl- keep faithful to the teachings edge and protect the basic hu- The International Meeting of the Church. man right of physicians to ful- ‘The future of Obstetrics and As a consequence, the num- fil their moral duty of refusing Gynaecology’ organized by ber of Catholic obstetricians is to take part in committing ac- the World Federation of decreasing continuously and tions intrinsically incompati- Catholic Medical Associations we are afraid that the respect ble with human dignity. Not and by MaterCare Internation- for human life, the moral atti- only aware that a formal al on ‘The Fundamental Hu- tudes of Catholic women, the recognition of the rights of man Right to Practice and be pastoral care of marriage and conscience can be insufficient trained according to Con- of families, and teaching and and sometimes meaningless, science’ has gathered in Rome future research in the field of you asked that ‘those who specialists of this discipline human reproduction could be have recourse to conscientious from 40 countries of the five deeply affected. objection must be protected 64 continents. The meeting, which started not only from legal penalties, Without any solid organiza- this morning, will address the but also from any negative ef- tion, 140 doctors came from main theme from the different fects on the legal, disciplinary, all over the world and we had constitutional, legal, profes- financial and professional pla to refuse applications because sional and moral perspectives, ne’ (Evangelium Vitae n. 74). of lack of space. and the implications for the We would like to thank you This kind of spontaneous an- different aspects of the pas- for which Evangelium Vitae, swer, testifies that the problem toral care of the Church will which we consider the Magna is deeply felt by obstetricians. be outlined by authoritative Carta of human living to- In fact, the changes which have interventions of the dicasteries gether and, for this reason, a occurred in this discipline over and institutions of the Holy great social Encyclical Letter the last 40 years, after contra- See related to the problem. In even before being a great ception, abortion, in vitro fer- addition, free communications moral teaching. tilization and embryo manipu- will describe the situation in We would like to thank you lations have become wide- different countries and partic- also for the support you are spread, have created a pro- ularly painful personal experi- giving to the struggle of all found discomfort, while ideo- ences will be presented. those who defend and promote logical, political and profes- We know, Holy Father, that human life. sional pressures to abandon the problem is partitularly For those submitted to a sort any moral conflict have caused close to your heart. In Evan- of social ostracism, your ap- a sort of social ostracism of gelium Vitae (n. 74 ) you invit- preciation is a source of courage, strength and human dignity. Thank you, Holy Father, al- so for the special audience you have granted us today. It is an- other sign of attention for the special problems we experi- ence in our daily witness. We are eager to hear your voice suggesting possible ac- tions in defence of the basic human right of obstetricians and gynaecologists to be trained and to practice accord- ing to conscience. We ask, Holy Father, your blessing on our activities.

Dr. GIAN LUIGI GIGLI President of the World Federation of Catholic Medical Associations (FIAMC)

DOLENTIUM HOMINUM N. 48-2001 Doctors Protest Conscience Discrimination THE HOLY FATHER’S ADDRESS TO THE INTERNATIONAL CONGRESS OF CATHOLIC OBSTETRICIANS AND GYNAECOLOGISTS, ROME, 18 JUNE 2001

Distinguished Ladies and Gentlemen, scientific research, the use of embryonic stem cells for the development of tissue for 1. I warmly welcome your visit on the oc- transplants, to cure degenerative diseases, casion of the ‘International Congress of and projects of full or partial cloning, al- Catholic Obstetricians and Gynaecologists’, ready done with animals: all of these have at which you are reflecting upon your future changed the situation radically. in the light of the fundamental right to med- Moreover, conception, pregnancy and ical training and practice according to con- childbirth are no longer understood as ways science. Through you, I greet all those health of cooperating with the Creator in the mar- workers who, as servants and guardians of vellous task of giving life to a new human life, bear unceasing witness throughout the being. Instead they are often perceived as a world to the presence of Christ’s Church in burden and even as an ailment to be cured, this vital field, especially when human life is rather than being seen as a gift from God. 65 threatened by the burgeoning culture of death. In particular, I thank Professor Gian Luigi Gigli for his kind words on your behalf, Gospel of Life has to Influence Idea and I greet Professor Robert Walley, co-orga- of Reproductive Health nizer of your Meeting. 3. Inevitably Catholic obstetricians and gy- naecologists and nurses are caught up in Certain Advances Create Problems these tensions and changes. They are ex- for Medical Ethics posed to a social ideology which asks them to be agents of a concept of ‘reproductive 2. Christian obstetricians, gynaecologists health’ based on new reproductive technolo- and obstetric nurses are always called to be gies. Yet despite the pressure upon their con- servants and guardians of life, for ‘the science, many still recognize their responsi- Gospel of life is at the heart of Jesus” mes- bility as medical specialists to care for the sage. Lovingly received day after day by the tiniest and weakest of human beeings, and to Church, it is to be preached with dauntless fi- defend those who have no economic or so- delity as “good news” to the people of every cial power, or public voice of their own. age and culture’ (EvangeliumVitae, n. 1). But your profession has become still more important and your responsibility still greater ‘in today’s cultural and social context, in which science and the practice of medicine risk losing sight of their inherent ethical di- mension, [and] health-care professionals can be strongly tempted at times to become ma- nipulators of life, or even agents of death’ (ibid., n. 89). Until quite recently, medical ethics in gen- eral and Catholic morality were rarely in dis- agreement. Without problems of conscience, Catholic doctors could generally offer pa- tients all that medical science afforded. But this has now changed profoundly. The avail- ability of contraceptive and abortive drugs, new threats to life in the laws of some coun- tries, some of the uses of prenatal diagnosis, the spread of in vitro fertilization techniques, the consequent production of embryos to deal with sterility, but also their destination to

DOLENTIUM HOMINUM N. 48-2001 The conflict between social pressure and Church’s Magisterium in every aspect of ob- the demands of right conscience can lead to stetric and gynaecological practice, including the dilemma either of abandoning the med- research involving embryos. They should al- ical profession or of compromising one’s so offer a qualified and internationally rec- convictions. Faced with that tension, we ognized teaching network in order to help must remember that there is a middle path doctors who are subject to discrimination or which opens up before Catholic health work- unacceptable pressure on their moral convic- ers who are faithful to their conscience. It is tions when specializing in obstetrics and gy- the path of conscientious objection, which naecology. ought to be respected by all, especially legis- lators. Church’s Mission to Support Obstetricians, Gynaecologists and Health Workers Never Cooperate Formally in Evil 5. It is my fervent hope that at the begin- 4. In striving to serve life, we must work to ning of this new millennium all Catholic ensure that the right to professional training medical and health care personnel, whether and practice that is respectful of conscience in research or practice, will commit them- in law and in practice is guaranteed. It is selves whole-heartedly to the service of hu- clear, as I noted in my Encyclical Evangeli- man life. I trust that the local Churches will 66 um Vi tae, that ‘Christians, like all people of give due attention to the medical profession, good will, are called upon under grave oblig- promoting the ideal of unambiguous service ation of conscienee not to cooperate formally to the great miracle of life, supporting obste- in practices which, even if permitted by civil tricians, gynaecologists and health workers legislation, are contrary to God’s law. In- who respect the right to life by helping to deed, from the moral standpoint, it is never bring them together for mutual support and licit to cooperate formally in evil’ (n. 74). the exchange of ideas and experiences. Wherever the right to train for and practice Entrusting you and your mission as medicine with respect for one’s moral con- guardians and servants of life to the protec- victions is violated, Catholics must earnestly tion of the Blessed Virgin Mary, I cordially work for redress. impart my Apostolic Blessing to you and to In particular, Catholic universities and hos- all who work with you in bearing witness to pitals are called to follow the directives of the the Gospel of life.

DOLENTIUM HOMINUM N. 48-2001 The International Meeting of Catholic Gynaecologists and Obstetricians: The History of an Event

One hundred and forty ogy because this was the only medical doctor has to acquire Catholic gynaecologicsts and way I could go on practicing practical experience in pre-con- obstetricians from over forty my profession” (Marek Drab, ception counselling and pre- countries of the five continents Slovakia). scribe oral contraceptives, the of the world, called together by “In 1998, after two hospitals coil, the tying of the fallopian the World Federation of Asso- joined together, I was forced to tubes, and other forms of steril- ciations of Catholic Doctors join four colleagues of the larg- isation, and in addition he or (FIAMC) and MaterCare Inter- er hospital in a situation which she must procure abortions dur- national (MCI), met in Rome involved a sharing of all the fi- ing the first and second for four days from 17 to 20 nancial resources. Given that a three-month terms as envis- June 2001 to discuss the future large proportion of their in- aged by the present level of of their profession. The focus come came from contraception techniques in this areas. If a of the meeting, which was or- and surgical sterilisation I re- medical doctor refuses in a per- ganised together with the Pon- fused to join them for obvious manent sense to follow the tifical Council for Health Pas- moral and ethical reasons. At practices adopted in his hospi- 67 toral Care, was the fundamen- the level of conscience I could tal he or she is marginalised” tal human right to practice a not accept any of that income. I (Tamas Csasky-Pallavicini, profession and to be trained in was soon dismissed and I thus Austria). a way that respects one’s own lost the privileges of working “In Australia, the training in ethical beliefs. in a hospital and surgical prac- the sub-specialisation in repro- The response to the call was tice” (André O. Devos, Bel- duction requires the person enthusiastic and all the partici- gium). who is specialising to dedicate pants expressed almost a feel- “In Lithuania procured abor- himself or herself for a certain ing of liberation at the fact that tion is an important problem period of time to artificial fer- they could at last talk about for Catholic gynaecologists be- tilisation. Those who raise their own difficulties and con- cause gynaecologists have an moral objections to artificial demn the pressures (and at official right to refuse to carry fertilisation are unlikely to times forms of oppression) that out abortions only in university pursue this field as a result, they have to undergo. hospitals. In the other hospitals Some sentences listened to these specialists are forced to during the speeches that were carry out all operations, includ- made bore witness, through ing abortions” (Vilune Intaite, their presentation of evidence, Lithuania). to the climate of difficulty “For a doctor whose con- and discrimination in which science is troubled by these im- Catholic gynaecologicists and plications it is difficult in the obstetricians now work. United States of America to “I began my work at the de- obtain specialisation in mater- partment of gynaecology and nal-foetal medicine given the obstetrics in a state-run hospi- emphasis placed on prenatal tal. I thought that I would have diagnosis and its ‘therapeutic’ been able to achieve my aims correlate, the interruption of and my wishes by helping peo- pregnancy” (John M. Thorp, ple and by helping life, which Professor of Obstetrics and is given to us by God: this was Gynecology, University of the motivation that led me to North Carolina at Chapel Hill, choose gynaecology and ob- USA). and thereby leave this area and stetrics as a personal vocation. “In Austria the curriculum also leave discussion about its But as soon as I began to work and the official legal training issues for the most part to I discovered that to implement for obstetrics and gynaecology those people whose ethical po- Christian principles and to act envisage practical participa- sition is often diametrically according to my conscience tion in certain kinds of tech- opposed to those who respect meant for me to enter into a niques which must be learnt life from its beginnings” state of war. I refused to pro- and which are immoral. If a (Adrian Thomas, Australia). cure abortions and the result Catholic medical doctor wish- “In Switzerland, abortions was that they forced me not on- es to specialise in obstetrics should in reality be handled as ly to leave the hospital where I and gynaecology he or she ‘service orders’ (in German the worked and go to another hos- must face up to a hostile legal word is Leistungsuftrag). Thus pital but also to leave gynaecol- and ethical environment. Each it is that the studies and the pro-

DOLENTIUM HOMINUM N. 48-2001 fessional work of colleagues The conference, in addition by the participation of the who do not wish to interrupt to listening to condemnations heads of all the Ministries of pregnancies or take part in and reports regarding forms of the Holy See concerned with procuring abortions is becom- discrimination, also addressed the subjects that were ad- ing very difficult. Studies are in itself to the legislative situa- dressed. On the speakers’ ros- fact almost impossible if a col- tion, and examined the conse- trum the following prelates league refuses to be involved quences, in the short and long spoke one after the other: the with contraception and techni- term, that the ideological pres- Secretary of the Congregation cally assisted reproduction and sure which can now be for the Doctrine of the Faith, operations involving sterilisa- breathed in hospitals and uni- H.E. Msgr. Tarcisio Bertone: tion” (Rudolf Ehmann, Direc- versities may have for Catholic the President of the Pontifical tor of the Department of Ob- women, the presence itself of Council for the Family, Cardi- stetrics and Gynaecology, the the Church, and at a more gen- nal Alfonso Lopez Trujillo; the State Hospital, Stans, Switzer- eral level for the culture of Secretary of the Congregation land). those societies where gynaeco- for Catholic Education, H.E. “In 1996 the Council for logical obstetricians who are Msgr. Giuseppe Pittau; the Graduate Medical Education discriminated against have to Vice-President of the Pontifical made training in abortion a re- work. Academy for Life, H.E. Msgr. quirement for the specialisation On this subject, it was em- Elio Sgreccia; and the Ecclesi- schools and for this reason a re- phasised that the constant fall astical Assistant to the Italian quirement as well for specialis- in the number of Catholic ob- Association of Catholic Med- ing in obstetrics and gynaecol- stetricians, brought about by ical Doctors, Cardinal Dionigi ogy. Fortunately, following a the social ostracism to which 68 large number of protests, Con- they are subjected, is giving gress passed a law which for- rise to concern in many bids federal, state and local spheres. First and foremost, it government from rejecting the involves problems for respect provision of official approval, for life, which has been de- licences or financial aid to based in the eyes of public medical schools or hospitals opinion by practices which that refuse teaching in abor- have by now been accepted tion” (John W. Seeds, Professor passively by the medical class- and President of the Depart- es. Secondly, for the moral ment of Obstetrics and Gyne- conduct of Catholic women cology of the Virginia Com- who are encouraged by med- monwealth University/Medical ical doctors to adopt choices College of Virginia, USA). that involve a removal of a “Catholic gynaecological ob- sense of responsibility and stetricians believe that only a which are in line with cultural few Catholic medical doctors dynamics and forms of behav- specialise in gynaecological ob- iour based upon practical he- Tettamanzi. H.E. Msgr. Javier stetrics today because of a donism. The fall in the number Lozano Barragán, the President process of self-exclusion from a of Catholic obstetricians also of the Pontifical Council for field which is perceived as be- generates concern as regards Health Pastoral Care, the body ing hostile. The medical doctors pastoral care relating to mar- which together with the FI- trained in maternal-foetal medi- riage and the family. Such pas- AMC and the MCI organised cine feel strong pressure to ac- toral care has been deprived of this initiative, acted as the gen- cept the interruption of pregan- the support of medical doctors eral host. cy where there are anomalies in who adhere to the Magisterium In addition to outlining the the foetus” (T. Murphy Good- of the Church and are con- moral foundations of conscien- win, Director of the Depart- vinced of the possibilities of tious objection, these distin- ment of Maternal-Foetal Medi- offering concrete proposals guished ecclesiastical figures cine, the University of Southern which are alternative to those discussed in their papers the re- California, USA). proposed by the dominant lationship between the profes- The pressure is endless and mentality in the field of choic- sional activity of gynaecologi- recently Rachel Masch, the Di- es relating to reproduction. cal obstetricians and the pas- rector of the Department of Re- Lastly, there is a negative im- toral activity of the Church, productive Choice at the New pact as well on teaching, which and presented to those taking York University Medical Cen- is deprived of every kind of part in the conference the op- ter - Bellevue Hospital, de- critical debate, and on scientif- portunities for support and clared that family planning in ic research, which increasingly co-operation that they could the future will become a matter lacks the input of scientists expect from the institutions of of full-time rotation where who are open to lines of in- the Holy See. those engaged in specialisation quiry which are not condi- For those taking part in the will spend from four to eight tioned by ideological pressure conference this was a very im- hours every week within the and by elements relating to portant event, of a really uni- programme, which includes economic convenience. versal dimension, which en- procured abortions. The conference was enriched abled them to strengthen their

DOLENTIUM HOMINUM N. 48-2001 moral beliefs and their convic- chotomy between the Catholic and final system of critical as- tion as to their reasonableness denomination of certain institu- sessment to ensure the accep- regarding the resistance exer- tions and the real contents of tance for publication only of cised by them against the pres- their educational programmes high quality research. sure of dominant ideologies. and activity, and professional Given the advances in infor- The explosiveness of the conduct, to be found within mation technology and data subjects addressed during the them. The ecclesiastical author- communication, those taking course of the meeting was easi- ities were requested to engage part in the conference decided ly perceived when, during the in suitable controls. to create a preparatory commit- audience granted by the Holy Secondly, it was decided to tee which would be able to de- Father, these subjects found a establish a legal forum of an in- velop (using suitable advice very great echo in the press, ternational character, with local and help where necessary) sys- television, and Internet sites points of reference at a national tems of distance learning and throughout the world. The ad- level, which would be able to computer-based libraries on the dress of the Holy Father, which study the situations of discrimi- issues and subjects of repro- was greatly applauded by those nation that are drawn attention duction, thereby encouraging present, was fully reported. to, and to set in motion, in the the circulation of texts and au- The conference, in addition relevant judicial contexts legal diovisual material. to being an opportunity for in- cases on behalf of gynaecologi- Lastly, the participants called formation, condemnation, train- cal obstetricians who are dis- for the periodic holding of sim- ing and encouragement, gener- criminated against during their ilar meetings so that they could ated certain important conclu- training or their careers, or who engage in a shared examination sions. are subject to wrongful forms of the developments in scientif- First and foremost, it was of pressure because of their be- ic research and of specific prac- 69 agreed that a register would be liefs. tical questions. They decided to created of all the university and From a scientific point of meet again in Rome at the end hospital institutions that are view, it was decided to create a of October 2002. able to offer training pro- highly qualified scientific jour- At the end of the conference, grammes that respect the ethi- nal with an international editor- MaterCare International com- cal values proposed by the ial board composed of mem- municated that it had asked the Magisterium of the Church. In bers of high standing which FIAMC to be recognised as an parallel fashion, a series of would publish papers on sub- affiliated body having the spe- study grants will be set up for jects that are usually neglected cialised ability to make cultural people in specialisation cours- by many other such journals and practical contributions to es, in situations involving (for example natural family the field of gynaecological ob- forms of discrimination, to pro- planning, the physical and stetrics. vide them with training oppor- physiological consequences of The climate of exchange, of tunities which respect their abortion, studies on the growth friendship, and of brotherhood moral beliefs. of the embryo within a frame- felt by all during this confer- On this question, those tak- work of the continued develop- ence should be observed in a ing part in the conference ex- ment of the embryo, etc.). Such special way, and such a climate pressed their desire for a deeper a journal, however, in order to allows us to hope that there will adherence to the proposals of resist the temptation of suc- be further positive develop- the Magisterium on the part of cumbing to works of a low ments in the future. certain Catholic hospitals and quality (although in line with Catholic universities, and com- the Magisterium of the Church) Dr. GIAN LUIGI GIGLI, plained about a deplorable di- would be endowed with a rigid President of the FIAMC

Protecting Human Life in a Changing World: the Responsibility of Catholic Obstetricians

The Catholic Church has al- life, and have it more abun- We know with certainty that ways been for life and has al- dantly” (Jn 10:10). Certainly, we are all part of the Church ways defended it in all circum- Christ died for our sins, but he and that, therefore, we must all stances. This is something that rose again for our salvation bear strong and clear witness to is obvious given that the (Rom 4:25). The Church car- the fact that Christ rose again Church is the Church of Christ, ries on the mission of Christ and is the Lord of life. The who came into the world with a and in so doing bears witness to world is not intended for death very specific mission: “I have the resurrection, to the fullness but for life, for the fullness of come so that they may have of life. life. And if there is someone

DOLENTIUM HOMINUM N. 48-2001 who is directly expected to bear culpable indifference and neg- whereas the world does not this witness it is specifically the ligence of those who could in have sufficient resources to health care professional, be- some cases remedy them. Oth- provide for, and to feed, the ex- cause, in being a health care ers are the result of situations cess in population. A sexual professional, he is also a minis- of violence, hatred and con- revolution, therefore, was spo- ter of life. His mission is to flicting interests, which lead ken about in the sense that sex- bear witness to the resurrection people to attack others through ual rights should have a legal of Jesus Christ our Lord. His murder, war, slaughter and status, without these rights nec- learning and expertise, his genocide’. He also speaks to us essarily implying human repro- technical skills, and his ability about poverty, about wars, duction. The question of abor- are all directed towards giving about the upsetting of the tion was also talked about, life, and thus if a health care world’s ecological balance, of where abortion was seen as a professional turns himself into drug abuse and of the bad prac- right held by women. It was a professional of death this is in tice of sexuality: ‘it is impossi- said that it was necessary to opposition to sense, it is a con- ble’, he goes on, ‘to catalogue broaden the traditional concept tradiction. This is true for hos- completely the vast array of of the family. The point was pitals as a whole, and above all threats to human life, so many reached of saying that all those else for medical doctors, para- are the forms, whether explicit who live under the same roof medics, nurses, pharmacists, or hidden, in which they appear constitute a family, defending voluntary workers, hospital today’.1 The Pope says that we thereby de facto unions, unions managers, certainly for those are dealing here with ‘a verita- between homosexuals, and priests who dedicate them- ble structure of sin. This reality every other form of living to- selves to the health and health is characterised by the emer- gether. The concept of the fam- 70 care sector, and, lastly, for all gence of a culture which denies ily which has at its base mar- the personnel who in some way solidarity and in many cases riage between the two sexes, are involved in the promotion takes the form of a veritable and which is one and indissolu- of health. ‘culture of death’’.2 The value ble, is increasingly being dis- My paper is organised into of life is today suffering from a tanced from agreed views at a three parts: threats to life; the kind of ‘eclipse’.3 Anti-concep- world level. Family planning responsibility of health profes- tion, abortion, prenatal diagno- was also spoken about, not in sionals; and some guidelines sis with a view to eugenics, the sense of an authentic regu- for action. death for the terminally ill and lating of the family but rather euthanasia, are upheld; fear is of the elimination of fertility, felt because the population in- and was especially directed to- I. Threats to Life crease is seen as being a very wards countries of the third great danger; no meaning at all world whose population in- 1. Their Description is to be found in suffering; ster- crease is intensely feared by in ‘Evangelium Vitae’ ilisation is imposed; and the so- rich countries. cial means of communication At the Conference of Peking God did not create death Ð are placed at the disposal of (UNO/Peking, 1999) the sexual He created life. But by the these policies.4 rights of girls and women were work of the Evil One, death spoken about with an underly- was placed in the world. Not 2. Their Description ing anti-conception mentality. only was it placed, but it is con- at the World Conferences Along these lines, even the end tinually being placed. The Evil on Population of violence and discrimination One did this at the beginning of against women was pro- human history, he has done it As evidence of what I have claimed. It was said that the during the course of that histo- just said, and after seeing how rights of women are human ry, he has done it at every stage these questions and issues have rights Ð which is obviously the of the life of mankind, and he existed until our times, let us case Ð and that this involved continues to do so today. He now see what the recent world the proclaiming of the right to has done this in different ways conferences on health care engage in an abortion as a hu- and today new threats have ar- have said. At these conferences man right. All this, in a more or rived. Wars, diseases, and mis- an attempt has been made to go less open way, was argued fortunes of every kind have al- to the heart of the matter, to the when reference was made to ways existed and continue to point of reaching the origins of the right of adolescent girls to emerge according to the vicis- life so as then to assault it. Here information about sexual and situdes of history. But, in a spe- some of the most significant as- reproductive health, and to use cific sense, what are the threats pects of what has been done medical services without inter- to life today which require the can be drawn attention to, ference from their parents. provision of special protection which are as follows. At the meeting of the United by health care professionals? Let us begin with the Confer- Nations Organisation known as The Holy Father John Paul II ence of Cairo (UNO/Cairo, Cairo+5 (1999), five years af- speaks about these threats in 1994). During its deliberations ter the Conference of Cairo, a his encyclical letter Evangeli- it was argued that sexual repro- proposal was advanced on the um Vitae. He argues that ‘some duction was dangerous for the lawfulness of the ‘morning af- threats come from nature itself, world because, it was said, it ter pill’ (an evident abortion-in- but they are made worse by the fostered population increase, ducing pharmaceutical prod-

DOLENTIUM HOMINUM N. 48-2001 tension, in diabetes, in cancer, in infectious diseases, in tobac- co use, in the death of mothers at childbirth, in ebola, in alco- holism, in traumas of every kind, etc. As will be obvious, this is not a general survey of health care in the world. We must not fall into a black pessimism, be- cause, at the same time, we find ourselves faced with wonderful uct), so-called emergency con- violation of human rights. In progress in the world of medi- traception, and unsafe abortion. this way an attempt was made cine, and life-expectancy has On that occasion the right to to proclaim sexual rights as hu- grown in most of the peoples of ‘privacy’ was presented as man rights, opening up the road the world. The realities that we something different: the right to the right to pornography, the have described hitherto refer to of adolescents to privacy and to right to prostitution, the right to some of the most significant sexual education from elemen- abortion and the right to sexual threats to life which exist in the tary school was talked about. perversion. At the final vote all world, which, precisely be- And all this in the sense of the these proposals were not ap- cause of their severity, make free practice of sexuality, obvi- proved.5 the question which we pose to ously not within the context of health care professionals Ð so procreation and even less of the 3. The Present-Day Panorama that they may provide a re- 71 creation of a family. Once sponse Ð ring out strongly. again reference was made to There can be no doubt that abortion as a human right and the present-day panorama of of the training of health care threats to life is distressing, that II. The Response of Health personnel in the practice, in the there exists a totally Malthu- Care Professionals best way possible, of abortion, sian mentality, that there is a without taking into account the wish to replace the family 1. The Causes dictates of their conscience. based upon marriage with vari- The last encounter of the in- ous types of union including In order to outline a response ternational conferences con- that of homosexuals, that sexu- we must examine the causes cerned with life was Peking+5 al life is seen as banal, that a behind this situation. The Holy (Peking+5, 2000), held five child is received as the out- Father does this in a detailed years after the Conference of come of a selfish desire. There way in the encyclical which has Peking. While it was being or- is no legal protection of the em- already been referred to when ganised, the Western countries, bryo, abortion is being le- he maintains that the threats to Europe and the United States of galised, life is valued only from life are due above all else to a America included, together the point of view of its produc- way of thinking which holds with the G77 group of dissi- tivity, throughout the world that a right belongs to someone dents, launched a serious attack there are situations of hunger, who has at the least an incipient and fought against the family illness and misery, war and autonomy and that freedom is and in favour of abortion. Their genocide, everywhere embryos absolute autonomy, and to formula was: ‘free and total ac- are used for commercial, ex- thinking with alleged altruism cess to all health services’, in- perimental or therapeutic ends, and pity in relation to possible cluding thereby abortion, and prenatal eugenics are practiced, deformations of a new life they were not prepared to ac- attempts to engage in human within the foetus; to a way of cept any clause protecting the cloning are looming on the thinking which holds that the right to conscientious objection horizon, the phrase ‘pre-em- right to life is something which for medical, nursing, or obstet- bryo’ has been invented in or- is exclusively the concern of rics personnel, with the conse- der to bestow legitimacy on parliamentary decisions; to the quence that such people would abortion, there is an increase in fact that an eclipse of the mean- be obliged to carry out an abor- gene banks, frozen embryos, ing of God and thus of man has tion. Another formula ad- artificial fertilisation, the use of taken place and that life is cata- vanced was that of ‘sexual ori- human stem cells, the use of logued as something, when entation’ and the ‘need’ to embryo and foetus tissues, and subjected to technological modify the role and the identity research into the human treatment, which can be manip- of the stereotypes of men and genome is prospering with in ulated absolutely; to the view women. There was an attack on mind its manipulation in line that nature must be seen not as the ‘traditional roles attributed with eugenics based on abor- something which is sacred and to a single gender... which tion.6 which comes from the hands of oblige women to take on all the To what has been listed God, but should be seen as a weight of family responsibili- above we can add the pandem- kind of mine, of building site, ties’. The non-recognition of ic of HIV-AIDS, the increase in of matter to be manipulated to- ‘sexual orientation’ (including malaria and tuberculosis, in tally according to human will; homosexuality) was seen as a respiratory diseases, in hyper- to the belief in the body and sex

DOLENTIUM HOMINUM N. 48-2001 as mere tools for the affirma- life is threatened encounters the recently addressed the mem- tion of the self and the selfish sure hope of finding freedom bers of the Pontifical Academy satisfaction of one’s own de- and redemption’.8 for Life (16 March 2001), say- sires and instincts; and to a de- ing that we should offer solid formation of the moral con- 3. The Effectiveness and enlightening contents to science of society, moulded by of the Resurrection the culture of life so as to re- ‘men who by their wickedness generate continuously the inner suppress the truth’ (Rom 1:18). For the professional of tissue of contemporary culture. health, even more, this purpose Human life must be presented 2. Inner Responsibility and this model are not some- as a gift from God and man thing external which acts must be presented as his free If we reflect on this set of through imitation or through a and responsible co-worker, giv- causes we see that the response merely volitional impulse with ing emphasis to the dignity of must spring from the innermost relation to the perceived pur- the human person and to the part of man, so that, in discov- pose, but, instead, a real engine family as a community of love ering himself, he also discovers of effectiveness. The risen and life. Life is persecuted but God, who is the source of life. Christ is he who encourages us it will manage to win Ð this is In fact, responsibility is the to provide a response and it is our sure hope because on the capacity to respond. And this he himself who offers the an- side of life there are freedom, capacity is centred in man him- swer. In the face of the impor- good, joy, real progress, and self. Man places himself in tance of the problems encoun- God. Jesus Christ gave his life front of his own fulfilment and tered there is no place for dis- to defeat death and to associate 72

begins to build that fulfilment. couragement and no place for man with his resurrection. The Responsibility consists of this us, when measuring our own Gospel of life is something capacity to build oneself. Free- strengths, to find that they are which is concrete and personal dom enters the picture as the not up to the task in hand, but because it means the preaching possibility to choose what is rather there is a place for the of the very person of Jesus, most useful in this construc- humble and total acceptance of who tells us: “I am the way, the tion. When we place ourselves the capacity of his personality truth, and the life” (Jn 4:6). on the plane of health care pro- together with the whole of con- The Pope goes on and says fessionals we realise that the temporary learning and tech- that all of this resides in the in- question raised by the threats to nology, at the service of the nermost part of the person; it is health care raises another vivifying force that realises, in not something which we know which is even more profound Ð concrete terms, life Ð that is to solely through Revelation. It that regarding one’s own per- say Christ who died and rose flows forth from the very rea- sonality as a health profession- again. In this consists the re- son of the creation, of the dig- al. This is a question which re- demption that Christ offers us nity of the human person, of quires us to raise our gaze to- in the concrete situations of the the dignity of the body as a hu- wards our own purpose and our world we live in. We can appre- man subject in a unitary con- own model which for the ciate in a clear way in these cir- ception. We should increase the Christian health care profes- cumstances the need for a re- dialogue between faith and rea- sional are nothing else than the demption which really rises son, joining together within the risen Christ. above all our strengths but human person dignity and sa- The Pope says the following which achieves the marvel of credness, freedom and respon- in the encyclical which has al- making health sacred, using sibility, giving emphasis to the ready been cited: ‘Israel comes our scarce but indispensable stewardship of the environ- to learn that whenever its exis- capacities. ment, the right to life from its tence is threatened it need turn conception until death, the only to God with renewed trust 4. The Pope to the Pontifical family, and the primary design in order to find in Him effec- Academy for Life of God for the reproduction of tive help... Today, too, by look- life. Great challenges are tak- ing upon the one who was Pope John Paul II spoke ing place within the context of pierced, every person whose again on this subject when he present-day progress and the

DOLENTIUM HOMINUM N. 48-2001 secularisation of society. Both the highest human solidarity do not have their foundation in dialogue and listening are ur- and communion, that is to say nature. gent. ‘Without a culture which marriage, which is baptismal As has already been ob- maintains solid the right to life life doubled in matrimonial served in this paper, for Christ- and promotes the fundamental love, in the full and indissolu- ian moral thought, including values of every person, one ble love of a man and a Revelation which for the mo- cannot have a healthy society woman. ment will be left to one side, or the guarantee of peace and ethics are a consequence of justice’.9 3. Bioethics metaphysics: if nature has a purpose, then it is rooted in an A profound practical form anthropology in which man is III. Guidelines for Action for the protection of life by presented as a being endowed health care professionals is to with purpose and as such on a 1. Prayer know and to apply bioethics in journey towards that goal. a correct way, especially with Ethics describe to us this jour- What are the guidelines for regard to the complicated ques- neying towards the eternal. action to implement this great tions and issues connected with But if we deny nature and responsibility in relation to the human genome. When we leave metaphysics out of the life? In the first place, says the speak about the correct applica- picture, there is no longer a Pope, ‘a great prayer for life is tion of bioethics we refer to au- purpose and there is not even a urgently needed, a prayer thentic bioethics which start metaphysical anthropology. which will rise up throughout with previously enunciated And, as a result, there are no the world. Through special ini- principles regarding life. real ethics. tiatives and daily prayer, may Indeed, the fundamental Bioethics are seen in this 73 an impassioned plea rise to problem of bioethics today, way from two standpoints. One God, the Creator and lover of their fundamental basic prob- standpoint accepts metaphysi- life, from every Christian com- lem, is the problem of their cal thought and Revelation, an- munity, from every group and principles. Bioethics is the sci- thropology and ethics based association, from every family entific study of human behav- upon metaphysics and Revela- and from the heart of every be- iour in the context of the sci- tion; the other does not accept liever’.10 ences of life and health, in con- this thought and tries to formu- formity with values and moral late other bases, or even no ba- 2. The Direction principles. The question imme- sis at all. The first standpoint is diately arises: which values? called ‘personalism’ and the We must also have a clear Which moral principles? It is second ‘positivist bioethics’. Christian idea of life, under- not difficult to find an answer An explanation of the princi- stood as a mission, a mystery, in the Catholic world Ð they are ples of ethical personalism will and communion. The point of the values referred to above. in an essential way help the departure for building a culture But bioethics are developing professionals of health to pro- of life is the recognition that rapidly in a forceful way in the tect life against the threats life is a mission. Christ said: “I non-Catholic world, especially which hang over it. have come so that they may in spheres of a Protestant ma- have life, and have it in abun- trix, and in this field neither the 4. The Principles of dance” (Jn 10:10) and the life values nor the moral principles Personalism in Bioethics that he has given us is the life are clear. This absence is also that he has in the Father and evident in ethical positivism, in 1. The human person is cre- that the Father has in him (Jn which it is not possible to speak ated by God, from God he 6:57). The life of God, the life about such principles in a ratio- comes and to him he is directed of the Most Holy Trinity, can- nal sense. as his first and final cause. The not be annihilated by death. In fact, in traditional Christ- human person is capable of re- The mission of Christ is that of ian thought the principles are flection, and in himself he is an offering us this life in the Most the law of God, the command- end and can never been seen as Holy Trinity, and his mission ments of the Law of God based a means. He is the synthesis of cannot fail. For this reason, upon the natural law itself, the universe and he that gives this life is a life which is the which were exalted in the life reason to everything that exists. fruit of communion and, even of Christ and which have just Here anthropology and ethics more, is it is the same commu- been discussed in this paper. find their foundation. nion as that of the Father with But in Protestant thought natur- 2. As a result, human life is the Son in the Holy Spirit (2 al law does not appear as some- sacred because it comes from Cor 13:13). Life cannot be thing acceptable because it is God. For the same reason, the separated from communion; thought that nature is simply dignity of the human person is indeed, the highest life of man spoiled, that it is bad, and thus inviolable. is that which is received in cannot be fixed as a norm upon 3. The human person has his baptism, divine life, and this which to act. In depriving na- own freedom and his own re- life is received in communion ture of the authority to be a sponsibility which he must ex- with the whole of the Church. source of morality, we must ercise to fulfil himself. There In the same way, the reproduc- look for other external and of- cannot be freedom without re- tion of this life is given only in ten very arbitrary forms which sponsibility, and this means re-

DOLENTIUM HOMINUM N. 48-2001 specting the freedom of other above must be expressed in the Two wings are given to the people. civil laws of States.11 woman so that she can take 4. Everything is above the refuge in a safe place in the interests of an individual and at 5. Application to Specific desert where she will give birth times it is necessary to abandon Cases and the dragon will no longer individual interests out of re- be able to do anything against spect for the whole. More than continuing now her and her offspring. Life is 5. The human person exists with a list of specific cases in protected against the threats of in solidarity and must aim for the sphere of biogenetics, what death. The triumph of life is the the common good. has been outlined above may resurrection. Mary is the source 6. In this context the three be sufficient as a response to of life, she is our model and our principles of autonomy, doing the specific problems, which safety in forging the new cul- good, and justice, which are without doubt will present ture of life.12 adopted by positivist bioethics, themselves to today’s health are accepted and justified. The care professionals, so that they H.E. Msgr. JAVIER LOZANO principle of autonomy means can protect life in the face of BARRAGÁN, the freedom of the moral agent, anti-conception, abortion, the Archbishop-Bishop Emeritus of Zacatecas, which in turn is said to indicate use of stem cells, banks of ge- President of the Pontifical Council for that an action is good if it re- netic material, in vitro fertilisa- Health Pastoral Care, spects the freedom of the moral tion, human cloning, the rent- agent and of other people. The ing of wombs, the production principle of doing good means of embryos, the freezing of em- that good should always be bryos, the use of foetal tissues, 74 done and evil should always be eugenics, arbitrary sexual free- Notes avoided. The principle of jus- dom, homosexuality, sexual in- tice means that every person formation without suitable 1 JOHN PAUL II, the encyclical letter Evangelium Vitae, 25 March 1995, 9-11. should be given what is due to training, divorce, euthanasia, 2 EV 1, 12. him. etc. 3 EV 1, 11. 7. The person is the image of We have sought to clarify the 4 EV 1, 13-17. 5 R. MARTINO, ‘Cinque anni dopo II God, part of the Body of Christ, panorama of life faced with the Cairo e Pechino’, in Pontificio Consiglio and a citizen of the people of culture of death and it is the re- della Famiglia, I figli, famiglia e società God. sponsibility of every health nel nuovo millennio (Vatican City, 2001), pp. 172-180. 8. Suffering, if assumed in care professional to bring this 6 J.E. I. Mart_ez, ‘Presentazione del union with the suffering of light into the daily situations Congresso Europeo dei Movimenti per la Christ, is something positive which he encounters in order to Vita’, in Pontificio Consiglio della Famiglia, I figli, famiglia e socità nel and is a source of salvation. always protect life. nuovo millennio (Vatican City, 2001), pp. 9. Life is inviolable from its Let us conclude as the Pope 181-188. conception to its natural end. does in his encyclical when he 7 EV 1, 19-23. 8 EV 1, 31; 2, 50. 10. Human life must have its observes that the model of life 9 JOHN PAUL II, ‘Discorso all Pontificia origin only in marriage. of the new culture is the Virgin Academia per la Vita’, L’Osservatore Ro- 11. Human life must have its Mary in relation to the birth of mano, weekly Italian edition (11), 16 March 2001, 2. origin in marriage, in the con- the Son of God, as she appears 10 EV 4, 100. jugal act. in the twelfth chapter of the 11 L. CICCONE, ‘Storia e problematiche 12. Sciences are at the ser- Apocalypse: the woman is oggi’, and A. Spagnolo, ‘Bioetica Fonda- menti’, in Camillianum, Dizionario di vice of human life and not vice about to give birth and the Teologia Pastorale Sanitaria (Camil- versa. dragon is awaiting the birth of liane, 1997), pp. 130-154. 13. What has been outlined the child in order to devour it. 12 EV, 103-104.

A Question of Conscience

It was quite a surprise, back had always, quite naively is direct taking of human life. I in 1973, to be informed by an seems, thought that the British refused and as a consequence eminent professor of obstetrics “system” was based on fair became unemployed with a and gynaecology, after an inter- play and above all, respect for wife and three children and had view for an appointment as a an individual’s right to consci- to leave country, home and senior registrar, that as a Ro- entious objection, for example family in order to practise my man Catholic specialist “there in the time of war. It soon be- chosen speciality in full free- is no place for you to practice came obvious that in order to dom. within the National Health Ser- stay in the specialities in the In 1976 I published a paper vice unless you are prepared to United Kingdom, I would have in the British Medical Journal change your views or to re-spe- had to compromise a conscien- about my experience and cialise in another field”. One tiously held abhorrence to the warned that the practice of ob-

DOLENTIUM HOMINUM N. 48-2001 stetrics in the UK would suffer, passed in the UK. As residents reason, most likely the inspira- as the main consequence of the we were exposed to a one- tion of the Holy Spirit, I re- denial of conscientious objec- sided, ill-informed and preju- read and thought about it and tion to performing abortion dice opinion by those deter- began to understand its impor- there would develop what I mined to change how we tance to marriage, human life called a “sameness of practice” thought and practised. Signifi- and family. which would stifle further cantly in later editions of Abortion and contraception thought and progress. This Williams that reference to the soon became the basis of the prophecy concerning obstetrics foetus as a second patient was health care of mothers. In spite in the UK has come to pass and dropped A subtle gradual of knowing so much about the discrimination against catholic process began to bring about a unborn child obstetricians con- and other pro-life doctors con- fundamental change in the nived in devaluing the human tinues in the UK and other parts way obstetricians considered being in the womb, thus mak- of the world. themselves. The difference be- ing it so much easier to destroy. It was early in my medical tween obstetrics (maternal Society accepted abortion as an student career that I decided to health care) and gynaecology easy solution for social and specialise in ob/gyn. The ap- (women’s health care) became economic problems and ob/gy- peal was that these specialities blurred. Reference to mother- ns have allowed their profes- required skills in medicine, hood was dropped and we now sional skills to be used for that surgery and special skills relat- find ourselves to be simply purpose. Many of our col- ed to obstetrics. It became clear women’s health specialists. leagues now destroy more ba- to me that obstetricians and midwives have a unique and privileged vocation in the ser- 75 vice to life as they are assis- tants to the co-creators of new life. We are specialists in moth- erhood. When I began obstetric resi- dency training back in 1968 residents were told that obste- tricians had one objective, which was to provide the best of care that was humanly possi- ble, to ensure that all pregnan- cies should result in a live healthy mother, and a live healthy baby. It was made clear that at the beginning of every pregnancy we had two patients to look after as the following statement taken from the of Williams Obstetrics (sixteenth edition) states; ‘Happily we live and work in an era in which the foetus is es- tablished as our second patient with many rights and privileges comparable to those previously achieved on the afterbirth.’ However, back in the early 70s, the general public and even Church leadership did At about the same time the bies than they deliver babies. not anticipate the dark changes Encyclical Humanae Vitae was Little effort is made to reduce that were about to occur that promulgated. I remember read- the number of abortions. It de- would turn maternal health ing it and my first reaction was fies belief that William Jeffer- care upside down, and cause to wonder if it had any rele- son Clinton, the President of many obstetricians to make se- vance to my practice. I started the United States of America, rious decisions about practice to rationalise that there was a should have twice vetoed a bill and living which had profound difference between contracep- which would have outlawed effects on their careers. As I tion and abortion Ð I could ac- the obscenity of partial birth finished training, the oral con- cept the former but not the lat- abortion. The world has accept- traceptive was being intro- ter. The decision was quite ed the culture of death at the duced, and I remember attend- simple and most of my friends cost of unborn children and a ing one of the first demonstra- and colleagues accepted that once noble profession. Pope tions of the intra-uterine de- idea too. There was no one John Paul has commented; vice. At the same time legisla- around to turn to for advice or ‘The medical profession to- tion permitting abortion was guidance. However, for some day is suffering fundamentally

DOLENTIUM HOMINUM N. 48-2001 from an identity crisis; the to get involved in abortion Ð it places of scientific and techno- grave danger exists that when is regarded as unpleasant work. logical research’. (E.V. 98). this profession is called upon to It is not surprising that very That group established suppress conceived life; where few Catholics are entering MaterCare International (MCI) it is used to eliminate the dy- ob/gyn, thus the Catholic which has adopted a preferen- ing; where it allows itself to be ob/gyn is now in danger of go- tial option for mothers and their led to intervene against the plan ing the same way as the di- unborn children. The intention of the Creator and the life of nosaur, having been frozen out was not to develop a talking the family or to be taken by the by the abortion/contraceptive shop, but an organisation that temptation to manipulate hu- asteroid. This should be a would breath life back into the man life; and when it loses source of grave concern to the care of mothers through new sight of its authentic direction Church, to pro-life organisa- initiatives of service, training, of purpose toward the person tions and to all people of good research, and advocacy in ac- who is most unfortunate and will. cordance with the teaching of most sick, it loses its ethos, it This raises important ques- the Encyclical, Evangelium Vi- becomessick in its turn, it loses tions; what effect does all of tae. MCI intends to place itself; and obscures its own dignity this have on mothers and ‘... at the service of a new and moral autonomy.’ women? Where will they ob- culture of life offering serious For the Catholic in training tain opinions and treatment for and well documented contribu- or in practice this has had pro- their health problems which are tions, capable of commanding found ethical, moral and prac- in accordance with their moral general respect and interest by tical significance. No other convictions? Are women being reason of merit’. (E.V. 98) branch of medicine has been unduly influenced by doctors MCI is developing a revolu- 76 so affected by these develop- or nurses who do not under- tionary structure for the 21st ments. It has simply not been stand or care about religious century i.e. no large buildings appreciated that obstetricians convictions? In other words with large heating bills but a of my generation had, from the who in the future will make small international central very beginning of these devel- any practical reality of the agency and national groups opments, to take a fundamen- Church’s teaching concerning that support flexible reference tal stand in defence of human maternal health care? centres, distributed throughout life. This caused them, and In 1995 a small international the world, all linked together their families, considerable group of Catholic ob/gyns/mid- through modern communica- pain as they found their ca- wives met at the Life Health tion technologies. MaterCare is reers in ruins. Many were Centre in Liverpool England. legally established in Canada, forced out of the specialty; All had have been asking them- Ireland, the UK (and therefore others sadly compromised in selves the same question; if we the European Union) and is in order to survive. In some don’t do something WHO the process in the USA, Aus- countries many are forced to WILL? This stubborn few be- tralia and Ghana. Each national participate in abortion or con- lieved that if they held to their group has an interdisciplinary traception programmes and ethical and moral principles, board of directors. With these sadly many decide to compro- they could be effective in car- national structures MCI can mise and separate what they ing for mothers and their un- access funding from private do from what they believe. born babies and that there are and government sources to car- In very personal ways mothers around the world who ry out projects and recruit col- Catholics specialists and their still want the sort of care that leagues to carry out the work. families have been subjected to they can provide. The international centre is a sort of professional totalitari- Pope John Paul II in his En- located in St John’s Newfound- anism. The Catholic ob/gyns cyclical Evangelium Vitae also land, Canada provides the spe- who remained faithful to the issued an urgent appeal to all, cialist support for national cen- Magisterial teaching were and but in a special way to Catholic tres. The centre presently con- are professionally and socially health professionals, to do sists of an obstetrician, a pro- ostracised. Sadly even in something extra for life; fessor of nursing, a secretary, a catholic hospitals they are con- ‘To the people of life for public education co-ordinator sidered an ‘embarrassment be- life’, ‘to offer this world of ours and a volunteer board. In the cause of their public stand and new signs of hope, and work to future we hope to have a staff are considered as ultra conserv- ensure that a new culture of hu- that will reflect the unique, in- atives, professionally outdated, man life will be affirmed, for ternational, interdisciplinary, and even possibly negligent the building of an authentic diverse vocational character and are subjected to the dis- civilisation of truth and love’ and experience of our Church, pleasure of the profession. (E.V. No 6). and will include an administra- Generally there is a recruitment ‘To all health care personnel tor, medical and nursing direc- crisis as few students are elect- who have a unique responsibil- tors, theologian/ethicist, health ing to specialise in ob/gyn basi- ity to be guardians and servants educator, communications ex- cally for three reasons; the of human life’. (E.V. 89). pert, and support staff. It is the lifestyle is quite hard; there is ‘A specific contribution must board of MaterCare Interna- fear of litigation especially in come from Catholic universi- tional which is made up of two North America and Europe and ties, Centres, Institutes and members from each national most doctors really do not want Committees of Bioethics and MaterCare groups that deter-

DOLENTIUM HOMINUM N. 48-2001 mines policy and chooses pro- when medical aid is not avail- MCI has had requests to jects. The international board able. find an obstetrician/adminis- meets quarterly by internation- An advocacy programme is trator for a Catholic hospital in al telephone conference calls also being developed to bring Bethlehem and the Archbish- which is quite cheap. In the fu- to international attention the op of Freetown Sierra Leone ture it aims to set up a method tragedy of maternal mortality has asked for help in develop- for international teleconferenc- and the suffering of mothers ing maternal health services. ing using the internet, which is with obstetric fistulae MCI is particularly con- free. National reference centres MCI is also developing a 60- cerned about the future of will be established, where there bed birth trauma centre to pro- ob/gyn and the training. Three is interest and according to lo- vide treatment and a rehabilita- years ago we tried to set up an cal needs. The first one will be tion centre for mothers with ob- international meeting to discuss in Ghana, West Africa. These stetric fistula, which will also the training of future specialists reference centres will be the have a special interest in train- but without success. In our initiators of local activities and ing nurses and doctors in the opinion there still remains will gather information, imple- management of these patients. throughout the world academic ment services and educational All of these projects are being and hospital departments of ob- programmes, conduct research carried out in partnership with stetrics and gynaecology which and also provide the group of the Catholic Conference of the could offer quality residency specialists. Bishops of Ghana. MCI is also courses and electives using the new information technologies and distance learning. All we have to do is to organise our- selves. 77

Conclusion

As we approach the twenty- first century, millions of moth- ers throughout the developing world are dying from childbirth complications frequent during MCI has shown, despite developing an obstetric fistula the middle ages. In the devel- scepticism and not without teaching CD which will be oped world millions of unborn considerable labour pains, that made available free of charge children are being destroyed by it can be relevant. In 1998 MCI and which also will be avail- the medical profession with developed a West African Ma- able on MCI’s website. surgical procedures which were ternal Health and Obstetric Fis- In 1999 Dr GigIi and I visit- common in the dark ages of hu- tula Project, the first phase of ed Albania and to cut a long man ignorance. which is now underway in story short we organised a rota- Obstetricians and midwives Ghana and consists of preven- tion of obstetricians to an Aus- share a unique and privileged tion, research and advocacy trian military field hospital to vocation in the service to life. A programmes. The prevention provide care for about 20,000 group of Catholic health pro- programmes are designed to re- refugees. The reason that it did fessionals has taken a preferen- duce maternal mortality and not get off the ground was that tial option to care for mothers morbidity in rural areas by im- the bombing of Kosovo and has created an international proving the care given to moth- stopped and the refugees went organisation which will be dif- ers by traditional birth atten- home. Last year I made three ferent to any other professional dants (TBAs) in villages by us- visits with Adrian Thomas and organisation as it will provide ing a pictorial antenatal card, then Gian Luigi Gigli to East mothers with the best of obstet- by training nurse/midwives in Timor to look at the problems rical care which is firmly based maternity centres to use the facing mothers. MCII with the on medical excellence, life and labour partograph, a visual help of FIAMC is in the hope. We know WHAT must be means of monitoring the process of developing a pro- done and for WHOM; this pro- progress of labour and by an gramme to provide essential posal is one way of answering emergency obstetric transport obstetrical care where as of the question HOW are we as system with blood transfusion now there is no obstetricians Catholic health professional are capability to transport mothers for a population of 700,000. going to do it. with complications to the dis- What we did discover however trict hospital safely. form these experiences is that Prof. ROBERT L. WALLEY, A research programme has there is no international organi- Frcsc, Frcog, Mph (Harvard) been completed which has sation that exists to provide Professor of Obstetrics and evaluated a new oral, effective mothers with specialist care. Gynaecology Memorial University of Newfoundland, and inexpensive method of Neither the ICRC nor MSF it- Executive Director managing life threatening post- self. Emergency services are al- Matercare International partum haemorrhage, which so being developed in East could be used safely by TBAs Timor.

DOLENTIUM HOMINUM N. 48-2001 The Importance of the Catholic Obstetrician-Gynaecologist for the Presence of the Church in the World of Health and Health Care

The pastoral care of the the effort was, and is, a witness Catholic health worker for the Church has always taken ad- to the fact that attention direct- pastoral care in health of the vantage of the contribution of ed to the human person is not Church. laymen, and this was even true unless the whole of man is Today, however, their role more the case after Vatican involved, even when he is frail, has become much more impor- Council II. Today the contribu- weak, and reduced, and all men tant and their responsibility is tion of laymen to such pastoral are involved, even when they greater. Up to a few decades care is even more necessary have been abandoned and their ago, in fact, the morals of doc- given the decrease of priestly social weight or their impor- tors and Catholic morality were and religious vocations. tance in the society of produc- rarely in contrast and the In particular, the pastoral tivity and commodities are no Catholic doctor had no difficul- care of the Church in the world longer significant. ties in making available to his of health and health care needs It is for this reason that we patients all that medical science 78 laymen in order to accomplish can say with pride that the ef- offered, without, as a result, Christ’s mandate: to preach the fort of the Church in the world suffering from conflicts of con- Gospel and to heal the sick. of health and health care has science. It is true that there Healing the sick is not some- greatly contributed to the de- have always existed doctors thing to be added as an after- velopment of human civilisa- and midwives who have per- thought, but it is rather an al- tion, favouring all over the formed abortions, but they did most integral part of evangeli- world the growth of a culture of so outside the common ethical sation, it is that which makes it mercy and of compassion, of codes recognised by the profes- believable. Jesus himself char- rights and of respect for man in sion and in a hidden manner acterised his message as ‘heal- all situations of life and in all because they would have been ing the sick’. stages of his existence. condemned. Until the begin- It is for this reason that down But the presence of the ning of the 1970s, textbooks of the centuries the Church has Church in the world of health forensic medicine listed only developed deaconries, hostels and health care was, and is, four types of abortion: sponta- for pilgrims, monastic infir- moved by the awareness that it neous, therapeutic (to save the maries, and religious orders is precisely when man express- mother’s life), eugenic and devoted to providing the assis- es the need to be healthy that he criminal abortion. In relation to tance to the sick. It is for this is led to question himself about the last two types professional reason that the Church invent- the fundamental questions of condemnation was extremely ed the very concept of the ‘hos- life: the meaning of birth, of clear. pital’ and largely contributed to suffering, of death. The Church Things have changed deeply developing those features we is aware that a correct answer over past decades. The avail- nowadays have before us. to these questions can also in- ability of methods of pharma- Even when the modern States, fluence the answer to other cological contraception, the after the French Revolution, questions on which the reli- feminist movement, the intro- began to be interested in gious consciousness of man is duction of abortion into a large health, in order to keep high founded. Who am I? Where am number of sets of legislation, the ideal of health care the I going? What meaning does the growing possibilities of- Church favoured the founding my life have? The need to re- fered by genetics to discover of Catholic health care institu- gain health can, that is to say, illnesses before birth, the de- tions all over the world: from lead to asking for salvation velopment of techniques of in the prestigious great hospitals (salus). vitro fertilisation, the conse- and faculties of medicine of It is for these reasons that, quent production of embryos Catholic universities to the dis- even in non-Catholic hospitals with the objective of curing pensaries in the missionary the Church has always favoured sterility, their availability to countries. Today, the Church is the presence of chaplains, of scientific research, the discov- still the major single non-gov- sisters belonging to nursing Or- ery of the potential of embry- ernmental health care provider ders, of doctors and nurses with onic cells for the development in the world. Catholic training and faith, and of useful tissues for transplan- This enormous effort was of volunteers inspired by the tation for the cure of degenera- not, and is not, aimed only at model of the Good Samaritan. tive illnesses, and the hypothe- making up for a lack of concern In this sense, the specialist sis of total or partial cloning, on the part of governments in doctor in obstetrics-gynaecolo- which has already been carried relation to some forms of gy and the obstetric nurse share out with animals, have all radi- poverty and marginalisation; the responsibility of every cally changed the scene.

DOLENTIUM HOMINUM N. 48-2001 Pregnancy and childbirth are in some developing countries to compromise and conformity, no longer seen as acts which in the world and in some disad- so as not to have to abandon the are, most of the time, physio- vantaged social strata in devel- profession. logical in character; they are, oped countries. This conflict takes place instead, often experienced as a The Catholic obstetrician-gy- every time the young doctor is disgrace and an illness which naecologist and the midwife asked to apply abortive intra- the doctor must take it upon are naturally in the middle of venous infusions during a peri- himself to cure. A child is no these tensions and changes. od of rotating internship, when longer seen as a gift, but as an The Catholic obstetrician-gy- he or she is asked about his or her independence from ‘reli- gious prejudices’ before he or she can have access to pro- grammess of specialisation, when during the period of training for specialisation he or she is forced to take part in stages of activity, foreseen in the curriculum of his studies, that require the performance of abortions or taking part in tech- niques of artificial fertilsation; when, after specialisation, he or she is refused jobs because they are reserved to personnel 79 who will guarantee all the ac- tivities of the service, abortions included; when some career possibilities are closed to him or her because he or she does not have experience in all the professional fields that the managing role requires; and when, lastly, the agencies of the United Nations or of other funding centres refuse the re- quests of NGOs which do not include abortion and sterilisa- tion among the methods for en- object of desire, to be made on- naecologist has always been suring family planning in de- ly if one wants one, when one the doctor of women, and he or veloping countries in their pro- wants, and to be accepted only she feels the pressure of a so- jects of international health if the gift is well packaged and cial ideology that would like to care co-operation. not damaged. make him or her an instrument If to this we add the fact that Medicine no longer has as its to by which to achieve repro- in any case the Catholic obste- objective the defence of life - it ductive health, understood in trician-gynaecologist faithful to is more worried about the qual- the terms mentioned above, in the Magisterium of the Church ity of life. International organi- a safe and efficient way, and is seen as a backward character, sations have given up the fight by which to develop the new one cannot be surprised if to ensure that fundamental technologies of reproduction everywhere Catholic obstetri- rights of health care are upheld in an unhindered way. While cians-gynaecologists are di- for all populations and social this pressure is being applied minishing in number and in strata; they are only concerned to his or her conscience, he or some situations risk disappear- about reducing the request for she also feels the responsibility ing completely. such rights, thereby favouring a of being the doctor of the Yet, this continuous, progres- fall in the birth rate all over the youngest and weakest among sive decrease of Catholic obste- world. men, the defender of those tricians-gynaecologists seems The ambiguous term ‘repro- who have no voice, who ex- to have taken place without ductive health’ has been creat- press no vote, who have no provoking excessive alarm in ed, behind which, together with economic or social weight. the Church. the prevention and control of In some situations the con- While, rightly, abortion has gynaecological illnesses, con- flict between social pressure continued to be condemned, traception, abortion, sterilisa- and the responsibilities of con- natural methods of planning tion, and a fall in the birth rate science can become unbear- have been proposed, the dan- are propagated, offered to and able. It can lead, on the one gers for the future of human imposed on governments and hand, to an abandonment of the civilisation involved in embryo health workers, while we con- profession, so as not to subject manipulation (for scientific tinue to overlook maternal the conscience to what is unac- purposes, for the cure of sterili- mortality, which is still too high ceptable, or, on the other hand, ty, for the selection of carriers

DOLENTIUM HOMINUM N. 48-2001 of genetic illnesses, and for the cialised in obstetrics can make pitals, clinics and convalescent production of stem cells) have a valuable contribution to the facilities. Those who have re- been denounced, perhaps we sexual education of young course to conscientious objec- have not sufficiently realised women, and to the preparatory tion must be protected not only that the defence against these courses for marriage. from legal penalties but also ills has become increasingly Only an obstetrician-gynae- from any negative effects on weaker as Catholic obstetri- cologist can contribute to the the legal, disciplinary, financial cians-gynaecologists have dis- education of future medical and professional plane.’ appeared and those remaining doctors and of future midwives We must make this appeal ended up by almost feeling in the respect of life. Only a ours and we must actively un- guilty at their own convictions. medical doctor who loves life dertake works and initiatives To whom in fact does a can promote research that is re- that will make it effective. woman address herself in order spectful of man. Some actions seem to be partic- to obtain information about It is for these reasons that the ularly necessary. how to control her fertility? Catholic obstetrician-gynaecol- Local Churches have to keep From whom does she ask ad- ogist medical doctor must not their attention focused on the vice in order to solve difficul- disappear. We must be alert so medical profession, proposing ties in the couple’s sexual life? as to ensure that this does not the ideal of a profession re- Whom does she wish to talk to happen, so that the right to be spectful of life, standing by when an undesired pregnancy trained and to exercise the pro- those health workers who re- radically upsets her planes and fession according to conscience spect the right to life, and par- those of her family? From is respected; we must object ticularly obstetricians-gynae- cologists, favouring their en- 80 counter and their self-expres- sion at a cultural level. The condemnation of cases involving the violation of the right to be trained and practice according to one’s own moral convictions must be co-ordinat- ed and systematic; it must reach the desks of the media, of professional associations, and of national and international or- ganisations for the defence of whom does she ask help in or- every time this right is violated; human rights. der to overcome the ever more we must help those who have Catholic universities and frequent cases of sterility? suffered discrimination be- hospitals must fully respect The woman first of all seeks cause they have borne witness the indications of the Magis- the help of a specialist doctor in to their loyalty to the teachings terium, both as regards re- obstetrics and gynaecology, a of the Church. search involving embryos and women’s doctor. This doctor, in This is the appeal of the Pope in all the spheres of obstet- fact, is also their confidant, the in the encyclical Evangelium ric-gynaecological practice, keeper of their innermost se- Vitae (no. 74): ‘To refuse to while bishops should feel re- crets, perhaps even more so take part in committing an in- sponsible for monitoring mat- than the confessor. justice is not only a moral duty; ters so that examples of mis- A medical doctor who is re- it is also a basic human right. conduct can be prevented, spectful of the needs of morali- Were this not so, the human which, despite everything, ty and who is convinced of the person would be forced to per- continue to take place. Magisterium of the Church can form an action intrinsically in- The same institutions should help a woman to experience compatible with human digni- provide a qualified and interna- her doubts and difficulties in ty, and in this way human free- tionally recognised teaching the light of faith. Only an ob- dom itself, the authentic mean- network to allow those medical stetrician who is convinced of ing and purpose of which are doctors who are discriminated his or her own responsibilities found in its orientation to the against or who are subjected to as a counsellor and guide of a true and the good, would be unacceptable pressures as re- Christian woman can con- radically compromised. What gards their moral beliefs at tribute to the strengthening of is at stake therefore is an essen- least the possibility of special- the family, to the culture of tial right which, precisely as ising in obstetrics and gynae- welcoming the newborn child such, should be acknowledged cology. as a gift. Only a Catholic obste- and protected by civil law. In trician-gynaecologist can sug- this sense, the opportunity to Dr. GIAN LUIGI GIGLI gest the use of natural methods, refuse to take part in the phases President of the World Federation can make the woman reflect of consultation, preparation of Catholic Medical Associations, upon the consequences of abor- and execution of these acts Member of the Pontifical Council tion, can advise her to adopt a against life should be guaran- for Health Pastoral Care baby rather than undergo IVF. teed to physicians, health-care Only a Catholic doctor spe- personnel, and directors of hos-

DOLENTIUM HOMINUM N. 48-2001 The Year 2001: The Activity of the Pontifical Council for Health Pastoral Care

Introduction tions of the Ministry, the World achieve their unification; the or- Health Organisation, the pas- ganisation and the celebration The work-plan for the Pontif- toral manual on drug-addicts, of the World Day of the Sick; ical Council for Health Pastoral the guidebook on pastoral care the universal right to health; the Care, which was created by the in health, conferences, the inter- Christian communication of Plenary Assembly in 1998 and national conference, research, goods; emergency illnesses: subsequently approved by the teaching centres, and the Pontif- AIDS, leprosy, and drug-addic- Holy Father, has fifty pro- ical Council’s special ‘dossiers’. tion; the relations between the grammes organised around the In the ministry of sanctifica- Ministries of the Roman Curia; Ministries of the Word, of Sanc- tion, an attempt was made to the bishops responsible for pas- tification and of Communion, sanctify the sick person and in toral care in health; the nuncia- and is entrusted to the eighteen general the world of health and tures; ‘ad limina’ visits, the people who make up the Min- health care by employing seven Ministry’s participation in, and istry - the Superiors, the Offi- programmes of notable impor- representation at, congresses cials, and the collaborators. Em- tance. These programmes in- ploying this work-plan, the volved: baptism, the anointing Pontifical Council in the year of the sick, other sacraments, 81 2001 as well engaged in intense the book of prayer and sacra- work directed towards ‘express- ments, the World Day of the ing the solicitude of the Church Sick, prayers, and the ‘Inten- for the infirm by helping those tion’ of the Apostolate of who engage in service to the Prayer. sick and the suffering so that the In the ministry of commu- apostolate of compassion that nion, which has thirty-two pro- they await will answer in an in- grammes to develop, the aim creasingly better way to new was: to attain solidarity-in- needs’ (Pastor Bonus, art. 152). spired communion with sick With regard to the Ministry people and health care workers of the Word, which has eleven throughout the Church. For this programmes, the following ac- reason, the above-mentioned tions were engaged in: an at- programmes sought to strength- tempt was made to give a mean- en or achieve this solidarity-in- ing to life and suffering, and to spired communion. These were nature and its manipulation, ex- programmes which involved the plaining such meanings, dis- Union of Catholic Medical seminating them, and extending Doctors, Nurses and Pharma- them to everyone, and in partic- cists and support for their asso- ular to those bishops who are ciations in the world, above all responsible for pastoral care in at an international level. In this health within their bishop’s con- plan, which aimed at the unifi- ferences. In this area, the cele- cation of pastoral care in health bration of the sixteenth interna- throughout the world, of great tional conference, the publica- importance as well was the cre- tion of the Pontifical Council’s ation of an International Union review Dolentium Hominum, of Catholic Hospital Chaplains the taking part in various con- and the Union of Catholic hos- gresses, conferences, and semi- pitals. Reference should also be nars by the Superiors and Offi- made here to the importance of and meetings outside the city of cials of the Ministry, etc., the Union of Hospital Religious Rome, where it is located; pas- proved to be of great help. and the bishops responsible for toral visits and journeys, etc. In With regard to the evangeli- pastoral care in health in their the work-plan account was also sation of the faculties of medi- bishops’ conferences. In addi- taken of the internal administra- cine, the Pontifical Council tion, an attempt was made to in- tive programmes of the Min- sought to keep in contact with crease the pastoral action of istry that form a part of the the most important Catholic Catholic voluntary workers in sphere of the sector of commu- faculties of medicine, of phar- the world of health care and to nion, that is to say: the secretari- macy, and of law, in order to increase the number of, and ex- at, the administration, the promote and secure the teaching pand, the associations of sick archives’ room, the documenta- of suitable courses in the future. people. Amongst the various tion section, the keeping and The other programmes promot- programmes in the sectors of cataloguing of documents and ed in the sector of the Word communion, reference may be publications. with due commitment and en- made to: the bioethical centres The above-mentioned fifty deavour related to: the publica- and the attempts made to programmes were implemented

DOLENTIUM HOMINUM N. 48-2001 under the guidance of the Presi- the dignity of suffering man’ Detailed information on this dent of the Ministry, H.E. Msgr. was the subject of this Ninth celebration can be obtained by Javier Lozano Barragán, with World Day of the Sick, and its readers in the review of the due commitment and endeavour particular aim was to lay em- Pontifical Council, Dolentium on the part of all the members phasis upon the need to evange- Hominum, number 47/2001. of the Ministry. The results gave lise this sphere of the human ex- rise to great satisfaction. perience in a renewed way, in In relation to this point, we order to favour it being directed 3. Participation in the would like to present in a more towards the overall well-being Tenth Ordinary General detailed fashion some of the of the person and towards the Assembly of the Synod salient features of the activity progress of all people in every of Bishops and the life of the Pontifical part of the world. Council during the course of the In the pontifical mission ac- The President of the Ministry, whole of 2001. companying H.E. Cardinal Ed- H.E. Msgr. Javier Lozano Bar- ward Clancy, the Special Envoy ragán, took part as an ex officio of His Holiness to the Ninth member in the above-men- 1. Appointments within World Day of the Sick, were tioned assembly which took the Ministry Rev. Krzysztof Nykiel, an Offi- place in the Vatican from 30 cial of the Pontifical Council for September to 27 October. Its Ð On 20 August 2001 the Health Pastoral Care, Dr. John subject was Epsicopus minister Holy Father renewed in aliud Callagher, and Judge John Slat- Evangelii Iesu Christi propter quinquennium the appointment tery. spem mundi. The Pontifical of H.E. Msgr. Javier Lozano Archbishop Javier Lozano Council contributed both to the Barragán, the Archbishop-Bish- Barragán, President of the Pon- preparatory stage and to the cel- 82 op Emeritus of Zacatecas, as the tifical Council for Health Pas- ebration of the Synod itself. The President of the Pontifical toral Care, together with the material drawn up and the con- Council for Health Pastoral Bishop-Secretary of the Pontifi- tributions made by the President Care. cal Council, Msgr. José L. Re- both in the conference hall and Ð By notes from the Secre- drado, O.H., led the delegation during the deliberations of the tariat of State, the Holy Father of a group of sixteen people: circuli minores on specific on 9 April 2001, confirmed in Officials of the Ministry, questions and issues met with aliud quinquennium H.E. Msgr. prelates, priests, religious and the support of the Synod Fa- José L. Redrado as Secretary of members of the laity who have thers. They agreed on the im- the Pontifical Council for always been involved in pas- portance of pastoral care in Health Pastoral Care, and Rev. toral care in health. health and increasing the pro- P. Felice Ruffini, M.I. as Un- The salient characteristic of claiming of the Gospel of hope der-Secretary of the same Pon- the celebration of the Ninth in the field of health and suffer- tifical Council until the age of World Day of the Sick was the ing by the pastors of the seventy. involvement of the Pontifical Church. Ð By notes from the Secre- Council for Health Pastoral tariat of State, the Holy Father Care, the Australian Bishops’ on 20 July 2001 appointed Rev. Conference of Catholic Bish- 4. Inter-Ministerial Krzsztof Jósef Nykiel, priest ops, and the Episcopal Com- Meetings of the Archdiocese of Lodz mission for Pastoral Care in (Poland), and Rev. Antonio So- Health. This convergent co-op- Within the context of the to Guerrero, priest of the Dio- eration made possible not only a Ministry of Communion, the cese of Zacatecas (Mexico), suitable preparation and cele- Pontifical Council strongly both Officials of the Ministry, bration of this Day, but also its maintained and sustained its re- ‘Chaplain to His Holiness’. special sensitising force in rela- lations with the other Ministries tion to increasingly large num- of the Roman Curia, and took bers both of the lay faithful and part in various inter-Ministerial 2. The Celebration of female religious and female meetings: of the Ninth World Day laity who are active in the field Ð At the Pontifical Council of the Sick of health and suffering. ‘Justice and Peace’ Rev. The salient moments of the Krzysztof Nykiel, an Official of The Ninth World Day of the celebration which marked the the Ministry, took part on 31 Sick of the year 2001 was days of 8-9-10 February, culmi- March in the inter-Ministerial solemnly celebrated in the nating in the concluding solemn meeting on preparations for the Cathedral of St. Mary’s in Syd- celebration of the Ninth World World Day of Peace (2002). ney, Australia. ‘The choice of Day of the Sick on 11 February, Ð At the Pontifical Council the Australian continent with its were the following: visits to a for Culture on 11 May Rev. An- cultural and ethnic richness’, as number of hospitals and clinics toni Soto, an Official of the the Holy Father observed in his (8-9 February), the meeting Ministry, took part in the special Message for this Day, with the Mayor of Sydney and inter-Ministerial meeting on the ‘illuminates the close tie of ec- the civil and ecclesiastic author- subject: ‘cultural identity in the clesial communion: it goes be- ities (9 February), the confer- era of globalisation: nostalgic yond distances, favouring en- ence on ‘the new evangelisation temptation or challenge for the counter between different cul- and the dignity of the suffering Church’. tural identities, fertilised by the person’ (10 February), and the Ð At the Pontifical Council unique proclaiming of salva- solemn celebration that was for Inter-Religious Dialogue tion’. ‘The evangelisation and held on 11 February. Rev. Krzystof Nykiel, an Offi-

DOLENTIUM HOMINUM N. 48-2001 cial of the Ministry, took part on meetings held during the period M.I. Under-Secretary of the the morning of 1 June in an in- of Lent, the Secretary of the Ministry, took part in the na- ter-Ministerial meeting and pre- Ministry, H.E. Msgr. José L. tional conference on ‘the Italian sented a number of observations Redrado, gave a paper on the Church in the world of health on the draft version of the docu- subject: ‘accompanying life in and health care’ organised by ment entitled: ‘A Christian Spir- weakness: illness and death’. the National Office for Pastoral ituality of Inter-Religious Dia- Ð From 20 to 23 March, in the Care in Health of the Italian logue’. Vatican, H.E. Msgr. Javier Bishops’ Conference, and gave Ð At the Pontifical Council Lozano Barragán, the President an address of greeting to the for the Family from 27 to 28 of the Ministry, took part in the participants. June the Secretary of the Min- plenary meeting of the Pontifi- Ð From 14 to 16 May, in istry, H.E. Msgr. José L. Redra- cal Commission for Latin Paris, the Official of the Min- do, took part in an inter-Minis- America and gave a paper on istry, Rev. Msgr. Jean-Marie terial meeting with a group of the subject: ‘Indios Theology’. Mpendawatu, took part as an members of the European Par- Observer of the Holy See in the liament in order to examine cer- APRIL Second Session of the Intergov- tain subjects and issues relating Ð From 2 to 4 April, at Ham- ernmental Committee on to the family as well as connect- mamet (Tunisia), Dr. Renzo Bioethics of UNESCO. ed ethical questions, and to ex- Paccini, a collaborator of the Ð From 15 to 22 May, in amine subjects and issues con- Ministry, took part as a repre- Geneva, the President of the nected with human life. sentative of the Pontifical Ministry, H.E. Msgr. Javier Council in the First Mediter- Lozano Barragán, took part as ranean Congress on Disability, head of the delegation of the which had been organised by Holy See, in the fifty-fourth ses- the ‘Opera Don Guanella’ in sion of the World Assembly on 83 conjunction with the Ministry Health Care, and presented dur- for Social Affairs of Tunis, the ing his speech a ‘position paper’ Church of Tunisia, and the of the Holy See on access to ba- ‘Oasi Federico’ Association for sic medicines for the poorest Solidarity and Rehabilitation populations of the world and on Studies of Calabria. It may be the juridical and economic observed that Calabria is a structures, including intellectual hinge region for the Mediter- property rights, which can ob- ranean. Dr. Paccini gave a paper struct such access. Rev. Msgr. on the subject: ‘human dignity Jean-Marie Mpendawatu, an in disabled people: a point of Official of the Pontifical Coun- departure for solidarity towards cil, was also a member of this them’. delegation. Ð On 26 April, in Rome, Rev. Krzysztof Nykiel, an Official of JUNE the Ministry, took part as a rep- Ð From 1 to 4 June, in Lodz resentative of the Pontifical and Krakow, accompanied by Council in the national confer- Rev. Krzysztof Nykiel, an Offi- ence of pre-surgical dentistry or- cial of the Ministry, H.E. Msgr. ganised by the Italian Society of José L. Redrado, in response to Odontostomatology and Maxil- an invitation extended by Frà lo-Facial Surgery (SIOCMF) Ambrozy Pietrzkiewicz, Provin- 5. Participation in, under the patronage of the ‘Col- cial of the Polish Province of the and Representation at, lege of Lecturers in Dentistry’ Fatebenefratelli, presided over a Conferences, Congresses under the Presidency of Prof. concluding concelebration of and Celebrations Giovanni Dolci, and gave an ad- the Eucharist on the fourth cen- dress of greeting to the partici- tenary of St. John the Great with Another programme of the pants. a homily suitable to the occa- Ministry of the Word was par- sion and took part in the sympo- ticipation in, and representation MAY sium on pastoral care in health at, conferences, congresses and Ð From 7 to 11 May, in on the subject of ‘the terminal- celebrations. The Superiors and Barcelona, the President of the ly-ill sick person amongst us’. Officials of the Ministry were Ministry, H.E. Msgr. Lozano Both in Lodz and in Krakow the involved in these throughout the Barragán, and the Secretary, President of the Pontifical year 2001: H.E. José L. Msgr. Redrado, Council visited the hospital took part in the twelfth national structures of the Order and met MARCH congress of hospitals on the medical staff and personnel, and Ð On 13 March Rev. subject ‘El hosptal y la salud, members of the community of Krzysztof Nykiel took part, as a más allá de la gestión’ organised the Fatebenfratelli. H.E. Redra- representative of the Ministry, by the Federación Española de do held three conferences on the at the ‘Colloquium’ on Prof. Gestión Sanitaria. The President following subjects: ‘the hospi- Gesulado Nosengo, which was gave a paper on the subject: tality of the Fatebenefratelli at organised by the Pontifical Ur- ‘Aportes para la identidad de un the beginning of the third mil- banian University. hospital católico’. lennium’, ‘the faces of suffering Ð On 14 March, in Rome, on Ð From 10 to 12 May, in Fi- and death’, and ‘consecration, the occasion of the pastoral uggi, Rev. P. Felice Ruffini, koinonia, and mission’.

DOLENTIUM HOMINUM N. 48-2001 Ð From 5 to 7 June, in Puebla Msgr. Javier Lozano Barragán cia en el Centro de Salud’, de los Ángeles (Mexico), H.E. took part in the proceedings and ‘Ejercicio de la Capitalidad de Msgr. Javier Lozano Barragán deliberations of the Sixth Gen- Cristo en al accion pastoral del took part in the meeting of the eral Assembly of the Pontifical Capallán’, and ‘La formación Members and Consultors of the Academy for Life on the sub- especifica del Capellán a través Pontifical Council for Culture, ject: ‘human nature and natural de las Asociaciones y Frater- as well as the First American In- law as a foundation of the right nidades’. tercontinental Conference of the to life’. Ð From 13 to 15 September, in Presidents of the Episcopal Rio de Janeiro (Brazil), accom- Commission for Culture of the AUGUST panied by Dr. Renzo Paccini, a Bishops’ Conferences of Ameri- Ð From 26 to 29 August, in collaborator of the Ministry, ca. He gave a paper on the sub- Seoul (Korea), accompanied by H.E. Msgr. Lozano Barragán ject: ‘Globalización de la salud Rev. Antonio Soto, an Official took part in the third Brazilian en la sociedad secularizada: re- of the Ministry, H.E. Msgr. congress of Catholic medical tos para Evangelización de la Javier Lozano Barragán took doctors on the subject ‘Vida Hu- cultura’. part in the eighth regional con- mana, Ciencia y etica’, which Ð On 7 June, on the occasion ference of the Asian continent had been organised by the Fed- of the feast of San Camillo de of the International Catholic eration of the Latin American Lellis, H.E. Msgr. Redrado Committee of Nurses and Med- Associations of Catholic Med- presided, at the San Camillo ical-Social Workers (CICI- ical Doctors (FAMCLAM). The hospital in Rome, over a cele- AMS) which was held on the President of the Ministry held a subject: ‘the protection of hu- conference on the subject: ‘Iden- man life in a changing world: tidad y Ministerio del Médico the responsibility of the Catholic Católico’. 84 heath care worker’. The Presi- Ð From 24 to 27 September, dent of the Pontifical Council in Madrid, H.E. Msgr. José L. gave a paper on ‘the protection Redrado took part in the Six- of human life in a changing teenth National Day of Pastoral world: the responsibility of Care in Health on the subject: Catholic obstetricians’. ‘Orar en la Enfermadad’, which had been organised by the Epis- SEPTEMBER copal Commission on Pastoral Ð From 1 to 8 September, in Care in Health of the Bishop’s Taipei (Taiwan), accompanied Conference of Spain. The Sec- by Rev. Antonio Soto, an Offi- retary of the Pontifical Council cial of the Ministry, H.E. Msgr. gave a paper under the heading: Lozano Barragán took part in ‘Lord: teach us how to pray (Lk the meeting of Catholic medical 11:1-4)’. doctors, nurses and medical stu- Ð From 27 September to 1 dents organised by the manage- October, H.E. Msgr. José L. Re- ment of the St. Mary’s hospital drado, the Secretary of the Min- of Loutung of the Camillian fa- istry, went to Mexico City and thers, on the occasion of the took part in the commemorative fiftieth anniversary of the mis- ceremonies to mark the ‘cente- sionary presence of Camillians nary of the restoration of the Or- in Formosa. The President gave der of St. John of God in Mexi- a paper on the subject: ‘the pro- co by San Benedetto Menni’. bration of the Eucharist and tection of human life in a He presided in the Sanctuary of gave a homily which stressed changing world: the responsi- Our Lady of Guadalupe over the the extraordinary importance of bility of health care profession- concluding solemn concelebra- San Camillo di Lellis and Santa als’. In addition, H.E. Msgr. tion of the Eucharist and gave a Giovanna Antida Thouret. Lozano Barragán visited the homily on that occasion. In ad- Ð From 25 to 27 June, in New various institutions of the dition, the Secretary of the Pon- York, the President of the Min- Camillians, met the medical tifical Council held two confer- istry, H.E. Msgr. J. Lozano Bar- staff and personnel of the hospi- ences on the following subjects: ragán, took part, as head of the tal in Lotung, as well as the ‘life, illness, and death’ and delegation of the Holy See, in sick, and the whole of the ‘consecration, koinonia, and the special session of the Gener- Camillian community. mission’. al Assembly of the United Na- Ð From 10 to 11 September, tions dedicated to the questions in Rosario (Argentina), the OCTOBER and issues connected with President of the Ministry, H.E. Ð From 9 to 13 October, in HIV/AIDS, and presented the Msgr. Lozano Barragán, took preparation for the celebration position of the Holy See on such part in the first conference of of the Tenth World Day of the questions and issues. Rev. P. Fe- hospital chaplains, organised Sick, accompanied by Rev, Vin- lice Ruffini, the Under-Secre- by the Episcopal Commission cent Arackal, a collaborator of tary of the same Ministry, was for Pastoral Care in Health of the Ministry, H.E. Msgr. also a member of this delega- Argentina, which focused on Lozano Barragán and H.E. Ms- tion. the following subjects: ‘Los gr. José L. Redrado went to the Professionales de la Salud, sanctuary of the ‘Madonna of JULY Servidores de la Vida’, ‘El Health’ in Vailankanny (India). Ð On 7 July, in Rome, H.E. Capellán: su perfil y la presen- A series of meetings were held

DOLENTIUM HOMINUM N. 48-2001 with the Episcopal Commission 6. The Sixteenth truth about man and God, and in for Pastoral Care in Health and International Conference its exercise respecting charity the organising committee. towards one’s neighbour in From 15 to 17 November the need, serves the health of man NOVEMBER sixteenth international confer- and of peoples in their harmo- Ð From 10 to 13 November, ence promoted and organised nious movement towards the in Rome, Rev. Krzysztof by the Pontifical Council for fullness of life. Nykiel, an Official of the Min- Health Pastoral Care was held During the proceedings and istry, took part as a representa- in the New Hall of the Synod. deliberations of the conference tive of the Pontifical Council at The subject of this sixteenth in- the eminent speakers focused in the Colloquium on the subject: ternational conference was on the following subjects: the ‘prayer for healing and charis- ‘health and power’. power of the economy in the matic renewal in the Catholic Under the guidance of H.E. world of health; power and Church’ which had been organ- Msgr. Javier Lozano Barragán, health care policy; power, ised by the Pontifical Council the President of the Ministry, health and society; the power of for the Laity together with the Cardinals, Archbishops, Bish- the mass media; the power of International Catholic Charis- ops, male and female religious, health care workers; the power matic Renewal Services (IC- and members of the lay faithful, of the pharmaceutical indus- CRS). from sixty countries, came to- tries; the power of international Ð On 13 November, in Rome, gether to attend this internation- organisations; religious power the President of the Ministry, al conference. All these people and health; power and health in S.E. Msgr. Javier Lozano Bar- were involved in the world of the context of inter-religious di- ragán, inaugurated the delibera- health, health care and suffering alogue with Judaism, Islam, tions and proceedings of the and/or were specialised in the Hinduism and Buddhism; and round table on the subject: various disciplines of the hu- power and health in history and 85 ‘community and health’ which manistic, social, biomedical in theology. had been organised by the and theological-pastoral sci- The participants at the con- ‘Camillianum’ International In- ences. ference were received by the stitute for the Theology of Pas- A large number of ambas- Holy Father at an audience held toral Care in Health. sadors and Ministers of Health, in the Paul VI Hall. In an au- Ð From 22 to 24 November, numerous students from med- thoritative address John Paul II in the Vatican, Rev. Krzysztof ical schools, and a large number emphasised among other things Nykiel, an Official of the Min- of students of the nursing sci- that ‘in the world of health, the istry, took part as a representa- ences, and of the theology of exercise of power should not be tive of the Pontifical Council in pastoral care in health, took part inspired by the wish for domin- the theological-pastoral con- in the proceedings and delibera- ion or profit but should be ani- gress on the subject: ‘Familiaris tions of this international con- mated by a sincere spirit of ser- Consortio yesterday and today ference. vice to the dignity of the human on its twentieth anniversary: the Amongst the distinguished person and the common good’. anthropological and pastoral di- speakers at the international The Holy Father also empha- mension’, which had been or- conference were: Cardinals, sised that health understood as ganised by the Pontifical Coun- Bishops, eminent researchers, physical, mental and spiritual cil for the Family. and scientists and scholars of health, and as health care, is the Ð On 23 November, in Rome, the humanistic, social, biomed- first, the most authentic, univer- Dr. Renzo Paccini, a collabora- ical and theological-pastoral sal and greatest power, because tor of the Ministry, took part as sciences. it is a force directed towards the a representative of the Pontifi- The President of the Ministry, fullness of life; and to under- cal Council in the first confer- H.E. Msgr. Javier Lozano Bar- stand and live out correctly ence of the Federation of the ragán, introduced the proceed- every form of ‘power’ in the Associations for Assistance to ings and deliberations of the world of health one must fix Disabled People. conference, and His Eminence one’s gaze upon Christ who Cardinal Fiorenzo Angelini, the came not to be served but to DECEMBER President Emeritus of the same serve, thereby teaching us to ex- Ð On 15 December, in Rome, Ministry, opened this important ercise every form of power as the Secretary of the Ministry, annual conference with an inau- service to our neighbour. H.E. Msgr. José L. Redrado, gural address on ‘health and presided over a celebration of power in the light of the word of the Eucharist at the inaugura- God’. 7. The International tion of the school year of the The general subject ‘health Symposium on Catholic ‘Beato Luigi Tezza’ nursing and power’ was addressed by Voluntary Work in Health school, and gave a homily at the various speakers in the light of Care on the theme time of that celebration. the word of God and theology ‘Vade et tu fac Similiter’ Ð On 21 December, in prepa- so as to bring out the contempo- ration for the Christmas cele- rary biomedical challenges to With the aim of achieving the brations, H.E. Msgr. José L. Re- health and health care which unification of pastoral care in drado presided over a celebra- come from the power of the health throughout the world, the tion of the Eucharist in the economy, of politics, of the sci- Pontifical Council for Health Basilica Liberiana di Santa ences, of technology, of culture Pastoral Care promoted and or- Maria Maggiore for the mem- and of society, as well as to con- ganised an international sympo- bers of the Norman Academy. sider the moral requirement of a sium on ‘Catholic voluntary power which, respecting the work in health care’. This took

DOLENTIUM HOMINUM N. 48-2001 place in the Vatican on 30 No- the symposium focused in on person, especially if he or she is vember to 1 December 2001. the following subjects: weak or fragile. It is he who The celebration of this impor- Ð The Magisterium of John took on painful humanity in or- tant symposium, strongly Paul II on voluntary work. der to restore to it the transfig- wished for specifically in the Ð The biblical and theological ured countenance of the resur- year 2001, which the United foundations of voluntary work. rection. With their gaze fixed on Nations had officially declared Ð From the Good Samaritan Christ, Christian voluntary as the International Year of Vol- to the Ecclesial Community of workers are bearers of hope, in untary Work, was a valuable op- the third millennium. the bitter experience of suffer- portunity for a new and more During the ‘round table’ dis- ing and precariousness as well, involving reflection on an as- cussion certain important forms fully respecting the dignity of pect of service to life which, in of witness based on life-experi- every human being. Catholic the Church, following the ex- ences were communicated one voluntary work is called upon to ample of Christ, has found, after another: by a sick person, a base its strategy on the charity from the outset, a new and ex- medical doctor, a voluntary of works, the real point of en- emplary impulse. worker, representatives of the counter for service to charity Under the guidance of the ‘Misericordie’ and of the Red and an effective instrument for President of the Ministry, His Cross, etc. the credibility of the Gospel of Excellency Msgr. Javier Lozano The first day of December Christ. Barragán, an attempt was made 2001 coincided with the World The service of voluntary to engage in a careful reflection AIDS Day and was dedicated to work is service to life, and as on the role of Catholic volun- reflection upon health care giv- such is a providential space for tary work in the world of health en to people suffering from intercultural dialogue and and suffering today; to identify AIDS; to people who live in co-operation with voluntary 86 future strategies by which to in- very bad conditions in cities - workers of other religions or crease pastoral action; and the homeless, drug-addicts...; to who are non-believers, because above all else to offer to the emigrants and refugees; to peo- the defence and promotion of Holy Father an opportunity to ple who are the victims of polit- life is entrusted to everyone. emphasise the fundamental ical conflicts and wars; to peo- principles by which to illumi- ple afflicted by catastrophes nate this gospel-inspired form such as earthquakes and floods; 8. Publishing Activity of participation in the suffering to the elderly, to the terminal ill, of one’s neighbour, specifically and to children, whether they Publishing activity is a part of during the year dedicated by the are in public or private institu- the programmes of the ministry United Nations to voluntary tions or live in their own homes. of the Word. We would like work. The large number of partici- above all else to point in this Amongst the distinguished pants were received by the Holy context to the journal of the speakers who intervened during Father in an audience held in the Ministry, Dolentium Hominum. the two days of reflection and Paul VI Hall. In his authoritative Church and Health in the witness from life experience, address the Holy Father empha- World, which came out regular- there was the Secretary of State, sised that in our society, which ly. It is offered to readers in four His Eminence Cardinal Angelo often feels the influence of ma- separate language editions (Ital- Sodano, who opened this im- terialism and hedonism, the vi- ian, Spanish, French and Eng- portant event with his opening tality of voluntary work is a lish). One of its issues contains address on the subject ‘Catholic promising sign of hope. The the complete proceedings of the voluntary work in health care’. presence of voluntary work fifteenth international confer- The representatives of States must be more than ever before ence organised and promoted and governments also took part animated and experienced in its by the Pontifical Council on the in the deliberations of the sym- truth of selfless service to the subject ‘health and society’. posium, as well as a large num- good of people, especially those The Charter for Health Care ber of voluntary-work associa- most in need and most forgotten Workers, which was published tions. about by the social services in 1994 in Italian as a result of The general subject of themselves. Voluntary work is the efforts of the Ministry, has ‘Catholic voluntary work in specifically marked out by its so far been translated and pub- health care’ was addressed by capacity to bear witness to lished by different countries in various speakers in the light of freely-given love to one’s neigh- the following languages: Span- the word of God, theology, and bour. ish, English, French, German, the Magisterium of the Church The Holy Father also empha- Dutch, Polish, Russian, Czech, so as to bring out the major sised that in order to under- Slovene and Rumanian. With challenges for voluntary work- stand, promote and live out the nulla osta of the Pontifical ers, and especially those who every form of voluntary action, Council the publication of the work in the field of health. The especially in the world of health Charter for Health Care Work- witness and life-experiences of and suffering, it is essential to ers in Hungarian and Lithuan- a number of voluntary workers, fix one’s gaze on the Counte- ian is also underway. This work who are involved in a large nance of Christ, who is the per- is also currently being translat- number of forms of solidarity fect model for Christian volun- ed into Madagascan, Albanian, and work in the name of the tary work. He who came not to and Thai. Church at the side of the poor be served (cf. Mt 20:28) but to Four editions in Spanish (two and the suffering, were not ab- serve teaches us that the service in Mexico, one in Peru, and one sent. of voluntary workers is a ser- in Colombia) have been issued The distinguished speakers at vice of freely-given love to the of the book by the President of

DOLENTIUM HOMINUM N. 48-2001 the Ministry, H.E. Msgr. Javier L. Redrado, was appointed one ambassadors, heads of organisa- Lozano Barragán, Telogia e of the members of the Norman tions and associations of the Medicina (‘Theology and Medi- Academy as Grand Spiritual world of health, and all those cine’), as well as an edition in Prior. who work in the vast field of Italian (Edizioni Dehoniane, pastoral care in health, was also Bologna). continued. The Manuale di Pastorale: 10. Conclusion The meetings with bishops Chiesa, Droga e Tossicomania who were on ad limina visits (‘A Pastoral Guidebook: the The above-mentioned pro- were of great help because they Church, Drugs, and Drug-ad- grammes of the work-plan of allowed the Pontifical Council diction’), written by the Min- this Pontifical Council in- to have a more direct knowl- istry, was also published. It is volved, in the first instance, the edge of the various problems of directed, as requested by the Superiors, Officials and internal pastoral care in health of the lo- Holy Father, to bishops, priests, and external collaborators of the cal Churches, a sine qua non in male and female religious, and Ministry. At the headquarters of order to be able to offer relevant members of the laity involved the Pontifical Council in Rome co-operation regarding the in pastoral care for drug-ad- activity was very intense. needs of the dioceses and of dicts. An edition in English is Meetings were held to prepare bishops’ conferences. currently being prepared. and organise congresses and Co-operation with the pontif- conferences, and inter-Minister- ical representatives was once ial meetings with experts were again valuable both because of 9. Various held within the context of study the work of sensitisation in rela- work-groups to examine the tion to health care problems The year 2001 was also a problems of drugs, AIDS, within the respective legations year of high recognition and ac- AISAC, the guidebook for pas- and because they acted as a 87 knowledgement of the work of toral care in health, the book of channel for communications, the Pontifical Council for prayers and sacraments, etc. initiatives, and consultations be- Health Pastoral Care: During the year 2001 the tween the Pontifical Council Ð On 5 September the Presi- epistolary correspondence be- and the bishops’ conferences. dent of the Ministry, H.E. Msgr. tween the Pontifical Council for As a result of this shared Javier Lozano Barragán, re- Health Pastoral Care and local commitment, many initiatives ceived an ‘honoris causa’ doc- Churches, pontifical representa- were implemented. Others will torate in theology from the ‘Fu tives (and in particular newly be continued in 2002. Jen’ Catholic University of Tai- appointed such representatives), wan. bishops, priests, and members Msgr. KRZYSZTOF NYKIEL Ð On 6 October the Secretary of religious Orders, civil and Official of the Pontifical Council of the Ministry, H.E. Msgr. José health care political authorities, for Health Pastoral Care.

DOLENTIUM HOMINUM N. 48-2001 PONTIFICAL COUNCIL FOR HEALTH PASTORAL CARE Church: drugs and drug addiction

Pastoral Handbook 88

hat should be done in the pastoral field with respect to the drug Wproblem? Many bishops, priests, religious men and women, anguished parents, addicted youths and non addicts, have asked themselves: What can we do as Christians, faced with the drug problem? With this Handbook, the Pontifical Council for Health Pastoral Care does not claim to offer a definitive answer, bu it seeks to give suggestions that could help in the pastoral work; we do not herewith intend to propose a new method, but to offer a simple answer, in the form of a practical guide, to basic questions for pastoral action and which perhaps will also be of service to those who through much dedication and care have become specialists in this field. The Holy Father indicated to us three actions in dealing with the drug problem: prevention, care and suppression of the traffickers of death ; here we only deal with the first two, leaving to the Governments to confront with courage the multifaceted figth against drugs, one to which we should all be united.

For the purchase of this volume in english, € 9 (which will be available beginning with June 2002) apply to the Libreria Editrice Vaticana - 00120 Vatican City

DOLENTIUM HOMINUM N. 48-2001