Dolentium Hominum N

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DOLENTIUM HOMINUM N. 65 – Year XXII – No. 2, 2007

JOURNAL OF THE PONTIFICAL COUNCIL FOR HEALTH CARE WORKERS (FOR HEALTH PASTORAL CARE)

CARDINAL JAVIER LOZANO BARRAGÁN, Editor-in-Chief BISHOP JOSÉ L. REDRADO, O.H., Executive Editor CORRESPONDENTS REV.FELICE RUFFINI, M.I., Associate Editor REV. MATEO BAUTISTA, Bolivia MONSIGNOR J. JAMES CASSIDY, U.S.A. REV.RUDE DELGADO, Spain REV.RAMON FERRERO, Spain REV.BENOIT GOUDOTE, Ivory Coast EDITORIAL BOARD 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 D’ERCOLE, F.D.P. DR. MAYA EL-HACHEM REV. GIANFRANCO GRIECO REV. BONIFACIO HONINGS MONSIGNOR JESÚS IRIGOYEN EDITORIAL STAFF REV.JOSEPH JOBLIN REV.VITO MAGNO, R.C.I. DR. COLETTE CHALON DR. DINA NEROZZI-FRAJESE MRS.STEFANIA CASABIANCA DR. FRANCO PLACIDI DR. ANTONELLA FARINA REV.LUCIANO SANDRIN DR. MATTHEW FFORDE MONSIGNOR ITALO TADDEI DR.GUILLERMO QWISTGAARD

Editorial and Business Offices: PONTIFICAL COUNCIL FOR HEALTH CARE WORKERS (FOR HEALTH PASTORAL CARE) VATICAN CITY; Tel. 06-6988-3138, 06-6988-4720, 06-6988-4799, Fax: 06-6988-3139 www.healthpastoral.org - e-mail: [email protected]

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Printed by Editrice VELAR, Gorle (BG)

Cover: Glass window Rev. Costantino Ruggeri

Poste Italiane s.p.a. Spedizione in Abbonamento Postale - D.L. 353/2003 (conv. In L. 27/02/2004 nº 46) art. 1, comma 2, DCB Roma DH n.65 ing 1-88 x6 19-09-2007 14:18 Pagina 2

Contents

4 Decree 43 Descriptive Report on the Results Apostolic Penitentiary of the Research of the Pontifical Council for Health Care Workers on Palliative Care XV WORLD DAY OF THE SICK 11 FEBRUARY 2007, SEOUL, SOUTH KOREA VII PLENARY ASSEMBLY OF THE PONTIFICAL 6 Letter by the Holy Father COUNCIL FOR HEALTH CARE WORKERS Benedict XVI 20-21-22 MARCH 2007 7 Account of the 54 Address of Homage XV World Day of the Sick H.Em. Card. Javier Lozano Barragán Rev. Dariusz Giers 55 Address of the Holy Father 9 Angelus Benedict XVI Benedict XVI 2 10 Address of the Holy Father TOPICS Benedict XVI 58 Treating and Caring 12 Homily Rev. Angelo Brusco, M.I. H.Em. Card. Javier Lozano Barragán 61 Cancer Pain, Death and Dying 13 Homily at the Opening Mass Prof. Pierluigi Zucchi, S.O. H.Em. Card. Nicholas Cheong Jinsuk Rev. Bonifacio Honings, O.C.D

15 Let us Accompany the Sick in the Spirit of the Gospel TESTIMONIES H.E. Msgr. Lazzaro You Heung-Sik 74 Towards the 2008 International 17 The Spiritual and Pastoral Care Eucharistic Congress in the Company of Patients with Incurable Illnesses of Mary the Immaculate conception H.Em. Card. Javier Lozano Barragán Rev. Felice Ruffini

9 FEBRUARY 2007 79 The Grace of illness Msgr. Eugenio Romero Pose 19 I. Beyond Palliative care H.Em. Card. Javier Lozano Barragán 80 Nicaragua: the Church and HIV/AIDS 22 II. Patients in a Vegetative State 82 Portugal: the Second National Congress and the Quality of Life on Pastoral Care in Health Prof. Suk Young Hong Msgr. Vitor F.X. Feytor Pinto

28 III. Ethical Issues in Nursing Care 85 The Life and Works at the End of Life of Blessed Don Luigi Monza Prof. Sung-Suk Han Prof. Massimo Aliverti

33 IV. The Bioethics of “Quality of Life and Sanctity of Life”. Rev. Dong-Ik Lee

10 FEBRUARY 2007 40 I. Hospice Palliative Care in Asia and the Experience in Korea Prof. Kyung Shik Lee The illustrations in this edition are taken from the book: 41 II. Evangelization in Medicine Al seguito di Gesù by Dante Alimenti P. Joong Ho Kim published by Editrice Velar, Gorle (BG)

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APOSTOLIC PENITENTIARY Decree Plenary Indulgences for the 15th World Day of the Sick

Since man fell in consequence of original sin which deprived him of both supernatural and preternatural gifts, God the Creator and Redeemer, in his infinite mercy, has closely united in a mysterious bond what justice demands and what forgiveness obtains; therefore, suffering that has a penal character becomes a favourable opportunity for expiating sin and for obtaining the growth of virtue, and hence, for attaining eternal salvation. This disposition of divine Providence is fulfilled for the faithful by virtue of the Paschal Mys- tery of Christ, who, in dying, made himself the dispenser of life and in rising is the cause of the firmest hope in our future resurrection. Therefore, if the very condition which subjects human beings to illness and the suffering that result from it is accepted through acts of Faith, Hope and Charity, as the subject of God’s most holy Will, it is a cause of greater holiness. It is also necessary to reflect with great attention on the fact that human remedies have a limit, and that a time will therefore come which will bring the human being to the end of his journey on this earth. Sick people in this condition must be given the most careful treatment and the 4 greatest love so that they may be comforted in their passing from this world to the Father by divine consolations. And therefore - as the Church’s prayer for the dying implores - the face of the meek Jesus Christ appears and his voice calling them to eternal glory and happiness resounds. Holy Mother Church, in her knowledge of this, deeply desires that the annual celebration of the “World Day of the Sick” become an effective catechesis on the teaching, recalled here, of the treasure of Revelation and the value and role of suffering. Consequently, in order that the faithful participating in the above-mentioned celebration - which will take place in the city of Seoul next 11 February, the liturgical Memorial of the Blessed Virgin Mary of Lourdes - may be increasingly motivated by these sentiments, the Holy Father has wished to enrich it with the gift of Indulgences, explained below. A Plenary Indulgence is granted to members of the faithful who, on the usual conditions (sacramental Confession, Eucharistic Communion, prayers for the Holy Father’s intentions) and in a spirit of total detachment from any inclination to sin, take part devoutly this 11 Febru- ary in the city of Seoul or in any other place established by the ecclesiastical Authority, in any sacred ceremony celebrated to implore from God the aims of the “15th World Day of the Sick”. The faithful in public hospitals or in any private home who charitably care for the sick as “Good Samaritans”, especially those with incurable or terminal diseases, and, because of their service are unable to take part in the ceremony mentioned above, will obtain the same gift of a Plenary Indulgence if on that Day, at least for a few hours, they generously devote their charitable assistance to the sick as if they were tending Christ the Lord himself (cf. Mt 25: 40), in a spirit of total detachment from any inclination to sin and with the determination to fulfil as soon as possible the conditions required for obtaining the Plenary Indulgence. Members of the faithful who, due to sickness, advanced age or other such reasons, are pre- vented from taking part in the above-mentioned ceremony, will obtain the Plenary Indulgence provided that, in a spirit of total detachment from any inclination to sin, with the intention of fulfilling the usual conditions as soon as possible and the desire to take part united with the Holy Father on that day, they share in spirit in the desire for the above-mentioned celebration and offer their physical and spiritual suffering to God through the Virgin Mary, “Health of the Sick”. Lastly, a Partial Indulgence is granted to all the members of the faithful who, from 9 to 11 February 2007, at any time, address fervent prayers to the merciful God with a contrite heart, imploring the above-mentioned benefits for the sick, especially for incurable and terminal patients. This Decree is effective for this occasion. Notwithstanding anything to the contrary. Given in Rome, at the Offices of the Apostolic Penitentiary, 25 January 2007, on the Feast of the Conversion of the Apostle St Paul.

CARDINAL JAMES FRANCIS STAFFORD Major Penitentiary

FR GIANFRANCO GIROTTI, O.F.M. Conv. Titular Bishop of Meta Regent

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XV World Day of the Sick

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TO OUR VENERABLE BROTHER XAVIER, CARDINAL OF THE HOLY ROMAN CHURCH, LOZANO BARRAGÁN PRESIDENT OF THE PONTIFICAL COUNCIL FOR HEALTH CARE WORKERS

Already for ten years, you, Our Venerable Brother, have pastorally attended to the professionals of health; at the same time you have borne them witness on how to imitate Jesus Christ who, when he was on earth, displayed a special benevolence towards the sick.

The Bishop of Rome has always wanted to be a participant in these thoughts and ac- 6 tions on behalf of the sick, and in a patent way has confirmed this through innumer- able ceremonies, prayers, greetings, and meetings.

For this reason, Our paternal feelings and pastoral obligation grow strong knowing that in a short while will be celebrated in Korea on 11 February – the Commemoration of the Feast of the Blessed Virgin Mary of Lourdes – with greater attention, the World Day of the Sick, which is usually celebrated every year in various continents.

So that Our love for the sick and the fraternal communication of the whole of the ecclesial community are not absent, we wish that there is present a person of Ours and all Our esteem. Nobody seemed to Us more suitable that you yourself, Venerable Brother, to be there Our representative, so that you will make heard Our voice, make our feelings known, and be the interpreter of the doctrine of the Supreme Pontiffs on this subject. Thus, trustingly, with these Letters We appoint you and We create you Our Spe- cial Envoy for the World Day of the Sick that will be celebrated on 11 February in Seoul in Korea.

You will be in Our place, repeating Our approach and Our words, you will inculcate strongly this pastoral care of the Church, and you will signally exhort to perseverance those who are involved in these praiseworthy works. You will comfort and you will console everyone with Our Apostolic Blessing. May your travelling companion be the most merciful Redeemer himself, who, both with words and with works, assimilated himself always to sick, weak and infirm people.

Given at the Vatican Palaces, the twelfth day of the month of January in the year 2007, the second year of Our pontificate.

BENEDICT P.P. XVI

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Account of the XV World Day of the Sick SEOUL, SOUTH KOREA, 9-11 FEBRUARY 2007

From 9 February to 11 Feb- palliative care and of the ques- illnesses known about, the ruary 2007, the fifteenth tions connected with such Pontifical Council for Health World Day of the Sick was care: euthanasia, exaggerated Care Workers presented its celebrated in Seoul, the mod- treatment and biological testa- ‘Descriptive Report on the Re- ern capital city of South Ko- ments. In addition to palliative sults of Research into Pallia- rea. Numerous meetings, con- care, however, as the President tive Care’ which was an initia- ferences, pastoral gatherings of the Pontifical Council ob- tive engaged in with apostolic and liturgical celebrations, served, spiritual care based Nuncios, bishops responsible spread over three days, helped upon pastoral care centred for pastoral care in health, and to explore the doctrinal-scien- around the sacraments and the Catholic health centres tific, pastoral and liturgical as- central role of the Eucharist throughout the world. pects of the subject of the World Day of the Sick – ‘The Spiritual and Pastoral Care of 7 Patients with Incurable Ill- nesses’. In his customary message the Holy Father Benedict XVI expressed his nearness to sick people: ‘the Church turns her eyes to those who suffer and calls attention to the incurably ill, many of whom are dying from terminal diseases. They are found on every continent, particularly in places where poverty and hardship cause immense misery and grief’. The Pope was present in Seoul which, when received by a pa- Pastoral care for patients through his Special Envoy, tient as Viaticum, opens him with incurable pathologies His Eminence Cardinal Javier to encounter with God and was at the centre of the reflec- Lozano Barragán, the Presi- with eternity, is also indis- tion engaged in on 10 Febru- dent of the Pontifical Council pensable. ary. With great interest the five for Health Care Workers, ac- In the subsequent papers the hundred participants listened companied by a group of peo- following subjects were ad- to the presentation in power ple who are part of the same dressed: the status of patients point by Cardinal Lozano Pontifical Council. This group with incurable pathologies in Barragán on pastoral care in was led by its Secretary, H.E. Asia, the treatment of these health, which is directed to- Msgr. José Luis Redrado OH. pathologies and experiments wards the sanctification of the The world celebration of the on stem cells, patients in a sick and of health care work- World Day of the Sick began vegetative state and quality of ers. Other speakers concen- with the official welcoming of life, and lastly the holiness of trated on practical questions the Special Envoy of the Holy life and bioethical questions. such as hospices, cancer pa- Father after the opening Holy Both the papers of the speak- tients and people with AIDS. Mass, which was presided ers and the contributions of Especial interest was pro- over by the Archbishop of the participants stressed the voked by the questions and is- Seoul, Cardinal Nicholas need to promote palliative sues connected with palliative Cheong, and held in the care and spiritual care in the care which, in recent years, Myeong-dong Cathedral on 9 Asian context. It was observed has become a real rediscovery February. Afterwards, the par- that this kind of approach to- in various Asian countries. ticipants met at the congress wards the gravely ill is rather One of the speakers even centre adjacent to the cathe- at the beginning stage in most thanked the Catholic Church dral where the proceedings Asian countries (except Hong for spreading the idea of the then began the day devoted to Kong, Singapore, Taiwan, hospice and for its constant doctrinal-scientific matters. In Japan and Korea). support for palliative care cen- his introductory speech, Car- In order to make the work of tres in the East. dinal Lozano Barragán em- the Catholic Church in rela- During the afternoon of the phasised the importance of tion to incurable and terminal same day, a meeting was held

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between the Special Envoy of The culminating moment of ple who had gathered in front the Pope and bishops and del- the celebrations of Seoul was of the altar. Tears of joy ap- egates responsible for pastoral the solemn Sunday Eucharist peared on many of their faces. care in health in Korea, Japan, of 11 February. About eight In addition to the large num- Thailand, Malaysia, India and thousand people gathered to- ber of participants, it is neces- Taiwan. From their papers it gether in a sports centre, the sary to refer to the presence of emerged that the situation of Jangchung Gymnasium, in the three major international the Catholic Church varies in middle of which a large altar health care federations: the FI- these countries: its numbers had been set up. In front of this AMC (Catholic medical doc- vary and thus its freedom altar the Special Envoy of the tors), represented by its Vice varies. Everywhere, however, Holy Father, together with a President, Dr. John Lee; the Catholics are esteemed, their conspicuous number of bish- CICIAMS (Catholic nurses), teaching is taken seriously and ops, priests and deacons, cele- represented by its President, their activities, especially in brated Holy Mass. In his homi- Mrs An Verlinde; and the the field of medicine and care ly Cardinal Javier Lozano Bar- FIPC (Catholic pharmacists), for the gravely ill, are exem- ragán went over the fundamen- represented by Dr. Pauline La plary and provoke amaze- tal points of the Message of Siew Mei. ment. His Holiness Benedict XVI The celebration of the fif- Saturday was a day rich in and ended with an invocation teenth World Day of the Sick appointments and ended with of our Mother Mary. He asked in Korea was a strong mo- a musical concert for medical her ‘to watch over all incurable ment, in particular for the students and students of the sick people and to intercede in countries of Asia, to call the nursing schools, the aim being a special way for those who attention of civil society and 8 to involve them in the World need that light and tenderness the institutions of public life to Day of the Sick. Performances that only the Lord can give’. the incurably and terminally by various artists and musical An evident sign of the ten- ill and to express true gratitude groups that are well known in derness and comfort of the towards those who, like the Korea alternated with docu- Lord was the rite of the Good Samaritan, take care of mentary films that sought to anointing of the sick. The Spe- them without paying attention demonstrate the specificity of cial Envoy of the Holy Father, to cost or profit. Catholic health care, which together with bishops and Rev. DARIUSZ GIERS, from being just ‘cure’ tries to priests, administered the Official of the Pontifical Council transform itself into the more sacrament of the anointing of for Health Care Workers, complex ‘care’. the sick to four hundred peo- the Holy See.

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Angelus ST PETER’S SQUARE, SUNDAY, 11 FEBRUARY 2007

Dear Brothers and Sisters, for Health Care Workers. I address a cordial Today, the Church recalls the first appari- greeting to him and to all those gathered tion of the Virgin Mary to St Bernadette, there. I would like to extend a greeting to the which took place on 11 February 1858 in the health-care workers of the entire world, grotto of Massabielle, near Lourdes. It was a knowing well of their important service to miraculous event which made that town, lo- the sick persons in our society. cated in the French Pyrenees, a world centre Above all, I would like to express my spir- of pilgrimages and intense Marian spirituality. itual closeness and affection to our sick In that place, now almost 150 years ago, brothers and sisters, with a particular remem- the Blessed Mother’s call to prayer and brance for those struck by graver illnesses penance resounds strongly, almost as a per- and pain: to them, our attention is dedicated manent echo of Jesus’ invitation which inau- in a special way on this Day. gurated his preaching in Galilee: “The time is It is necessary to maintain the development fulfilled, and the kingdom of God is at hand; of palliative care that offers an integral assis- repent, and believe in the Gospel” (Mk 1: 15). tance and furnishes the incurably ill with that 9 Moreover, that Shrine has become the goal human support and spiritual guide they great- of numerous sick pilgrims who are encour- ly need. aged by listening to Mary Most Holy to ac- This afternoon, in St Peter’s Basilica, cept their sufferings and offer them for the many sick will gather around Cardinal world’s salvation, uniting them to those of Camillo Ruini, who will preside at the Eu- Christ Crucified. charistic celebration. At the end of Holy Precisely because of the bond that exists Mass, I will have the joy, as last year, to between Lourdes and suffering humanity, 15 spend some time with them, reliving the spir- years ago our beloved John Paul II willed itual climate that I experienced at the Grotto that, on the occasion of the Feast of Our Lady of Massabielle. of Lourdes, the World Day of the Sick would I would now like to entrust to the maternal also be celebrated. protection of the Immaculate Virgin, with the This year the heart of this celebration is in prayer of the Angelus, the sick and suffering the city of Seoul, South Korea, where I sent in body and spirit of the entire world. as my representative Cardinal Javier Lozano Barragán, President of the Pontifical Council BENEDICT XVI

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Address of Benedict XVI to the Sick at the Conclusion of the Holy Mass, Celebrated on 11 February 2007 in the Basilica of St. Peter’s, on the Occasion of the XV World Day of the Sick. The Solemn Concelebration of the Eucharist was Presided over in the Name of the Holy Father by Cardinal Ruini VATICAN BASILICA, SUNDAY, 11 FEBRUARY 2007

Dear Brothers and Sister, abroad. I further greet the delegation of rep- It is with great joy that I meet you here in resentatives of Cammini d’Europa [European the Vatican Basilica on the Feast of Our Lady Ways]. of Lourdes and the annual World Day of the But my most cordial greeting is directed to 10 Sick, at the end of the Eucharistic celebration you, dear sick people, to your families and presided over by Cardinal Camillo Ruini. the volunteers who care for you and accom- To him, first of all, I address my greeting, pany you with love today. Together with all which I extend to all of you present here: to of you I want to unite myself with those who the Archpriest of the Basilica, Archbishop today take part in the various events of the Angelo Comastri, to the other Bishops, the World Day of the Sick held in Seoul, South priests and religious. I greet the heads and Korea. There, Cardinal Javier Lozano Bar- members of the UNITALSI, who dedicate ragán, President of the Pontifical Council for themselves to the transportation and care of Health Care Workers, presides at the celebra- the sick on pilgrimage and in other meaning- tions in my name. ful events. Today is the Feast of the Blessed Virgin I greet the heads and pilgrims of the Opera Mary of Lourdes, who a little less than 150 Romana Pellegrinaggi and those who will years ago appeared to a simple youth, St take part in this 15th Theological-Pastoral Bernadette Soubirous, showing herself as the National Convention, both from Italy and Immaculate Conception. Also in that apparition the Blessed Mother has shown herself as a tender mother to her children, recalling that the little, the poor are the beloved of God and to them the mystery of the Kingdom of Heaven is revealed. Dear friends, Mary, who with her faith accompanied her Son beneath the Cross, she who by a mysterious plan was associated to the sufferings of Christ her Son, never tires to exhort us to live and share with serene trust the experience of sorrow and sickness, offering it with faith to the Father, thus complet- ing in our flesh what is lacking in the sufferings of Christ (cf. Col 1: 24). In this regard, I recall the words with which my venerable Predecessor Paul VI concluded the Apostolic Exhortation Mari- alis Cultus: “Contemplated in the episodes of the Gospels and in the reality which she already possesses in the City of God, the Blessed Virgin Mary offers a calm vision and a reassuring word to modern man, torn as he often is between anguish and hope, defeated by the sense of his own limitations and as- sailed by limitless aspirations, troubled in his

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mind and divided in his heart, uncertain be- Face of Christ, who said: “As you did it to fore the riddle of death, oppressed by loneli- one of the least of these my brethren, you did ness while yearning for fellowship, a prey to it to me” (Mt 25: 40). boredom and disgust. She shows forth the Dear brothers and sisters, in a short while, victory of hope over anguish, of fellowship this evening, a meaningful candlelight pro- over solitude, of peace over anxiety, of joy cession will reawaken the atmosphere that is and beauty over boredom and disgust, of created among pilgrims and those devoted to eternal visions over earthly ones, of life over Lourdes. Our thought goes to the grotto of death” (n. 57). Massabielle, where human sorrows and They are words that shine light on our way, hopes, fears and trust, meet. even when the sense of hope and the certain- How many pilgrims, comforted by the ty of healing seem to vanish; they are words gaze of their Mother, find at Lourdes the that I would like to be of special comfort to strength to accomplish more easily the will those who are struck by grave illnesses and of God even when it costs renunciation and pain. pain, aware that, as the Apostle Paul affirms, And it is precisely to these our particularly all works to the good of those who love the tried brothers that today’s World Day of the Lord (cf. Rom 8: 28). Sick is dedicated with special attention. We May the candle that you hold alight in your would like them to feel the material and spir- hands be for you, dear brothers and sisters, itual closeness of the entire Christian com- the sign of a sincere desire to walk with Je- munity. sus, refulgence of peace, who shines in the 11 It is important not to leave them aban- darkness and urges us in our turn to be light doned and in solitude while they try to face a and support for those near to us! very delicate moment in their life. Praisewor- May no one, especially those who find thy are those who with patience and love themselves in the difficult situation of suffer- place their professional skills and human ing, feel alone and abandoned! warmth at their service. I entrust you all this evening to the Virgin I think of doctors, nurses, health-care Mary. She, after having known unspeakable workers, volunteers, religious and priests suffering, was assumed into Heaven, where who without sparing themselves stoop down she awaits us and where we too hope to be to them like the Good Samaritan, not consid- able to share one day the glory of her Divine ering their social condition, skin colour or re- Son, the joy without end. ligious affiliation, but only their needs. In the With these sentiments I impart my Bless- face of every human being, and still more if ing to all of you present here and to those tried and disfigured by sickness, shines the dear to you.

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The Homily of Cardinal Javier Lozano Barragán, the Special Envoy of the Holy Father for the XV World Day of the Sick SEOUL – KOREA, 11 FEBRUARY 2007

I have the honor of repre- be able to meet death in a dig- temporary culture tendes to senting the Holy Father Bene- nified way. The Holy Father hide death, because it seems to dict XV at this celebration of praises all those in the Church fear death; and since it cannot the 15th. World Day of the who, following the example of overcome it despite the Sick, here in Seoul. It is true the Good Samaritan assist, progress of medicine, it prefers that this is a world event, how- these sick people and encour- not to think about it and hides ever today it is celebrated in a age them to continue. He says it away. It is also paradoxical special way in Asia, and for that the Church, in offering as- to see that contemporary cul- this purpose, Korea represents sistance through its priests and ture declares itself to be ab- the whole of Asia in praying all her pastoral workers, stands solutely in favor of life, how- for sick people. alongside the incurably ill, ever only healthy life without The Catholic Bishops’ Con- showing the loving mercy of defects. It values only that life 12 ference of Korea proposed the Christ to those who suffer. He that corresponds to wellbeing, pastoral care of patients suffer- finally asks the Blessed Virgin to the extent that today health ing from incurable illnesses as Mary “Health of the Sick” to is defined as a state of perfect the subject of the Day. The intercede for all those who in wellbeing. And paradoxically Holy Father Benedict XVI the Church all over the world the same culture fights life it- benevolently accepted the sub- dedicate themselves in a self, right from abortion to eu- ject, and our goal in these three Gospel spirit to the care of thanasia. This attitude is, on days of the World Day has these brothers and sisters of the other hand, a consequence been to reflect upon the situa- ours. of secularism. According to tion of these sick people and pray for them. Today, in this solemn liturgical celebration, we offer to God our Father all the sufferings and pain of our brothers and sisters, and unite them to the passion, death and resurrection of the Lord Jesus. In his message for this World Day of the Sick, the Holy Father reminds us that the Church turns her eyes to all who suffer, especially those who suffer even more because of poverty, and calls our attention to the incurably ill, many of whom are dying from terminal diseases. The Holy Father would like to be united with all of us now, in order to encour- One reality very much relat- secularism there is no tran- age us to show the tenderness ed to incurable illness is death. scendence, and if there is no and mercy of the Lord to the At the beginning of his Mes- transcendence, one must have sick. The Pope affirms that the sage the Holy Father states everything in this world so as Church desires that the incur- that: “Human life, however, to achieve happiness in the ably ill and those in the termi- has intrinsic limitations, and present life. Consequently, nal stage be offered support sooner or later it ends in death. happiness has to be comfort through just social policies This is an experience to which and nothing more. A person which can help to eliminate each human being is called, seeks to be immortal, he al- the causes of many diseases; and one for which he or she most deludes himself that he is he urgently calls for improved must be prepared.” immortal, and when the death care for those who because of Pope John Paul II, while de- of others arrives, it must re- poverty cannot afford better scribing some of the negative main hidden in such a way that medical care and are dying. He aspects of the contemporary it does not disturb him. stresses the need for palliative global culture spoke of “the Within the framework of care so that they may bear culture of death.” It is, howev- such a mentality, suffering ap- these incurable illnesses and er, interesting to note that con- pears to be absurd and every-

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thing must be done to elimi- terminal diseases. I encourage curable illnesses – surrender nate it; and when this is not you to contemplate the suffer- our spirit to the hands of God possible, it is judged to be ings of Christ crucified, and, in our Father as Christ did on the something unacceptable and union with him, to turn to the cross, sure of reaching the joy therefore recourse is made to Father with complete trust that of resurrection with him. For euthanasia. Often public opin- all life, and your lives in par- we Christians, death is the last ion is induced to consider the ticular, are in his hands. Trust stage of earthly life and the existence of the incurably ill or that your sufferings, united to gateway to eternal life full of of those who bear the burden those of Christ, will prove love and joy. of extreme suffering as useless fruitful for the needs of the We have heard how the and not worth living. If the life Church and the world”. Holy Father invokes Mary of a person is not considered The spiritual fruitfulness when concluding his Message; as a value in itself, just be- about which the Pope speaks in fact he says: “May the cause it does not correspond to springs from the mystery of Blessed Virgin, our Mother, the vision of a culture in which the cross and resurrection of comfort those who are ill and material wellbeing, efficiency Christ. Christ passed through sustain all who have devoted and productivity are the funda- death to resurrection. In the their lives, as Good Samari- mental “values” for existence, resurrection is full fruitfulness tans, to healing the physical then the way is open for laws and full happiness. Conse- and spiritual wounds of those that favor the “culture of quently, if we are united to who suffer.” It is often the case death.” Christ in death we shall be that spiritual wounds are the Opposed to this attitude, the united with him in the resur- deepest. Our world is wound- Pope exhorts us to follow the rection. This faith and solid ed, physically, but also spiritu- example of the Good Samari- hope give peace and joy to the ally and many mental illness- 13 tan, employing all our efforts Christian even in front of es, especially depression, to alleviate the pain of termi- death and the “cortège that which is so widely spread in nally-ill patients, making use precedes death,” that is in front the world today, have their ori- of palliative care. Basically, of illnesses, especially incur- gins in the lack of hope. May the Christian position is very able ones. In these realities of our Blessed Mother, Mary, distinct from that which con- life, the Christian perspective watch over all the incurably ill, fuses wellbeing with happi- offers one the capacity to pre- and in a special way intercede ness. Certainly, wellbeing and serve peace and happiness that for all those who need the light sickness cannot coexist togeth- are born from faith in Christ, and tenderness that only the er. However, this is different who died and rose again. Lord can offer! Amen when it comes to sickness and Having happiness in illness happiness. These, yes indeed, is the fruit of the love, which H. Em. Card. JAVIER they can coexist together. The the Holy Spirit emanates in LOZANO BARRAGÁN President of the Pontifical Council Pope says: “I now turn to you, our hearts. With this love we for Health Care Workers my dear brothers and sisters can continuously – though in a the Holy See. suffering from incurable and special way in the case of in-

Opening Mass Homily by His Eminence Nicholas Cardinal Cheong Jinsuk

MYEONG DONG, CATHEDRAL OF SEOUL, FEBRUARY 9, 2007

Dear Brothers and Sisters! person, has sent his special en- for this, by changing ourselves voy and has always taken the first. Thanks to the abundant lead in calling for concern for On behalf of the Catholic grace of God, today we are the poor and sick and the mar- Church in Korea, I would like celebrating the opening Mass ginalized. Conforming to his to extend my cordial greetings for the XV World Day of the will, let us pray that through to the papal special envoy His Sick 2007 here in Seoul, Ko- the efforts of the Church our Eminence Javier Cardinal rea. First of all, I would like to society may pay warm atten- Lazano Barragán, President of express my heartfelt gratitude tion to the sick in the world the Pontifical Council for to His Holiness Pope Benedict and be committed to their ser- Health Care Workers, and the XVI who, even though he can- vice. First and foremost, we papal delegation. not attend this celebration in believers should make efforts I also would like to extend

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greetings of peace and bless- cell research, which is safe illnesses, we can receive grace ing in Christ to everyone at- from the perspective of only if we approach our Lord tending this Mass, including bioethics and free from the and entrust everything to him many bishops, priests and the danger of destroying human with the firm faith in him. faithful. life. I believe that adult stem Let us recall the Gospel that For this solemn and holy cell research sooner or later we have just read. When peo- event to bear much fruit of the can produce a useful result ple brought to Jesus a deaf Holy Spirit in the Providence and give light and hope to the man, Jesus healed him with of God, I call on the Catholic incurably ill and their families. the saying, “Ephphatha!” that faithful for incessant prayer For our Lord the Healer alis “Be opened!” Today Jesus and collaboration. ways accompanies all those also says to us “Ephphatha!” In particular, I hope that this who are suffering from illness- to open our closed minds, celebration of the World Day es and those who take care of eyes and ears. When we open of the Sick can become a festi- them. ourselves to Christ the Healer val for the sick, health care The right to the dignity of and trust in him, we human workers and all those serving human life first and foremost beings can be saved from the sick in the Catholic should be guaranteed for the every sort of suffering and un- Church in Korea as well as in sick. Therefore, we took as our happiness, from trivial illness- the whole world. subject for the XV World Day es to serious illnesses at the By a pontifical letter of May of the Sick 2007 “The Spiritu- terminal stage. 13, 1992, His Holiness Pope al and Pastoral Care of Pa- Therefore, I hope that this John Paul II instituted a World tients with Incurable Illness- World Day of the Sick can be- Day of the Sick, which is cele- es.” For it is the most funda- come a good opportunity for 14 brated every year on February mental mission of the Church our society to remember the 11, Feast of Our Lady of Lour- to proclaim the teaching of sick and help them, on the des. Christ that the human life foundation of respect for hu- The institution of the World must not be used as an instru- man dignity. We should al- Day of the Sick had clear pur- ment. ways pray for the sick and poses and causes. This day aims at enabling Catholic medical facilities to provide the best care to the sick and to assist Christian communities to be committed to health pastoral care in a special way. In fact, the development of scientific technology and medical science has enriched the life of humanity. However, it is also true that scientific development is threatening human life, which it should serve. Moreover, the materialism prevailing in our society has caused a serious crisis in respect for human dignity from many aspect In this regard, the Church In his message for the XV their families and should not should give priority in her pas- World Day of the Sick, His close our eyes to their suffer- toral concern to “protection of Holiness Pope Benedict XVI, ing. We do not need to say that the dignity of human life.” consoling the sick, wished medical research and study Whatever the case, material them to recognize the true can have true meaning and and wealth must not have pri- meaning of suffering and to be value only when they have ority over the value of human freed from the overwhelming their foundation in human dig- life. I have a sincere wish that shadow of suffering. So we nity. the celebration of the World chose as the biblical theme for I also hope that with this Day of the Sick will contribute the World Day of the Sick Day we can more actively to establishing sound and de- 2007 “The prayer of faith will practice love for our neigh- sirable views of values. For in save the sick person” (Jas bors, not being confined to our modern society, values and 5:15). This is because Jesus al- nation but extending our love conscience are very important ways said to the healed “your to those in various countries in for respect of life. faith has saved you” (Mt the world. In fact, there are so The Catholic Church in Ko- 9:22). Indeed, without faith many people in the world who rea has shown much interest in there is no healing or salva- are poor and sick. First of all, the study of incurable dis- tion. For we believers, what we can think of so many eases, especially in the field of matters is faith which leads us brothers and sisters in North cell therapy. In this context, to entrust everything to Jesus. Korea who are poor, sick and we actively support adult stem Even during the suffering of starving. Praying that the real-

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ity there may be improved conveying the love and mercy occasion of the XV World Day soon with the grace of God, of our Lord. of the Sick. we should try to convey the In addition, the Church And I also promise that the affectionate touch of God to should constantly appeal to Church will renew her efforts our North Korean brethren. society and the government to to establish sound values to re- Beginning with this opening establish just social policies spect life through this celebra- Mass, the World Day of the which can improve care for tion of the World Day of the Sick 2007 will proceed with the sick. Of course the Church Sick. many meetings, academic will make her best efforts to In this way, we all can ma- conferences, pastoral gather- promote policies which create ture our faith by finding anew ings and liturgical rites. All the conditions where human be- the image of Jesus who always events should be the place ings can bear even incurable accompanies the sick and suf- where the Church gives hope illnesses and death in a digni- fering. Amen. and courage to those suffering fied manner. H. Em. Card. NICHOLAS from various illnesses and en- Concluding my words, I CHEONG JINSUK, courages many Christian com- once more call on everyone to Archbishop of Seoul and Apostolic munities that are dedicated to pay attention to the sick on the Administrator of Pyong-yang

15 Let Us Accompany the Sick in the Spirit of the Gospel! Homily by H. E. Msgr. Lazzaro You Heung-sik

MYEONGDONG CATHEDRAL OF SEOUL, FEBRUARY 10, 2007

Jn 3:9-24 the door of genetics, the dis- sinned, this man or his par- Mk 8:1-10 covery of the molecular struc- ents, that he was born blind?” ture of DNA in the 1950s gave (Jn 9:2), Jesus answered, Jesus our Lord showed pref- rise to the new field of genetic “Neither he nor his parents erential love for the sick and engineering, which has ad- sinned; it is so that the works the weak. He also performed vanced to date. Today, we face of God might be made visible mighty deeds by healing the many unexpected challenges through him” (Jn 9:3). Jesus sick and feeding the hungry. and threats with regard to life did not respond in words to We, the children of the Church and ethical issues. Therefore, Pharisees who disputed instituted by Jesus, inherited it is urgent for us to return to whether the cause of sin is the what Jesus said and acted. Jesus the Lord of life and heal- sick themselves or their par- Throughout history, the ing and to think about our ents, but responded to them in Catholic Church has always identity as health-care workers the very act of healing. been at the forefront in taking in the field. I would like to 3. Jesus met with the suffer- care of, and helping, the suf- share my reflections on Jesus’ ing, especially the poor, fering and needy. With deep mission for healing in five cat- through the act of healing. He concern for the healing of the egories. offered everything for man poor and sick, the Benedictine 1. Jesus saw a disease as an and the value of life beyond brothers studied the writings evil which severs the relation- economic or utilitarian consid- of Hippocrates. In the late ship a person has with God erations. He did not turn his Middle Ages, when epidemics and with others in the commu- back on the cry and solicita- spread along with the growth nity and destroys communion tion of those who suffered in of cities, Pope Innocence III in the family. Thus, he healed misery as well as because of established the first charity and struggled against a dis- that of their neighbors. He was hospital for the sick and poor. ease, perceiving that it was his radically present in the place Following the example of this mission to free man from dis- of their life. In many parts of charity hospital, many hospi- eases. the Bible we can recognize his tals of this kind were estab- 2. Jesus liberates us from just indignation and sympathy lished in Christian countries. the punitive logic of the Old for the suffering and illnesses Furthermore, Mendel (1822- Testament which regards a which oppressed humanity. 1844), the father of modern disease as the result of person- 4. The healing of Jesus was genetics, was a religious al evils. To the disciples who the holistic recovery of the hu- priest. After Mendel opened asked him “Rabbi, who man person. His healing was

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something more than physical suffering and invited them to the sick from the part of dioce- recovery from illness, like that become the people of the san and regular priests, as well of doctors, and meant the invi- Kingdom of God. This means as of those who live near to the tation to the coming salvation that he treated everyone as the suffering and serve them.” (and to the Kingdom of God). beloved children of God. To- Hopefully, in celebrating the The physical healing of illness day, we, the followers of Jesus World Day of the Sick, eccle- has limits of temporality and Christ, in order to carry out the sial communities and Chris- partiality. Beyond the simple mission of healing entrusted tians can offer the suffering healing of illnesses, Jesus let by him, firmly declare “no” to along with the sick who suffer us anticipate the eternal world the personal, structural and so- from illness and recognize in of new heaven and new earth. cial evils that cause illness and the faces of their suffering Therefore, for him, healing “yes” to sharing our neigh- neighbors the face of Christ and salvation are not different bors’ suffering. In this sense, who achieved the salvation of in their implications. the celebration of the World humanity through his passion, 5. Jesus’ healing aimed to Day of the Sick is significant. death and resurrection. I also let the healed return to their The late Pope John Paul II ex- hope that on this occasion we daily life with a healthy body pounded the purpose of this can appreciate our health and and a sound mind. It was to day as follows: “The annual be more committed to helping free them from the place of celebration of the World Day the sick and weak. Christians suffering and lead them to the of the Sick has the evident should make every effort to place of peace. It was not a scope to remind the People of cure illnesses and pay more at- simple rehabilitation but as- God and, of consequence, tention to hospice activities sumed a new dimension of re- many catholic health care in- which help the sick to die in 16 turning to the beautiful order stitutions and the civil society dignity and happiness in the created by God. itself, of the necessity to en- embracing love of God. In this light, there was a sure the best assistance to the Whenever in great difficuly, striking contrast between Jesus sick; to help the sick appreci- Pope John Paul II asked the and his contemporaries. Re- ate the suffering on the human sick and children to pray a garding the sick and the handi- dimension and especially on special prayer. It was because capped as the condemned by the supernatural one; to in- he knew that God listens to the God, the Jews in his times volve dioceses, Christian com- prayer of the sick who are sin- eliminated them from the communities, and religious fami- cere amid their suffering and munity and deprived them of lies in the health pastoral work of children who are pure and the right to partake in divine in a particular manner; to innocent. On this World Day holiness. In this way, they de- favour the ever more precious of the Sick, let us pray togeth- monized illness and the sick. labour of volunteers; to recall er sincere and pure prayer for However, Jesus presented us the importance of the spiritual the sick and suffering. with a new vision. Even and moral formation of health H.E. Msgr. LAZZARO YOU though he disapproved an ill- care workers; finally, to help HEUNG-SIK, ness as an evil, he had sympa- understand better the impor- President of the Committee for thy towards the sick and the tance of religious assistance to “Caritas Corea” of the CBCK

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The Spiritual and Pastoral Care of Patients with Incurable Illnesses Opening Address

9 FEBRUARY 2007

It is for me a great honour to therapy, palliative care, and aggressive therapy. Palliative represent the Holy Father the biological will. These are care consists in treatment Benedict XVI at this XV issues that would require a aimed at alleviating pain in a World Day of the Sick, which wider discussion; however, terminally ill patient. It does is celebrated here in this great due to the time limit, allow me not heal; it mitigates pain. The nation of Korea, and especial- to present them briefly. biological will is the expres- ly here in your beautiful capi- To speak adequately about sion of the personal wish of an tal city of Seoul. these issues requires full an- individual regarding the last I thank with all my heart the thropological knowledge. The moments of his earthly exis- Catholic Bishop’s Conference position that one adopts on tence. of Korea and all Korean fundamental issues such as Catholics for the warm wel- life, suffering and death will come and for the great work depend on the vision of man 17 you have done in preparing that one has. For any correct with great precision the vari- way of thinking, human life is ous activities of this World untouchable, since it is to be Day of the Sick. identified with the dignity of At the beginning, we im- the human person. For the plore the indispensable help of Christian, life is a gift from the Lord of Life, the divine God, of which we are the ad- physician, Jesus Christ, and ministrators and not the mas- the intercession of Our Lady ters. Death is the maturity of ‘Salus infirmorum’, so that we life. It is the conclusion of a may be blessed with an effica- very important stage, which is cious Day for the good of sick but transitory; it is the begin- people in the whole world, ning of true life, it is the day and especially in Asia and in when authentic life is born. If Korea. pain is very acute, it is very As you know, the World propitious because it is symp- Day of the Sick involves ac- tomatic and helps in diagno- tivities that cover three con- sis. If it is chronic, it must be secutive days, during which dealt with following the ex- we shall reflect on the spiritual ample of the Good Samaritan. and pastoral care of patients But, whatever the case, suffer- Euthanasia is homicide and with incurable illnesses. The ing subsists because it belongs it is never permissible. Ag- first day, which is today, will to the progression of death. gressive therapy should not be be dedicated to scientific and Suffering united with that of practiced. Palliative care theological problems; the sec- Christ associates us to Christ, should always be used, even if ond day, tomorrow, to the pas- who redeems us with His pas- in mitigating pain one may ar- toral situation of these sick sion, death and resurrection. rive at the unconsciousness of people; and finally we shall Uniting ourselves to Christ in the patient, with the presuppo- offer our study and reflections this way does not give us sition, however, that the per- to the Lord in the liturgical cli- wellbeing in pain, but happi- son has fulfilled all his end-of- max of 11 February. ness. life duties. Palliative care As a framework for this sci- Euthanasia is every deliber- helps the sick person to live entific and theological day on ate action or omission meant with greater fullness the hour the spiritual and pastoral care to terminate the life of an in- of death as the most important of patients with incurable ill- nocent terminally ill person, moment of his life. The bio- nesses, allow me in this brief with the intention of eliminat- logical will is acceptable not opening address to highlight ing pain. Aggressive therapy as service to euthanasia but as in summarising form some consists in the use of useless help in avoiding aggressive points of Christian teaching or disproportionate therapies therapy. which will serve as references on a terminally ill patient With regard to aggressive for us in what we are reflect- which, in the face of imminent therapy, we may note that it ing upon today. I am referring death, do nothing else but pro- contains terms whose mean- here to our understanding of long painful agony. Hydration ing keeps on changing. It re- illness, euthanasia, aggressive and nutrition are not part of gards disproportionate and

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useless treatment. It is obvi- portionate treatment that is of framework for the topics that ous that the uselessness and no help other than that of pro- will be treated during the day: disproportionateness depend longing painful agony. In the sacramental care of these pa- on the progress of medicine, biological will the freedom of tients, their state and treat- although not totally. The prob- the testator, who may change ment, the quality of life, ethi- lem is: who is to judge use- the will when and how he cal problems, the sanctity of lessness and disproportionate- likes, must be guaranteed. It life and bioethics ness? The answer is: the pa- must be remembered that the I thank all of you for the ho- tient, the physician, the family uselessness and dispropor- nour you have given me, to and the bioethics committee. tionateness of the treatment is open in this way these pre- In the biological will one not fixed; this changes with cious days of study, pastoral should pay particular attention the progress of medicine. The care and prayer for the sick to the following points: not to biological will presupposes a people of the whole world. confuse euthanasia with ag- ‘trustee’, and the trustee(s) gressive therapy and vice ver- has to make sure that in no H. Em. Card. JAVIER LOZANO BARRAGÁN sa; above all one has to keep way should euthanasia take President of the Pontifical Council in mind that aggressive thera- place. for Health Care Workers py applies useless or dispro- In this way, we offer a the Holy See.

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I. Beyond Palliative Care 9 FEBRUARY 2007

When we speak of patients Viaticum as life, as commu- ly at the moment of our death. who suffer from incurable ill- nion and as eternity. In every Eucharist our con- nesses it is logical to think of I will begin with three sec- crete time and that of all cen- palliative care. In fact, pallia- tions taken from two Constitu- turies is inserted into the high- tive care offers treatments that tions of the Second Vatican est event of history in which do not cure the sick person, Council: Lumen Gentium and everything achieved its culmi- but relieve pain in such a way Sacrosanctum Concilium. nating point: the paschal Sup- that the patient suffers less and As regards the sacrament of per, the death and resurrection lives in a better way the most the Anointing of the Sick, the of the Lord; or, to be more all- important moment of his Dogmatic Constitution on the embracing, the whole mean- earthly existence, that is death. Church Lumen Gentium, tell ing of the mystery of the In- With the help of palliative us that ‘by the sacred anoint- carnation in its completeness, care, the sick person prepares ing of the sick and the prayer from the eternal Decree of the himself more consciously for of the priests the whole Father, concealed before all this passage. Very often pain Church commends the sick to centuries, until the current does not leave room for a the suffering and glorified eternal presence of Christ at serene attitude, which is nec- Lord, so that He may heal the right hand of the Father. 19 essary for a personal domi- them and save them (Ja 5; 14- nance of this overwhelming 16) and also exhorts them, so moment of death. that by uniting themselves We know that there are vari- freely to the passion and death ous types of palliative care; of Christ (Rom 8:17; Col 1:24; the physical, psychological, 2 Tim 2:1-12; Pt 4:13) they family and social, as well as contribute to the good of the the spiritual. All these are nec- people of God (LG n. 11)’. essary; however, I will deal In the same Constitution, only with spiritual palliative we are further told that “par- care. ticipating in the Eucharistic When it comes to Christian sacrifice, which is the source spiritual palliative care, this is and summit of the whole truly more than just “palliative Christian life, they offer the care”; it goes beyond, it does Divine Victim to God, and of- not only alleviate pain, it turns fer themselves along with it into happiness. Christian him…They manifest in a con- spiritual palliative care real- crete way that unity of the izes the paradox of converting people of God… which is Following this guiding illness and death into a source wondrously achieved by this thread, I will seek to refer to of life. Through this spiritual sacrament” ( LG n.11). certain ideas about life, com- care, one arrives at the apex of In the Constitution on the munion and eternity that are life, where all the vital desires Sacred Liturgy Sacrosanctum implied in the reception of Vi- of the person are satisfied. Concilium, it is stated: ‘and aticum. These wonders are realized the same apostle exhorts us to especially through the Sacra- constantly bear mortification ments of the Church, above all in our bodies so that the life of 1. Life through the sacraments of Jesus is also manifested in our Anointing of the Sick and the mortal lives (Cor 4, 10-11). It Viaticum is the apex of life. Sacrament of the Eucharist re- is for this reason that we ask The Eucharist is the actual ceived as Viaticum. the Lord in the sacrifice of the source of life because it is the After a brief comment on Mass that in ‘accepting the of- simultaneous presence of the the Sacrament of the Anoint- fering of the Spiritual Victim, whole mystery of Christ. We ing, allow me to present some he may make of us an eternal are dealing with the recreation reflections on the Viaticum, offering for himself’ (Roman of a new creature. In the Eu- since in the Eucharist received Missal, Secret for Monday charist one always partakes of as Viaticum the mystery of within the octave of Pentecost; the medicine of immortality. overcoming the paradox of SC, 12). However, in the Viaticum, tak- death, becoming life and hap- In the following reflections en at the brim of death, there is piness, fully comes true. After we shall begin with the con- the contemporaneity of the a brief presentation of the doc- temporaneous character that fullness of life and the reality trinal points, I will, in line the mandate of the Lord: “Do of death; medicine is received with the Second Vatican this in memory of me,” real- to defeat death by the highest Council, address three points: izes in the Viaticum, especial- explosion of life.

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Our death is this – death as actly from our death. A para- merciful and benevolent judg- the ultimate end. But in union dox that converts suffering, ment of our Saviour. It is the with Viaticum our death ceas- sickness and pain which in- merciful love of the eternal es to be the final point. It is stead of a funeral procession Father that lives in the person converted from a burial that accompanies us through- who dies, because of the Eu- mound into a cradle in an au- out our lives become a tri- charist, and which is the all- thentic rebirth. umphal procession of merits powerful Love of the Holy On the cross, Christ aban- that through the only true mer- Spirit. In the Viaticum we en- doned himself into the hands it of Christ obtains for us un- ter the communion of the Trin- of the Father and surrendered ending new life. ity as the last step of the ladder his spirit to Him. This surren- This union of the painful of the perfection of our earthly dering of Love, the Spirit, is precedents that come before life, so as to open ourselves to the power by which the Father death, as well as death itself the supreme perfection of converted the death of Christ with all its suffering, and in heaven. into a source of life, or rebirth. union with the very powerful In Christ, the Head of the Our abandoning of our- death of Christ, is what we call total Church, we enter into selves to the Father at the final the Eucharist as Viaticum. In a communion of the saints with moment is like a total loving summary: Viaticum offers us the Most Holy Virgin Mary, embrace in the Spirit; an em- the contemporaneity of the with St. Joseph, with all the brace with the hands of Christ whole of our life and the total- saints, with all those who are nailed on the cross; and with ity of the life of Christ, and in the state of purgatory and Christ in the Viaticum, our makes us heirs of the true eter- with all the Christians with mortal embrace is converted nal life. whom we are in communion. 20 into the special immortality of All of them accompany us at the resurrection. Christ spoke the definitive moment of the about his last hour as the hour 2. Communion passing over and help us to of his glorification; in the Vi- take the fundamental leap to- aticum Christ ensures that our People talk about the terri- wards absolute happiness. final hour is also the hour of ble loneliness of death be- In Christ, Alpha and our glorification. cause nobody can take the Omega, the first born of the universe, the whole creation is virtually found. And at the moment of death, with the Eu- charist received in Viaticum, the whole of creation hopes for its redemption through the dying person. This is the moment to enter into the inheritance of the whole universe, each one of us uniting ourselves to Christ, the centre of the universe, the first born of the whole creation. Especially at this moment, each person shares in this central quality of Christ and also becomes in Christ the centre of the universe and the first born of all creation (Col 1:1-20). Thus with the Viaticum for In the Viaticum our death is place of anyone else, and we each Christian arrives the cul- united to the death of Christ all have to die individually. minating moment to which St. and thus completes what was This is true, however for a Paul refers in his Letter to the lacking in the passion of Christian, through the Vi- Ephesians: the Lord has called Christ for the salvation of the aticum, this loneliness is not us ‘For he has made known to whole world. The highest as terrible as it would appear us in all wisdom and insight event of our existence reaches at first sight. the mystery of his will, ac- that culmination when we are In the Eucharist received as cording to his purpose which in synchrony with Christ and Viaticum, we are in full and he set forth in Christ as a plan with Christ we offer our life intimate union with Christ for the fullness of time, to for the salvation of the world. who dies in each one of our unite all things in him, things Thus we come to give a full deaths; not in the shadows of in heaven and things on earth. meaning to suffering, sickness annihilation but in the lumi- In him, according to the pur- and pain, which are accepted nosity of the resurrection. This pose of him who accom- so that they may complete in luminosity is the company of plished all things according to our bodies what was lacking the personal Truth of the the counsel of his will, we in the passion of Christ so as whole existence which, lived who first hoped in Christ have to give them full meaning, ex- in Christ, brings with it the been destined and appointed

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to live for the praise of his glo- giving of love that is the Most love of the Spirit in the Lord ry’ (Eph 1: 9-12). Holy Trinity. It is a dynamism Jesus. This giving is the sum The experience of the lone- that does not wish to possess of all the daily acts of giving liness of death involves priva- because in itself it is every- by which we wish to demon- tion for those who do not have thing. This is because it is lov- strate to the Lord God our de- faith. In the Viaticum, faith ing self-giving without devotion in our own lives. This sustains us through the defini- crease, loving reception with- is because in this giving we do tive presence of Christ. The out increase: God is love. He not give something to the Viaticum is the crowning of is not only infinitely lovable Lord – we give everything. the individual, the triumph of but also infinitely loving. This We place life itself in its total- solidarity, communion, broth- immutability of perfect joy in ity in the hands of God. We erhood, friendship, total love, loving self-giving is the au- then begin to truly live and the and self-giving of future hap- thentic divine immutability, paradox of death in life is piness. The proportion of the very nature of God. solved. loneliness to faith at the mo- To share in the nature of ment of death is inverse, i.e. God is to enter this communi- greater faith means less loneli- ty that is full of love; it is to Conclusion ness and greater loneliness enter the circle of the Trinity, means less faith. defeating the mutability of de- Let us state the paradox: the sire and progressive growth, in fullness of health is death. But the full satisfaction of the not any death: only death in 3. Eternity creature through the filling of Christ. That is to say: death his capacities to the brim. This experienced intimately united The definitive presence of is true life, and thus this to the death of Christ and thus 21 Christ in the Eucharistic host supreme communion of love with his resurrection. The offers us a foretaste of eternity. constitutes true health, which achievement of such a death is Christ appears independently is usually called eternal health. the Viaticum. of conditions of time and The Eucharist achieves this It was for this reason that I space. His dimension tran- wonder. Thus Christ says: ‘if said at the beginning of this scends all imagination, which one eats of this bread, he will paper that spiritual care of is always conditioned by ma- live forever…He who eats my those suffering from incurable terial measurements. This re- flesh and drinks my blood illnesses goes beyond pallia- ality that is given in all Eu- abides in me, and I in him. As tive care. All spiritual care charistic acts takes place, in a the living Father sent me, and comes from the Eucharist as very special way, when cross- I draw life from the Father, so its fountain. Therefore the Eu- ing the threshold of eternity in he who eats me will also draw charistic care of the sick is the the Viaticum. life from me’ (Jn 6:51; 54-57). principal spiritual care. This is In a classic way, Boetius de- As we know, this is the Eu- the core of pastoral care in fied eternity as ‘Interminabilis charistic bread that was given health, and the Viaticum is its vitae tota simul atque perfecta to us and the blood that was most complete exponent. This possessio’: the unending, si- shed on the cross (Lk 22:14). is because it is the only hori- multaneous and perfect pos- Such is Viaticum: to share zon towards which the health session of life. In this defini- in the body of Christ who of mankind can really ad- tion we can perceive a trace handed himself over to death vance. that allows us to unveil, and in his blood that was shed With Pope John Paul II though stuttering, the partici- on the cross, so as to then en- health was defined as ‘tension pation in divine life. ter into eternity. The frontier towards physical, mental, so- Indeed, the frontier, so to of the mutability of the crea- cial and spiritual harmony.’ speak, between what is of the ture is crossed in death with The Viaticum is not tension to- divine and what is of the crea- Viaticum. This is because the wards harmony but the ture, is movement. God is im- frontier between the divinity achievement of harmony, mutable; the creature is muta- and the creatureliness is where the disharmony of ble. This is certainly not only a crossed through that bridge, death leads back to the harmo- quantitative movement that the cross. Viaticum is Christ ny of the resurrection. can be measured with the co- who died and rose again, as In the Viaticum the disorder ordinates of time and space, the fullness of the times of the of death is converted into the but is also an essential move- individual life of each one of greatest order; anxiety is con- ment that becomes perfect us. Thus death is no longer verted into the greatest tran- progressively. Divine im- darkness that is feared and re- quillity. One finally reaches mutability is not a state of stat- jected, but the loving embrace the wished for peace in dying ic quietness that is lacking in that conforms us to the Lord because this is especially what dynamism, but a fullness of Jesus. In the Viaticum, our peace is: ‘tranquillity in or- activity that means omni–per- death becomes full giving to der’. fection. This omni-perfection the Father through the total H. Em. Card. JAVIER is not only the concept of ‘im- love of the Spirit in the Lord LOZANO BARRAGÁN mobile engine’ (Motor inmo- Jesus. In the Viaticum, our President of the Pontifical Council bilis) but also the fullness of death becomes full self-giving for Health Care Workers passing over in the infinite to the Father through the total the Holy See.

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II. Patients in a Vegetative State and the Quality of Life

Introduction ward legally approving eu-2 vegetative state could be with- thanasia in the United States.” held or withdrawn if the treat- Theresa Marie “Terri” Schi- Bishop Elio Sgreccia, Presi- ments were burdensome. avo (December 3, 1963 – dent of the Pontifical Acade- The ethical issues connected March 31, 2005) was a my for Life, told Vatican Ra- with patients in a vegetative woman from St. Petersburg, dio March 11, 2005 that with- state are expressed in the fol- Florida. Schiavo, then 26, col- drawing Schiavo’s gastric tube lowing question: if a patient is lapsed in her home in 1990 would not be a matter of al- competently and securely di- and experienced respiratory lowing her to die, but would agnosed to be in a vegetative and cardiac arrest. Within “inflict death.” Bishop Elio state, does the continuation of three years, she was diagnosed Sgreccia said: “Terri Schiavo life support efforts become as being in a persistent vegeta- must be considered a living ethically optional? Of special tive state. In 1998, Terri’s hus- human person…whose juridi- concern is the question of arti-

band and guardian Michael cal rights must be recognized, ficially delivered4 nutrition and Schiavo petitioned the courts respected and defended. The hydration. The relevant crite- to remove her gastric feeding removal of the gastric tube ria for determining whether 22 tube. But Terri’s parents, used for nourishing her cannot the artificial feeding of pa- Robert and Mary Schindler, be considered an ‘extraordi- tients is morally required are opposed this. The courts found nary’ measure or a therapeutic clear. Such feeding is obliga- that Terri Schiavo was in a measure. It is an essential part tory unless it is either useless persistent vegetative state and of the way in which Terri or excessively burdensome. that she should not be kept Schiavo is nourished and hy- But applying these criteria to alive. In 2003, the matter be- drated. As far as we are con- persons said to be in a “vege- gan to receive United States cerned, denying someone ac- tative state” is a matter of seri- national attention. By March cess to food and water is a cru- ous controversy. Some con- 2005, the legal history around el way of killing someone. tend that such feeding is futile the Schiavo case included The removal of the gastric and hence not obligatory. Oth- fourteen appeals and numer- feeding tube from this person, ers maintain that, unless the ous motions, petitions, and in these conditions, may be contrary can be clearly shown, hearings in the Florida courts. considered direct euthanasia. such feeding is neither futile Despite intervention by the For these reasons we regard as nor unduly burdensome and is other branches, the courts con- illicit the decision to remove therefore morally obligatory

tinued to hold that Schiavo the gastric feeding3 tube from as an ordinary means of pre- was in a persistent vegetative Terri Schiavo.” serving life. state and would want to cease Nowadays, we observe that In this paper, I will try to life support. Her feeding tube patients in a vegetative state show that the latter position is was removed a third and final are increasing in number due correct. I will firstly provide time on March 18, 2005. She to the development of medical an accurate description of the died thirteen days later of de- science, especially life-sus- vegetative state; secondly hydration at a Pinellas Park taining treatments. The condi- summarize the Catholic teach-

hospice on March1 31, 2005, at tion known as ‘vegetative ing on prolonging life; and the age of 41. state’ is one in which the per- lastly provide the arguments In 2004, Pope John Paul II son is still alive but is perma- that artificially feeding is stated that health care nently unconscious even morally obligatory unless it

providers are morally obliged though the patient gives the can 5be clearly shown to be fu- to provide food and water to outward appearances of being tile. patients in persistent vegeta- alive. We have also observed tive states. A Vatican Cardinal, a strengthening in the concept Renato Martino, the head of of quality of life and a weak- What is the Vegetative the Pontifical Council for Jus- ening of the concept of sancti- State? tice and Peace, opposed re- ty of life and of the strength of moving the feeding tube keep- solidarity. Added to limita- The vegetative state itself is ing Terri Schiavo alive. Cardi- tions or a lack of sufficient a form of deep unconscious- nal Renato Martino told Vati- support to families to cover ness. The upper part of the can Radio February 24, 2005 the costs of prolonged care for brain (the cerebral cortex) that if Michael Schiavo (Terri patients in a vegetative state, gives evidence of impaired or Schiavo’s husband) “legally this has caused a gradually in- failed operation. Since this succeeded in provoking the creasing pressure to remove part of the brain is neurologi- death of his wife, this would burdens. Therefore some ar- cally involved in such activi- not only be tragic in itself, but gue that life-sustaining med- ties as understanding, willing it would be a serious step to- ical treatments for patients in a and communicating, patients

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in a vegetative state are not vegetative when the diagnosis Magisterium12 of the Catholic able to engage in these activi- of irreversibility is established Church. The first explicit ties. But the brain stem, which to a high degree of clinical treatment of what one is oblig- controls involuntary functions certainty, that is when the ed to undergo to prolong life such as breathing, blinking, chance of regaining con- came from the great sixteenth-

circulating blood, cycles of sciousness10 becomes extremely century Spanish Dominican waking and sleeping, etc., is unlikely.” theologian, Franciso De Vito- still functioning. As a result, ria (1486-1546). In his Relec- patients in a vegetative state tiones Theologiae, Vitoria may open their eyes and considers whether one violates sometimes follow movements the natural-law obligation to with them or respond to loud protect and to preserve life if or sudden noises (although one fails to eat certain foods such responses will not be when sick. Vitoria replies: “If

long sustained nor are they6 ap- a sick man can take food or parently purposeful). It is nourishment with some hope commonly held that patients of life, he is held to take the in a vegetative state have no food, as he would be held to consciousness experience and give it to one who is sick. are incapable of experiencing [However], if the depression pain, and that it is unlikely that of spirit is so low and there is patients in this state will represent such consternation in cover consciousness. Howev- the appetitive power that only er, their condition has stabi- with the greatest of effort and 23 lized and they are not in im- as though by means of a cer- mediate danger of death so Since patients diagnosed as tain torture can the sick man long as they are given appro- being in a vegetative state are take food, right away that is priate ‘food,’ and this can be by no means imminently in reckoned a certain impossibil- provided them by various arti- danger of death, and since ity, and therefore he is ex-

ficial means made possible by7 their lives can be protected, cused, at least from moral sin,

modern medical technology. perhaps for several years, the especially where there is little13 Therefore, patients in a vege- ethical question in caring for hope of life or none at all.” tative state are not comatose. them is whether providing Vitoria also addressed the is- A coma is a state of “unarous- them with food and nourish- sue of the use of medicinal able unresponsiveness” which ment by tubes is morally drugs. Here, too, he pointed may last as long as six months obligatory or “ordinary” or out that one is not obliged to

but will inevitably resolve8 it- whether withholding or with- use every possible means to self into another state. drawing food so provided is prolong life: “One is not held, Here is a definition of the “extraordinary”. It is impor- as I said, to employ all the persistent vegetative state that tant to note that patients in a means to conserve his life, but is understandable in layman’s vegetative state can, in fact, be it is sufficient to employ the terms: “Condition in which fed orally in the beginning. means which are of them- the patient is awake without However, those caring for selves intended for this pur- being aware. In this state the them will usually prefer not to pose and congruent. Where- brain stem is functioning but feed them orally because this fore, in the case which has the cerebral cortex is not, and is quite time-consuming, par- been posited, I believe that the the patient lies with his eyes ticularly if there are other pa- individual is not held to give open, looks around, but has no tients for whom they must his whole inheritance to pre-

meaningful interaction9 with care. Thus feeding them by serve his life… From this it is the environment.” G. L. Gigli means of tubes is far more also inferred that when one is and M. Valente hold that convenient. If not fed orally, sick without hope of life, “there is no clinical difference the ability of patients in this granted that a certain precious

between vegetative state state to take food11 orally gradu- drug could produce life for (plain) and persistent vegeta- ally atrophies. some hours or even days, he tive state and it is actually im- would not be held to buy it but possible to predict, on an indi- it is sufficient to use common The Historical Development vidual basis, those patients remedies, and he14 is considered who are candidates to recov- of Catholic Teaching as though dead.” ery. For these reason, the use on Prolonging life Another Dominican theolo- of the term persistent, meant gian from Spain, Domingo to imply the irreversible na- Catholic teaching on pro- Bañez (1528-1604), played an ture of vegetative state, has longing life has formally important part in the historical been discouraged. However, evolved over the course of development of Catholic more recently, the term perma- five hundred years from the teaching on prolonging life. nent to imply an irreversible foundational works of certain He introduced the terms ‘ordi- state has been recommended. sixteenth- and seventeenth- nary’ and ‘extraordinary’ into A patient in vegetative state century theologians to recent the discussion of morally would be defined permanently statements issued by the moral obligatory and morally option-

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al means of preserving life. the following modified defini- fail in some more serious du- Bañez remarks: “He is not tions: “Ordinary means are all ty.” By situating the discus- bound absolutely speaking. medicines, treatments, and op- sion of the means necessary to The reason is that, although a erations, which offer a reason- prolong life against the back- man is held to conserve his able hope of benefit and which drop of one’s ultimate end in own life, he is not bound to can be obtained and used God, Pope Pius XII specified extraordinary means but to without excessive expense, even more precisely the mean- common food and clothing, to pain, or other inconvenience. ing of ordinary and extraordi- common medicines, to a cer- Extraordinary means are all nary means. He implied that

tain common15 and ordinary medicines, treatments, and op- medical treatment must be pain.” erations, which cannot be ob- evaluated in the light of the tained and used without exces- patient’s overall medical con- sive expense, pain, or other in- dition and the patient’s ability convenience, or which, if to pursue spiritual goods. Thus used, would not offer a rea- ordinary means are those that sonable hope of benefit. With are morally obligatory be- these definitions in mind, we cause they offer a reasonable could say without qualifica- hope of benefit in helping one tion that the patient is always to pursue the spiritual goods obliged to use ordinary means. of life without imposing an On the other hand, insofar as excessive burden; and extraor- the precept of caring for his dinary means are those means health is concerned, he is nev- that are morally optional be- 24 er obliged17 to use extraordinary cause they do not offer a rea- means.” sonable hope of benefit in In an address delivered to terms of helping one to pursue the International Congress of the spiritual goods of life, or

Anesthesiologists18 on 24 No- because they impose an exces- vember 1957, Pope Pius XII sive burden on one and pro- Subsequent theologians (1876-1958) confirmed the foundly frustrate one’s pursuit were quick to pick up on the foundational teaching on pro- of the spiritual goods of life. ordinary-extraordinary means longing life and Kelly’s speci- The Congregation for the distinction articulated by fication of the meaning of or- Doctrine of the Faith provided Bañez, and in a short time the dinary and extraordinary further confirmation of the tra- distinction became firmly es- means. In discussing one’s ditional teaching on the moral tablished in the Catholic moral moral obligation to use me- responsibility in prolonging Declaration on tradition. In fact, the distinc- chanical ventilation to pre- life in its 198019 tion is still operative today, serve life, Pope Pius XII out- Euthanasia. Addressing the even though some contempo- lined some of the major fea- issue of whether all possible rary commentators have chal- tures of the ordinary-extraor- means must be used to pre- lenged its practical relevance. dinary means distinction as it serve life, the Congregation In a 1950 article, Gerald had developed since Vitoria. for the Doctrine of the Faith Kelly (1902-1964) examined Pope Pius XII declared: “Nat- noted that the means “ordi- the Catholic tradition on the ural reason and Christian nary” and “extraordinary” are moral responsibility in pro- morals say that man has the less clear today, and that per- longing life decisions and right and duty in case of seri- haps the terms “proportionate” summarized the traditional de- ous illness to take the neces- and “disproportionate” are finitions of ordinary and extra- sary treatment for the preser- more accurate. In order to as- ordinary means: “Speaking of vation of life and health…But sess the proportionality of the means of preserving life normally one is held to use on- means, the Congregation for and of preventing or curing ly ordinary means - according the Doctrine of the Faith noted disease, moralists commonly to circumstances of persons, that one should “study the distinguish between ordinary places, time and culture - that type of treatment to be used, and extraordinary means. is to say, means that do not in- its degree of complexity or They do not always define volve any grave burden for risk, its cost and the possibili- these terms, but a careful ex- oneself or another. A more ties of using it, and [compare] amination of their words and strict obligation would be too these elements with the result examples reveals substantial burdensome for most men and that can be expected,” taking agreement on the concepts. By would render the attainment of into account one’s overall ordinary they mean such the higher, more important medical condition and physi- things as can be obtained and good too difficult. Life, health, cal and moral resources. The used without great difficulty. all temporal activities are in Congregation for the Doctrine By extraordinary they mean fact subordinated to spiritual of the Faith also remarked that everything which involves ex- ends. On the other hand, one is one need make do only with cessive difficulty by reason of not forbidden to take more the normal means that medi-

physical pain, repugnance,16 ex- than the strictly necessary cine can offer, without having pense, and so forth.” In a steps to preserve life and recourse to established med- 1951 article, Kelly proposed health, as long as he does not ical treatments that carry a risk

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or disproportionate burden. It unless death is imminent or judgment artificially provid- made clear that one’s refusal they impose an excessive bur- ing food to patients in a vege- of disproportionate treatment den on the patient. But these tative state is “clearly benefi- “is not the equivalent of sui- reports lack the authoritative cial in terms of preservation of cide”; rather, “it should be doctrinal status of papal teach- life,” nor does it, in almost considered as an acceptance of ing and of statements of the every case, add a “serious bur-

the human condition,” a desire Congregations. These reports den.” Consequently,25 it is to avoid excessive burdens, or were actually given to the morally obligatory. a wish not “to impose exces- Pope but they have not been On March 24, 1992, the Ad- sive expense” on one’s family “officially promulgated by ministrative Committee of the

or the community. It also spec- him to date or made part22 of au- United States Conference of ified that when death is immi- thoritative teaching”. Catholic Bishops (USCCB) nent, one may withhold or authorized the publication of a withdraw certain forms of substantive document pre- medical treatment that “would Providing Food to Patients pared by the Committee for only secure a precarious and in a Vegetative State is Pro-Life Activities of the burdensome prolongation of Obligatory USCCB. This document sur- life”. The Declaration on Eu- veyed, somewhat extensively, thanasia establishes that Nutrition and hydration relevant medical literature Catholic teaching on prolong- should always be provided to dealing with the issue and the ing life has continued largely all patients, including patients different positions adopted by unchanged from the time of in a vegetative state, unless moral theologians. In their Vitoria to today. Introducing they cannot be assimilated by view of the theological opin- the terms “proportionate” and a person’s body, they do not ions, the authors of this docu- 25 “disproportionate” did not sig- sustain life, or their only mode ment explicitly state that they nificantly change the tradi- of delivery imposes grave bur- do not find persuasive the rational teaching. dens on the patient or others. tionale of some theologians The consequence of decisions that since patients in a vegeta- on nutrition and hydration tive state can no longer pursue withdrawal is the death of pa- the spiritual goal of life, feed- tients in a vegetative state. ing them artificially is futile Death by starvation and dehy- and unduly burdensome. In dration “denies the respect we the conclusion of their paper, have for the dying person. the authors have this to say: Even a dead person is treated “We hold for a presumption in with respect and we would not favor of providing medically carry out acts on a dead body assisted nutrition and hydra-

simply because23 they would tion to patients who need it, not be felt.” Gigli and Va- which presumption would lente maintain that “We be- yield in cases where such pro- lieve that, although unintend- cedure have no medically rea- ed, the withdrawal of nutrition sonable hope of sustaining life

and hydration to patients in or pose26 excessive risks or bur- vegetative state…can actually dens.” turn out to be, in the long The view, like that of the Two other Catholic reports term, the Trojan horse to make Pennsylvania Bishops and the on moral responsibility in de- active euthanasia acceptable Pro-Life Committee of the

cisions prolonging life have to societies24 and health profes- United States Conference of been advanced by pontifical sionals.” Catholic Bishops, holds that agencies. First, the Pontifical The United States Pennsyl- artificially providing food to Council Cor Unum issued a vania bishops issued a docu- permanently unconscious per- report in 1981 dealing with the ment dealing with artificially sons (patients in a vegetative ethical aspects of providing providing food to patients in a state) is to be regarded ordi-

medical care20 to person at the vegetative state on January 14, narily as morally obligatory end of life. Second, the Pon- 1992. This document conclud- insofar as it is neither useless tifical Academy of Sciences ed by declaring: “As a general nor unduly burdensome. In issued a report in 1985 dealing conclusion, in almost every in- Directive no. 58 of the Ethical with the moral obligation to stance there is an obligation to and Religious Directives for use life-sustaining medical continue supplying nutrition Catholic Health Care Services treatment and the criteria nec- and hydration to the uncon- (November 1994), the bishops

essary for determining21 the ex- scious patient. There are situa- of the United States hold that act moment of death. These tions in which this is not the “There should be presumption reports seem to indicate that case [for example, when pain favor of providing nutrition medically assisted nutrition tient can no longer assimilate and hydration to all patients, and hydration should be con- the food and its provision is including patients who require sidered “ordinary or propor- hence useless], but these are medically assisted nutrition tionate” means of prolonging exceptions and should not be and hydration, as long as this life and thus should be used made into the rule.” In their is of sufficient benefit to out-

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weigh the burdens27 involved to ever be regarded32 as medical life often hide a kind of evalu- the patient.” treatment. If we define “med- ation typical of the interper- Some argue that the expense ical treatment” as “an action sonal relationships in our soci- entailed in feeding patients in or group of actions performed ety, based on the ability to pro- a vegetative state must realisti- to alleviate or neutralize some duce and to be useful. In this

cally be regarded as terribly sort of pathological33 condition society, not only the lives of burdensome in our society. or disease”, the logical ques- patients in vegetative state, but But, no one, we can presume, tion arises: if food and water also those of gravely disabled would want his or her family are medical treatment, what patients and of every person bankrupted in order to provide precisely do they treat? Pa- marginalized out of the pro-

patients in a vegetative state tients can be weaned from res- ductive system34 are considered with tubally assisted feeding. pirators, to be sure, but they less worthy.” Therefore E. Therefore, the costs of taking cannot be taken off nutrition Sgreccia and I. C. de Paula care of patients in a vegetative and hydration. Because there “have made a positive propos- state must be increasingly is a distinction between tube al. The concept of quality of covered by insurance or other feeding and other forms of life, which is often used as a programs. Now we should le- life-sustaining treatments such pretext for the propagation of gitimately strive to avoid ex- as ventilation or dialysis, tube euthanasia and eugenics, has cessive expense without aban- feeding for patients in a vege- been declared to be positive, doning care for the patients in tative state is not a medical on condition, however, that it a vegetative state and without treatment but basic care. is considered in the light of a

bringing about their death 28by person in his or her entirety, starvation and dehydration. and with reference to the hier- 26 The total cost of caring for Conclusion archy of values within each patients in a vegetative state person and those of our soci- (providing them with a heated Patients in a vegetative state ety. In other words, the quality room, nursing care, etc.) could have been challenged from the of life must favour within each be quite great, but it would be ethical point of view with the person a balance between unfair and unjust to deprive proposal to withdraw assisted what is beneficial at a corpore- the patients in a vegetative nutrition and hydration. How- al, emotional and spiritual lev- state of their fair share. Ger- ever, this ethical point of view el, each aspect being consid- main Grisez develops the truth can be very dangerous. Pa- ered as part of the harmony that another human good tients in a vegetative state are and hierarchy of values; at the served by feeding patients in a not in fact dying of some fatal same time, the good of society

vegetative state in this way is29 pathology. They are simply and the development of the the good of human solidarity. persons who are seriously im- environment must be the re- In another work Grisez ex- paired. If tube feeding is result of the commitment of presses this idea as follows: moved, patients in a vegeta- every individual for the good “life-sustaining care for the se- tive state will die from starva- of all people in the context of verely handicapped does have tion and dehydration. In other justice and of a new and a human and Christian signifi- words, death is the inevitable greater solidarity. Therefore… cance in addition to the one it consequence of the withdraw- quality of life can depend only would derive precisely from al of assisted nutrition and hy- on respect for life and the right the inherent goodness of their dration. Obviously, the pur- to life… it must be a quality lives. This additional signifi- pose of removing the feeding- which is founded on the invio- cance is…profoundly real, just tube is to hasten the death of lability and dignity of each as is the significance…which patients in a vegetative state. person, where the notion of continues to benefit not only Nutrition and hydration is not dignity and inviolability is ex-

the person being cared30 for but a form of medical treatment, tended to include a person’s the one giving care.” which, in analogy to other corporeal dimension, which is

The entire story of with- forms of life-sustaining treat- a fundamental value of one’s35 drawal of nutrition and hydra- ments such as the use of the own personal existence.” tion is a turning point for our respirator, may be discontin- Therefore the quality of life of civilization, it is paradigmatic ued in accordance with the a patient in a vegetative state of the direction in which we principles and practices gov- must be a quality which is want to orient our mutual rela- erning the withholding and founded on the inviolability tionships, of the way in which withdrawal of other forms of and sanctity of his or her life. we want to care for and relate medical treatment. Nutrition to elderly, handicapped and and hydration is a form of ba- Prof. SUK YOUNG HONG unconscious people for the sic ordinary care, which Gyeongsang National University, years to come. There is the should always be provided to Korea. concrete risk of further weak- all patients, including patients ening the ties of solidarity in- in a vegetative state.

side families31 and inside the so- Gigli and Valente criticize cial body. the current discussion about Notes Some moralists profess a quality of life. They maintain 1 http://en.wikipedia.org/wiki/Terri_ certain uneasiness with granti- the following: “In our opinion, schiavo 2 ng that food and water can the discussion about quality of W. A. MOORE, “Vatican official en-

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13 ters Schiavo feeding tube fray,” St. Pe- F. DE VITORIA, Relectiones Theolo- tain Conditions,” in D. A. Cronin, Ibid., giae Relectio IX, de tersburg Times online, Feb. 26, 2006. (Lugdini, 1587), pp.23 233-275. http://sptimes.com/2005/02/26/Tampabay Temperentia, n. 1 (translated as in D. A. K. ANDREWS, “Euthanasia in chron- /Vatican_official_ente.shtml Conserving Human British Medical 3 Cronin, Life (Brain- ic severe disablement,” OODEN Bulletin C. W , “Vatican bioethicist tree, Mass.: Pope John Center, 1989), p, 24 1996, 52, pp. 280-288. IGLI ALENTE Ibid., says removing Schiavo’s tube ‘direct eu- 35).14 G. L. G and M. V , E ITORIA Relectiones Theolo- thanasia’,” Catholic News Service, F. D V , p. 245.25 March 11, 2005, http://www.catholic giae (Lugdini, 1587), Relectio X, de Pennsylvania Conference of news.com/data/stories/cns/0501419.htm Homicido, 4 n. 35 (translated as in D. A. Catholic Bishops, “Nutrition and Hydra- ATALDO ORACZEWSKI Origins: P. J. C , A. S. M Cronin,15 Ibid., p, 37). tion: Moral Considerations,” in ed. Catholic Health Care Ethics: A D. BAÑEZ, Scholastica Commen- NC News Service 21 (1992), pp. 542- Manual for Ethics Committes, taria in Partem Angelici Doctoris S. (Boston, 553.26 Mass.: The National Catholic Bioethics Thomae (Duaci, 1614-1615), Tom. IV, Committee for Pro-Life Activities, Center, 2001), Ch. 17 Ethical Consider- Decisiones de Jure et Justitia, in II:III, United States Conference of Catholic ations Concerning Persistent Vegetative q. 65, a. 1 (translated as in D. A. Cronin, Bishops, Nutrition and Hydration: Moral and Pastoral Reflections State.5 Ibid.,16 p, 42). (Washington, WILLIAM E. MAY, Catholic G. KELLY, “The Duty of Using Ar- D.C.: United States Catholic Conference, Bioethics and the Gift of Human Life Theo- tificial Means of Preserving Life,” 1992),27 Publication No. 516-X, p. 7. logical Studies ILLIAM AY (Indiana: Our Sunday Visitor Publishing 11 (June 1950), pp. 203- 28 W E. M , Ibid., p. 263. ILLIAM AY Division Our Sunday Visitor, Inc., 220.17 29 W E. M , Ibid., p. 269. ELLY RISEZ 2000),6 pp. 263-270. G. K , “The Duty to Preserve G , “Should Nutrition and Hy- R. CRANFORD, “The Persistent Veg- Life,” Theological Studies 12 (Dec. dration Be Provided to Permanently Co-

etative State: The Medical Reality,” 1950),18 pp. 550-556. matose and Other Mentally Disabled Hastings Center Report 18 (1988), POPE PIUS XII, “The Prolongation Persons?” Linarcre Quarterly 57 Critical Choice and Critical pp.27-32.7 of Life,” in (1990),30 pp. 30-43. ILLIAM AY Ibid., Care, RISEZ Difficult Moral Questions 8 W E. M , p. 264. ed. K. W. Wildes (Netherlands: G , Council on Scientific Affairs and Kluwer Academic Press, 1995), pp. 189- (Quincy, IL: Franciscan Press, 1997), p.

Council of Ethical and Judicial Affairs, 196.19 223.31 “Persistent Vegetative State and the De- Congregation for the Doctrine of G. L. GIGLI and M. VALENTE, Ibid.,

cision to Withdraw or Withhold Life the Faith, “Declaration on Euthanasia,” p. 248.32 Support,” Journal of the American Med- in Quality of Life: The New Medical P. J. CATALDO, A. S. MORACZEWSKI ical Association Dilemma, Ibid., 9 263 (1990), p. 427. ed. J. J. Walter and T. A. ed., ch. 17 “Ethical Considerations 27 Dictionary of Medical Terms for the Shannon (New York: Paulist Press, concerning33 Persistent Vegetative State”. Nonmedical Person EANEY (3d ed. Hauppage, 1990),20 pp. 259-264. S. J. H , “‘You Can’t Be Any NY:10 Barron’s Educational Series, 1994). Pontifical Council Cor Unum, Poorer Than Dead’: Difficulties in Rec- G. L. GIGLI and M. VALENTE, “Questioni etiche relative ai malati ognizing Artificial Nutrition and Hydra- “Quality of life and vegetative state,” in gravi e ai morenti,” in D. A. Cronin, tion as Medical Treatments,” Linacre Quality Ibid., Quarterly Pontificia Accademia Pro Vita, 21 pp. 286-304. 34 61,2 (1994), p. 79. of Life and the Ethics of Health (Libreria Pontificia Accademia delle Scien- G. L. GIGLI and M. VALENTE, Ibid., Dichiarazione circa il prolungamen- Editrice11 Vaticana, 2006), p. 239. ze, p. 240.35 ILLIAM AY to artificiale della vita e la determi- GRECCIA DE AULA 12 W E. M , Ibid., p. 264. E. S , I. C. P , “Pre- M. PANICOLA, “Catholic Teaching nazione esatta del momento della morte, sentation,” in Pontificia Academia Pro Quality of Life and the Ethics of on Prolonging life: Setting the Record 21 2ott.2 1985. Vita, Straight”, Hasting Center Report (Nov.- A. S. MORACZEWSKI, “The Moral Health (Libreria Editrice Vaticana, Dec. 2001), pp. 14-25. Option Not to Conserve Life Under Cer- 2006), pp. 6-7.

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III. Ethical Issues in Nursing Care at the End of Life

Introduction nurse must ask in order to presence, discreet and atten- gain moral courage and not tive, that can procure the re- Respect for human life and fall into despair. lief so much needed, by al- respect for human rights are There are a variety of clini- lowing the sick person to ex- two basic values which the cal problems; and the focus of press his thoughts and by giv-

organized nursing profession this paper will be on benefi- ing him human7 and spiritual has urged its members to ad- cence, respect for autonomy comfort.”

here to 1in their service to and veracity in particular. In However, nurses are often mankind. To nurse at the end addition, moral principles, confronted with fear about in- of life, we need to be more duties and conduct related to terfering with this goal. For conscious of how value-laden palliative care are also ana- example, when a nurse stops the choice of medical and lyzed. listening attentively to pa- nursing interventions can be. tients, it may be thought that We practice nursing in an eth- the nurse is afraid of alleviat- ical minefield. Ethical con- Moral Principles ing the patient’s suffering. We 28 flicts can be caused by the and Duties might be afraid to comfort be- most ordinary nursing mea- cause we are afraid that the 1. Doing good, beneficence sures, such as2 turning, feeding medication to relieve suffer- and bathing. In many cases, ing will kill the patient. physicians, patients and their Doing good to others in- Therefore, beneficent nursing families should take certain volves being virtuous and ex- practice requires courage to decisions. Nurses are also tending goodness to them. At confront our own fears. If a asked to carry out their value- the end of life, beneficence is nurse is afraid to listen to a laden choices. In performing expressed through attentive patient talking about how tasks, such as eliminating listening, knowing the patient much he or she is in pain, the tube and lines, or overseeing as a person, inquiring about nurse will not be able to ac- morphine intake, nurses are well-being, and persistently cess and relieve pain. If a faced with critical moments trying to relieve suffering. In nurse is afraid of calling the when they have to execute relation to a dying patient’s physician to request more value judgments. Physicians suffering and severe pain, the pain medication, he or she have sometimes ordered nurs- U.S. Bishops’ Conference will not be able to relieve

es, without discussion, to in- says that “what is hardest to pain. Such fears render us un-8 tervene in ways that may face is the process of dying it- able to practice beneficence. cause permanent uncon- self, especially the dependen- sciousness, or in cases where cy, the helplessness, and the 2. Respect for Autonomy a patient’s life will end. In pain that so often accompany these cases, their value-laden terminal illness.” “One of the Respect for autonomy usu- choices induce great moral primary purposes of medicine ally belongs to the moral

confusion in nurses. “Nurses in caring for the dying is the sphere of the patient’s9 right to experience moral distress relief of pain and the suffering self-determination. Autono- when they are unable to trans- caused by it. Effective man- my is closely linked to the no- late their moral choices into agement of pain in all its tion of respect for persons and

moral action or when they forms is critical in the appro-5 is an important principle in

feel that nursing3 virtues are priate care of the dying.” cultures where all individuals undermined”, or when they “Patients should be kept as are seen as unique and valu- know how they should act free of pain as possible so that able members of society. Au- morally but that act is deemed they may die comfortably and tonomy implies that each per- impossible: among other re- with dignity, and in the place son has the freedom to make straints are those of the indi- where they wish to die. Since decisions about personal

vidual’4s beliefs and self- a person has the right to pre- goals. It is a state in which worth. pare for his or her death while each of us is free to choose Therefore, naming and fully conscious, he or she and implement our own deci- clarifying ethical issues is a should not be deprived of sions, free from lies, restraint, permanent nursing role at the consciousness without a com- or coercion. 6 Code of Ethics end of life. Nurses must con- pelling reason.” The Pontifi- The 10ICN stantly ask the question: “Are cal Council Cor Unum de- (2001) states: “the nurse en- we doing good for this person clares: “Drugs can diminish sures that the individual re- and his or her family? Is this anguish but, more often than ceives sufficient information what the person wants?’ not, are powerless to relieve it on which to base consent for These are questions that the completely. It is only a human care and related treatment.” In

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Code of the Korean Nurses’11 a situation where, from the dilemmas for nurses and other Ethics (2006), which was re- nurse’s point of view, the pa- health professionals. These vised very recently, section 4, tient may not want what the challenges include uncertain “the right to know and respect doctor orders; however, the and denied truth, informed for autonomy”, states “the nurse cannot go against the consent, decisional capacity, nurse has the duty to explain doctor’s order. A doctor who non-compliance, advance in detail to patients with accu- does not agree with the pa- planning, and surrogate deci- rate information in order to tient or his or her family as re- sion-making. Despite these make their own decision gards treatment may make the challenges, however, nurses about their medical and nurs- nurse find himself or herself should play an active role in

ing care (treatment), and nurs- in a more difficult situation. promoting 16autonomy at the es have to respect patients With respect to “ordinary and end of life. With regard to that they have their rights to extraordinary means to pro- uncertain and denied truth, choose or deny the treat- long life”, a nurse also recog- the truth about illness and ments.” Offering food and nutrition becomes merely a biological event. That is, the very core of human relationships have to do with the sharing of food and offering nourishment should symbolize concerning and care. Moreover, offering food can be offering care, which is synonymous 29 with treatment on some levels. When a patient refuses to eat, it could mean that they are “giving up on life” but looking at this from the perspective of keeping one’s health, one cannot dismiss it with the pretext of preserving the patient’s autonomy. Nurs- es should understand that “in nize and defend a patient’s prognosis always has an ele- order to advocate the autono- right to refuse “extraordi- ment of uncertainty. It is com- my of the patient, the patient nary” means, namely means mon for providers to disclose must be informed of and un- which provide no benefit or only incomplete information, derstand the nature of treat- which involve too grave a while emphasizing positive ments and results.” Also, only burden. In cases where pa- aspects. Without complete in- under voluntary consent can tients cannot speak for them- formation that includes their

the patient be administered12 selves, we urge family mem- terminal condition, patients treatment or care. For exam- bers and physicians to be are unable to make decisions ple, when an ethical dilemma guided by these fundamental about their last days. Autono-

is presented by a patient re- moral principles. 14 my is denied. fusing his or her food, and The study by Um (1994) In recent years there has “when the patient’s autonomy showed that the values nurses been a growing awareness is respected, there is no inter- gave greatest importance to that the patient must also take vention in part by the nurse were “saving life” and “main- part in medical decisions. The

and the13 situation is left taining care”, and the next patient must be able to take alone.” The nurse’s dilemma most important value was “re- decisions according to his or lies in his or her duties con- specting the patient’s autono- her own values and priorities, nected with the patient’s au- my/self-determination’. which could differ from those tonomy and liabilities stem- I will now examine chal- of the doctor. This is the right ming from failure to provide lenges to respect for autono- that informed consent seeks care for the patient. In this in- my at the end of life. to establish. The informed stance, the nurse should as- consent of the patient is the sess the reasons why the food Challenges to respect rational acceptance of a med- was refused and offer other for autonomy at the end ical intervention or a choice means of nourishment to im- of life between different possible al- prove the patient’s quality of For a person to act au- ternatives. In other words, it is life. Similar to this, other in- tonomously he or she must the patient’s voluntary and stances where a nurse’s have truthful information, be conscious acceptance of med- morality has been questioned free from controlling influ- ical intervention and of possi-

have occurred in doctors’ or- ences, and possess the capaci- ble alternatives with their re-17

ders relating to transfusions, ty to 15make deliberate deci- spective benefits and risks. antibiotics, diet and supple- sions. There are many chal- To give such consent, certain ments. A nurse might experi- lenges to this ideal at the end conditions need to be met: ence complicated emotions in of life which pose ethical having sufficient information,

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Veracity adequate understanding of the bility2 0of the nurse to inter- 3. information, being free to de- vene. cide according to one’s own Therefore, the nurse must The term veracity relates to values, and competence in judge whether or not the pa- the practice of telling the taking decisions. tient has the ability to make truth. Truthfulness is widely In order to make an au- rational decisions. When a accepted as a universal virtue. tonomous decision, a patient patient has the ability to make Communication with dying must possess and understand rational decisions on life-sus- patients raises the moral ques- the necessary information rel- taining treatments involving tion of their right to know the evant to that decision. The resuscitation, artificial respi- truth. Nursing literature pro- doctrine of informed consent ration, diet, transfusion, dialy- motes honesty as a virtue and has two dimensions. First, the sis, chemotherapy, operations truth-telling as an important physician is expected to truth- or antibiotics, decisions on function of nurses. We can fully disclose diagnosis, prog- the refusal of such treatment support the practice of nurses nosis, treatment possibilities, should be taken in consulta- telling the truth in many risks, benefits, and the conse- tion with the patients’ family ways. Truth-telling engenders quences of accepting and re- and caregivers. respect, open communication, trust, and shared responsibilities. It is promoted in all pro-

fessional23 codes of nursing ethics. Lying or deception creates a barrier between people and prohibits both mean- 30 ingful communication and the building up of relationships. In recognizing that communication is the cornerstone of the nurse-patient relationship, an arrangement can be made for a nurse to be truthful in or-

der to communicate24 effectively with patients. The hospice nurse is sometimes “the first person they can talk to about the issues that happen”. Di- mensions of speaking truth include asking difficult questions, saying difficult words, speaking truthfully when the fusing treatment. Second, the Decisional capacity usually truth is in transition and often patient must have the mental deteriorates at the end of life, uncertain, and facing the nor-

capacity to understand this in- due to illness and medication, mal human tendency25 to avoid formation and the conse- and evaluating decisional ca- and deny the truth. Violating

quences18 of accepting or refus- pacity entails21 asking the fol- the principle of veracity ex- ing it. The nurse frequently lowing: presses lack of respect. ends up by asking the patient 1) Can the person under- Telling lies, or avoiding dis- to sign papers indicating in- stand and communicate infor- closure, implies that the spe- formed consent and is often mation? cific function of the nurse or asked to witness this process. 2) Is the person able to de- of another person involved Sometimes he or she must liberate on, and reason about, takes precedence over the pa- question whether the patient the decision? tient or, at the very least, the comprehends the decision he 3) Can the person identify autonomy of the patient. or she is making and whether personal values and goals? To inform someone that

he or she possesses the19 mental they are dying is always a dif- capacity to decide. It is the When the patient’s deci- ficult task. However “this dif- nurse’s responsibility as an sional capacity is impaired, ficulty is not to be mistaken as advocate for the patient to en- family members or legally ap- a right to bypass the duty to be sure that all the criteria for au- pointed surrogates make deci- truthful. Death is too essential

tonomous decision-making sions about the patient’s deci- an event for the envisioning26, 27 of are met. If the nurse believes sions in the patient’s stead. it to be avoided.” Would that the patient does not un- But in the Christian per- depriving end-of-life patients derstand the implications of spective, autonomy does not with their rights to know the any part of the process, in- have the first or the last word: truth be in their best interests cluding non-treatment and alit exists thanks to “creatural” and respect the patient’s dig- ternative options, or that the solidarity and is a necessary nity? Do you think it is ac-

patient is unable to deliberate condition for the22 fulfillment ceptable to deceive a patient

on, and reason about, the vari- of this solidarity. in order to prevent28 unneces- ous choices, it is the responsi- sary suffering?

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However, to what extent The Importance person is. Listen to his or her can nurses answer end-of-life of the Responsibilities of story. patients’ questions directly? Nurses 2) Honor the dying person’s To what extent do nurses pro- wishes. vide a context in which pa- In this paper, I would like 3) Question emphasis on tients can ask these ques- to emphasize the words of complicated medical inter- tions? In addition, in clinical Cor Unum: “Despite the fact vention that ignore the reality settings the reality is that the that many doctors tend to of approaching death. responsibility of informing look upon them as purely 4) Question inappropriate the patient of the nature of his auxiliary, nurses have a fun- technology that is burden- or her illness lies with the damental role of mediation some and futile. doctor, and in a case where between doctors and patients. 5) Create a comforting per- the doctor has not informed Although nurses are, it is true, son-centered environment for the patient of his or her prog- by no means free of danger of caring.

nosis, the nurse is not in a po-29 avoiding the patients during 6) Insist on physical, emo- sition to inform the patient. the final stages of his illness, tional and spiritual comfort. Actually, self-determination they are nevertheless respon- 7) Refuse to participate in a is not possible without know- sible for actions that can be conspiracy of silence about ing the truth. At any rate, often be of crucial impor- dying. whoever is nearest the patient tance. They must decide, for 8) Prevent isolation and must inform him or her of the example, whether or not to abandonment of the dying. possibility that he or she will call the doctor when they find Encourage providers and die. The family, the chaplain, that the patient has suddenly loved ones to draw near. and the group providing med- become worse; or must de- 31 ical care must assume their cide whether or not to give Nursing practice at the end share in performing this duty. the patient a calming sub- of life intimately influences Each case is different, de- stance the doctor has left it up the quality of life in a pa- pending on the sensitivities to their judgment to use ap- tient’s final days. Nurses can and capabilities of all con- propriate moment, etc…. make a difference between a cerned, and on the condition Therefore doctors and nurses’ dehumanizing experience for

of the patient and his or30 her close collaboration is essen- a dying patient and a family

ability to relate to others. tial to the relief and32 proper that ensures comfort and care of each patient.” guidance for him or her to- “The nurse must possess as ward closure. Training for the Nursing well a no less imposing array To highlight the unmet of the Incurably Ill of moral qualities: an unas- needs of dying people, it is suming, sensitive and fine important to grasp the context I would like to quote from tact, which can understand the of death and dying today. Af- the document of the Pontifical sufferings of the sick and ter all, it is important that Council Cor Unum “Training forestall their needs, which nurses advocate, comfort,

for the Nursing of the Incur- can distinguish what must be and, care for dying35 patients ably Ill”: “The familiariza- said from that which is better and their families. tion of hospital personnel unspoken; tactful, too, in the with the demands made by relations with the doctor, Prof. SUNG-SUK HAN, death and by the care of the whose authority must always College of Nursing, dying, does not take place at be respected and upheld, and The Catholic University of Korea the intellectual level. The ac- with fellow nurses, particular- tual face-to-face encounter ly those who are younger, with suffering, with a pa- who must never be embar-

tient’s anxiety, with death, can rassed or shamed, but rather33 be a source of great anguish. aided when the need arises.” Here is one of the main reasons why many professional people today are beginning to Conclusion Notes 1 avoid having anything per- YOUNG-RHAN UM, ‘Ethical prob- sonal to do with the incurably In this paper I would like to lems experienced by nurses in the care of terminally ill patients’. Ph.D. Disser- ill, and are abandoning them conclude with humanization tation. Seoul National University, 1994, to their loneliness. Thus must goals: “Humanization Goals, pp.2 18-19. be added to the teaching of to identify nursing goals that JOYCE V. ZERWEKH. (2006). Nurs- ing care at the end of life Palliative the theory and study of pro- humanize the dying person care for patients and families. F.A.

fessional ethics, an education and deliberately counter the Davis3 Company. VOLBRECHT, R. (2002). Nursing in how to relate to people, and dehumanizing forces34 de- especially to the incurably ill. scribed.” Zerwekh, the best ethics: Communities in dialogue. Upper Saddle4 River, NJ: Prentice-Hall. If this is not taught, then any writer on nursing care at the JAMETON, A. (1993). ‘Dilemmas of teaching of ethics is in danger, end of life, listed “Humaniza- moral distress: Moral responsibility and nursing and nursing practice. in the long run, of not being tion Goals” in the following AWHONNS’s Clinical Issues in Perina- tal and Woman’s Health Nursing, 4, applied to the real situations31 way: encountered professionally.” 1) Learn who the dying 542-551.

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5 15 25 Ethical and Religious Directives ERSEK, M. (2004). ‘The continuing JOYCE V. ZERWEKH. (2006). Op. for Catholic Health Care Services th Journal of cit. , 4 . challenges of assisted death’. 26, p. 13. ed.. 2001, United States Conference of Hospice and Palliative Nursing, 6(1), Pontifical Council for Health Care Charter for Health Care Catholic6 Bishops, p. 22. 46-59.16 Workers, Ibid OYCE ERWEKH Op. Workers 7 . J V. Z . (2006). . Translated by Pastoral De- OURKE EVIN OYLE cit. R , K D. and B P. 17, p. 186. partment of Catholic Medical Center. (1993). Medical ethics: Sources of KIM, M. ‘Informed Consent. Catholic University Publication. 1998, Catholic teachings . 2nd ed. George- Bioethics in patients’ rights’. The Sec- p. 106.27 town University Press/Washington, ond Conference of the Catholic Institute Pontifical Council Cor Unum,

D.C.,8 p. 224. of Bioethics.18 2006. 10. 57-64. ‘Questions of ethics regarding the fatal- OYCE ERWEKH Op. cit LANNON Biomedical Samok 9 J V. Z (2006). . G , W. (2005). ly ill and the dying’, 1981. , 79 REIPP ethics G , M.E. ‘Undermedication for . New York: Oxford University (1982),28 125. Adv. Nurs. Sci. URKHARDT ATHANIEL pain: an ethical model’. , Press.19 B M.A and N OYCE ERWEKH Op. Op. cit 1992.10 15(1): 44-53. J V. Z . (2006). A.K.29 (2002). . cit. OUNG HAN M Op. cit International Council of Nurses 20, pp. 188-189. Y -R U (1994). ., Code of Ethics for Nurses URKHARDT (ICN),11 . 2001. B , M.A. and pp.30 42-44. Korean Nurses’ Association NATHANIEL, A.K.. Ethics & Issues in ROURKE, KEVIN D. and BOYLE, P. (KNA), Code of Ethics for Korean contemporary nursing. 2nd ed., Del- (1993). Op. cit., p. 330. Nurses 31 12 . 2006. mar,21 2002. Pontifical Council Cor Unum, WHEDON, M.. and FERRELL, B.R. DALINIS, P. ‘Informed consent and ‘Questions of ethics regarding the fatal- (1991). ‘Professional and ethical con- decisional capacity’. Journal of Hos- ly ill and the dying’. 1981. Samok, 79 siderations in the use of high-tech pain pice and Palliative Nursing, 7(1), 52- (1982), p. 125. Oncol Nurs Forum 32 Op. management’. , 57.22 Pontifical Council Cor Unum,. ILDES BEL ARVEY cit 18(7):13 1135-1142. W , K.W. A , F. H , .33 WATSON, R. (1993).’ Measuring J.C. Birth, suffering, and death. ROURKE, KEVIN D. and BOYLE, P. Catholic perspectives at the edges of Op. cit. feeding difficulty in patients with de- (1993).34 , p. 212. mentia: perspectives and problems’, life. Kluwer Academic Publishers. JOYCE V. ZERWEKH. (2006). Op. Journal of Advanced Nursing cit. , 18:25- 1992.23 35, pp. 7-8. URKHARDT ATHANIEL OYCE ERWEKH Op. 31.14 B M.A and N J V. Z (2006). OUNG HAN M Op., Op. cit Cit. Y -R U (1994). A.K.24 2002. . , p. 4. cit.., pp. 257-259. Ibid. 32

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IV. The Bioethics of ‘Quality of Life’ and ‘Sanctity of Life’

Prologue allows research that destroys the main term to assess hu- the human embryo, which is a man life and changed rapidly After World War II, the perfect human being, for the after World War II. Just as term ‘quality of life’, which improvement of the ‘life qual- various forms of, and desires came from social and eco- ity’ of patients with incurable for, the happy life are repre- nomic development in the illnesses. sented by the ‘well-being’ of West in the 1950s, slowly ex- As stated above, ‘quality of today, so lifestyle has made tended its domain to the med- life’ in our society has be- attempts to change itself to ical field. The term ‘quality of come a yardstick that mea- more of a happy life with a life’ was not only used as a sures a ‘good life’, a ‘happy healthy physique rather than concept of requiring a life life’, a ‘fun life’, and a ‘valu- simple survival; and these at- without illness but also as one able life’, and this yardstick tempts to pursue a life involve

with social welfare1 as its ba- has turned the lives of pa- living a nature-friendly life sic requirement. However, as tients with HIV, handicap or mediated by organic foods or the medical field and scientif- vegetative state into worthless raw foods. 33 ic field used improved tech- lives that exist in pain. As above, the core point lo- nology, new problems arose Pope John Paul II warned cated in the very center of the in the field of human life and that the term ‘quality of life’ desire to change lifestyle into ‘quality of life’ expanded it- is at the center of economic various forms of life is ‘quali- self to become the standard to efficiency, intemperate con- ty of life’. The desire for well- judge these problems. sumption, physical appear- being behind the lives of The term ‘quality of life’, ance, and pleasure, and when modern people is used as a and more specifically at- this ‘quality of life’ becomes representation of happiness, tempts to fix the standards of the center of our lives, the welfare, peace, etc., but the ‘quality of life’, naturally en- profound dimension of spiri- term ‘quality of life’ empha- tered the question of deciding tuality, the religious dimen- sizes more the subjectivity

whether to use all kinds of sion of human3 mutuality, are side of well-being. technological means and re- ignored. Therefore, the term ‘quality sources in the treatment of pa- As pain seems inevitable of life’ is recommended in re- tients at the last stage of incur- and hope about the near fu- lation to satisfaction or dis- able illnesses and the activi- ture seems to be lost, all lives content about psychological, ties to find the answer to that are considered meaningless physical or social conditions question, According to the and this connects to the de- which makes a division into

‘quality of life’ that scholars mands for4 rights to control high or low ‘quality of life’ so and doctors deliberately de- that life. Therefore, this that to have a higher quality cided, some lives are classi- writer would like to state that of life painful or miserable fied as lives not valuable the ‘quality of life’ cannot be conditions should be elimi- enough to be carried on, and a means to judge and compare nated. in some countries mercy the value of life. And in par- Generally speaking, we can killings are considered to be a ticular that the standard called easily see that productivity

legal answer to lives that are2 ‘quality of life’ as stated in the and usefulness is in the back- painful and no longer needed. Korean Bio-ethics and Safety ground to the ‘quality of life’ In law in Korea the prob- Act neglects and destroys life, argument. This is something lem of ‘quality of life’ plays a and that the ‘sanctity of life’, we can witness everyday in very important role as a legal which is the basic view of our society: unconscious pa- guide. The Bioethics and Christian life ethics, comes tients lying in bed for a long Safety Act (BSA) which was before ‘quality of life’. When period of time; patients with passed in 2005 indicates the emphasizing ‘quality of life’, AIDS being alienated because improvement of ‘quality of the ontological value that hu- they are not useful to society; life’ as a goal of the law and man life bears is neglected or people who can not enjoy numerous life-destructing and errors in judging the val- their lives being undervalued practices are connived with ue of life and in ranking lives because they are no longer under this law. For example, take place. valuable in the process of even though most life scien- mass production. Therefore, tists insist that the law (BSA) for a higher quality of life should endeavor to be suit- 1. ‘Quality of Life’ some insist that it is much able for life ethics and safety, more reasonable and advis- and not violate the dignity 1.1. As stated above, the able to eliminate the condi- and value of human life, yet it term ‘quality of life’ became tion of being alienated and

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miserable. This opinion is al- abilities on which many communicate within relation-

ready emphasized in our med-5 scholars place emphasis, I ships; instead, it is something ical world very naturally. would like to present an ob- natural which does not disap- In addition, as the term jective basis. While many au- pear when one or a part of ‘quality of life’ triggers many thors, including Engelhardt, those characteristics disap-

problems related to a healthy understand 7these abilities as pear. life, the area has widened. brain skill, self-awareness Whatever the case, the con- The content of the healthy and the perfection of reason- cept of quality of life can nev- lives of patients now gradual- ableness, some other authors, er be a standard by which to ly includes direct and indirect including Fletcher, think that judge and compare the values economic values related to quality of life lies in human of each life, as if some lives everyday life, as measured by life including a minimal have much higher quality and production, labor conditions, amount of intelligence, self- some others do not. This com- free time etc., and has en- awareness, self-restriction, re- parison can bring errors by ig- larged itself to include the lationship ability, interest in noring the values that lie in quality of nature which con- others, time awareness, com- human life. Because of this tains a very large range in- munication ability, inter- very reason, judging and

volving ideal happiness, the change ability, a balance be- ranking the values of a10 life is possibility of leisure, partici- tween rationality and sensibil- sort of a utopian idea. This

pation, harmony, and social ity, and the abilities8 of the attempt would eventually agreement. cerebral cortex. bring discrimination in rela- As ‘quality of life’ remains Because of the need to tion to people who have lost in economic and materialistic share the same view on what intellectual ability, people 34 views and pushes itself to- should be the typical ability who are considered to be use- wards individualism, pragma- of a human, there have been less, or people who seem to tism and Epicureanism, the many attempts to examine not have the ability to enjoy ethical and spiritual dimen- quality of life. However, these their lives. Clearly, when em- sions are undermined. As attempts cannot provide an phasizing ethical standards by Pope John Paul II stated: “the answer to questions about utility and pleasure, when the term ‘quality of life’ is prefer- whether the lives of people meaning of life cannot be entially and exclusively inter- who cannot express or do not found in pain, or when con- preted as economic utility, in- possess those abilities have sidering life as meaningless temperate consumptionism, values or not and whether we or full of pain and not a con- physical beauty and pleasure, have duties to care for and tribution to society, the re- ignoring much more profound save these lives. That is, quirement of ending life

dimensions of the being inter- whether we rate people comes11 to be seen as justifi-

humanist, 6 spiritualistic and through the ability to reach able. religious”. happiness and enjoy good, or When quality of life is un- the ability to demonstrate the derstood in this way, discrimi- abilities and activities of a nation in relation to human typical human being; the cate- beings at the level of dignity gory of quality of life, after and rights of necessity fol- all, overlooks the core onto- lows. The equality of all hu-

logical, non-utilitarian9 dimen- man beings on this earth sion itself. should be the shared basis and Given that attempts to mea- an absolutism for our lives, sure quality of life and the and an essential principle un- meanings of quality of life derlying democracy. Howev- cannot include the whole of er, when quality of life is used the existence of human life as the standard to measure the but remain in a simple quanti- value of human life, the natur- tative dimension, it eventually al and cultural basis of equali- makes errors by assessing hu- ty is denied and instead the man life within the quantita- ethics of discrimination are tive dimension. However, if established. quality of life relies not only 1.2 The Measurement on the social and economic of ‘Quality of Life’ part of human life but also on 2. The Ethics of At this point, we need to the ethical and spiritual side, ‘Quality of Life’ and see how ‘quality of life’ can it definitely remains a proper Negligence of Life be defined objectively. That concept based on the dignity is, as quality of life is empha- of the human being and the The fact that ethics using sized in the subjective dimen- unified calling of human exis- the ‘quality of life’ include er- sion, people fall into some tence. This human dignity is, rors of discrimination is clear kind of relativism and finally of course, not dominated by because the term ‘quality of deny all objective evalua- certain characteristics such as life’ measures the value of life tions. Therefore in measuring self-regulation, self-con- by numbers, insisting that the quality of life by certain sciousness or the ability to some lives have higher quali-

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ty and some have lower quali- This ethical awareness of that “doctors can provide help ty. However, our society al- doctors can be seen in the for patients to have a digni- ready has ‘quality of life’ as Code of Medical Ethics as it fied death” in article 57 its standard in many fields, can in the poll. Because of shows that doctors can some- for example policies and this Code, the purpose of pro- times be helpers of mercy norms that are based on the viding a safety net for doctors killing, while at the same time practical materialism of utili- to practice medicine ethically it emphasizes that doctors

ty and productivity, and ulti- has changed into the level of should 14 not support mercy mately in the principal con- ethical awareness most doc- killing. cepts of our national law and tors have. Moreover, in some The fact that in this Code of the main norms of our society. clauses, the lives of human Medical Ethics the lives of I would like to take a brief are handled according to utili- human beings should always, glance at the relationship be- ty and productivity, as is the in any circumstance, be pro- tween judging the standard of case with quality of life. Let tected with the doctors’ faith quality of life and the negli- us now take a look at some of in human life, means that the gence of lives through the the details. protection of all lives should Code of Medical Ethics pub- Article 30, n. 3: “When the always be emphasized. With lished by the Korean Medical patients or representatives of the object of this code clari- Association in 2001 and the the patient such as the family fied, doctors should try their

Bio-Ethics and Safety Act en- require medically useless or best to “extend the right to15 acted in 2005. unprofitable treatment, after life and the health of people” enough explanation and per- and in all circumstances en- 2.1 The Code of Medical suasion the doctor does not gage in their practice ethical- Ethics of the Korean have to fulfill this require- ly. But this Code defames 35 Medical Association ment.” doctors’ noble duty by divid- (2001) Article 57, n. 2: “The doc- ing the value of all patient’s “As the standard of living tor can provide help for the lives. of people improves, the de- patient to take their deaths”. The standard of ‘quality of mand for medical service in- Article 58, n.1: “Mercy life’ established by the Code creases, as does the demand killing exists to end an incur- of Medical Ethics of the Ko- for the ethical practices of able illness and pain that the rean Medical Association can doctors as the consciousness patient cannot endure, by us- be seen as below. When the of consumers increases. As ing injection or anything to thought that patients who are medical science and the life give death in an intentional considered useless at the level sciences rapidly progress, and direct way before the nat- of utility and productivity,

new medical 1ethical2 problems ural death, given by someone and people who are consid- have arisen.” This statement other than the patient.” ered useless in terms of value tells us why the Code of Med- The point in the basis of the as a human, is applied to the ical Ethics was needed. Be- Code of Medical Ethics is al- health and medical side, the fore drawing up this code, the so ‘quality of life’. The stan- idea of providing treatment administrative workers in dard of a doctor’s treatment for chronic patients appears a charge of enacting the code towards patients with no waste of resources and the polled 1,000 doctors about prospect of recovery is to no idea of investing in the sys- the awareness of medical avail and uselessness, and tem for the cure or at the least ethics of doctors. The results treatment for these people is independence of patients who show that, excluding the guar- thought to be a waste of time. can be cured are already sited antee of patients’ secrets, However, the lopsided judg- deeply in our society. there were no impulse of doc- ment of the doctor can harm Especially in rich countries, tors in favor of medical the right of the patient to re- where most of the population ethics, and positive answers ceive proper treatment. Of relies on medical help, the were shown especially in recourse, the doctor’s decision fact that expenditure on lation to the questions of mer- to cease proper treatment af- health is becoming the object cy killing, scientific reproduc- ter all sorts of treatment is of hatred has become main

tion, and organ transplants. based on the professional in- principle behind16 changing the Half of them answered that tellect and medical technolo- social system. problems such as the discon- gy, but sometimes that deci- tinuation of the treatment of sion can grow into mercy 2.2 The Bio-Ethics patients with incurable dis- killing. and Bio-Safety Act eases or doctor-assisted sui- As was seen above, the (2005) cide are possible, and half of Code of Medical Ethics has The law enacted four to them answered affirmatively provided direct mercy killing five years after the argument

on abortion in terms of family as mercy killing (article 58, about17 life ethics began in Ko- planning. Not only that, but clause 1), and by not stating rea, is the Bio-Ethics and affirmative answers were giv- that the stopping of treatment Bio-Safety Act (2005). Many en on the subjects of surro- at the last stage of illness is a professionals from various gate mothers, the donation or part of mercy killing it sup- fields made efforts for a long

selling of sexual cells,13 and ports passive mercy killing. time to enact a proper commerce in organs. Not only that, the statement bioethics law, but the present

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Bio-Ethics and Bio-Safety period referred to in the pro- is a monster embryo that is Act has disappointed people visions of Article 17 has ex- half human and half animal who participated in that pired may be used in vitro, and the ethical problems cre- process. only before the ontogenetic ated by this genetic mutation Even though the name of appearance of a primitive rise above our imagination. the law is the Bio-Ethics and streak, for one of the purposes Bio-Safety Act, the main pur- referred to in the following pose of this law is ‘to improve sub-paragraphs: provided, the health and quality of peo- that in a case where a person ple’s lives’, which, indeed, intends to use a residue em- demonstrates most of the con- bryo whose conservation pe- tents of this law. riod is less than 5 years, the Article 1 (Purpose) person should receive new “The purpose of this Act is consent to the use for the cor- to contribute to enhancing the responding purpose from the health and quality of life of person entitled to consent: the people by ensuring bio- 1. Research for developing ethics and bio-safety in bio- the medical treatment of in- technology to prevent in- fertility and contraception fringement on human dignity technology; and value and to prevent harm 2. Research for treating to the human body, and to fos- muscular dystrophy and other ter conditions in which bio- rare or incurable diseases 36 technology can be developed specified in the Presidential 2.3. The Vatican has made and utilized for preventing Decree; its views clear on the prohibi- and curing human illnesses.” 3. Other research which is tion of cloning and the pro- We can easily understand subject to the deliberations of duction of embryos in its The from the purpose of the law the Deliberative Commission Position of the Vatican on emphasizing the improve- and are specified by the Presi- Cloning Human Embryos. ment of quality of life that dential Decree.” The main ideas are below. most of the contents of this Article 22, clause 1: “No “Cloning for ‘reproduction’ law judge the health and hap- person shall, except for the and cloning for ‘research’ piness of people as something purpose of researching on have their difference only at that is materialistic and phe- treatment for rare or incurable the level of purpose. Cloning nomenal. The core meaning diseases in accordance with for ‘reproduction’ (so called of an original bioethics law the provision of sub-para- therapeutic cloning) trans- should contain efforts to pro- graph 2 of Article 17, perform plants the cloned embryo into tect and secure bioethics and a somatic nuclear transplanta- the womb and the baby safety problems, but in reality tion.” grows, while cloning for ‘re- this law specifically clarifies According to the above search’ uses the cloned em- quality of life as its purpose law, the BSA considers a hu- bryo only to destroy it. Pro- and under that name it allows man embryo as a simple mass hibiting only cloning for ‘re- research to destroy human of cells and takes an open po- production’ while not pro- embryos by cloning them sition on all research that uses hibiting cloning for ‘re- through cloning somatic cells. it. This contradicts the posi- search’, allows producing a Not only that, it allows the tion of the Catholic Church human life to destroy a hu- cloning of embryos of differ- which sees a human embryo man life so as to study a hu- ent kinds for the treatment of as a whole human being. A man life. The early stage of illnesses. Below are the relat- human embryo should not be the human embryo that has ed clauses. degraded as a simple object not yet been transplanted into Article 2, clause 2 (defini- and because it should be a the womb is also a human life tion): “The term “embryo” in- subject in itself the law is try- and a self-regulating being cludes a fertilized egg and ing to destroy human dignity which would develop into a any differentiated cell group by degrading the embryo as a perfect human fetus. There- in the period between the time biological material under the fore, destroying these em- of fertilization and the time name of the improvement of bryos is killing an innocent

when all organisms 18are the quality of life. That is, by human being intentionally20 formed ontogenetically”. treating a human embryo as which is an ethical disorder.” Article 2, clause 4: “The mass of cells and not as a life, Therefore the Vatican urges a term “somatic nuclear trans- the intention of avoiding ethi- perfect prohibition on all

plantation” means a trans- cal problems at the19 root can technologies of making hu- plantation of a nucleus of a clearly be seen. Not only man embryos through human somatic cell into an that: under the name of the cloning, including the trans- enucleated ovum of a human improvement of quality of plantation of somatic nuclear being or an animal.” life, the BSA allows the hy- cells, the division of embryos Article 17 (research on bridization of the ovum of an and all the technologies that residue embryos): “A residue animal and human nucleus. might be developed. This pro- embryo whose conservation The embryo made in this way hibition definitely includes

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making a half man, half mon- ing with various forms24 of ex- that of dignity. Similarly, this ster by hybridizing various periences of existence. dignity has a very close rela- creatures. We should not only tionship with the subject and remove the possibility of de- 3.2. The key conception the research in the field of formed monsters or monster supporting the outlook of bioscience, and this is espe- humans but also dangerous Christian bioethics is the dig- cially important for the re- and irresponsible research nity of human life. That is, searcher. cannot be justified when the humans should be dignified Third, this is not an effects of the protoplasm of because of the fact that they achievement but something

animals on humans21 has not are human. We now should beyond human nature; it is the been explained. take a look at how the Christ- natural dignity of the sacred

ian tradition25 understands hu- human being. It is a jewel of man dignity. the innocent favor of God, 3. ‘Quality of Life’ The tradition of Christian and therefore this should be and Catholic on human dignity can be ex- protected and fostered by hu- Bioethics plained as below. First, humans. This dignity has an inti- man dignity is original, natur- mate relationship with every 3.1. Therefore the ethics of al and cannot be transferred. activity of humans and is the ‘Quality of Life’ will in- Also it is a present, something subject of ethical activities. evitably be connected to the that is taken for granted. Gen- Therefore this means that hu- discrimination of humans re- esis 1:26-27 states that God mans can lose dignity through lated to the dignity of rights created the human in his im- the acts of humans, the sub- of human, and most likely age and likeness. According jects of activity. would use humans as the ma- to this, human existence is The proposition of human 37 terial of biology by material- God’s created words, and dignity is a core principle that izing them as stated above. something living that makes should be respected at a basic The ethics of ‘quality of life’ the world full of God’s figure level in the field of bio- approves that the discrimina- and love. This is the dignity science. Pope John Paul II tion between humans can ex- created directly from God and once said: “The standard of ist while premising qualita- no one can disturb this digni- judging ethics should be tive standards. In contrary ty. When created, a human is based on human dignity and fashion, Catholic bioethics a being that surpasses every- every result made by this does not rely on the evalua- thing else created in the uni- should be examined and ap-

tion and recognition of inverse in his value and dignity plied at28 every stage of re- equality of value in life but because of this natural exis- search.” basically emphasizes the fact tence. As the Constitution of that all of that is just a human Theology of the Second Vati- 3.3. In this approach, when life. However, in finding can Council states, a human is recognizing human life, the sanctity in all human beings “the only creature that God value of a human does not

by approving equality, it does wanted26 for its own exis- come from an activity or ex- not deny a variety of intact tence”. Especially in today’s pression but from the fact of human beings. Also it does scientific studies which the existence itself and the not deny the fact that life is should be for all scientists and fact that God created humans not always perfectly happy or the subjects of research, this as a gift. The value of every intact for some or a majority dignity should be very impor- human being, whether they of people. It is just as opposed tantly considered in relation are old or young, healthy or to the fact that the value or to the subject of research. unhealthy, embryo or new- dignity of those who are This fact is the basic ethic of born, intelligent or limited, is

much weaker22 or in pain is less all bio-scientific27 research on irrelevant to their value or important. human beings. ability, but has its importance The starting point of this The second tradition is also in the fact that a human is basic awareness is the point original. However, this is not something related to God di- of view on the value of each something that is taken for rectly. The body of a human human life. That is, instead of granted but is understood as cannot include all human val- giving value to human life it- some kind of achievement. ues and cannot express the self, we should take the fact This is the dignity called a best good that God gave us – of humans with dignity and free human living life with eternal life. This is the basis the value of inviolability as it the ability of intellectuality of the right to life that every is. That is, “the expression of and interior by free will. This human possesses in any con- the value of human life dignity is given to us by free- dition (‘from the womb to

should be the value of living ing our acts and choices by death’) and is a mark and29 re-

humans because of23 the fact the truth. As the Second Vati- quirement of inviolability. that we are alive”. Life is can Council teaches us: “man Christian bioethics starts not a good that humans pos- has his own law which God with this kind of outlook of sess and destroy when it carved, and dignity is given in life, emphasizing the sanctity seems to be undesirable or obeying this law”; the con- of human life. Even though useless but should be under- science and free will of hu- some bio-scientists ignore the stood as something that is liv- man beings is another mark sanctity of life and consider

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7 Cf. ENGELHARD H.T., The Founda- human life simply in terms of human beings, their families, tions of Biothics, Oxford: Oxford Uni- scientific value, the sanctity and the original dignity of all versity8 Press, 1966, p.239. of life cannot be understood human beings. Cf. FLETCHER F.J., ‘Indicators of just as part of the chain of re- Health is not a right for Humanhood: a Tentative of Man’, 30 Hastings Center Report 9 1975, 2(2): 1-4. ligion. What is clear is the those who have a planned and FAGGIONI M., ‘The quality of life fact that a human is different fixed quality of life. All peo- and health in the light of Christian an- in his excellence and incom- ple have a right to a healthy thropology’, in Elio Sgreccia and Igna- tio 10Carrasco (eds.), pp. 26-27. parable value and he tran- life and this right comes from However, preparing a standard by scends characteristics of the the right to live given by God which to measure quality of life is never 31 a useless attempt. The attempt in the scientific dimension. who has and is the root of area of health would help to define every life. Because of this, ‘life’ much better and to understand the taking care of the health of primary factor of a decision. On this point, the book referred to below is End Statement another person or of oneself is helpful. LEPLEGE A. AND COSTE J., an ethical responsibility given (eds.), Mesure de la Sant Perceptuelle The argument of ‘quality of to all of us, and through this et de la Qualitè de vie: methodes et ap- plications, under the direction of Alain life’ started from health and we address others as our Leplge and Joel Coste (De Boeck, involved the private view of neighbor, a humans like our- 2002),11 p.336. happiness, and this developed selves and a creature of God SIMARD N., ‘Quality of life and pa- into qualitative difference in formed in God’s image and tients with AIDS’, in in Elio Sgreccia 33 and Ignatio Carrasco de Paula (eds.), expressive lives, and ended at likeness. Quality of Life and the Ethics of Health the point that ‘sanctity of life’ I would like to end this pa- (Pontificia Academia pro Vita, Ed. Li- can be differentiated with the per by stating that all human breria Vaticana, Vatican City, 2006), pp.12 215-217. opposite of bio-ethics. In ad- life has the same quality of HWANG SANG IK, ‘The process of 38 dition, along with the con- value; and the dignity of a hu- establishment of the Code of Medical Ethics and its plan of practical use’, cerns about the negligence of man life is not simply a mat- The Korea Medical Association, 44th

life brought about by ‘quality ter of physical numbers or (2001)13 article 10, p. 1067 HWANG SANG IK, ibid. of life’ as the standard of conditions of health. 14 The Korean Medical Association, bioethics, this paper has em- Code of Medical Ethics, (2001), article

phasized the ‘sanctity of life’, Rev. DONG-IK LEE, 58 15clause 2. which forms the basic The Catholic University of Korea. The Korean Medical Association, bioethics of the Catholic Code of Medical Ethics, (2001) article 1. 16 Church. Cf. GIGLI G.L. and VALENTE M., The argument of ‘quality of ‘Quality of life and vegetative state’, in Elio Sgreccia and Ignatio Carrasco de life’ should be attentive to the Paula (eds.), Quality of Life and the fact that the point of departure Ethics of Health (Pontificia Academia for overall awareness about pro Vita, Ed. Libreria Vaticana, Vatican City,17 2006), pp. 240-241. health and illness has gone The Bio-Ethics And Bio-Safety wrong. This means that the Act published by the Advisory Com- fact that health and illness are mittee of Bio-Ethics, the Ministry of Science and Technology, in Au- intimately related is denied. gust,2001 constitutes the very first at-

Humans cannot be contracted tempt18 to enact the bioethics law. into a simple biological di- “When based on the perfect biological analysis, a living human embryo mension and because of the at the moment of combining reproduc- natural variety in humans, the tive organs is a human subject with health of humans, too, cannot identity, and from this moment it develops synthetically and gradually which be contracted into one dimen- can not be considered as a cluster of sion but must be related to the cells at any other stage after that. There- harmony and integration of Notes fore this subject gets all the right of its 1 life as a human existence and all the in- the physical and spiritual di- Cf. PACCINI RENZO, “Qualità della tervention not for the embryo is the in- mensions and human energy. vita” in Pontificio Consiglio per la tervention of the right.” (The Pontifical Famiglia, LEXICON Termini ambigui e Academy for Life, ‘The produce of hu- Therefore, improving one’s discussi su famiglia, vita e questioni man embryo stem cells and its use of health means helping one to etiche (Edizioni Dehoniane, Bologna, scientific way and treatment’, Aug. 2003), pp. 763-768. live one’s life by starting to 2 2000).19 In fact, article 30, clause 3, of the ‘The produce of human embryo improve the most truthful Code of Medical Ethics which was an- stem cells and its use of scientific way nounced on November 2001 by the Ko- path of one’s physical32 and and treatment’ which was published spiritual condition. There- rean Medical Association states that Pontifical Academy for Life in 2000, “when a representative or a family states as below. “When based on the fore, finding the harmony of member of a patient with incurable dis- perfect biological analysis, the living the objective standard of life ease alleges treatment that is medically human embryo at the moment of com- and the subjective conscious- not useful or even harmful for the pa- bining reproductive organs is a human tient, the doctor does not have to accept subject with identity, and from this mo- ness, and the harmony of so- that”; and this means that the ‘Quality ment it develops synthetically and grad- cial and economic living con- of Life’ already became an important ually and can not be considered as a standard for medical judgment. ditions and spiritual values, is 3 cluster of cells at any other stage after The Gospel of Life, clause 23. that. Therefore this subject gets all the the most important things. To 4 Ibidem 5 . right of its life as a human existence and achieve this, an overall under- More will be discussed in the next all the intervention not for the embryo standing of man and his des- section on the Code of Medical Ethics is the intervention of the right. Ethical tiny is needed. Also we need (2001) and the Bio-ethics and Safety theology has always taught that for the Act6 (2005). “very perfect right (jus certum tertii)” to embark on the improve- The Gospel of Life, clause 23, by the theory of probability does not ap- ment of social welfare for all Pope John Paul II ply.”

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20 25 The State Department of the Vati- Cf. WILLIAM E. MAY, ‘Human dig- ( ) should not be limited to life but is can, ‘The Position of Catholics on the nity and biomedical research: the re- something given by the sky ( ). This Cloning of the Human Embryo’, July spective positions of the subject of re- will of God is absolute. This is not

17,21 2003 search and the researcher’, in Juan de something that can be removed by hu- These incidents do not come from Dios Vial Correa and Elio Sgreccia mans. Therefore the life of humans science fiction anymore. The Nation (eds.), ‘Ethics of Biomedical research does not belong to humans but to the Academy of Science of the U.S. stated in a Christian Vision: Proceedings of sky who gave that life to humans and that experiences of chimeras from hu- the ninth assembly of the Pontifical this means that life is absolute. Dong-Ik man-animal experiments would in- Academy for Life’ (Vatican City, Lee, The Manager of Life, 1994, the crease and that therefore an index on the 2004), pp. 172-176. Catholic University Press, pp 36-38. 26 Gaudium et spes 31 research on chimeras would be com- 27 , n. 24. Clause 14 of the Second Vatican piled. Some bioethics experts are also The Gospel of Life n.4 states: “The Council’s’ Constitution of Theology preparing new ethics regulations be- body of human itself that starts a specif- explains the problem very well. “The cause of the new emergence of ic life in this world can not include all human that is a single existence by the chimeras. This research will threaten of the values of human nor express the body and soul, has all the essential ele- the biological condition of humans un- supreme good of humans called to an ments in his body through the physical der the name of human development. In eternal life. However in some sense, the condition. Just like this the material injecting the essential elements of homo human body contains the ‘basic value’ world gives praise to God through hu- sapiens, they can merge some species as well”. 28 mans.”32 into the human genome and make an JOHN PAUL II, ‘Address to the Rep- Cf. EDMUND D. PELLEGRINO and ‘inferior human being’ or ‘superior hu- resentatives of the Italian Society of DAVID C. THOMASMA, Helping and man being’. The widely known scholar, Medicine and the Italian Society of Healing: Religious Commitment in Jeremy Rifkin, said in an interview with General Surgery’, (Oct. 27, 1980), in Health Care (Georgetown University The LA Times: “In my point of view, the Insegnamenti di Giovanni Paolo II, III, Press, Washington, D.C., 1997), pp.26- price we need to pay for this would be 2 (Libreria Vaticana, Vatican City, 38. Recovering health does not just

too much. We need to stop at this stage 1980),29 p. 1009. n. 3. mean being cured of an illness. The of making a chimera. Making a chimera Congregation for the Doctrine of word ‘cure’ has the same meaning as out of human and animal cells should be the Faith, Donum vitae, preface, n. 4. ‘care’ and means psychological and Chosun Daily 30 stopped.”22 ( , Apr. 22). The outlook of life in Eastern ide- spiritual help. It comes from the Latin Cf. FAGGIONI M., ‘The quality of ology also starts from sanctity. The word ‘curare’. This means that recov- life and health in the light of Christian Chinese character myung ( ) comes ery of health means perfect recovery of anthropology’, in Elio Sgreccia and Ig- from everything from the sky and the both one’s physical and one’s psycho- 39 op. cit. natio23 Carrasco (eds.), , p. 29. world and not from the land. This logical condition and not just the physi- Cf. CARRASCO DE PAULA, ‘Dignità myung ( ) has a comprehensive mean- cal 34condition of eliminating the illness e vita umana nell’etica medica’, Medic- ing and does not just refer to breathing Cf. FAGGIONI M., ‘The quality of ina e Morale 45(1945), pp. 213-222. but to every rule of the whole universe. life and health in the light of Christian

(reference24 p. 220). It includes not only the lives of humans anthropology, in Elio Sgreccia and Ig- Cf. FAGGIONI M., op. cit., pp. 29- but also the rule of nature, the ethics of natio Carrasco (eds.), op. cit., pp. 29- 30. human behavior, etc. Therefore myung 33.

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I. Hospice Palliative Care 10 FEBRUARY 2007 in Asia and the Experience in Korea

In most Asian countries, ex- of all cancer deaths. The fig- ated the reimbursement of na- cept Hong Kong, Singapore, ure of the ‘certified expert tional medical insurance for Taiwan, Japan and Korea, hos- nurse’ (CEN) was started in hospice palliative care in Tai- pice palliative care is just at 1998 in Japan and by 2004 wan. The Natural Death Act the beginning stage, or if it is 100 had been approved for was passed in Taiwan in 2000. not, it is planned only in a hospice palliative care, 157 for small part of the country. And cancer pain management, and Hong Kong because hospice palliative 68 for cancer chemotherapy. care originated in countries of An education course for A hospice was started in the western part of the world physicians was started in 1981. In 1986, the Society for with a strong background of 1999. And in 2005, the figure the Promotion of Hospice Christianity, direct application of the ‘specialist nurse for hos- Care was established. In 2003, of the idea of hospice pallia- pice homes’ was started with a 65% of cancer death were tive care to Asian countries view to gaining approval. helped by hospice care. The may evoke problems associat- average number of home care ed with the differences in cul- patients per day reached 40 ture and religion. 1,000 in 2003. In 1996, there was an international hospice symposium Singapore in Singapore where hospice workers from most of the The first hospice in Singa- Asian countries were present, pore was started in 1985. And and this was the second inter- in 1995 the Singapore Hospice national hospice symposium Council, the umbrella body of held in Singapore after the one hospice organizations, was of 1992. At that time, the rep- formed with eight charities resentatives of each country providing community hospice gathered together to talk about services. In 2004, there were adequate hospice system for four services providing hos- the Asian countries with a pice home care which accept- similar cultural background. ed 2,802 referrals and visited So they decided to hold an 32,801 patients. And there Asia Pacific hospice sympo- were also four services pro- sium every 2-3 years, and the viding in-patient hospices city which held the next sym- which accepted 921 admis- posium was Hong Kong, fol- sions with 129 beds. It was es- lowed by Taipei, Taiwan, and timated that community hos- Osaka, Japan. pice services covered 74.9% of cancer deaths and 19.4% of Taiwan total deaths. The Current Status of Hospice Palliative Care The Taiwan Hospice Foun- Korea in Each Asian Country dation was established in 1990 and the first hospice ward was The first activity in Korea Japan started in the Mackay Memor- was started in 1964 by the Sis- ial Hospital in the same year. ters of the ‘Little Company of Hospice palliative care in The Taiwan Hospice Organi- Mary’ who came from Aus- Japan was initiated by an Or- zation was launched in 1995 tralia with home hospice. But ganized Care of Dying Patient and the Taiwan Academy of no more activity was started (OCDP) team in Yodogawa Hospice and Palliative Care until the early 1980s. The first Christian Hospital in 1973. was started in 1999. There was hospice ward was started in They started the reimburse- a large-scale nationwide study 1988 with ten beds in Kang- ment for the Palliative Care for the cost of hospice pallia- nam St. Mary’s hospital. It Unit (PCU) which meets with tive care in Taiwan, compar- was in 1995 that ‘the WHO the criteria in 1990. And the ing the cost of taking care of Collaborating Center for Hos- Japanese Ministry of Health terminal cancer patients in on- pice and Palliative Care’ was provided the guidelines for the cology units, palliative-care established in the Catholic approval of the PCU in 1998. units and home hospices. The Nursing College. The Korea In 2004, there were more than cost in home hospices was Hospice Association led by 131 PCUs with 2,449 beds, a 35.8% of that in oncology the members of the Protestant death in a PCU is about 4.4% wards and this result acceler- Church was started in 1991

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and the Korea Catholic Hos- versity in terms of population, couraging many other coun- pice Association was begun in race, language and wealth. tries in Asia to develop the 1992. The Korean Society for There are now more than 600 hospice system by supporting Hospice and Palliative Care palliative care services in the education systems and spe- was launched in 1998 with the region but a great variation in cialists to train the trainers in participation of physicians, the level of services provided. each country. nurses, pastors, social work- There are many obstacles to In Pakistan, the Shaukat ers, pharmacists and volun- the development of hospice Khanum Memorial Cancer teers regardless of their reli- and palliative care in Asia. Hospital has a well established gion, and it now has more than Difficulty in economic condi- palliative care program, but 600 members. There are about tions, problems in drug avail- they need a palliative care 125 hospice activities, but still ability, a lack of specialists in physician. In Nepal, there is only 7.5% of terminal cancer hospice palliative care and the Nepal Hospice in Kath- patients are being cared for by their education, and a lack of mandhu and there is a hospice hospices in this country. In legislation and law for hospice building in Bharatpur and 2003 there was a pilot study palliative care are common, Kathman Cancer Hospital in for hospice models sponsored major challenges in the devel- Bharatpur. Myanmar has a by the Korean Ministry of opment of hospice palliative forty-bed hospice unit in Health and Welfare (MOHW). care in this region. In 2001, Uanggon and Mandalei, and Drug availability has very the Asia Pacific Hospice Pal- another hospice unit is under much improved over the last liative Care Network (APHN) construction in Taungi. In Sri 10 years. Now the MOWH is was launched to accelerate the lanka, there is a hospice unit in preparing for the hospice law. development of hospice pal- Colombo and they need pallia- liative care in this region as tive care specialists and volun- 41 well as to develop hospice pal- teer educations. New Frontiers of liative care suitable for Asian Palliative Care in Asia culture. Fourteen sites have Prof. KYUNG SHIK LEE MD, been accepted as members up Kangnam St. Mary’s Hospital, This region is an area of di- to now and the APHN is en- The Catholic University of Korea.

II. Evangelization in Medicine

As we can see in the physically and spiritually, and reduction of physical hard- Gospel, Jesus went around was the outer expression of ship, we are very much aware the land of Palestine to preach his deep love and compres- of our obligation to share the news of the salvation sion for all people, especially medical help now with coun- promised by God and he be- the poor. tries which are still lacking in gan his public life in the syna- When the early missionar- proper medical facilities and gogue of Nazareth by saying: ies came to Korea, it was still care. “The Spirit of the Lord is up- underdeveloped. They estab- The Korean Association of on me. He has chosen me to lished clinics in places where Catholic Hospitals and the bring good news to the poor. there were no medical facili- Catholic Physicians’ Guild He has sent me to proclaim ties in order to provide relief have provided medical sup- liberty to the captives and re- for the many suffering people. port for the underprivileged covery of sight to the blind, to In their missionary work, they and deprived people in Pal- set free the oppressed and to combined the teaching and mar, Ecuador, Latin America announce that the time has healing ministry of Jesus, since 1988. There we came to come when the Lord will save and, in imitation of the Jesus see again the pitiful poverty his people” (Lk 4:18-19). portrayed in the Gospels, they which our people experienced At all times and in all were firmly convinced that in the past. The majority of the places, Jesus preached the preaching the Good News indigenous people live in message of liberation and must be accompanied by ef- primitive housing, in large, proved it by healing the ill- forts to heal people from poor, families. Employment is ness and wounds of the many physical, spiritual and social very difficult to find. There is poor people who came to seek pain. no doctor at all in this district. relief from their suffering. His Since 1980, the Korean There is only a medical visita- whole life was devoted to the economy has made rapid tion of 2 or 3 weeks from Ko- challenge of healing, both progress. With the resulting rea once each year to treat the

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sick. The team provided clini- From 1992 to the present, must be determined to send cal laboratory testing equip- our team has treated the sick more and more doctors and ment and a portable X-ray ma- for whom a Korean Sister, skilled personnel and to pro- chine, and taught the people Josepha, has operated a mo- vide free medical services for how to use them. We also pro- bile clinic for a long time. She people in destitute areas. This vided many of the pharmaceu- is especially making great ef- aid must be continued for ticals the people needed. We forts to educate the local peo- years to come. built a dispensary for them to ple in the generation and Especially for us Koreans, administer themselves. treatment of parasitic dis- when we freely provide med- In 1992 we adopted a plan eases. To support her work we ical services to poverty- to help poor people in rural have provided $30,000 in aid. stricken people we are fol- areas of Kenya and the Cen- Since 1997, we have visited lowing the command of Jesus tral African Republic. We vis- rural areas in Mongolia and to his disciples “to give freely it Chesongoch, a small moun- also in Colombia and have what you have freely re- tain village 450km from been providing medical sup- ceived.” (Mt 10:8) Nairobi, the capital of Kenya. port for the poor. As we move towards the About 20,000 poor people It must be strongly empha- third millennium of Christian- live here by farming and rais- sized that there is a great ur- ity, we do so with the brief ing livestock. In the center of gency for us, in the medically that evangelization must walk the village there is a Catholic developed nations, to provid- hand-in-hand with the healing Church and a dispensary run ed all the help we can to our power of Jesus which is ex- by Benedictine Sisters, and brothers and sisters who are emplified through our God- volunteers work together in suffering from all types of given medical skills. 42 this dispensary. There is no disease and misery in many doctor. Only nurses treat the parts of the world. Even if Rev JOONG HO KIM, sick. there are risks involved, we The Catholic University of Korea.

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Descriptive Report on the Results of the Research of the Pontifical Council for Health Care Workers on Palliative Care

The Pontifical Council for know about the very many as- cannot be eliminated, it dedi- Health Care Workers, on the pects of the service they pro- cates its capacities to alleviat- occasion of the XV World Day vide to suffering sick people. ing the suffering of terminally- of the Sick 2007 which will be In particular, I would like to ill patients. On this point Pope celebrated at Seoul (South Ko- thank the local Church of Benedict XVI has emphasised rea) on the subject ‘The Spiri- South Korea which this year ‘the need for more palliative tual and Pastoral Care of Pa- has offered us their hospitality care centres which provide in- tients with Incurable Illness- to celebrate the World Day of tegral care, offering the sick es’, in order to broaden the the Sick as testimony to a the human assistance and spir- knowledge horizon of the Church that is alive and com- itual accompaniment they work of the Church in the mitted in the field of health as need. This is a right belonging world of suffering and in par- well. There are very many to every human being, one

ticular of the incurably ill, has Catholic health-care structures which we must6 all be commit- thought it advisable to present working in this country, some ted to defend’. 1 43 in this Descriptive Report2 an of which are dedicated in a I would like to end by em- up-dating of a study that was particular way to palliative phasising that this document presented to the XIX Interna- care, bearing witness thereby does not seek to describe all tional Conference on Pallia- to a strong role and constant the work of the Church in the tive Care on Catholic health- care at the side of suffering field of palliative care but it

care centres that are 3 spe- sick people. does allow us to know the cialised in palliative care. contexts in which Catholic This survey was carried out health-care structures work, at the beginning of 2004 in the questions and issues that 121 countries of the five conti- they have to face, and their nental areas of the world daily activity intended in an (Africa, America, Asia, Eu- overall way for the person. rope, Oceania), after a number of months spent in drawing up H. Em. Card. JAVIER a questionnaire with the help LOZANO BARRAGÁN, President of the Pontifical Council of an ad hoc study group on for Health Care Workers the question. The questionnaire was filled in by the heads of some of the most rep- Notes 1 resentative Catholic health- Drawn up by the statistics and data care centres for palliative care section of the Pontifical Council for

in these five continents that Health2 Care Workers. 4 FIORENZA DERIU, ‘The Catholic had been indicated by 127 World and Palliative Care: A Survey bishops who at that time were carried out by the Pontifical Council for responsible for pastoral care in Health Care Workers, in Dolentium health in various countries of Hominum n. 58. XX, 2005 n.1, pp. 20- 23.3 the world. The attention that this Pon- The definition of palliative care I would like to thank for tifical Council has always paid adopted in this study is that of the Na- tional Council for Hospice and Palliative their valuable help the apos- to the world of suffering Care Services of the World Health Or- tolic nuncios that allowed con- grows greater in the light of ganisation of 1990, modified by the tact to be made with bishops the debates and the ethical Ministerial Committee for Palliative Care of 1999. Thus palliative care is care with offices for pastoral care questions and issues raised by intended to improve the quality of life of in health, the bishops respon- the end of life and in particular the patient but care that does not act on the developmental process of the illness. sible for pastoral care in health by the accompanying of the 4 The number of bishops responsible who offered their help during dying. As I observed in my for pastoral care in health was greater the preliminary stage of the book Metabioethics and Bio- than the number of countries because in survey and indicated the most medicine: ‘the right to life ex- some of these countries there were two representative Catholic health- presses itself in the terminally- bishops responsible for pastoral care in health.5 care structures of their country ill patient as a right to die with J. LOZANO BARRAGÁN, Metabio- ethics and Biomedicine (Editrice Velar, dedicated to palliative care, as serenity, with human5 and 2005),6 p. 187. well as all the heads of health- Christian dignity’. With pal- BENEDICT XVI, Message for the care centres for palliative care liative care, medical science World Day of the Sick 2007, in www. vatican.va/holy_father/benedict_xvi/mes who with competence and places itself at the service of sages/sick/documents/hf_ben-xvi_mes_ care filled in the questionnaire life because, even though it is 20061208_world-day-of-the-sick-2007_ and thereby allowed us to known that a grave pathology it.html

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A DESCRIPTIVE STUDY AND ANALYSIS OF ANALYSIS OF THE QUESTIONNAIRE THE SURVEY Structure and organisation In all, 75 questionnaires were sent back. The distribu- Question 2) Indicate tion in percentages of the the kind of structure questionnaires that were re- Type of structure turned in terms of geographi- Valid Cumulated cal areas was as follows: Frequency Percentage percentage percentage Europe 56% Hospital Unit Asia 12% Valid providing 31 41.3 41.3 41.3 Africa 10.7% Palliative Care America 18.7% Valid Oceania 2.6% Hospice 44 58.7 58.7 100.0

Below is a list of the coun- Total 75 100.0 100.0 tries that replied to the request and the corresponding number of centres that filled in the: Those who answered could and a clinic is present in choose between two types of 68.4% of these structures. List of Number of Centres structure, namely between op- Missing 44 Countries that Replied erative hospital palliative care Question 5) Indicate the units and hospices. From a professional figures AFRICA study of the data it emerged involved, and express your Ghana 2 that 58.7/% of the health-care opinion on the adequacy of Total Kenya 3 centres providing palliative the resources that are Malawi 1 care that filled in the question- available compared to the Uganda 1 naire are hospices and 41.3% needs of the context in Zambia 1 are operative hospital pallia- which the structure tive care units. operates: AMERICA Bolivia 2 Question 3) Specify if the Professional figures Brazil 3 structure has a Day Hospi- involved Ecuador 1 tal, Hospital Beds, Outpa- %of %of El Salvador 1 tient’s Dept, Home Based Name Count Responses Cases Guatemala 2 Care Peru 2 Medical doctors D_5A 71 13.9 94.7 United States Nurses D_5B 73 14.3 97.3 of America 3 Psychologists D_5C 47 9.2 6.7 Social Workers D_5D 54 10.6 72.0 ASIA Volunteers D_5E 65 12.8 86.7 Korea 4 India 2 Auxiliary Technical Type of structure Operators D_5F 43 8.4 57.3 Pakistan 1 Hospital Unit

t providing %of %of

n Physiotherapists D_5G 51 10.0 68.0

Thailand 2 u Palliative Care

o Name Count Responses Cases

C Hospice Presence Absent Catholic Spiritual EUROPE Home Assistance Service Assistant D_5H 70 13.8 93.3 Public D_6A 52 28.6 70.3 Austria 1 Spiritual Assistant Private D_6B 44 24.2 59.5 Belgium 3 of Other Religions Donations D_6C 61 33.5 82.4 Czech Republic 3 on Request D_5I 35 6.9 46.7 Others D_6D 25 13.7 33.8 France 3 Germany 2 Total 509 100.0 678.7 Total 182 100.0 245.9 Holland 5 Ireland 2 Italy 2 Type of structure In the centres that filled in Poland 15 Hospital Unit the questionnaire, the predom-

t providing n Palliative Care Slovakia 3 u inant professional figures are o Hospice C Spain 3 Presence Absent women nurses (indicated by Hospital beds 14.3% of the answers and OCEANIA 97.3% of the centres that filled Australia 2 As can be seen from the two in the questionnaire), followed graphs, 64.1% of the hospices by medical doctors (13.9% of provide a home care service the answers given by 94.7% of and 50.9% have beds. 49.1% the centres). These were fol- of the operative hospital pal- lowed by the figure of the liative care units have beds Catholic spiritual assistant (in-

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dicated in 13.8% of the answers by 93.3% of the centres that filled in the questionnaire). The presence of voluntary workers and social workers is also notable. Opinion on the adequacy of medical doctors compared to the needs of ulated the context in which the ntage structure operates Valid Cumulated .3 Frequency Percentage percentage percentage Valid Insufficient 19 25.3 27.9 27.9 0.0 Just 39 52.0 57.4 85.3 sufficient More than 10 13.3 14.7 100.0 sufficient Total 68 90.7 100.0 Missing Not applicable 4 5.3 No answer 3 4.0 45 Total 7 9.3 Total 75 100.0

85% of the centres declared Pastoral activity and that they have just a sufficient the Local Support Networks number of medical doctors in their structures. Of these, 28% Question 7) Does a pastoral declare that they do not have a programme of the local sufficient number of medical Church dedicated doctors. In general, the other specifically to the subject of professional figures are con- palliative care exist? %of ses Cases sidered just sufficient for the Question 16) Indicate if needs of the structure and this there exists a specific 9 94.7 points to problems concerning catechesis for pastoral care 3 97.3 the availability of human re- in relation to palliative care: 2 6.7 sources. Question 23) Does a body 6 72.0 responsible for the co- 8 86.7 Question 6) Indicate the ordination of pastoral care sources of finance of the which deals with palliative 4 57.3 structure care exist in your structure? 0 68.0 %of %of Existence of pastoral programme Existence of catechesis on pastoral ministry for palliative care Name Count Responses Cases 8 93.3 Public D_6A 52 28.6 70.3 Private D_6B 44 24.2 59.5 Donations D_6C 61 33.5 82.4 9 46.7 Others D_6D 25 13.7 33.8 y y c c n n e e u 0 678.7 u q Total 182 100.0 245.9 q e e r r F F SI NO SI NO Existence of pastoral programme Existence of catechesis on pastoral ministry for palliative care In general, the Catholic structures that filled in the Body responsible for the co-ordination of pastoral care questionnaire finance their ac- Valid Cumulated Frequency Percentage tivities with resources that percentage percentage come from donations (this was indicated in 33.5% of the an- Valid YES 22 29.3 31.9 31.9 swers by 82.4% of those who NO 47 62.7 68.1 100.0 filled in the questionnaire). This could be a reason for the Total 69 92.0 100.0 relative shortage of human re- Missing No answer 6 8.0 sources employed in these Total 75 100.0 structures.

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77.8% of the centres that As can be seen from the filled in the questionnaire analysis of the data, in nearly complained about a shortage all the centres a minister for of specific pastoral pro- the sacraments is available (the grammes of the Church in pal- Eucharist, anointing of the liative care: 68.1% referred to sick, reconciliation). The ad-

an absence of bodies for the ministration of the sacrament Missing co-ordination of pastoral care; of baptism is less frequent (in- 64.3% mentioned the question dicated in 12% of the answers of an appropriate catechesis. by 37.1% of the centres).

Question 10) Indicate if Question 17) In your structure, Very satisfactory spiritual resources are do you organise training employed and indicate courses in health pastoral care which ones in particular: that pay specific attention to palliative care? Missing Spiritual Resources Question 18) What form %of %of Name Count Responses Cases do they take in general? Sacraments D_10A 70 27.5 93.3 Question 19) How often Pastoral Visits D_10B 68 26.7 90.7 do they take place? Funerals D_10C 53 20.8 70.7 Question 20) For how long Help during do they last? mourning D_10D 64 25.1 85.3 Question 21) In these courses is Total 255 100.0 340.0 specific attention paid to the pastoral questions and issues connected with palliative care? Question 22) In your structure With respect to Catholic are the ethical questions worship, a minister for the connected with the following sacraments is available in subjects addressed? many centres (this was indicat- Courses in pastoral care ed in 27.5% of the answers from 93.3% of the centres), as Valid Cumulated Frequency Percentage well as pastoral care visits, of percentage percentage which 92.6% are carried out by priests, although religious and Validi SI 36 48.0 51.4 51.4 secular people are also en- NO 34 45.3 48.6 100.0 gaged in such activity. The Totale 70 93.3 100.0 structures also organise funerals which are generally held in- Mancanti Non risponde 5 6.7 side these centres; the pastoral Totale 75 100.0 care service actively co-operates in providing help at the moment of bereavement (indi- Type of Health Pastoral Care Courses 51.4% of the centres that %of %of cated in 25.1% of the answers filled in the questionnaire or- Name Count Responses Cases by 85.3% of the structures that ganise training courses for pas- filled in the questionnaire). toral care in health, principally Pharmacological treatment D_28A 70 10.7 94.6 on the subject of palliative care. Pain-killing treatment D_28B 72 11.0 97.3 In general, these courses take Nutritional support D_28C 65 9.9 87.8 y c

Question 11) If in answering n the form of an internal seminar e Physiotherapy D_28D 56 8.5 75.7 u q

question ‘10’ you indicated e r and are mainly organised at Rehabilitation D_28E 49 7.5 66.2 F Internal Seminar Conference Other ‘sacraments’, specify which /Meeting least once a year and last from Support for the family D_28F 68 10.4 91.9 Type of Health Pastoral Care Courses sacraments are celebrated two to three days. During these Telephone/computer home assistance D_28G 34 5.2 45.9 Sacraments courses, pastoral questions and Caregiver training D_28H 51 7.8 68.9 Frequency of the Health Pastoral Care Courses issues connected with the end Relations with the family doctor D_28I 42 6.4 56.8 %of %of of life (89.9%), the patient ap- Support for the family relatives Name Count Responses Cases proach (92.8%) and the use of in managing mourning D_28J 59 9.0 79.7 The Eucharist D_11A 68 31.3 97.1 pharmaceuticals (81.5%), are addressed. Assistance in an overall approach with a Anointing the Sick D_11B 67 30.9 95.7 single project of assistance shared by

Reconciliation D_11C 56 25.8 80.0 y c the whole team D_28K 40 6.1 54.1

n Question 25) Indicate the e

Baptism D_11D 26 12.0 37.1 u q Involvement of the family relatives

e realities with which forms r F Once a year 1 every 3 months of pastoral link-up in the in the programme of assistance D_28L 50 7.6 67.6 Total 217 100.0 310.0 twice a year at least 1 a month Frequency of the Health Pastoral Care Courses local area have been experimented and the level Totale 656 100.0 886.5

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of satisfaction experienced in relation to The medical services that the results of such forms of collaboration: are offered privilege anti-pain Dioceses Parishes treatment (indicated by 11% of the replies of 97.3% of the Not satisfactory Not satisfactory centres that filled in the ques- Not very satisfactory Not very tionnaire), followed by phar- satisfactory Missing Missing macological treatment. In many centres (10.4% of the answers expressed by about 92% of the structures) support Quite satisfactory for families is offered and a Quite satisfactory Very satisfactory good percentage of centres al- Very satisfactory so offer nutritional support as a medical service. Voluntary work bodies/associations Catholic NGO’s

Missing Not satisfactory Not satisfactory 30) For each category of Not very satisfactory Not very satisfactory patients indicate the age Quite satisfactory band of most of those who have had access to the

Quite services provided by the satisfactory Very structure during 2003 satisfactory Persons with other infectious diseases Missing 47

Very satisfactory

In cases where forms of co- y c n

operation with realities of the e u q e local area have been experi- r F enced, these were found to be 0-18 19-65 66 e oltre very satisfactory in the case of Persons with other infectious diseases Catholic NGOs (44.4%), and in the main forms of co-operation Persons with AIDS at the terminal stage with dioceses, parishes, health- ulated care structures, voluntary work ntage and secular associations were 1.4 found to be quite satisfactory. 0.0 y c n

Activity Involving Assistance e u q e r Question 28) Indicate the kind F 19-65 66 e oltre of medical services offered by Persons with AIDS at the terminal stage your structure during 2003 Kind of medical services Oncological %of %of Name Count Responses Cases Pharmacological treatment D_28A 70 10.7 94.6 Pain-killing treatment D_28B 72 11.0 97.3

Nutritional support D_28C 65 9.9 87.8 y c n e

Physiotherapy D_28D 56 8.5 75.7 u q e r F Rehabilitation D_28E 49 7.5 66.2 0-18 19-65 66 e oltre Support for the family D_28F 68 10.4 91.9 Oncological Telephone/computer home assistance D_28G 34 5.2 45.9

Caregiver training D_28H 51 7.8 68.9 Persons with chronic degenerative pathologies Relations with the family doctor D_28I 42 6.4 56.8 Support for the family relatives in managing mourning D_28J 59 9.0 79.7 Assistance in an overall approach with a single project of assistance shared by y

the whole team D_28K 40 6.1 54.1 c n e u

Involvement of the family relatives q e r in the programme of assistance D_28L 50 7.6 67.6 F 0-18 19-65 66 e oltre Persons with chronic degenerative pathologies Totale 656 100.0 886.5

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As can be seen from the Question 34) Indicate in order graphs, the age band in which of importance, beginning with most of the AIDS patients at the most important (1) and the terminal stage of their ill- ending with the least important ness, those with other infec- (3), the first three components tious diseases, and cancer pa- that in your experience help to tients are located is the 19-65 reduce the overall suffering of a age band, whereas the people dying patient (put the numbers with chronic degenerative 1, 2, or 3 in the empty boxes pathologies are over 66 years next to your choices in order to of age. indicate the scale of importance): %of %of Pain-killing treatment Name Count Responses Cases Question 32) The therapeutic intervention Valid Cumulated In general it is discussed with the patient D_36A 45 31.5 64.3 Frequency Percentage lays emphasis on: percentage percentage It is rarely addressed with the patient D_36B 21 14.7 30.0 In general it is only discussed Therapeutic intervention Valid 1 position 31 4.3 64.6 64.6 with the relatives of the patient D_36C 45 31.5 64.3 %of %of 2 position 5 6.7 10.4 75.0 Name Count Responses Cases It is only discussed by the health workers D_36D 17 11.9 24.3 3 position 12 16.0 25.0 100.0 It is left to the priest D_36E 9 6.3 12.9 The pharmacological Total 48 64.0 100.0 It is left to the psychologist D_36F 5 3.5 7.1 aspect D_32A 65 46.1 94.2 It is not discussed with anyone at all D_36G 1 0.7 1.4 The aspect of Missing not applicable 24 32.0 psychotherapy D_32B 46 32.6 66.7 no answer 3 4.0 Total 143 100.0 204.3 The aspect of Total 27 36.0 rehabilitation D_32C 30 21.3 43.5 Total 75 100.0 Total 141 100.0 204.3 64.6% of the centres that filled in the questionnaire af- It is certainly the case that firmed that anti-pain therapy is therapeutic action privileges the most important element in the pharmacological aspect helping to reduce the overall (indicated in 46.1% of an- suffering of the dying. This was swers by 94.2% of centres), followed by the support of faith even though the psycho-thera- and the support of the family. peutic and rehabilitative aspects are present in a sizeable Question 35) Which of the percentage of centres. definitions listed below is closest to your idea of Question 33) What ‘exaggerated treatment’? percentage of your patients Definitions listed below is closest to your idea of ‘exaggerated treatment’ %of %of die with physical pain that Name Count Responses Cases requires palliative care? Valid Cumulated Frequency Percentage Percentage of patients who die with physical pain percentage percentage Medical doctors who are experts in ative the treatment of pain D_37A 48 43.2 70.6 What is done Medical doctors who belong to a Valid against the will of 21 28.0 29.6 29.6 the patient specific team D_37B 37 33.3 54.4 The Medical doctors of the hospital What does not when a specific team is not present D_37C 26 23.4 38.2 y c improve the n

e 35 46.7 49.3 78.9 u

q quality of life of Totale 111 100.0 163.2 e r F the patient

10-20% 30-40% oltre il 50% Percentage of patients who die with physical pain What does not improve the life 13 17.3 18.3 97.2 expectancy 52.2% of the centres replied of the patient that the percentage of people Other 2 2.7 2.8 100.0 who die in physical pain is 10- 20%. Unfortunately 36.2% of Total 71 94.7 100.0 the structures declared that Missing not applicable 2 2.7 over 50% of patients die with No answer 2 2.7 physical suffering. Total 4 5.3 Total 75 100.0

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For 49.3% of the centres that filled in the questionnaire, the definition that comes close to the idea of exaggerated treatment is: “What does not improve the quality of life of the patient”.

Question 36) With whom do you discuss how to address the death of the patient? %of %of Name Count Responses Cases Question 39) Is the prescribed pharmacological ulated In general it is discussed with the patient D_36A 45 31.5 64.3 protocol communicated to entage It is rarely addressed with the patient D_36B 21 14.7 30.0 other people? In general it is only discussed 4.6 with the relatives of the patient D_36C 45 31.5 64.3 Question 40) If ‘yes’, 5.0 It is only discussed by the health workers D_36D 17 11.9 24.3 indicate whom the prescribed pharmacological 0.0 It is left to the priest D_36E 9 6.3 12.9 protocol is communicated to: It is left to the psychologist D_36F 5 3.5 7.1 %of %of It is not discussed with anyone at all D_36G 1 0.7 1.4 Name Count Responses Cases Total 143 100.0 204.3 It is explained to the patient D_40A 57 45.2 95.0 It is explained to In many centres, how to the “family leader” D_40B 45 35.7 75.0 face the death of the patient is It is communicated discussed above all with the to the medical doctor relatives but also with the pa- of the local area D_40C 24 19.0 40.0 tient himself or herself. Total 126 100.0 210.0 Question 37) Indicate who prescribes the pharmacological treatment: 83.3% of the centres provided information on the pharma- Question 38) Indicate which cological protocol that is pre- category forms the basis of scribed. 45.2% of the answers the use of the expressed by 95% of the struc- pharmacological protocol: tures that filled in the ques- Who prescribes the tionnaire indicated that this pharmacological treatment protocol is explained to the patient. In many of the centres %of %of Name Count Responses Cases this protocol is also explained ulated to the family head. ntage Medical doctors who are experts in the treatment of pain D_37A 48 43.2 70.6 Medical doctors who belong to a Question 42) Do the 9.6 specific team D_37B 37 33.3 54.4 pharmacies and the ways in which they are administered The Medical doctors of the hospital benefit the patient? when a specific team is not present D_37C 26 23.4 38.2 8.9 Totale 111 100.0 163.2 Question 43) If ‘yes’, indicate the kind of benefit they give to the patient: Pharmacological therapy is Drug benefit generally prescribed by med- 7.2 ical doctors who are special- NO ists in pain therapy (43.2% of the answers expressed by 0.0 70.6% of the centres that filled in the questionnaire). The pharmacological protocol is largely based upon the use of weak opiates or strong opiates, YES together with anti-depressives and general adjuvants.

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Improvement in pain levels 73.6% of the structures that Valid Cumulated filled in the questionnaire stat- Frequency Percentage percentage percentage ed that they are supported by links with informal realities. Valid presence 66 88.0 95.7 95.7 In 55.6% of cases by family absence 3 4.0 4.3 100.0 heads, followed by other family relatives and neighbour- Total 69 92.0 100.0 hood friends. Missing not applicable 6 8.0 Total 75 100.0 Some theological – pastoral principles 92% of the health-care struc- Question 47) Does your underlying the research tures that filled in the question- structure have links with naire explained that the phar- institutional realties in the a. General considerations maceuticals and the ways in local area? which they are administered 1. The structures that replied are of benefit to patients. In Question 48) If ‘yes’, to the survey are composed as particular, 95.7% of the centres indicate the level of formal follows: hospices, 58.7%; hos- declared that there is an im- help received from the such pices; operational hospital pal- provement in terms of pain re- institutional bodies: liative care units, 41.3%. Over lief. In addition, their adminis- 50% of the centres that replied tration helps in the retrieval of Question 49) Indicate the work in European countries, 50 the affective sphere of patients. level of usefulness of such even though there are excel- forms of collaboration: lent structures also in other Links with institutional realities in the local area Question 44) Are innovative countries of the world. therapeutic ways practiced? 2. The centres that filled in Question 45) If ‘yes’, which the questionnaire are of vari- ones? ous sizes: this goes from the smallest, generally a hospice,

Innovative therapeutic ways practised y c

Missing n e capable of providing home u

NO q e r care to about ten patients a F YES NO Links with institutional realities in the local area day, to medium size centres, which are generally operational hospital palliative care 86.5% of the centres de- units that can register more clared that they are linked than two hundred clinic and YES with institutional realities in home visits a day. However, their local areas (formal net- few of the structures which works). In particular the most filled in the questionnaire 73% of the centres that filled significant level of help comes have day hospitals. in the questionnaire implement from hospice/palliative care innovative therapeutic ways associations, followed by the 3. Overall, the waiting time such as physiotherapy associ- third sector, public hospitals, to access palliative care is not ated with music therapy. and religious Orders and Con- excessively long: this ranges gregations. from three to ten days for ad- Question 46) Specify if missions and home care, and occasions for the assessment three to eighteen days for clin- of programmed activity are Question 50) In your daily ic visits. envisaged: work are you supported by Assessment of programmed activity links with informal 4. In the centres that filled in realities? the questionnaire, traditional professional figures are pre- Question 51) If ‘yes’, sent: medical doctors, nurses indicate the level of informal and auxiliary technical staff. help received from the Next to these figures, the pres- y c

n following individuals: ence of volunteers and e

u Supported by links with informal realities q

e Catholic spiritual assistants r F Never Every six month Every month and spiritual assistants of other Once a year Ogni tre mesi Assessment of programmed activity religions is effective, even though the majority of the centres that filled in the questionnaire stress that their num-

52.3% of the Catholic y c n health-care centres every e ber is only just sufficient in re- u q e r

month organise moments for F lation to the needs of the con- YES NO the assessment of the activities Supported by links with informal realities text in which the structure op- planned within that structure. erates.

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5. The shortage of sources from the family leader and tion of the spiritual guidance of funding from the public other family relatives, is high- of workers, fostering periodic sector and having to finance er than the satisfaction gener- meetings with other structures themselves above all from pri- ated by the help offered by the in the local area, with chap- vate donations, certainly formal support structures of lains, with volunteers and with makes the administration of local areas, even though patients. human and material resources amongst these the level of difficult, and this could be a help received above all from 12. In those cases where cause of the low level of the the hospice/palliative care as- forms of local pastoral net- numbers of professional fig- sociations is high. works have been tried, they ures available. have proved to be very satis- 10. As regards Catholic factory with the Catholic 6. In general, the typology of worship, in almost all of the NGOs (44.4%) and the collab- medical services offered by centres that filled in the ques- oration with dioceses, parish- these structures involves anti- tionnaire the ministry of the es, health-care structures, vol- pain treatment and pharmacol- sacraments, such as the Eu- unteers and secular associa- ogy. Support for families is of- charist, anointing of the sick, tions was found to be suffi- fered in many centres and a reconciliation and baptism, is ciently satisfactory. good percentage of centres al- assured, even though in many so offer nutritional support as cases the number of Catholic 13. The various realities that part of their medical services. spiritual assistants is just suffi- emerged in this survey show Patients for the most part have cient to carry out this service. that there is still a great deal to a clinical profile characterised One notes the need to promote be done but the path that has by cancer or chronic-degenera- pastoral programmes of the lo- been undertaken is the right 51 tive pathologies. The pharma- cal Church that are specifical- one. A commitment is neces- cological protocol, which is ly dedicated to palliative care sary at all levels to foster and generally communicated to the patient or the family leader, is based prevalently on the use of weak opiates or strong opiates together with anti-depressives and general adjuvants.

7. The activity at the level of assistance of centres providing palliative care is not limited to the medical and supportive approach. Indeed, the personnel, according to the specific character of their mission, work to support the family and the faith of the patient. All of this is translated not only into the reduction of physical pain but also into the recovery of an affective life. and to the need to promote an support centres and palliative 8. Despite all these efforts, a appropriate catechesis. How- care units which, beyond any notable percentage of the cen- ever, when a pastoral pro- logic of exaggerated treatment tres state that over 50% of gramme has been drawn up, a and in opposition to every their patients die in physical priest or a religious is respon- temptation of euthanasia, as- suffering. However, in order sible for it, with whom lay sure overall assistance for sick to improve the quality of life people work in a significant people and their right to a dig- of patients, in the majority of way. In general, the principal nified natural death. the centres that filled in the objectives of pastoral pro- questionnaire innovative ther- grammes concern the overall apeutic ways such as physio- accompanying of patients, b. Theological – pastoral therapy associated with music with special attention being principles therapy are also implemented. paid to care for their spiritual dimension. 1. Every human being is 9. From an analysis of the unique and unrepeatable. There- system of formal and informal 11. Even though most of the fore, his human life is a value in help received by patients, it centres that filled in the ques- itself and must be respected emerges that the satisfaction tionnaire complained about from conception up to its natur- of the patient and the utility the inexistence of a body for al end. that he or she receives from the co-ordination of pastoral the system of informal help, care, when such a body does 2. The human being (human above all the help received exist it is oriented in the direc- person) is a unity of body and

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spirit. Every illness and all suf- as well as the importance of sion, the Pontifical Council for fering and pain have repercus- the necessary involvement of Health Care Workers, entrust- sions on this whole unity. the family and friends. ed with the duty of manifest- Hence the necessity to make ing “the Church’s concern for sure that all treatment and care 4. The death of a person is a the ill, assisting those who ren- takes into consideration the to- “passage.” Spiritual care can- der services to the sick and tality of the human person, even not, neither should it be con- suffering, so that the apostolate if the illness could be localised sidered “optional,” something of mercy they carry out will in a part of the body. that one can do without, an ir- increasingly respond to the relevant practice for the be- new demands” (Pastor Bonus, 3. The human being (human liever. Therefore, it is not to be art. 152), is always inspired by person) is by nature a social confused with psychological these principles, reiterating being (social animal according support and other similar aids. their fundamental goodness, in to Aristotle). And the Bible The sacramental life and spiri- that they respect and promote states: “It is not right that man tual accompaniment should be human dignity, especially in should be alone. I shall make done with much care and dili- the case of people who suffer him a helper who is similar to gence, especially when it con- or are seriously ill. Testimony him” Gn 2, 18. Hence the fun- cerns accompanying someone to this are the themes of its an- damental characteristic of the to cross the threshold towards nual international conferences doctor–patient relationship, the meeting with the Lord. and various publications, espe- which is necessarily an inter- cially the Charter for Health personal relationship of trust, 5. In carrying out its mis- Care Workers. 52

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VII Plenary Assembly of the Pontifical Council for Health Care Workers

20-21-22 March 2007 Domus Sanctae Marthae Vatican City DH n.65 ing 1-88 x6 19-09-2007 14:18 Pagina 54

Address of Homage

Most Blessed Father, This plenary assembly has be collaborators of Your Holi- had another purpose: to draw ness in the specific field of The members and some of up a draft of study for a new pastoral care in health. Thus the consultors of the Pontifical work plan for another five what will be done in the future Council for Health Care years. We have discussed and in the Pontifical Council for Workers, together with the formulated the general goal, Health Care Workers will be staff of our Pontifical Council, the specific objectives and the exactly what Your Holiness in- have come together for our programmes and their actions dicates. Thus this draft which plenary assembly. Our meet- to be engaged in of this work we present in its totality only ing has had as its purpose that plan. We have formulated the briefly, contains what the of assessing the work plan that general goal as follows: ‘To members, the consultors, the was drawn up five years ago, promote, to direct and to co- officials, the under-secretary, which your predecessor, the ordinate pastoral care in health the secretary and myself pro- Servant of God John Paul II, within the Church according pose to Your Holiness, think- approved, and which Your Ho- to the directives of the Holy ing that we interpret your liness benevolently accepted. Father’. As specific objectives wishes in relation to the future This work plan was planned in we propose, in the area of the work of our Pontifical Coun- the year 2002 for a five-year word: ‘To direct pastoral care cil, but subordinating our- 54 period. Half way through this in health within the Church in selves totally to your approval period, in 2005, the previous line with its Magisterium’; in and endorsement. plenary assembly was held to the area of sanctification: ‘To Thanking you once again, assess the performance of the promote the specific spirituali- Holy Father, for the great hon- work plan and to add to or to ty of pastoral care in health in our that you have granted to us correct what had been estab- line with the directives of the in working with you in pas- lished. Today, in taking into Supreme Pontiff’; and in the toral care in health, we prepare consideration what was estab- area of communion: ‘To co- ourselves to listen to your illu- lished at that plenary assem- ordinate and promote pastoral minated words and we bly, we have carried out the care in health within the humbly implore you apostolic latest revision of the work Church in the name of the blessing. plan, and we give thanks to Supreme Pontiff’. In this work God that we have been able to plan, as well, there are fifty- His Eminence Cardinal JAVIER complete the fifty-three pro- three programmes, divided ac- LOZANO BARRAGÁN, grammes of which this work cording to these specific ob- President of the Pontifical Council plan was made up in a reliable jectives. for Health Care Workers, way. We have the great honour to the Holy See.

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Address of His Holiness Benedict XVI to the VII Plenary Assembly of the Pontifical Council for Health Care Workers

THURSDAY, 22 MARCH 2007

Your Eminence, the natural ethical principle of the duty to care Venerable Brothers in the Episcopate for the sick, on the basis of which every hu- and in the Priesthood, man life must be defended in accordance with Dear Brothers and Sisters, its own particular difficulties and with our I am pleased to welcome you on the occa- practical possibilities of providing help. Go- sion of the Plenary Assembly of the Pontifical ing to the aid of the human being is a duty: Council for Health Care Workers. I address both in response to a fundamental right of the my cordial greeting to each one of you, who person and because the care of individuals re- have come from various parts of the world as dounds to the benefit of the group. Medical an effective expression of the commitment of science makes progress to the extent that it is 55 the particular Churches, the Institutes of Con- willing to constantly discuss diagnosis and secrated Life and the Christian community’s methods of treatment, in the knowledge that it numerous institutions in the health-care sec- will be possible to surpass the previous data tor. I thank Cardinal Javier Lozano Barragán, acquired and the presumed limits. Moreover, President of the Dicastery, for the courteous esteem for and confidence in health-care per- words with which he has expressed your sonnel are proportionate to the certainty that common sentiments, describing to me the these official guardians of life will never con- current goals you are working to achieve. I demn a human life, however impaired it may greet with gratitude the Secretary, the Under- be, and will always encourage endeavours to secretary, the Officials and Consultors present treat it. Consequently, treatment should be ex- and the other collaborators. tended to every human being, meaning Your aim is not to examine a specific theme throughout his or her entire existence. The at this meeting, but rather, to check on the im- modern conception of health care is in fact plementation of the programme you estab- human advancement: from the treatment of lished previously and consequently, to deter- the sick person to preventive treatment, with mine your future objectives. Thus, meeting the search for the greatest possible human de- you on an occasion such as this gives me the velopment, encouraging an adequate family joy, so to speak, of making each one of you and social environment. actually feel in your ecclesial service the closeness of the Successor of Peter, and through him, of the entire Episcopal College. Indeed, the pastoral care of health is a typical- ly evangelical context, which immediately recalls the work of Jesus, the Good Samaritan of humanity. When he passed through the vil- lages of Palestine proclaiming the Good News of the Kingdom of God, he always accompanied his preaching with signs that he worked for the sick, healing all those who were prisoners of every kind of disease and infirmity. The health of the human being, of the whole human being, was the sign chosen by Christ to manifest God’s closeness, his merciful love, which heals the mind, the soul and the body. Dear friends, may this always be the fundamental reference of your every initiative: the following of Christ, whom the Gospels present to us as the divine “doctor”. It is this biblical perspective that enhances

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This ethical perspective, based on the dig- I can now add to the Encyclical the recently nity of the human person and on the funda- published Post-Synodal Apostolic Exhorta- mental rights and duties connected with it, is tion, which in a broad and structured way confirmed and strengthened by the com- treats the Eucharist as the “Sacrament of mandment of love, the heart of the Christian charity”. It is precisely from the Eucharist message. Christian health-care workers that health pastoral care can continuously therefore know well that there is a very close draw the strength to relieve human beings ef- and indissoluble bond between the quality of fectively and to promote them as befits their their professional service and the virtue of proper dignity. In hospitals and clinics, the charity to which Christ calls them: it is pre- Chapel is the vibrant heart where Jesus cisely in doing their work well that they give ceaselessly offers himself to the Heavenly people a witness of God’s love. Charity as a Father for the life of humanity. The Eu- task of the Church, which I made the object charist, distributed to the sick in a dignified of reflection in my Encyclical Deus Caritas and prayerful way, is the vital sap that com- Est, is implemented in a particularly mean- forts them and instils in their souls the inner ingful way through the care of the sick. This light with which to live the condition of sick- is attested to by the history of the Church, ness and suffering with faith and hope. I with countless testimonies of the men and therefore also entrust this recent Document to women who either individually or in groups you: make it your own and apply it in the have worked in this field. Thus, among the field of pastoral health care, drawing from it 56 saints who practised charity in an exemplary the appropriate spiritual and pastoral guide- way, I was able to mention in the Encyclical lines. emblematic figures such as John of God, I offer you my best wishes for the success Camillus de Lellis and [Giuseppe] Cottolen- of your work in these days and accompany it go, who served the poor and suffering Christ with a special remembrance in prayer, as I in- in the person of the sick. voke the motherly protection of Mary Most Dear brothers and sisters, allow me, there- Holy, Salus infirmorum, and with my Apos- fore, to present to you in spirit the reflections tolic Blessing, which I cordially impart to I proposed in the Encyclical with the relative you who are present here, to all those who pastoral instructions on the charitable service work with you in their respective depart- of the Church as a “community of love”. And ments and to all your loved ones.

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Topics

Treating and Caring

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Treating and Caring

Introduction subject appeal is made to the man, now it is seen as an of- unbearable nature of the suf- fence, an outrage. A person In his message for the World fering that is endured and to who dies is almost accused of Day of the Sick, Benedict XVI the dignity of the person. betraying those who stayed be- pays especial attention to the hind…This is our frightening incurably ill, above all those blasphemy: wanting death to who are living out the last Understanding die. We have expelled death stage of their existence. The from the sphere of our Supreme Pontiff extended an As citizens who are believ- thoughts, and thus we have be- invitation to promote ‘fair so- ers, what attitude should we come the ridiculous puppets of cial policies that can contribute adopt towards this phenome- a mechanical vitality that re- to the elimination of the causes non, a sign of the establish- quires us to ignore its final des- of many illnesses’ and called ment of a culture that is op- tiny. We are unhappy, coward- for the provision of ‘better care posed to Christian values? It ly, and specifically at a time for those who are dying and seems to me that the first ap- when we speak repeatedly those who cannot rely upon proach to be adopted is the about safety and energy’. medical treatment’. In the good expressed in a phrase of Secondly, the question words of the Pope emphasis is the philosopher Spinoza: do should be posed: what image 58 placed on the need to ‘promote not cry, do not laugh, under- of man emerges from the ap- policies that are able to create stand! proach that is in favour of ex- conditions in which human be- This is a matter first of all of aggerated treatment and eu- ings can bear incurable illness- understanding that at the roots thanasia? ‘That of the absolute es as well and face up to death of the policies of euthanasia master’, answers Dionigi Tet- in a dignified way’. and exaggerated treatment tamanzi, ‘that of the arbiter Amongst the various initia- there is an established tenden- against whom there is no ap- tives that are able to meet in a cy of contemporary culture peal of the self, its decisions, more adequate way the needs which leads to the removal of its choices, the realities of its of the dying, Benedict lays em- death. This process of removal life, and thus also of that spe- phasis above all on centres for has always been present in the cial reality – death’. The same palliative care, and hopes that experience of human beings. author points out that exagger- their number will grow so that In fact it finds its origins in the ated treatment and euthanasia a growing number of sick peo- psychology of the human per- ‘are apparently different but in ple will be offered the ‘human son, as Freud pointed out at the reality identical ways for man help and spiritual accompany- beginning of the twentieth cen- to address the reality of death’. ing that they need’. tury when he stated that ‘in ba- The hypothesis of Tettamanzi sic terms, nobody believes that is confirmed by Prof. Mal- they will die, or, which is the herbe, a medical doctor and The Debate on same thing, each person is un- philosopher of the University the ‘End of Life’ consciously convinced of their of Louvain. In the view of this own immortality’. scholar, there is a logical conti- The Pope’s appeal for over- If the tendency to remove nuity between exaggerated all care for a person at the ter- death is something that is nat- treatment and euthanasia be- minal stage of his or her life ural, and thus to be observed in cause in them both there is also occurs at a time when Italy is every epoch, it nonetheless a man who does not allow involved in a keenly-felt de- takes on particular connota- himself to be measured in a bate about the questions and tions in different historical pe- human way by death: with ex- issues connected with the end riods. With respect to our aggerated treatment man does of life. Recent cases, where times, it is sufficient to read everything to postpone death, chronically ill people have what Giovanni Arpino writes to delay its arrival, and with asked to be helped to die, have in his novel Passi d’addio, to euthanasia man does every- helped to bring to the fore sub- have an idea of the limits thing to bring forward death. jects that have been discussed reached by the process of the And thus in both cases man for a long time, such as exag- removal or concealment of wants to exercise his command gerated treatment and euthana- death. ‘It is a grave sin of our over, his domination of, death. sia. world, of our years’, he writes, This vision of reality finds The mass media pay great ‘not to want to speak about support in a certain kind of sci- attention to these situations death anymore. We hide it, we entific-technical progress and call upon public opinion to camouflage it as an accident which confirms what is to be take a stance in relation to that should be immediately found in Gaudium et Spes: these questions and issues, of- eliminated. Whereas death was ‘there is the danger that man, ten appealing more to people’s always honoured in times that trusting too much in his daily emotions than to their feelings. were truly human, times that discoveries, will think that he In all pronouncements on the were perhaps terrible but hu- is sufficient unto himself and

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will no longer look for higher spiritual in character than tised and eliminated through things’ (n. 57). What is written physical because it is brought the intervention of euthanasia. in this Constitution of the Sec- about by a lack of the commu- On the contrary, he remains a ond Vatican Council makes an nication of the truth, the so- person ‘in whom the values of implicit reference to the fact called ‘conspiracy of silence’, intelligence, will, conscience that the question of health, life by the tendency to provide and brotherhood excel’ and death have been removed prevalently technical answers (Gaudium et Spes, n. 61), and from the metaphysical sphere, to suffering, and this impedes as such he is capable until the as a result of which questions the meaning of suffering being end, if placed within a rela- about the end of life move understood. tionship, to make of his own from the terrain of meaning life an experience of growth and value to the terrain of in- and completion’. creasingly powerful means. In Responding facing up to death and in helping the dying the words that Given that a patient needs Caring death utters about the human his appeal – which refers to the condition, and which are ex- finiteness and mortal condition This experience of growth pressed in the cry that is ut- of the individual – to be lis- requires that side by side with tered by those who are at the tened to and the emotions that treatment there is also care, end of their lives to those who accompany him (disquiet, fear, and this within a creative syn- are near them, are no longer hope) to be taken on board, thesis. The verb ‘to care for’ heeded. what approach that is an alter- expresses the personal in- The words spoken by a dy- native to exaggerated treat- volvement of a health-care ing person reveal a gap be- ment and euthanasia should be worker with the person who is 59 tween what he or she is and proposed? suffering, an involvement that what he or she would like to be In the humanistic and Chris- is expressed through compas- clear to him or her. This is be- tian domain this alternative sion, concern, encouragement cause suffering is always a way of addressing a dying per- and emotional support. In the wound for human narcissism. son takes the name of ‘accom- concept of caring, therefore, Through suffering, the real ir- rupts into the imagination. And this ‘real’ of death, which is made present in suffering, shakes and breaks the suffering of our imaginary ‘egos’; it makes us feel the reality of the subject that lives in us, this other who is more intimate to us than we ourselves and who can never be conceived adequately as the image that a man has of himself. Continuing in the sphere of understanding, it should be observed that the rejection of death has consequences for our approach both to the process of dying and to dying people. People are now much less ex- panying’, and has as its aim are included both professional posed to the sight of dying, helping the individual to live expertise and scientific train- which in the past was a part of until his or her end. ing and that personal involve- people’s ordinary experience. In the anthropological ap- ment that leads to a centring of Most people still die in health- proach to accompanying, the attention on the person of the care institutions which regulate dying patient, on the one hand, patient, whose experiences, the sequences of that process bears witness to the precari- even though they may not be with detailed prescriptions in- ousness of the human condi- fully penetrated by us, can, tended to isolate both the event tion, which should not be re- nonetheless, touch us deeply of the dying person and the jected, which, however, hap- because we share the same hu- corpse of the dead person. The pens in the case of exaggerated manity. Caring for a patient is period that precedes death is treatment. As the Pope ob- thus a synthetic act in which thus desocialised because soci- serves in his Message: ‘human intelligence, no less than the ety, which is sick with the re- life has intrinsic limits, and, heart, has its role and its place. moval of death, is powerless to sooner or later, ends with In a significant book written take on the last moments of the death’. For that matter, the dy- at the beginning of the 1980s life of those who die. A dying ing patient is not seen as a entitled ‘In a Different Voice’, person is often abandoned to a mere ‘biological residue for the American Carol Gilligan heavy loneliness, a loneliness whom nothing can any longer expressed in a very significant that is more psychological and be done, a being to be narco- way what this synthesis re-

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quires. The ‘different voice’ to of a specific human relation- necessary in order to really un- which the author refers is ship are implemented not only derstand what those who pro- made up in the world of health the rules that structure the mote exaggerated treatment or and health care of drawing health-care profession. At a euthanasia experience and in- near to people with an ap- deeper level one gives form to tend – for example the suffer- proach of participation rather the specific moral identity of ing experienced by a person than detachment, and of har- people. In this way, the experi- who has to face up to death mony and compassion rather ence of the health-care profes- without the support of faith than abstract rationality. A sional makes possible the and openness to hope that does voice that stresses the primary epiphany of otherness, to not disappoint. place of the person, his or her which Levinas refers, which Discussion is directed to- singularity, in that he or she involves making the essence of wards illuminating reason with asks to be taken into consider- moral experience specifically the light of faith so that it can ation for what he or she really encounter with the other, with interpret in a more just way the is. A voice that has been spo- the face of the other. great subjects of the dignity of ken down the centuries for the The accompanying of a dy- life at its final sage and the most part by women, but a ing person in the terms that right sense of personal autono- voice that is not only of have just been outlined occu- my. women, even though our tradi- pies an essential place in pal- As regards the principle of tion has relegated this voice to liative care, to which, indeed, autonomy, for example, it is them. the Message of the Pope important that the patient is ex- refers. As the Oxford Textbook amined with greater attention of Palliative Medicine ob- and honesty: ‘is this question 60 serves: ‘palliative care up- really free? Is it listened to holds life and see dying as a carefully? And deciphered cor- natural process; it neither rectly? What is its precise speeds up nor delays death; it meaning? Careful listening offers relief from pain and oth- and correct deciphering are re- er unpleasant symptoms; it quired above all else when one takes into account the psycho- takes into account the state of logical and spiritual aspects of physical, psychological and treatment; and offers practical spiritual vulnerability in which conditions that help the patient the patient in the terminal stage to live as actively as possible of his or her illness finds him- until his or her death and help self or herself. the family to address the suf- Who is the subject that asks fering of the patient and then to be helped to die? Is it the pa- of mourning’. tient or the environment that The etymological root of the surrounds him or her? What is term ‘palliative’ is to be found the goal of the request: is it the in the Latin noun pallium right to act autonomously in which means a ‘cloak’. From relation to one’s own death or this comes the idea of spread- is it, rather, the right to be ing a cloak over a body, which helped and looked after until provides a concrete idea of a the end without feeling that protective and curative action one is a burden and without that is able to provide benefit, being ashamed? that is to say warmth, but at the same time, from a spiritual point of view, to provide com- The Force of Love fort and protection to those who are in a condition of suf- Dialogue and discussion ac- fering. quire a particular force when In moving from treating to they are advanced by gestures caring one goes beyond pro- that visibly transmit, as the fessional conduct based only Dialogue and Discussion Pope states at the end of his on the rights of sick people and Message, the desire of the the duties of those who are re- At the present time the posi- Church to help the dying and sponsible for them. One tion of the believer clashes in a ‘be at their side…making the comes, that is to say, to experi- strong way with the position loving mercy of Christ be pre- ence what it means to listen to supported by a significant part sent’. the appeal that comes from the of the Italian population, special condition lived out by a which in turn is influenced by Rev. ANGELO BRUSCO, person who is near to his or her pressure groups of undeniable M.I. Lecturer in Pastoral Psychology, death. In responding to this ap- effectiveness. The position to the ‘Camillianum’ peal, therefore, one does some- be adopted in this situation is International Institute thing more than one’s simple to be defined through dialogue for the Pastoral Theology of Health, ‘duty’. Within the concreteness and discussion. Dialogue is Rome.

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Cancer Pain, Death and Dying

CLINICAL, THERAPEUTIC AND ETHICAL-THEOLOGICAL ASPECTS

The authors of this paper, in age to tissue or described with Illness-pain is to be identi- addressing such an important terms that refer to such dam- fied with chronic pain which and sensitive subject, wish to age. Sub-committee of the In- lasts for months or years and establish points of reference ternational Association for the often induces syndromes or that are very clear and also Study of Pain for the Taxono- anxiety and/or depression shared from a terminological my – I.A.S.P., 1982. ‘Pain (rheumatic pain, post-herpetic point of view in relation to the Terms: a List with Definitions pain, causalgic pain, arthrosis definition of: life, health, pain- and Notes on Usage’, PAIN, 6 and osteoporosis pain, cancer symptom, pain-illness, illness, (1979) 249; 14 (1982) 205. pain). cancer, treatment (therapy), palliative care, proportionate Definition of the term ‘pain’. Definition of ‘illness’. and disproportionate therapies, The Algologic School of The interruption of balance euthanasia, death, and dying. Florence, 1983. Pain is a psy- (homeostasis) in the organism cho-physical entity of univer- which leads to a physical Life is a good that cannot be sal meanings in the perception and/or mental and/or social al- disposed of at will and is a of which different individual, teration which in English is 61 good that is inviolable because cultural and religious factors well expressed with the terms it belongs to God and is there- are at work and in the defini- ‘disease’, which refers to the fore sacred (Charter for tion of which take part not on- organic component of the ill- Health Care Workers, n. 43, ly the disciplines of medicine ness (algos); ‘illness’, which Pontifical Council for Health and biology but also those of refers to the moral suffering Care Workers, Vatican City, the human sciences (philoso- (pathos) of the individual; and 1995). phy and psychology). Zucchi, ‘sickness’ which refers to the P.L., Vivaldi Forti, C., Mi- illness as a social perception Definition of the term ‘health’. laneschi, E., and Obletter, G., (ethos). World Health Organisation, ‘Definizione del termine do- 1978. Health must been seen lore’, in ‘Test di personalità Definition of ‘cancer’ as a state of complete physical, proiettivi (Rorschach, T.A.T.) (or ‘terminal illness’). mental and social wellbeing e non proiettivi (M.M.P.I.) A state of illness whose pres- and not only the absence of af- nella cefalea psicogena e nella ence induces in the minds of flictions and illnesses. cefalea da tensione musco- the medical doctor, the patient lare. Indirizzi terapeutici’, Al- and the family an expectation Definition of the term ‘health’. gologia, 1 (1983) pp. 41-82. of the individual’s death as a The Pontifical Council for direct consequence of the ill- Health Care Workers, Vatican Symptom pain (acute pain). ness itself (Lasagna, 1970). City, 2000. Health is a tension This is the symptom par ex- Lasagna, L., ‘The prognosis of towards physical, mental, so- cellence, with a very acute out- death’ in Levine, S, The dying cial and spiritual health and is break, with a single clinical patient (Russel Sage Founda- not only the absence of illness; sign, often involving safe- tion, New York, 1970). it makes man able to carry out guarding, of the set of symp- the mission that God has en- toms underway (acute appen- Definition of ‘therapy’. trusted to him, according to the dicitis, cluster headache, my- (Therapy = to cure = the car- moment in his life in which he ocardial heart attack) which rying out of a therapeutic ac- finds himself. This definition creates a relationship of alarm tion; therapeia = to care = to of health was formulated by such as to induce an immedi- take care of). By medical thera- His Eminence Cardinal Javier ate remedial therapeutic ac- py should be understood that Lozano Barragán and was con- tion. This situation is to be health-care, medical and/or firmed by His Holiness John identified with acute pain and paramedical act that links the Paul II at the time of the World with its organic parameters. administration of treatment Day of the Sick (Vatican City, (therapy, to cure) in its various 11 February 2000). Illness-pain (chronic pain). (pharmacological, surgical, This is the pain that emerges physiotherapeutic) to forms of Definition of the term ‘pain’. as a primary element from the taking caring (therapeia, to Sub-committee of the Inter- framework of illness and loses care) of the patient in his or her national Association for the its characteristic of being a most overall, mental, physical Study of Pain for the Taxono- symptom which is useful for and spiritual meaning. my (I.A.S.P., 1982). Pain is an the patient and the medical unpleasant sensorial and emo- doctor. The emergence is grad- Definition of ‘palliative care’. tional experience associated ual and a recurrent sub-contin- (E. A. P. C.: European Asso- with a real and potential dam- uous development. ciation for Palliative Care,

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Newsletter, n. 1, 1989). Pallia- means a difficult or troubled fined the death of a person as tive care is total care provided death. the irreversible cessation of all to a person afflicted with an ill- the functions of the en- ness that is no longer respon- Euthanasia cephalon. sive to therapies whose aim is By ‘euthanasia’ is meant an the cure of the patient. The action or an omission which by Definition of ‘dying’. control of pain, of the other its very nature, or in its inten- An evolving process that symptoms and of the psycho- tions, procures death with the gradually strikes the cells of the logical, social and spiritual as- purpose of eliminating all pain. various tissues and the relative pects is of prevalent impor- This is a homicidal act that no sub-cellular structures on the tance. From the definition of end can justify (Charter for basis of their different resis- the E.A.P.C one may stress that Health Care Workers, the Pon- tance to a shortage of oxygen to palliative care: 1. upholds the tifical Council for Health Care the point of the extinction of value of life and sees death as a Workers, Vatican City, 1995,. n. every vital activity with the natural event; 2. aims neither 147). continuation of the colliqua- to prolong nor to shorten the tive-putrefactive enzyme phe- life of the patient; 3. works for Hospice nomena alone. The process of the relief of pain and other Cicely Saunders, a nurse and dying ends when the whole of symptoms; 4. supplements the social assistant, who then took the organism has reached com- psychological and spiritual as- a degree in medicine, spread a plete necrosis. pects of care; 5. offers a system very precise philosophy about of support for the family; 6. the hospice throughout the Anatomical-physiological and helps the family during the world, from which, indeed, we aspects. 62 stage of mourning. can take the following defini- To have a better idea of the tion: admission into a family clinical aspects, a short paren- Proportionate and environment, with constant as- thesis should be inserted here disproportionate therapies. sistance, in a multi-disciplinary on the anatomical-physiologi- When a health-care worker approach, where all the symp- cal aspects. Pain is due to the is unable to cure a patient he or toms of malaise are taken into activation of receptors (pain re- she must never forgo treat- account, with special attention ceptors) and the peripheral and ment. He or she is obliged to being paid to manifestations of central afferent paths that make practice all the proportionate pain. up pain reception (fig. 1). The forms of treatment and there is receptor is a structure that no obligation to engage in dis- Definition of ‘death’ transforms thermal energy, me- proportionate forms of treat- The concept of ‘death’ is de- chanical energy, chemical ener- ment (Charter for Health Care fined by the total and irre- gy and light energy into an Workers, the Pontifical Coun- versible loss of the capacity of electrical phenomenon, that is cil for Health Care Workers, the organism to maintain its to say a sequence of action po- Vatican City, 1995). Life is a own functional unity au- tentials. The pain receptor has a good that cannot be disposed tonomously. In Italy the legisla- high threshold and is excited of at will and it is inviolable tive decree n. 578 of 1983 de- only by painful stimuli. because it belongs to God, and is, therefore, sacred (Charter Fig. 1. Various kinds of pain perception for Health Care Workers, the with their equivalent neuro-anatomical correspondents Pontifical Council for Health Neuro-anatomical Substratum Clinical Substratum Care Workers, Vatican City, 1995, n. 43). CORTEX AND CONSCIOUS PAIN Exaggerated treatment. LIMBIC SYSTEM= PERCEPTION ‘Exaggerated treatment’ is (MENTAL) PAIN that medical action which involves the application of important therapies (surgical op- = erations, resuscitation, the ad- BRAIN STEM UNCONSCIOUS ministration of drugs and medi- AND THALAMUS PAIN PERCEPTION cines) to a patient at the end of his or her life with the goal of prolonging life in a forced and = mechanical way. Exaggerated treatment SPINAL COLUMN REFLEX PAIN takes place when the PERCEPTION intention is to prolong life by = any means without there being any hope of a cure or a residual life of good quality. This is PERIPHERAL PERIPHERAL contrary to euthanasia. In RECEPTORS PAIN PERCEPTION bioethics the word ‘exaggerat- OR PAIN RECEIVERS ed’ can be replaced by the Greek word distanasia which

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The algic situation creates deaths caused by cancer is ic anamnesis (description of at the level of the organism an around 23% of all deaths pain: the beginning, localisa- anatomical lesion of the tis- every year. The pain symptom tion), intensity (VAS), length, sues with the freeing of al- in cancer-related pathologies frequency, emotional partici- gogenic substances which is present in 30-40% of all pation, physical and/or mental stimulate the reception appa- cases. In the terminal stage the malaise; 3. the general (se- ratus (peripheral pain percep- incidence of pain reaches 60- meiological-clinical) physical tion) which the transforms the 80% in cancer cases. objective examination; 4. the stimulus into a pain-perceiv- algological examination with ing input which, through the Psychological aspects. algometric tests: physical order I neuron, then reaches The perception of pain. The measurement of the pain (hy- the spinal chord (reflex pain perception of pain is provided peralgesia) and mental mea- perception). At this level, the by the pain-perceiving, dis- surement (projecting and non- order I neuron enters into criminating, cognitive and af- projecting tests; Vs); neuro- synapsis with order II neuron fective component. The pain- logical examination; and psy- which then informs the thala- perceiving component is made cho-social examination. mus (unconscious pain per- up of the activation of al- ception). From the thalamus, gogenic receptors (the pain re- The monitoring of pain the II order neuron projects ceptors) and the peripheral The monitoring of pain in a the pain-perceiving input to and central afferent pathways clinical context has a notable the somatoestesic cortex that make up pain perception. importance in the assessment (conscious pain perception) The discriminating component of: a. intensity (VAS); b. pain- (fig. 2). refers to the capacity of the relief; c. impact on the affective and cognitive compo- 63 Fig. 2. Schematic portrayal of the path followed nents; d. the side effects of the by the algogenic stimulus therapy; and e. the compliance NVPM = Ventroposteromedial nucleus of the thalamus. of the patient. NVPL = Ventroposterolateral nucleus of the thalamus. Questions that arise from the relationship between the Somatic health-care workers and the sensorial cortex cancer patient. Faced with the pain of a cancer patient it is advisable III order for the health-care worker to neuron pose himself or herself certain questions in order to enter into empathy in a better way with Thalamus his or her patient. The most (NVPM/NVPL) frequent questions are: 1) how does the patient with multi- cancer experience his or her II order pain? Pain is experienced by a neuron cancer patient as the most concrete expression of his or her illness and to such an extent that it is referred to by 60% to Algogenic Receptors Spinal Column 80% of samples subject to ex- stimulus I order neuron amination; 2) what role does the environmental context play in the cancer patient who has mental suffering (pathos) Epidemiological aspects pain pathways to transmit the and physical suffering (algos)? Cancer pain is a problem of spatial and temporal informa- Although pharmacological relevant importance from the tion of the painful stimulus. treatment is able to control health-care point of view be- The cognitive component cancer pain in 90% of cases, cause of its frequency and the refers to how the painful stim- the results of pain-killing psycho-physical invalidity ulus is likened to emotional treatment are often unsatisfac- that this symptom causes. At experiences (memory of men- tory and achieve pain-relief in the present time in the world tal pain). 50% of cases. about fourteen million people suffer from cancer, of whom Assessment of pain. Reasons for an inadequate five million die because of it. In the clinical assessment of control of cancer pain Cancer is responsible for 8% pain the points to be taken into The reasons for an inade- of all causes of death and this consideration are 1. general quate control of cancer pain percentage tends to increase in (recent pathological, remote can be connected with: 1. the the most developed countries. pathological, physiological, patient or his or her family rel- In Europe, the percentage of family) anamnesis; 2. algolog- atives because of the follow-

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ing: a. the belief that the pain changes in relationships and needs; and d. raises the thresh- is inevitable and/or cannot be interests; c. inability to work; old of tolerance. Bad co-oper- treated; b. the acceptance of d. obligations at the level of ation between the patient, the pain because of the religious lifestyle; and e. decrease in family and the health-care approach of the patient who in quality of life. The painful ex- workers: a. creates depression this case wishes to join his or perience of cancer tends to and loneliness in the patient; her sufferings to those of bring about the interaction at b. creates difficult compliance Christ; c. non-compliance; different moments of: a. the with the treatment; c. creates and d. intolerance of the treat- brain with the mind, the body closure to dialogue; d. makes ment. 2. the health-care work- with the soul in reaction the pain chronic; and e. lowers ers because of the following: whose parameters tend to uni- the threshold of pain a. the belief that in this specif- son; b. the patient with the ic case pain is inevitable family, with the health-care Clinical aspects and/or cannot be treated; b. an workers, and with the social, The subject of pain and of incorrect assessment of the cultural and religious context. suffering from a clinical point physical pain and the emotion- Unfortunately, however, the of view has been addressed in al responses; c. an erroneous result is not satisfactory and a particular way by the School use of pharmaceuticals in leads the patient to total suf- of Florence (Teodori, Neri- terms of molecule typology, fering (total pain), facilitating Serneri, Procacci, Galletti, dosages and length of admin- the appearance in those who 1973; Zucchi, Duranti, 1979). istration, which are not appro- are near to the patient (family This school makes a distinc- priate when the chrono-bio- relatives and health-care tion between symptom-pain logical parameters are taken workers) the syndrome of and illness-pain. Symptom- 64 into account; d. a lack of in- burn-out. pain is the symptom par ex- struction by the health-care cellence with a very acute workers given to the patient Semantic diagnosis of pain. emergence, a single clinical and/or his or her family rela- A semantic diagnosis of sign, often involving safe- tives as regards the length etc. pain takes place at an oral lev- guarding, of the set of symp- of the administration of the el through dialogue and vocal- toms that are underway (acute drugs and medicine; and e. isations (groans, complaints) appendicitis, cluster headache, fear of the development of de- and at a non-oral level through myocardial heart attack) pendence; f. non-compliance. expressions and muscular ten- which creates a reaction of sion. alarm such as to induce remedial therapeutic action. Illness- Kinds of pain (psychological). pain is the pain that emerges From the description of the as a primary element of the pain referred to by the patient framework of illness, losing and examined by the medical its characteristic of being a doctor, we can divide psycho- symptom which is useful to logical pain into acute pain both the patient and the med- and chronic pain. From a psy- ical doctor. The emergence is chological point of view, acute gradual with a recurrent sub- pain is characterised by a di- continual evolution. Illness- rect, visible and observable pain is to be identified with expression through the study chronic pain which lasts for of oral behaviour. Chronic months or years, gives no pain is characterised by truce to the patient and often blocked and non-communicat- induces syndromes of anxiety ed expression, with oral be- and/or depression. Examples haviour and at times gestures of this kind of pain are: that are not in conformity with rheumatic pain, the pain of the intensity of the pain; this is post-herpes neuralgia, causal- difficult to believe and, at gic pain, pain in arthrosis and times, difficult to recognise. osteoporosis, and cancer pain. Psychological strategies in A clear exposition of these im- the treatment of cancer. There portant concepts helps to un- are psychological strategies derstand how pain can charac- Cancer pain as a result (good-co-operation, bad co- terise a clinical situation that is of physical, mental and operation) that the medical variegated from a physical, environmental interaction. doctor must follow in order to mental and social point of Cancer pain should be seen obtain good results from the view, and which English man- as a very variegated entity ob- treatment. Good co-operation ages to express very well with tained through the interaction between the patient, the family the word ‘disease’ which of the physical and mental lev- and the health-care workers: a. refers to the organic compo- els of the patient with the envi- facilitates the exchange of in- nent (algos) of the illness, with ronmental level, giving rise to formation; b. improves the the word ‘illness’ which refers inevitable consequences such monitoring of the therapies; c. to the moral suffering (pathos) as: a. personality change; b. allows the expression of experienced by the patient and

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Tab. I. Causes of his or her family relatives, and ings-Voegelin, 2001), cultural the syndrome of anxiety with the word ‘sickness’ formation (Zborowski, 1952; which refers to the (painful) Jacox, 1977; Wolff, 1985) and a) Fear of pain illness as social perception family formation (Waring, b) Fear of death (ethos). 1978), on his or her social c) Fear of being admitted to a hospital From this elaborate mean- context (Craig, 1978; Mc d) Worry for family relatives ing which English offers us of Caffery, 1979) and on expec- e) Economic problems the Italian word ‘malattia’, tations of recovering (Saun- f) Uncertainty about the future one can understand how the ders, 1979). A patient afflict- Scarcity of therapeutic results (terminally ill) patient lives ed by cancer encounters phys- his or her state of total pain in ical pain (fig. 3) and alter- all three (physical, mental and ations in the emotional sphere The causes that characterise social) dimensions, involving which are characterised by the syndrome of depression in his or her own tragedy also anxiety and depression (men- are indicated in tab. II. family relatives, acquain- tal pain) (fig. 4). Tab. II. Causes of the tances, and health-care per- These two psychological as- syndrome of depression sonnel (Sindrome di burn-out, pects of pain, namely anxiety Mayou, 1987). Pain in a ter- and depression, characterise a) Loss of role within the family minally-ill patient and the the outbreak and the intensifi- b) Loss of social position suffering that accompanies cations of the illness, accord- c) Loss of prestige at work such a difficult situation de- ing to its chronic levels. The d) Loss of income pends on his or her ethical-re- causes that characterise the e) Insomnia ligious formation (Zucchi- outbreak of the syndrome of f) Asthenia Honings, 1996; Zucchi-Hon- anxiety are indicated in tab. I. g) Dyspepsia 65

Fig 3. Stages of physical pain Low Threshold High Threshold

PHYSICAL PAIN The syndrome of anxiety Anxiety Therapeutic relief of pain and the syndrome of depres- Depression sion tend to lower the pain Fear threshold (that is to say they Mental and environmental isolation make the patient feel greater Malaise Superficial (skin, pain). Other factors, however, Asthenia subcutaneous, influence the level of the algic Adequate pharmacological treatment muscle threshold, raising it or lower- (analgesics, anxiety-reducers, anti-depressants). ing it, as is described in tab. Hyperalgesia Alteration of the function III. Tab. III. Factors that Visceral influence the level of the pain threshold Low Threshold I STAGE II STAGE Anxiety Depression Fear Mental and environmental isolation Malaise Muscular contraction Muscular hypertonia Asthenia Hypertonia Muscular hypertrophy Adequate pharmacological treatment (analgesics, anxiety-reducers, anti-depressants). High Threshold Fig. 4. Stages of mental pain. Therapeutic relief of pain Sleep Rest MENTAL PAIN Affection of family relatives Understanding of friends Improvement in mood

ANXIETY DEPRESSION (I stage) (II stage)

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A patient with cancer has within seven days gives rise to different symptoms according hypertonia and muscular hy- to whether he or she is at an pertrophy with an alteration of early or late stage of the illness function (II stage) (fig. 3). The (tab. IV). pain tends to have a der- Tab. IV. Recurrence of matomeric (fig.5), metameric symptoms in the initial stage or neuromeric distribution ac- and the late stage of cording to the sectors that are cancer pain affected. From an anatomical- CANCER PAIN Symptoms of the initial stage Symptoms of the late stage The action of faith and a) Asthenia 47% a) Vomit 40% prayer on the physical, men- b) Anorexia 67% b) Diarrhoea 4% tal, cultural and social para- c) Nausea 40% c) Hiccups 5% meters of pain. The state of d) Insomnia 29% d) Cough 50% pain of a patient afflicted with e) Constipation 47% e) Dyspnea 51% cancer constitutes the result of f) Incontinence 23% f) Decubitus 19% the activation of the anatomi- g) Permalleol edemas 31% g) Dropsy 31% cal and neurochemical circuits h) Weight loss 77% h) Anaemia 23% of pain perception and is char- i) Drowsiness 10% i) Lung discharge 31% acterised by physical pain (algos) and moral suffering 66 (pathos), parameters that are Physical pain can give rise clinical point of view, the fol- in continual interaction to hyperalgesic areas which lowing definitions apply: a) through cortical integration can be on the surface, affect- the cutaneous sector that (ratio) with the environment ing the cutaneous zone, the forms a part of the metamere as custom and culture (ethos). sub-cutaneous zone, the mus- is the dermatomere; b) that Faith, joined to the valu- cular zone, and/or the visceral sector of the organism made able instrument of prayer, illu- zone (Galletti, Duranti, Zuc- up of the organs, the muscles minates and co-ordinates the chi, 1979; Obletter, Zucchi, and the skin that are innervat- interaction between the vari- Giamberardino, Vecchiet, ed by a single spinal nerve is ous parameters present in the 1988; Wall, Mense, Cervero, the metamere; c) that sector of life of each man (fog. 6), rais- Foreman, Janig, 1993). So- the spinal column that is a ing the pain threshold (Zucchi, matic pain creates a muscular tributary of the sensitive fibres Honings, 1996; Zucchi, Hon- contracting beneath the hyper- of a single spinal nerve is the ings, Voegelin, 2001; 2003; algesic area (I stage) which neuromere. 2005). Fig. 5. Dermatomeric distribution of the sensitive roots

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Fig. 6. Influence of faith on various (anatomical, physical, moral, rational, psychological, cultural) discriminants in cancer pain Pain perception: activation of the receptors and the peripheral and central afferent paths. Pain (algos and pathos): physical, moral and mental state produced by the activation of the pain-perception circuits.

FAITH PRAYER

NOCICEZIONE ALGOS PATHOS RATIO HABITUS ETHOS Anatomic Physical Moral Mind DOLOROSUS Culture paths of pain pain suffering Anxiety Environment Brain Depression Society

PALLIATIVE CARE uring of the dies natalis. The The practitioner of pallia- word ‘palliative care’ comes tive care must be an algologue 67 Introductory aspects from the famous pallium of St. with multi-disciplinary skills Augustine who with a charita- and with a rigorous ethical ap- Definition ble gesture helped a poor man. proach that allows him or her Palliative care is the total In historical terms palliation in the most difficult moments care provided to a person af- has always existed but only for of the sensitive relationship flicted by an illness that is no some twenty years has it really between the patient and the longer responsive to therapies emerged from its obscurantist medical doctor to transform whose goal is recovery. The period because of that cultural himself or herself into an ex- control of pain, of the other positivism that tended to em- cellent pharmaceutical for his symptoms and of the psycho- phasise only the triumphant as- or her patient. logical, social and spiritual aspects of medicine and did not pects, is of prevalent impor- dwell upon its failures. Therapeutical aspects tance (European Association Modern pharmacology, for for Palliative Care, that matter, has not managed to The treatment of cancer-re- Newsletter, n. 1, 1989). suggest a therapeutic response lated pathologies are effective The term ‘palliative’ which for the relief of pain other than and lead to a 40% recovery marks out this therapeutic ap- that of the administration of the rate in the cases treated, proach offered by pain-reduc- ancient remedy of morphine whereas 60% of the popula- ers, has not been very much and its derivatives. Unfortu- tion remains in an incurable welcomed by medical doctors nately, this substance has often state which in turn leads to an or patients. The negative been used in an insufficient inevitable terminal stage. meaning, above all at the out- and inappropriate way, al- Algology, which is by now set, of this term, lies in its er- though remaining the best drug twenty years old, has created roneous pietistic and lacking for the relief of pain and man- a specific section of palliative in finality interpretation of aging to give patients lives that care which takes care of the ‘having to do something’ are greater in quality and patient and not of the illness, which places the health-care longer as compared to aggres- which has become by now worker in an equivocal posi- sive forms of anti-cancer treat- devastating for the organism. tion given that the term ‘pal- ment represented by radiother- The principal goal of pallia- liative care’ is interpreted as apy, chemotherapy and hor- tive care is the control of all exaggerated treatment. mone therapy. the symptoms connected with Palliative care, which is also A large number of misun- physical and mental suffering supported by the Catechism of derstandings have arisen which a patient in the termi- the Catholic Church (n. 2279) around palliative care with the nal stage of his or her illness is in fact the real solution to interpretation of this medical usually complains about. The the increasing policy of eu- practice as exaggerated treat- approach of palliative care is thanasia because it provides ment or as a procedure of eu- not only clinical-therapeutic relief from pain and other thanasia. We can see palliative in character but also wants to symptoms, offering the patient care as euthanasia if we at- offer psychological and so- supports that enable him or tribute to this term the etymo- cial support to the patient and her to appreciate the value of logical or philosophical mean- his or her family so that the life, even during the terminal ing of the ‘good death’ and not end of the life of each patient moments, which are experi- the clinical meaning of the with cancer takes place with enced in this way as a pre-fig- control of pain. dignity.

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Tab. VI. Three-level analgesic scale From an organisational point of view, multidiscipli- POWERFUL OPPIATES nary work in a team is re- (Morphine) + quired where that team is Anti-inflammatories (FANS) +/– made up of a medical doctor, a Support (steroids; nurse, a psychologist, a priest, psycotropic drugs) a volunteer and above all the INTENSE PAIN family of the patient. The aim of palliative care is to follow the patient who is no WEAK OPPIATES (Codeine, Dextropropoxyphene) + longer responsive to specific Anti-inflammatories (FANS) +/– cancer therapies, that is to say Support (steroids) surgical, pharmacological (chemotherapy), radiological MODERATE PAIN (radiotherapy) and immuno- logical (immunotherapy) therapies (the healing stage), and Anti-inflammatories (FANS) +/– to indicate a therapy for symp- Support (Steroidsi) toms in order to improve the LIGHT PAIN quality of life (treatment stage) (tab. V), controlling, above all else, the symptom of It should be borne in mind tions to ensure that from the pain. that the weak opiates, as op- mind of each suffering man 68 Tab.V. Therapy of the stage posed to the strong opiates, all there become distant requests, of healing and the stage of have a ceiling effect, that is to which are unjustified, for as- treating say above a certain dose they sisted suicide or euthanasia. do not increase their analgesic In addition to the administra- HEALING STAGE 40% power but there is the appear- tion of appropriate pharmaco- Specific cancer therapy ance of greater side effects. logical therapy (WHO Scale - surgery This effect explains why after 1986), other therapies have al- - chemotherapy thirty to forty days it is neces- so been reported (psychologi- - radiotherapy sary to move from weak opi- cal therapy: Zucchi et al., 1983; - immunotherapy ates to strong opiates (mor- music therapy: Zucchi, Hon- phine) ings, Voegelin, 2005; ethical STAGE OF TREATING 60% The supports (steroids; dex- therapy: Zucchi, Honings, Palliative care ametasone, metylprednisolone, 1996). - treatment of symptoms acetate medroxiprogesterone - improvement in quality of life and certain psychotropic drugs Criteria for the ascertainment - dignified death -clorpromazine, haloperidol, of death triazolam, oxazepam) make up The criteria for the ascertain- a group of very important phar- ment of death have undergone maceuticals that can be associ- a change in time in line with The WHO (World Health ated with the analgesics (FANS the evolution of scientific dis- Organisation) has drawn up a and drugs). coveries in the medical field. ‘three-level analgesic scale, An approach of analgesic During the pre-technological (tab. VI) which indicates the therapy organised in this way age the diagnostic criteria for path that a medical doctor has takes into account, in Italy, the death were: a) the anatomical to follow with pharmacothera- needs of about thirty-thousand criterion (traumatic devasta- py involving 1) FANS (non- terminal patients with the in- tion); b) the cardio-respiratory steroid anti-inflammatory tention of improving their con- criterion (stopping of the heart pharmaceuticals): acetylsali- ditions of quality of life. Unfor- and breathing for a period cylic acid, paracetamol, dy- tunately, because of groundless longer than twenty minutes). clophenac) and the help of fears that lurk in the mind and The neurological criterion of possible support steroid phar- in the culture both of medical brain death (irreversible prima- maceuticals: metilpred- doctors and patients, the use of ry cerebral injury with com- nisolone, dexametasone, ac- opiates in the fight against pain plete necrosis of the en- etate medroxyprogesterone); is of a very low level, placing cephalon) was introduced with 2) weak opiates (codeine, de- Italy in the hundredth and sec- the resuscitation technologies stropropoxyphene) with sup- ond place in the world as re- (Manni, C., Proietti, R., Della ports (steroids); 3) strong opi- gards the use of these sub- Corte, F., ‘La morte cerebrale: ates (morphine) with supports stances. The United States of aspetti diagnostici’, Medicina e (steroids; psychotropic drugs). America and Sweden are at the Morale, 43 (1993) 903-917). top of the list. From a physio-pathological It is right, therefore, to argue point of view, brain death is that an appropriate therapy secondary to the arrest of the against pain represents not only cerebral flow (because of the the right of each person not to elimination of the pressure of suffer but also lays the founda- cerebral perfusion following

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the fall in arterial pressure) or of death and dying with partic- From a historical point of because of an increase in the ular reference to what can be view, the theorisation and the intracranial pressure (usually seen as a real abuse of power application of these principles NS) +/– because of cranial trauma, that an individual or a group of took place in 1974 in the Unit- brain haemorrhage, or an ex- individuals in a ‘vertical’ posi- ed States of America when re- pansive process of a neoplastic tion exercises over a person in search was carried out on indi- nature). From an anato- a ‘horizontal’ position who, un- viduals who were unaware that mopathological point of view, fortunately, is experiencing the they were guinea pigs. To this brain death is characterised by terminal stage of his or her ill- end the National Commission the total and irreversible necro- ness. These bodies are: 1) the for the Protection of Human sis of the intracranial nervous Pontifical Council Cor Unum Subjects of Biomedical and structures of the brain stem-en- which refers to keeping a sense Behavioral Research was cre- cephalon which control vegeta- of proportion in therapies; 2) ated. The result of this com- tive life and of the cortex struc- the Pontifical Council for mission led to the Belmont Re- tures which control relational Health Care Workers, which port in which three principles life. drew up the Charter for Health were formulated. It appears ev- The diagnosis of brain death Care Workers in which it is ident that the most important is formulated by a medical col- made clear that the dying per- role in the principle of provid- lege made up of an anaes- son has the right to be accom- ing benefit is that of the med- thetist, a neurologist who is an panied spiritually by a medical ical doctor, in the principle of expert in electroencephalogra- doctor as well because ‘it is autonomy that of the patient, phy, and by a legal doctor. The necessary to evangelise death’; and in the principle of justice period of observation must be 3) the Congregation for the that of society. six hours for adults and chil- Doctrine of the Faith which de- 69 dren over the age of five, fines exaggerated treatment as twelve hours for children be- being: a) useless from a thera- tween the age of one and five, peutic point of view because it and twenty-four hours for chil- employs extraordinary and dis- dren under the age of one. Re- proportionate means; b) painful cently the proposal has been from the point of view of the made to identify brain death patient who is subjected to use- with cortical death as well less suffering; 4) the Code of when necrosis of the cortical Medical Professional Ethics area of the central nervous sys- (art. 37) which emphasises that tem alone has been verified, ‘in the case of the terminally ill even though the brain stem-en- the medical doctor must limit cephalon structures remain his work to moral assis- whole and functioning, a clini- tance…and appropriate forms cal condition defined as the of treatment’; 5) Pius XII who The principle of providing permanent vegetative state. in his ‘Speech to Medical Doc- benefit (in its two components From a medical and ethical tors’ spoke about alleviating of doing good or providing point of view one cannot identi- the sufferings of the sick per- benefit and not doing harm) fy brain death with death of the son with the use of anaesthetics emphasises the obligation of cortex because given that the and the use of ordinary means the medical doctor to always centres of the paleo-encephalon – nutrition and hydration; and have in mind the highest good remain integral the capacity to 6) John Paul II who in Salvifici of his or her patient and thus to carry out the vital functions, in- Doloris emphasised living the act in a way to avoid, remove cluding autonomous breathing, Christian meaning of suffering and prevent any injury. remains active. and in Evangelium Vitae n. 65 This principle natural to Hip- spoke about using proportion- pocratic paternalism was main- Bodies and Popes especially ate therapeutic means, stating tained until twenty years ago concerned with health, that ‘forgoing extraordinary or when in the context of social suffering and therapy disproportionate means is not and individual needs the princi- The right not to suffer, which equivalent to suicide or eu- ple of autonomy was devel- fits in very well with what has thanasia… but acceptance of oped. The principle of autono- been observed in this paper so death’. my imposes respect for the au- far, does not only have the tonomous decisions of individ- meaning of distancing pain and Ethical-theological aspects uals who must be informed so suffering. It also means that At every stage of the rela- that they can express their con- each individual has in living tionship between the medical sent, which must be free and the sacrosanct right to die and doctor and the patient, but voluntary. Except in cases in to die in peace without becom- above all at the stage of the end which the patient is also a med- ing a useless instrument or the of the life of the patient, the ical doctor, every diagnostic victim of absurd uses of the health-care worker must bear in and therapeutic indication can technical which have no pur- mind certain bioethical princi- only be made by the health- pose. ples represented by the princi- care worker. In every case, be- Recently, various bodies ple of providing benefit, auton- cause of his or her dignity as a have pronounced on the event omy and justice. person, the patient decides

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whether to accept or to refuse above all else of not being in a ism, which at the present time the medical pathway proposed continuous contrast between are dominant, affirm, there is to him or her thanks to a sub- the ideal self and the real self in no discontinuity between na- stantial assessment of his or her the context of a rational con- ture and culture, which are own case as a result of the cap- science that stresses the mean- physiologically directed to- illary information that has been ing of limit provided by: a) the wards a bio-anthropology that received. However, the princi- poverty of material and moral is placed between man and ple of autonomy must not place wealth; b) the poverty of effec- death, for the reason as well, as the medical doctor in a neutral tive or potential power; and c) Heidegger observed, that position or even put him or her the poverty of self-sufficiency. ‘death is what stewards man’. in a condition of subordination This poverty that pervades man Man, in not taking into ac- as regards the presumed respect depends on fear of death as a count that life is a transcendent for the fee autonomy of his or result of which the power of in- gift, tends to come to take pos- her patient. In such a case he or telligence gives way at times, if session of it to the point of she would no longer be a valu- not well formed ethically, to sharing as extrema ratio the eu- able guide at specific moments partisan economic, cultural and thanasia-informed idea in such as those of illness and political power in order to which the aspect of emotive- pain. This approach is held to share in its privileges. It ness which is adjudged philan- have the same negative charac- should, however, be borne in thropic prevails in relation to ter as that offered by the op- mind that the efficacy of the pain and suffering which are no posed position of medical pa- power of intelligence depends longer accepted. In these cir- ternalism in which the health- on the power of the will, whose cumstances, life is no longer care worker alone was given engine is made up of the ethical lived in its ontological reality 70 the power to decide the diag- formation of the individual as an individual gift which is nostic and therapeutic pathway who tends to accept death as unique and irreplaceable from to be followed by his or her pa- dies natalis, that is to say the conception until death but as a tient. The principle of justice day of birth because in this cir- material instrument in the stresses that all people should cumstance man can finally be- hands of the will of man who is be treated in the same way, hold the face of the Father. an absolute arbiter of natural quite apart from any difference Contemporary culture, how- events. that an individual may have at a ever, tends to distance and to medical, social, cultural, eco- neglect the idea of death and to nomic or religious level. give value solely to concepts These three principles form that justify the various forms of the basis of the ethical ap- functionalism that identify proach defined as principalism. man with categories in which In 1990 principalism was the individual is characterised flanked by virtue ethics, which by being an instrumental ob- was also called the new para- ject (homo faber), by the activ- digm or the experience para- ity of the mind and by its func- digm. From virtue ethics in an tional integration at the level of experiential sense we have the neuronal activity of the en- In addition to the objective passed to the ethics of caring. cephalon (homo sapiens), and and irrevocable biological pa- In relation to the triad of princi- by language (homo loquax), rameter, death emerges as an palism, virtue ethics and the which represent the various ex- event characterised by a strong ethics of caring we should not pressions of the establishment charge of subjectivity given forget the principles proposed in being of form on content that the way in which an indi- by personalist bioethics which (Sinolo). vidual dies demonstrates the we can find in the teaching of Despite the cultural approach way in which he or she has the Magisterium of the that man imposes on himself in lived both as a subject and as a Catholic Church. The most im- rejecting physical pain, moral human person. However, when portant principle, which is the suffering and even more the man in the delirium of his om- fundamental condition for concept of death and the fear of nipotence accepts aggression every other value, is the de- death, knowledge about death against the transcendent gift of fence of life as an inviolable is not one of many forms of life to the point of the destruc- good and one that cannot be knowledge but primordial tion of this unique and unre- disposed of at will, from the knowledge because man as peatable good, this means that first moment of existence, that such because he knows that he he has placed himself in the is to say from conception until will die. condition of being defeated by its natural end. The human being (antropos) the culture of violence and ha- The physical end of man, remains attracted by the influ- tred against which he has not above all in non-believers but ence that nature (physis) can known how to counterpose the at times in believers as well, have on each living cell (bios) culture of Good which is Love creates fear of death and anxi- and by the possibilities that above all towards his poor, sick ety about life which are in fact each living cell can have in re- and suffering brothers. two sides of the same coin. The lation to his organism. In oppo- Only when the concept of anxiety created by the general sition to what pragmatic sociol- Life-Man as a divine creature is perception of not having but ogism and hedonistic cultural- shared as the only leading para-

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meter indicated by the Creator beyond medicine to the essence and technology are valuable re- will it be possible to lay the re- of the human condition in this sources for man when placed at al, authentic and saving bases world. It is easy to see, there- his service and when they pro- for a new Evangelisation that fore, how important in socio- mote his integral development proposes a true path which is medical service is the pres- for the benefit of all; but they an alternative path to the woe- ence… of workers who are cannot of themselves show the ful artificial selection of human guided by a holistic vision of meaning of existence and of hu- lives, to an indifferent society, illness and hence can adopt a man progress. Being ordered to

to a form of medical science wholly human approach3 to the man, who initiates and devel- that is often dehumanised, sci- suffering patient’. ops them, they draw from the entistic and mechanistic and In the Christian-human vi- person and his moral values the

which tends to see at times in a sion of life and health, profes- indication of their purpose and9 suicidal way the whole of sional expertise, humanitarian the awareness of their limits’. mankind solely as a good to be service and love for neighbour The fathers of the Second Vati- used and to be exploited. are mutually integrated. Treat- can Council observed realisti- ing and serving the sick is thus cally: ‘ All the endeavours of Conclusion a religious act, in an act of co- technology, though useful in the

From an ethical point of operation with God to 4 restore extreme, cannot calm his anxi- view, it follows as a conclusion health to a sick person. Aware ety; for prolongation of biologi- that above all in relation to can- that physical evil imprisons the cal life is unable to satisfy that cer patients the activity of spirit and that evil of the spirit desire for higher life which is health-care workers is the ex- weakens the body, the Church inescapably lodged in his pression of a profoundly hu- has always seen medicine as a breast. Although the mystery of man and Christian commit- support for her redemptive mis- death utterly beggars the imagi- 71 ment. This is activity that sion in relation to man. nation, the Church has been should be taken on and carried This means that the healing taught by divine revelation and out not only as a service of sci- ministry of health-care workers firmly teaches that man has

entific-technical professional- shares in the pastoral and evan-5 been created by God for a bliss- ism but also and above all else gelising action of the Church. ful purpose beyond the reach of as a sign of dedication and love Pope Wojtyla teaches here: earthly misery. In addition, that towards neighbour. John Paul ‘The ethical norm, based upon bodily death from which man II, who for years was an exem- respect for the dignity of the would have been immune had plary sick person, saw each person and the rights of sick he not sinned will be van- medical-health care activity as people, must illuminate and quished, according to the Chris-

a form of humanitarian1 and discipline both the stage of re- tian faith, when man who was Christian witness. This is an search and the stage of the ap- ruined by his own doing is re- encounter between a trust and a plication of the results of that stored to wholeness by an

conscience, or rather between a research 6 that have been almighty and merciful Saviour. man who is marked by suffer- achieved’. For God has called man and ing and illness and who en- Faithfulness to the moral still calls him so that with his trusts himself to another man, norm is, therefore, participation entire being he might be joined who takes on responsibility for in the wisdom of the divine to Him in an endless sharing of

his needs and comes to him to Legislator but also faithfulness a divine10 life beyond all corrup-

assist him, treat him and if pos- to man and a guarantee of7 the tion’. sible heal him. A patient is nev- sacred character of his life. It is er only a clinical case, an advisable to observe that the di- Prof. PIERLUIGI ZUCCHI, anonymous individual to rect consequence of this value S.O., Lecturer in Illnesses of the Locomotive whom should be applied the re- of life is its non-disposability, Apparatus (Physiochinesitherapy), sults of one’s knowledge but al- its untouchability, which every Faculty of Medicine and Surgery, ways a human being, towards upright intelligence can recog- the University of Florence, Lecturer in Physiopathology whom should be adopted a sin- nise, even prescinding8 from re- cere approach of ‘sympathy’ or, ligious faith. This should be and the Treatment of Pain and Cluster Headache, to put the point in better terms, underlined at a time of the inva- Faculty of Medicine and surgery, of ‘empathy’ in the etymologi- sive development of biomedical the Bio-Medical University Campus, cal sense of the term. Medical- technologies where there is an Rome, health care activity, as ethical increasing risk of an abusive Consultor to the Pontifical Council action, requires love, readiness manipulation of the beginning for Health Care Workers, to help, attention, understand- of human life and its natural the Holy See. ing and sharing. Pope Wojtyla death. It is also advisable to affirmed in addition that ‘scien- make clear that the techniques Rev. BONIFACIO HONINGS, O.C.D., tific and professional expertise in themselves are not called in- Professor Emeritus is not enough; what is required to question, indeed quite the of Moral Theology, is personal empathy with the contrary, but their purported The Pontifical Lateran University and the Pontifical Urbanian University, concrete situations2 of the indi- ethical neutrality is. This is be- vidual patient’. ‘Sickness and cause not everything that is Consultor to the Pontifical Council for Health Care Workers, suffering are phenomena technically possible can be held Consultor to the Sacred Congregation which, when examined in to be morally admissible. Sci- for the Doctrine of the Faith, depth, ask questions which go ence and technology ‘Science the Holy See.

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Studio controllato in cieco su GALLETTI, R., DURANTI, R., and ZUC- un gruppo di soggetti affetti da patologie CHI, P.L., ‘Rilievi sulle modificazioni dei dolorose croniche’, Dolentium tessuti cutaneo e sottocutaneo nel quadro Hominum, 33 (1996), pp. 16-28 (It-Engl). dell = iperalgesia sperimentale’, Il Do- ZUCCHI, P.L., HONINGS, B., and lore, 3 (1979), pp. 111-121 VOEGELIN, M.R., ‘Pain, Faith, Prayer’, in JOHN PAUL II, Evangelium Vitae, 25 P.L. Zucchi (ed.), Compendium of Pain March 1995. Semantics, published by the Institute for JOHN PAUL II, Salvifici Doloris, 11 the Study and Therapy of Pain, Florence- February 1984. Italy, n.11, 2001, pp 1-383 (It-Engl.). GRACIA, D., Fondamenti di Bioetica ZUCCHI, P.L., HONINGS, B., and (Ed. San Paolo, Cinisello Balsamo (MI), VOEGELIN, M.R., ‘Effetto della lettura 1993). evangelica meditata sulla area iperalgesi- HONINGS, B., ‘Algologia e principi ca e sulla percezione del dolore nella sin- bioetici nella dottrina della Chiesa’, in drome algica lombare’, Dolentium Compendium of Pain Semantics, (It-En- Hominum, 53 (2003), pp. 44-51 (It-En- gl.), 12 (2003), pp. 85-95, published by gl.). the Institute for the Study and Therapy of ZUCCHI, P.L., HONINGS, B., and Pain, Florence, Italy. VOEGELIN, M.R., ‘Dolore, Musica, HONINGS, B. and ZUCCHI, P.L., ‘Diritto Preghiera’, Dolentium Hominum, 60 di non soffrire. Dovere di soffrire. La sof- (2005), pp. 14-30 (It-Engl.). ferenza nel mistero della salvezza’, Il ZULEHNER, P.M., Passaggi. Pastorale Volto dei Volti, 1 (2004), pp. 35-48. delle fasi della vita (Queriniana, Brescia, HONINGS, B., Iter Fidei et Rationis. 1992), p 304. Teologica, Moralia, Iura (P.U.L., Rome, 2004). HONINGS, B., ‘Un dialogo pluridisci- PORTENOY, R.K., PAYNE, D., and JA- Notes COBSEN plinare sulla vita umana. Un presunto , P., ‘Breakthrough pain: charac- 1 conflitto fra progressi medico-tecnici e teristics and impact in patients with can- Cf. GIOVANNI PAOLO II, ‘Durante la norme morali’, Dolentium Hominum, 62 cer pain’, Pain, 81 (1999), pp. 129-134. visita al «Mercy Maternità Hospital» di (2006), pp. 36-40. RUSSO, G., Bioetica e sessuologia (Ed. Melbourne’, 28 nov. 1986, in Insegna- menti HEIDEGGER, M., Dell’essenza della Ellenici, Turin, 20049. 2 IX, 2, 1986, 1734, n. 5. verità (Davos, 1930). SAUNDERS, C., ‘The nature and man- Cf. GIOVANNI PAOLO II, ‘Al Con- International Association for the Study agement of terminal pain and the hospice gresso dei Medici Italiani’, L’ Osserva- tore Romano of Pain (I.A.S.P.), ‘Pain terms. A list with concept’ in Bonica , J.J. and Ventafridda, 3 , 18 October 1988. definitions’, Pain, 14 (1982), p. 205. V. (eds.), Advances in pain research and JOHN PAUL II, Motu proprio Dolen- JACOX, A.K., ‘Sociocultural and psy- therapy 2 (Raven Press, New York, tium hominum, 11 Feb. 1985, quoted in chological aspects of pain’, in Jacox, 1979), pp. 635-651. Charter for Health Care Workers of the A.K. (ed). Pain: a source book for nurses SGRECCIA, E., Bioetica, vols. I-II (Edi- Pontifical Council for Health Care Work- and other health professionals (Little, zioni Vita e Pensiero, Milan, 1994). ers,, 1995, fourth edition, n. 3, hereafter GRECCIA ARRASCO DE AULA Brown, Boston, 1977), pp. 57-87. S , E., C P , I., ‘Charter’.4 Qualità della vita ed etica della salute JANIG, W., ‘Spinal visceral afferents, 5 Cf. Charter, n. 4. sympathetic nervous system and referred (Libreria Editrice Vaticana, Vatican City, 6 Cf. Charter, n. 5. pain’. in L. Vecchiet, D. Albe-Fessard, U. 2006). GIOVANNI PAOLO II, ‘Ai partecipanti Lindblom, and M.A. Giamberardino SPAGNOLO, A. G., Bioetica nella ricer- a un Congresso di chirurgia’, 19 feb. (eds.), New trends in referred pain and ca e nella prassi medica (Ed. Camilliane, 1987, in Insegnamenti X/1 (1987), 375 , hyperalgesia, Elsevier, 7 (1993) pp. 83- Turin, 1997). n. 3.7 EODORI Trattato di Patologia 98. T , U., 8 Cf. Charter, n. 6. Medica KOSAMBI, D.D., ‘Living prehistory in (S.E.U., Rome, 1973). 9 Cf. Charter, n. 43. India’, Sci. Amer., 216 (1967), p. 105. TETTAMANZI, D., Nuova Bioetica Cris- Congregation for the Doctrine of the KROEBER, A., Anthropology (Har- tiana (Edizioni, Piemme, 2000). Faith, Instruction Donum vitae, 22 Feb, IENGO AAS court, 1948). T ,M., ‘Nocicezione e Dolore’, in in 10 80 (1988), 73. LASAGNA, L., ‘The prognosis of M. Tiengo, Cervello e mente nella ter- Pastoral Costitution Gaudium et spes death’, in Levine, S, The dying patient apia del dolore. Pathos, 4 (1995), pp. 4-9. of the Ecumenical Second Vatican Coun- (Russel Sage Foundation, New York, VENTAFRIDDA, V., RIPAMONTI, C., and cil on the Church and the contemporary 1970). BIANCHI, ‘A randomized study on oral ad- world nn. 18, 22.

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Testimonies

Towards the 2008 International Eucharistic Congress in the Company of Mary the Immaculate Conception

The Grace of Illness

Nicaragua: the Church and HIV/AIDS

Portugal: the Second National Congress on Pastoral Care in Health

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Towards the 2008 International Eucharistic Congress in the Company of Mary the Immaculate Conception

The Holy Father Benedict ‘The Eucharist, Gift of God ther and for us, which seals the XVI, at the audience granted for the World’. New Covenant….It appears in to those taking part in the sev- this way as the gift that the Fa- enth plenary session of the ther makes to the world in his Pontifical Council for Health I. ‘International Eucharistic Only Son, made flesh and cru- Care Workers, on 22 March Congresses’ cified, which draws around his 2007, said ‘allow me therefore table the dispersed children of to deliver again to you at the The institution within the God…Lastly, (it is) the gift of level of ideas the reflections Church of this strong time of the Trinitarian communion for that I proposed in the encycli- research and solemn celebra- the life of the world through cal (Deus Caritas est) with the tion of the ‘holy mystery’ is the action of the Holy Spirit relative pastoral orientations rather recent. The first such that assures the intimate par- on the charitable service of the congress was celebrated in ticipation of the faithful in this Church as a ‘community of 1881 in Lille in France. This mystery of the Covenant’. love’. And to that encyclical I initiative began with a woman This will be an intense week 74 can now add also the post-syn- called Emilie Tamisier (1834- of celebrations and cultural od apostolic exhortation pub- 1910) who derived inspiration events, catechesis and brother- lished recently which in a from St. Pier Giuliano Ey- ly meetings, and of witness to broad and structured way ad- mard, the Apostle of the Eu- sharing with sick and poor dresses the Eucharist as a charist (1811-1868). Members brethren. It would be good to ‘sacrament of charity’. It is of the lay faithful, priests and be present, to take part person- specifically from the Eucharist bishops, with the blessing of ally and to be immerged by that pastoral care in health can Pope Leo XIII, gave rise to the the healing wave that the ec- constantly draw strength to ‘First International Eucharistic clesial community will receive come effectively to the aid of Congress’ whose subject was as a gift from the Holy Spirit man and promote him accord- ‘The Eucharist Saves the during those days. One can do ing to the dignity that is World’. this spiritually, trusting in specifically his. In hospitals The ‘Eucharistic Congress- what Pope Benedict XVI and rest homes the chapel is es’ have always been a source promised us: ‘ Not only those the pulsing heart where Jesus of spiritual revision, an oppor- who have an opportunity to offers himself unceasingly to tunity of God for a renewal of take part personally but also the heavenly Father for the life the relationship of life with the the various Christian commu- of mankind. The Eucharist, Most Holy Eucharist. An in- nities that are invited to join distributed decorously and strument for penetration into themselves to it at the level of with the spirit of prayer to the the most valuable treasure left ideas will be able to benefit sick, is the vital lymph that to us by Our Redeemer. from the special graces that comforts them and infuses in The preparations for the the Lord will dispense at the their spirit inner light by congress of Quebec began in International Eucharistic Con- which to live with faith and October 2004 when Pope John gress. In those days the hope the condition of illness Paul II entrusted Cardinal Catholic world will fix its eyes and suffering. I thus also en- Marc Oullet, the Archbishop on the heart of the high mys- trust to you this recent docu- of the first diocese of Canada, tery of the Eucharist in order ment: make it yours, apply it with the honour and task of or- to draw from it renewed apos- to the field of pastoral care in ganising it. The Cardinal tolic and missionary drive. health, drawing from it appro- Archbishop is proud to stress This is why it is important to priate spiritual and pastoral in- that ‘the congress will be cele- prepare oneself well and I dications’. brated during the year that thank you, dear brothers and This authoritative Petrine commemorates the four hun- sisters, for the work that you message calls on the Pontifical dredth anniversary of the are carrying out to help the Council to promote an intense foundation of the city of Que- faithful of every continent to and special journey of those bec, the seat of the first understand ever more the val- who are involved in ‘pastoral Catholic diocese north of ue and the importance of the care in health’ in that direc- Mexico’. And referring to the Eucharist in our lives…How tion, which is already under- subject of the congress, he much need mankind has to re- way in the Church, and which stresses that ‘the Eucharist, as discover in the sacrament of is being prepared for by the we receive it from the account the Eucharist the source of its International Eucharistic Con- of its institution is witness to own hope! I thank the Lord gress, which will be celebrated the gift of love that the Son that many parishes, side by in Canada, in Quebec, on 15- makes of himself for the side with the due celebration 22 June 2008, on the subject many, a gift of love for the Fa- of the Holy Mass, are educat-

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ing the faithful in the adora- this pathway of encounter is ‘Eucharistic’7 woman with tion of the Eucharist and I with the Lord who comes. In her entire life’. hope, in view of the next Inter- her we find realised the Where the smallest Christ- national Eucharistic Congress essence of the Church in the ian community sings the prais- as well, that this practice will most perfect way. The Church es of the Most Holy Mary, the

become 1 increasingly wide- sees in Mary, ‘Eucharistic Eucharist is at the centre of the spread’. woman’, as the Servant of fraternal encounter as the God John Paul II called her unique and absolute principle

(cf. John Paul II, encyclical of the generative force8 of the 2. Let us Answer letter Ecclesia de Eucharistia unity of the Church. the Invitation (17 April 2003), 53: AAS 95 The words of the consecra- (2003), 469), its most success- tion said on the separate The ‘delivery’ of the Holy ful icon and contemplates her ‘signs’ of the bread and the Father finds this Pontifical as the irreplaceable model of wine make Christ present in Council strongly involved in Eucharistic life’ (n. 96). the act of his offering to the calling the attention of those Father on the Cross. ‘Let us who are pastorally involved in place ourselves above all to the field of health care and 3. ‘Mary Eucharistic listen to the Most Holy Mary, health to the potential value of Woman’ in whom the Eucharistic mys- ‘suffering’ for the whole of the tery appears, more than in any human community because Ancient Fathers and theolo- other, as a ministry of light. In ‘Christ has also raised human gians always proclaimed in looking at her we know the suffering to level of the Re- the Church that ‘the flesh born transforming power that the demption. Thus each man, in of Mary, coming from the Eucharist possesses…In the 75 humble sign of the bread and the wine, transubstantiated in- to his body and his blood, Christ walks with us, as our strength and our viaticum, and

makes9 us all witnesses to hope’. We have affirmed and seen that the Blessed Virgin Mary is existentially involved in this ‘Holy Mystery’. Historically, Holy Scripture demonstrates that ‘she has been personally associated with the Sacrifice of the Cross, with her consent, with her motherly love, with her faith, with the offering of herself into the hands of the Father. With this complete personal union with the unique sacrifice of Calvary, Mary perfectly lived what the

his suffering, can also become Holy Spirit, is bread4 descend- Church has continued to live

a sharer in the redemptive2 suf- ed from heaven …her womb down the centuries in the fering of Christ …In the body has made a fruit flower, bread sacramental celebration. By of Christ, which is ceaselessly that has filled us with angelic means of the Eucharistic Con- born of the Cross of the Re- gift. Mary has restored to sal- secration, Christ gives himself

deemer, it is precisely suffer- vation what5 Eve destroyed by to us by offering himself to the ing permeated by the spirit of her sin …That body that the Father in an act that is the re- Christ’s sacrifice that is the ir- most blessed Virgin generated, actualisation of his sacrificial replaceable mediator and au- nourished in her womb with offering on Calvary. Now, thor of the good things which maternal care, that body, I say, Mary was present at this sacri-

are indispensable for the without doubt and not another, fice and was 10intimately associ- world’s salvation. It is suffer- we now receive from the sa- ated with it’. ing, more than anything else, cred altar, and we drink its It is in this prerogative of which clears the way for the blood as the sacrament of our ‘Mater Dolorosa’, who with

grace that which3 transforms redemption. This is held by dignity is at the foot of the

human souls.’ the Catholic faith, this the holy6 cross (cf Jn 19:25) that the And it will do this following Church faithfully teaches’. ‘sensus fidelium’ strongly in- the pathway indicated by the The Blessed Virgin is not volves her when the Ecclesial Sacramentum Caritatis: ‘Most only a ‘mother’ but is also ex- Community gathers around its Holy Mary, Immaculate Vir- istentially involved in the ‘Eu- ‘limbs’ that bear in its body gin, ark of the new and eternal charistic Mystery’ and thus the signs of the ‘infirmitas’of covenant, accompany us on John Paul II states that ‘Mary Man.

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The Church feels and be- and the suffering…The sick way in the sufferings of the lieves that ‘finally, bearing discover in Lourdes the ines- Son, made the mother of with a strong and trusting spir- timable value of their suffer- mankind, ready to intercede so it her immense pains, more ing. In the light of the faith that every person can obtain than all the Christian faithful, they come to see the funda- salvation (cf. SD, n. 25). At as true Queen of martyrs mental meaning that pain can Lourdes it is not difficult to ‘completes what is lacking in have not only in their lives, in- understand this special partici- the sufferings of Christ…for teriorly renewed by that flame pation of Our Lady in the

his Body,11 the Church’ (Col that consumes and transforms, salvific role of Christ. The I:24)’. And one can well say but also in the life of the wonder of the Immaculate that ‘the divine Redeemer Church, the mystic body of Conception reminds believers wishes to penetrate the soul of Christ. The most holy Virgin of a fundamental truth: it is every sufferer through the who on Calvary courageously possible to obtain salvation heart of His Holy Mother, the stood at the foot of the cross of only by taking part meekly in

first and most12 exalted of all the the Son (Jn 19:25) took part the project of the Father who redeemed’. personally in his passion, wanted to redeem the world knows how to convince ever through the death and resur-

new souls to join their suffer- rection15 of his only begotten 4. The ‘World Day ings to the sacrifice of Christ Son’. of the Sick’ in a choral ‘offertory’ which in going beyond times and The Pontifical Council spaces embraces the whole of 5. The Message of Lourdes which received the pressing mankind and saves it’. This is 76 invitation of the Holy Father what the Pope said at the In the Eucharistic celebra- to apply ‘to the field of pas- homily of the Holy Mass cele- tions with the sick, wherever toral care in health, drawing brated with the sick in the these take place, one cannot from it appropriate spiritual Basilica of St. Peter’s on 11 but look to Lourdes and hear and pastoral indications’ sees February 1980. echo the message of the in the next ‘World Day of the Sick’, which is centred round the Liturgical Memorial of the Blessed Mary of Lourdes, the providential celebration of creating a ‘mystical bridge’ between the Marian little town of the Pyrenees and Quebec in the sign of the ‘Eucharistic woman’, making available to the community of men ‘human sufferings (which), united to the redemptive suffering of Christ, constitute a special support for the powers of good, and open the way to the

victory13 of these salvific powers’. For a hundred and fifty years Lourdes has been a priv- ileged place for the sublima- tion of human suffering in the Eucharist passing by way of And it was twelve years af- ‘White Lady’ entrusted to the Mary the Immaculate concep- ter that day that John Paul II of little Bernadette. Penance and tion. venerable memory on 13 May prayer for sinners she was A ‘holy place’ which for 1992, the anniversary of the asked by Our Lady, making John Paul II from the early attack on his life of 1981, es- her hear all the weight of the years of his pontificate was tablished the World Day of the Passion of the Son during the the geographical point par ex- Sick which he expressly want- vision of 25 February 1858. A cellence in which was to be ed to link to Lourdes because witness who was next to her, found the ‘Reality of faith, of Lourdes is ‘one of the most Mrs Marie Pailhes, attested hope, and of charity. A reality loved Marian sanctuaries by that ‘it seemed that she bore

of sanctified and sanctifying the Christian people, it is the all the16 sufferings of the suffering. Realty of the pres- place and at the same time the world’. ence of the Mother of God in symbol of hope and of grace Bernadette carried on her the mystery of Christ and his in the sign of the acceptance body until her death the suffer-

Church on earth: a presence and the 14offering of salvific ings of the Passion which especially living in that cho- suffering …At the foot of the were invisible but burning. ‘I sen portion of the Church, cross Mary suffers in silence, am ground down like an ear of which is made up of the sick a participant in a very special corn’ she said one day as her

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17 life was coming to a close. Goodness of God, established with the whole of its local Lourdes is truly ‘the place and that ‘as a woman she helped to community, in whose territory at the same time the symbol of give death, as a woman she today are to be found ‘invisi- hope and grace in the sign of helped to give life… who gave ble and anonymous wards’ of the acceptance and offering of to the world the very Life that human suffering as a result of salvific suffering’. It is the renews everything, and was the global trend of the shorten- place that gives the message enriched by God with gifts ing of the times spent in hospi-

that ‘love is greater than consonant20 with such an of- tal, can frequently celebrate its death’, as is proclaimed by the fice’. ‘little Lourdes’ directed to- fifteenth station of the Via Of she who had already wards the great Mystery of the Crucis with the great tomb achieved in her person the ‘Sacramentum Caritatis’ in stone that was brushed aside overall and total health of the company of the Blessed on the morning of the Resur- body and soul through the Immaculate Virgin Mary. rection. merits of the Son Jesus, and is The Christian people, which The water that springs from the ‘image and beginning of has always perceived the the rocks of Massabeille, the Church which will its providential motherhood of which the tender and white la- completion in the future age, Mary in its own existence, ex- dy indicated to Bernadette in so that on the earth shines be- periences it especially in the the ‘eleventh apparition’ of fore the People of God in pil- ‘sacred table – the liturgical Thursday 25 February, is ‘the grimage as a sign of certain celebration of the Mystery of

sign of Christ from whose rib hope and consolation, until21 the the Redemption – in which sprung water and blood to day of the Lord comes’. Christ becomes present, his re- wash away our sins. It is in The Blessed Virgin Mary al body born of the Virgin memory of baptism and the places herself at the side of Mary’. Rightly the piety of the 77 celebration of reconciliation mankind in pain that goes to Christian people has always Salus infirmo- that this water18 acquires full Lourdes as ‘ seen a profound link between meaning’. The Missal of the rum’, and she comes as a devotion to the Holy Virgin Parish of Lourdes proposed ‘sign’ of certain hope because and the cult of the Eucharist…

that day for the celebration of she is the ‘Immaculate Con- Mary guides23 the faithful to the the Eucharist the reading of ception’. Eucharist’. this passage from the passion In our small and domestic (cf Jn 19:34) but Bernadette ‘Lourdes’, with one’s eyes and did not know it. Our Lady had 6. Our ‘Lourdes’ for Quebec heart directed towards Que- guided her to portray and live bec, one can, one must, in- the Passion of the Son for sin- The Holy Father has told us volve the whole local commu- ners. that ‘in hospitals and rest nity, the ‘pained’ part and the And it was only on the day homes, the chapel is the beat- part of the ‘Good Samaritan’, of the Annunciation, Thursday ing heart in which Jesus offers so that the next ‘International 25 March, that the ‘Lady himself unceasingly to the Eucharistic Congress’ will clothed in white… with a blue Heavenly Father for the life of light up in the whole of the band and a yellow rose on mankind’. Church a new fire for the Holy both her feet of the same And where there is a crea- Mystery given by the Re-

colour 19of the crown of her ture that suffers in body and deemer… set in motion a radi- rosary’ revealed her name: ‘I soul there ‘is manifested also cal revolution in every eccle- am the Immaculate Concep- the dignity and the meaning of sial community, so as to arise tion’. human existence. The witness as a rampart against ‘the sin of How can one not think of a that my beloved predecessor the world’ that every say be- specific decision to place in a John Paul II remains inscribed comes more burning and dev- very close relationship with in our hearts: from the teach- astating. the moment of the Incarnation ing chair of suffering he made The suffering of man is a her being ‘full of grace’ and a summit of his Magisterium. mystery. John Paul II, who the descent to Lourdes, Illuminated and encouraged was an incomparable Teacher amongst the People on the by such great witness, the on the subject for the whole of march, tired, lacking in confi- Church is called to express his pontificate, taught us that it dence, sick, and in disorder? solidarity and concern towards can be bent and channelled for Immense crowds of pilgrims those who have to address the the salvation of the world. over the last one hundred and trial of illness, first of all help- With his ‘Lectio fifty years have come to this ing them to see illness and Magistralis’ that he gave us ‘city of ‘yes’ to the will of death itself not as a negation during the last month of his God’ to implore light, hope, of the human but as a pathway life, Pope John Paul II be- and health of the body and of which, in the wake of the suf- queathed to us the right and the soul. fering, death and resurrection healing direction to follow in

Lourdes is a constant sign of of Jesus, leads22 us to true and the company of Mary the the revelation of the irruption eternal life’. Mother of the Word made of our history as a People on Every chapel in public or Flesh, providing broad witness the march of Mary the Immac- private places of care can live that what he had written was ulate Conception. Of she, that out its ‘little Lourdes for Que- experienced intensely: ‘it was is to say, that the infinite bec’. But also each parish on Calvary that Mary’s suffer-

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6 stood beneath the cross ST. PIER DAMIAN (+1072), in ing, beside the suffering of Je- (Jn TMPM, p. 872, n. 6. sus, reached an intensity 17:11, 21-22), we pause be- 7 EdE 8 , n. 53. which can hardly be imagined side all the crosses of contem- Cf. JOHN PAUL II, EdE, chapter II, 25 ‘The Eucharist Builds the Church’. from a human point of view porary man’. 9 Ibid. 10 , n. 62. but which was mysteriously AMATO ANGELO SDB, ‘Eucaristia’, and supernaturally fruitful for Rev. FELICE RUFFINI MI, in Nuovo Dizionario Mariano, edited by Under-Secretary S. De Fiores and S. Meo (Edizioni Pao- the redemption of the world… line, 1986), p. 535, col. Ia. of the Pontifical Council 11 In the light of the unmatchable PIUS XII, encyclical letter Mystici for Health Care Workers, Corporis example of Christ, reflected 12 , 29 June 1943, ‘Conclusion’. The Holy See. JOHN PAUL II, SD, n. 26. with singular clarity in the life 13 Ibid. 14 , n. 27. of His Mother, the Gospel of JOHN PAUL II, letter to Cardinal F. suffering, through the experi- Angelini establishing the World Day of the15 Sick, 13 May 1992, n. 3. ence and words of the Apos- JOHN PAUL II, letter to Cardinal J. tles, becomes an inexhaustible Lozano for the World Day of the Sick 2004 in Lourdes on the occasion of the source for the ever new gener- th 150 anniversary of the definition of the ations that succeed one anoth- Notes dogma of the Immaculate Conception, 1 er in the history of the Church. December 2005. 1 16 The Gospel of suffering signi- Speech to those taking part in the J. BORDES, Lourdes – Seguendo i plenary assembly of the Pontifical Com- passi di Bernadette (MSM, 1991), p. 23. fies not only the presence of 17 Ibid. mittee for International Congresses, Sala 18 , p. 55. Ibid., p. 84. suffering in the Gospel, as one Clementina,2 9 November 2006. 19 OHN AUL Salvi- Ibid.,p. 15. of the themes of the Good J P II, apostolic letter 20 fici doloris, 14 February 1984, n. 19 The Second Vatican Council, Dog- News, but also the revelation (hereafter SD). matic Constitution Lumen gentium, n. 3 Ibid. 56. of the salvific power and 4 , n. 27. 21 HILARY OF POITIERS (+367), in Testi Ibid., n. 68. 78 salvific significance of suffer- 22 Mariani del primo millennio (Città Nuo- Message to the Italian Bishops at ing in Christ’s messianic mis- va Editrice, Rome, 1990), vol. 3, p. 125, Assisi for the fifty-fifth general assem- TMPM bly – Assisi, 14-18 November 2005. sion and, subsequently, in the n. 185 (hereafter ) 23 mission and the vocation of Sacramentarlo Bergomense, manu- JOHN PAUL II, encyclical letter Re- 24 script of the ninth century, ‘Prefatio del- demptoris Mater, 25 March 1987, n. 44. the Church …Together with 24 SD la Domenica VI di Avvento’, in TMPM, 25 , n. 25. Mary, Mother of Christ, who p. 969. Ibid., n. 31.

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The Grace of Illness MSGR. EUGENIO ROMERO POSE WROTE THIS TESTIMONY DURING LENT IN THE YEAR 2006. IT WAS PUBLISHED IN THE REVIEW MAGNIFICAT.

‘Your grace is worth more have given me Your love; so Cross; reach out your hand to than life’ are words of the many times my inability to me so that despite the darkness psalmist that are experienced hold You and to hold in my of my journey I may have the as truth when one is blessed by hands the gifts that You offered sincere certainty of one day illness and one touches the lim- me from Your hands, distanced opening my eyes and seeing its of one’s own precarious- me from You. I know that al- you at the right hand of the Fa- ness. To feel the chill of the though You distance me, You ther with the Holy Spirit. weakness of one’s body that will never allow me to escape During many sunsets, in becomes consumed, of one’s from Your creative hands. moving towards sleep, I hoped mind that darkens, and of the The sweetness with which to meet you in that morning corruptibility that takes posses- You directed Your face to that has no end. But only you, sion of what one thinks one Adam who was sick and lost in Lord of my life and illness, possesses, acquire a new a paradise that he thought be- know when that day will come meaning when one opens one’s longed only to him reached to that has no sunset. In the mean- eyes to the truth of pain. And my ears. I know how Your ser- time allow me never to leave 79 one can only look forward and vant Job in the silence of being you and I give thanks because exit from the spiral of the ab- abandoned, kept himself alive every moment is a miracle surd when in prayer one allows thanks to Your support. The while I await another, greater one’s heart to receive the light nearness of Your being and re- miracle – eternal life, living of he who suffered and tasted maining next to the sick, the with you. the bile of suffering unto the fi- poor and the weak that Your I abandon myself, sick and nal extreme. Son, Jesus Christ, encountered weak, to your arms, which In feeling the inexorable in- and healed in the roads of made me, and to those of your ability of illness that involves feeling that you are the master neither of life nor of death, then, and only then, do you raise your eyes to on high and receive the balsam that makes existence sweeter. You look inside and find he who, the first of all, did not deny giving of himself for a non-definitive end that opens the doors to a life in fullness. Illness is prophecy of death. Death when it arrives is an ex- Galilee, Samaria and Judea, brethren who on the journey of perience that makes us touch to reached my ears. I still feel the pain communicate to me your the depths our smallness so healing hand of the Nazarene warmth. Your hands are full of that we can wait for a new life, who, more than any other, tast- mercy. In them do I take refuge and in waiting for it we give ed suffering, the darkness of and in them do I hide with all thanks to it. One cannot appre- pain, and delivered it unto those who feel the announce- ciate life if one does not accept death as a manifestation of the ment that earthly life is the an- death. To wait for the fullness glory of God. nouncement of that other life in of life means to ensure that fear Yours, Lord Jesus, is the glo- which illness and death are al- and death do not imprison ry of the Father, that glory that ways defeated. one’s soul and one’s heart. To illuminates the flesh that suf- Thank you, Lord, for my life live illness and not to kill the fers, that glory that opens up and my illness because you tenderness that is born with it, unending horizons, and that have taught me that you grace means to ensure that one glory that gives the commu- is worth more than life, that the speaks the truth about life and nion that saves and offers in- cold of death will not allow the says ‘no’ to falsehood. To con- corruptibility. Thanks to your fire of your love to be extin- ceal and not to contemplate ill- Cross, Humanity is trans- guished. ness means that true speech is formed by the Spirit of Life. silenced for ever. I pray to you Lord that I may Alpha and Omega, 29.3.2007 Good Father who gives to know in pain to ask you for the Msgr. Eugenio Romero Pose was the everyone and to all people life Spirit so that my life, on this auxiliary bishop of the diocese of Madrid. so that we may know Your pilgrimage which one day will He died during the dawn of the fifth love. Father the Creator you die, and my death, be on your Sunday of Lent, 25 March 2007.

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Nicaragua: the Church and HIV/AIDS

‘The pandemic of your trust in the God of Life cess to the drugs and medi- HIV/AIDS is one of the and to say with the psalmist: cines that are necessary to mil- gravest health, socio-econom- ‘God is my refuge and my lions of infected people, is im- ic, security and human-devel- strength, in You I trust’ (Ps moral, as indeed are the exag- opment crises that the planet is 91:1). Offer your sufferings gerated profits of the interna- facing. It is killing millions of and worries to the Lord and tional pharmaceutical laborato- adults with its full force. It master of every living being. ries. breaks up and impoverishes In addition, it is an absolute families, weakens the work- requirement of your love to force, transforms millions of live a disciplined life so as not Faithfulness in Marriage children into orphans, and en- to infect other people. dangers the social and eco- In order to achieve effective nomic tissue of communities prevention of this epidemic it and the political stability of na- Promoting the Civilisation is important to emphasise the tions’ (CELAM, letter on of Love value of faithfulness in mar- AIDS letter). riage and conjugal commit- In the year 2005 more than The Church demonstrates ment as fundamental factors in 80 5.5 million people were infect- her concern and compassion containing the pandemic of ed by HIV/AIDS and three with concrete facts, the need AIDS: ‘abstinence and faith- million people died from it. In for which encourages us to act fulness are not only the best Nicaragua this threat is silently with greater commitment pathway by which to avoid be- growing. every day. At a world level, ing infected by HIV/AIDS, or 27% of cases of care are in the infecting others, they are also hands of the Church and in the best pathway by which to Central America this figure obtain a long and happy life’ reaches 75%. We thank the re- (CELAM letter on AIDS). ligious and all those who look ‘Remedy for AIDS: a man after these sick people with with a woman for the whole of self-denial. To deal with these life’ (slogan of the Bishops’ matters and problems in a Conference of Argentina). more effective way, Caritas in To protect our young people, Nicaragua in March 2006 education in values is indis- formed a commission made up pensable. As a Church we must of members from various parts preach with strong public pres- of the country. sure that true happiness lies not in libertarianism and hedonism but in a life that is led accord- Drugs and Medicines ing to the will of God where for the Sick abstinence and sacrifice are the signs of inner freedom which The compelling need to treat leads to true happiness. To be The Approach of the Church these sick people can be met free means to free oneself from with the advance of medical all the forms of slavery that im- We encounter the problem of science. Unfortunately, the cost prison one. stigmatisation which con- of medical treatment is high demns these people to social and it is often beyond the reach death before the disease has not only of the poor but also of Education in Values provoked their physical death. the middle classes. This eco- Many infected people live in nomic problem is made worse Information on condoms is a fear of being distanced from by legal questions, for example simplistic response to what their families and marginalised the contentious interpretations young people need. It does not by society. We turn to you, of intellectual property rights. transform immaturity into ma- their relatives and friends: do As a Church, we join in the turity. Education, and not only not distance them from their requests made by other organi- information, is what is re- families, thereby making the sations and we request univer- quired. More than talking cross that they bear even heav- sal access to the drugs and about condoms, it is much ier. Accompany them with un- medicines that this disease re- more effective to provide par- derstanding and love. In these quires. This need must be ents and educators with suit- moments they have greater transformed into a public poli- able knowledge so that they need than ever. cy for all countries. The abso- can educate their children and We invite you, our infected lutisation of intellectual prop- students about the value of sex- brothers and sisters, to put all erty rights, which obstructs ac- uality, deep human relation-

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ships, and dialogue between test for AIDS is usually carried of justice towards those suffer- people and not only between out only with the express per- ing from HIV/AIDS and for bodies, even though it is true mission of the individual con- their environment and its rela- that one expresses oneself cerned. tionships, and to declare that it through one’s corporeity. The One of the principal causes must be addressed with full re- need for love and tenderness of this disease is an inadequate sponsibility. Curiously, those has been banalised, with its re- concept of ‘gender’ by which who are opposed to analysing duction solely to a question of the international and national its causes are also opposed to genitals and what is purely bio- organisations, which have ma- identifying it. logical. jor funds at their disposal, are seeking to change the fundamental values of our people Called to Conversion Necessary Changes who believe – for example the family. The Church remains The Church does not seek to Just as the Church defends faithful to the concept of the be a judge of her brothers and the rights of people who are af- Creator: ‘God created man in sisters, but she does feel the re- flicted with this pandemic, so his image, in his image he cre- sponsibility to point out every- also does she look with con- ated them; male and female he thing that attacks the original cern at the right of other people created them’ (Gen 1:27) truth of man. to be protected against it. In or- Thus it is an inescapable ‘Mary, Mother of the der to avoid the stigmatisation mandate of the commandment Church, teach us to be at the of infected people, their situa- of love to eliminate the dis- side of those who suffer with tion is kept in complete criminatory condition of those the solicitude and generosity anonymity so that they do not who suffer from this disease, that are specific to a mother. 81 infect other people in an un- something that makes the cross Her silent nearness to the dying controlled way. HIV/AIDS that they bear even heavier. For Jesus suggests to us perhaps should be classified like any that matter, we ask ourselves the only pastoral presence that other infectious disease, such whether the time has not come is possible in the face of early as tuberculosis. At the present to move out of the secrecy and death’ (CELAM letter on time in prison systems, for ex- the aim of silencing the grave AIDS). ample, where there are certain- causes and consequences of Managua, 24 January 2007. ly people infected with this epidemic and to declare The President of the Department of HIV/AIDS, a test for tubercu- that it is like any other conta- Social Pastoral Care of the losis can be requested, but a gious disease, both for reasons Bishops’ Conference of Nicaragua

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Portugal: the Second National Congress on Pastoral Care in Health THE SECOND NATIONAL CONGRESS ON PASTORAL CARE IN HEALTH ON THE SUBJECT ‘AT THE SERVICE OF THE PERSON – TREATING AND CARING’ WAS HELD IN FATIMA (PORTUGAL) ON 1-3 FEBRUARY 2007.

1. Pastoral Care in Health care in health has striven to medicine; to promote solidari- in Portugal mobilise agents who could im- ty for the poor; to accompany plement organised action in an sick people and health care On 18 April 1985 the Bish- overall way. One of the most workers at a spiritual level; to ops’ Conference of Portugal important factors of this pas- support the actions promoted established the National Com- toral dynamic has without by health units and parish commission for Pastoral Care in doubt been the national meet- munities; to energise the Chris- Health, responding thereby to ings on pastoral care in health. tian life; to guarantee that the appeal of John Paul II, who Twenty major meetings have everyone has religious support, in his apostolic letter Salvifici been organised which have al- with respect for the creed of doloris and his Motu Proprio lowed people to reflect on the everyone; to foster the action Dolentium hominum created a problems raised by society. Be- of the Church above all in sup- 82 new pastoral dynamic in the yond the ethical reflection, on porting motherhood and ac- field of health and health care, the basis of which subjects companying the elderly and to which the contemporary have been studied such as the the sick, especially during the world is very sensitive. right to life, the right to health terminal stage of life; to pro- Following this direction, care and health education, the mote in all the dioceses of Por- pastoral care in health has en- right to family health, and the tugal a new pastoral dynamism gaged in very intense action duty to engage in responsible in the health care field. not only in caring for sick peo- fatherhood, healthy mother- b. The congress was organ- ple but also in education in hood, these national meetings ised into three parts. The first health; the training and accom- have allowed people to engage studied the human person and panying of health care work- in a profound reflection on his or her right to health. The ers; the humanisation of care health policies in Portugal with second part involved a survey and treatment, relationships special attention being paid to of the pathologies that most and structures; and in working assuring health for everyone, frequently afflict the person with all those who in the field solidarity, and the spiritual ac- from the physical, psychologi- of health and health care are companying of patients during cal and social point of view. concerned to engage in an ethi- the whole of the treatment, In the third part an attempt cal evaluation of treatment, with respect being paid to the was made to define clearly the scientific research, clinical ex- religious freedom of everyone. mission of the Church through perimentation, and research in- Every ten years, after these new forms of evangelisation, to drugs and medicines. It is in national meetings, a national beginning with the observation this context that pastoral care congress on pastoral care in that to humanise, to accompa- in health in Portugal has a con- health is organised. The first ny and to take care of, are an stant relationship with the Min- such congress took place in expression of the preaching of istry of Health with which, in- 1995 and this had a subject of the Gospel which invites us ‘to deed, it works conjointly notable importance – ‘service preach good news to the where this is necessary. One to life’. In 2007 another con- poor… to proclaim release to could say that pastoral care in gress was held, this time on a the captives and recovering of health in Portugal constitutes a fundamental subject for the hu- sight to the blind, to set at lib- form of new evangelisation. It manisation of medicine – ‘at erty those who are oppressed, helps in a spiritual way sick the service of the person – to proclaim the acceptable year people and health care work- treating and caring’. of the Lord’ (Lk 4:18-19). ers, it takes care both of hospi- c. Some of the most signifi- talised people and those at cant moments of the congress home, it is present in hospitals 3. The Second National deserve special reference: and clinics through chaplains, Congress on Pastoral Care – The ‘magisterial lecture’ and it is present in parishes in Health given during the inaugural ses- through parish units for passion of the congress by the toral care in health. a. The goals of this scientific President of the Pontifical and pastoral congress were Council for Health Care Work- clearly defined: to recognise ers, Cardinal Javier Lozano 2. The Factors of Pastoral the importance of health in Barragán, provided a working Dynamics people’s lives; to define the outline for subsequent reflec- concrete area where the tions by analysing in a deep From the outset, pastoral Church has to act; to humanise way the evolution of those

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philosophical currents that such as, for example, portance of the active partici- over the centuries, and pro- HIV/AIDS, hepatitis, drug ad- pation of Christians in de- gressively, have given rise to a diction, obesity, cancer, and nouncing situations that com- radical rationalism that has Alzheimer’s. For this reason, promise the health of the per- compromised personalist today, the need is felt to sensi- son and promoting suitable ethics, the only ethics that al- tise people and health care proposals to make health care ways allows respect for the hu- structures so as to adopt forms structures more effective and man person. The title of his pa- of behaviour that are suited to efficient. per was ‘Beyond Science’ and responding in an adequate way in it the Cardinal emphasised to these challenges. Society, that science is insufficient at too, has many responsibilities 4. Conclusions the level of defending and pro- in this field and the Church it- moting the human person in all self has to the duty to make its The approximately one his or her dimensions and that contribution to improving the thousand and two hundred contemporary culture, permis- health of the population. people taking part in the con- sivism, principialism, liberal- – The congress chose seven gress, who came from the ism and ethical contractualism subjects which were the start- whole of Portugal to participate in the second national congress on pastoral care in health, attempted to provide responses to the great questions that were analysed and emphasised. They were as follows: The importance of health in 83 the contemporary world which must be expressed in the desire to ‘give more years to life’ and ‘more life to years’ and in the need to defend and promote the quality of life of the human person during the whole of his or her life cycle. The duty of the Church to intervene in pastoral care in health without confining itself to condemning errors and comforting people with prayers and requests for sacrifices. The challenge of the new are all currents of thought that ing point for conclusions. The evangelisation which requires strongly influence behaviour fields where the Church has to new methods and new expres- and lead to the sacrifice of the the duty to intervene in a sys- sions at a pastoral level, with human person rather to taking tematic form are certainly the innovatory dynamisms which care of him or her. following: training and educa- respond in an adequate way to – Various experts in medi- tion at various levels; support the new problems of man and cine and philosophy during the for associations of sick people; the world. congress made their contribu- the creation of ongoing and Pastoral care in health is tion in the form of a reasoned palliative care units; the pre- one of the areas where initia- reflection on the human per- vention of drug addiction; fam- tives at the level of training, son, his or her identity, his or ily planning; parish assistance treatment or accompanying her rights and his or her duties, for home assistance; and the must be improved with new concluding that health is a right collaboration of religious conforms of evangelisation, ani- of the person which must be gregations with specialised mated by the creativity that adopted as a value in contem- clinics, above all in the area of comes from the ‘creativity of porary culture. From this reali- psychiatry. charity’. ty is born the need to educate – At the end of the congress, The urgent need to create in people in health and to pro- stress was laid on the impor- every diocese of the country a mote the health of children, tance of faith in care and treat- permanent group for pastoral young people, elderly people ment. The promotion of health, care in health that brings to- and adults and to provide sup- with initiatives of support in gether medical doctors, nurses, port to families and elderly the most difficult areas, allows pharmacists, chaplains, social people. intervention in contexts where workers, administrative auxil- – During the congress it was the quality of the health service iaries, other health workers and observed that there are numer- is poor. There was also discus- voluntary workers, and which ous threats to health and that sion of the humanisation of is present in health care struc- some of these come from ill- medicine, medical ethics and tures and in parishes and seeks nesses that are often contracted spiritual accompanying. The to energise initiatives in this because of behaviour at risk, congress emphasised the im- field.

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To this end the following pital order, the Faculty of The- health centres and family sup- policies are proposed: ology and the Institute of port units, so as to provide in- Health Sciences of that univer- formation and education in the 1. The adoption of necessity. field of health lifestyles and fa- sary initiatives so that pastoral 4. Responding to the pas- cilitate the accompanying of care in health creates in every toral challenges that have sick people and above all el- diocese a work group/commit- emerged from the reflections of derly sick people. tee that brings together chap- this congress and which are ex- lains, medical doctors, nurses, pressed in various proposals, These conclusions about the voluntary workers and other privileging the following three various aspects of pastoral care health care workers in order to actions to be developed in all in health require the involve- create a diocesan commission dioceses: a. the creation of cen- ment of all Catholic health care for pastoral care in health. tres for the support of life workers. 2. The training of priests, where pregnant women are re- Within the horizon of the deacons, religious and mem- ceived, accompanied, guided, New Evangelisation, a new bers of the lay faithful that are after giving birth as well, with time is envisaged for pastoral specifically trained for engag- help being provided to families care in health, aware that, as ing in pastoral activity within with problems; b. the better was the case at the time of Je- hospitals, clinics and parish organisation at a diocesan sus, the Good News of ‘life in communities. level of pastoral care for elder- abundance’ is preached 3. The promotion of the ly people so as to transform through service to the human training of workers in pastoral some homes for elderly people person, and this pastoral care is care in health, sensitising them into ongoing and palliative expressed at a concrete level in 84 to the concrete problems of care units, without forgetting gestures and words and re- pastoral care in health and en- about day hospitals and home quires as its protagonist the couraging them to engage in help for sick people; c. the de- whole of the Church and formation and updating in the velopment of connections with everyone within the Church. pastoral field through courses institutional realities that can such as the course on ‘ethics, foster work within a network, Msgr. VITOR F.X. spirituality and health’ which is which is in short supply at the FEYTOR PINTO, organised by the Catholic Uni- present time, in mutual co-op- National Co-ordinator of the National Commission versity of Portugal, the out- eration between parish com- for Pastoral Care in Health, come of co-operation between munities and local health insti- the Bishops’ Conference of Portugal, pastoral care in health, the hos- tutions such as hospitals, Portugal.

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The Life and Works of Blessed Don Luigi Monza (1898-1954) Pioneer in Care for Children with Disabilities

When he opened a new whom parents hand over to us of university teaching chairs home of ‘Our Family’ in 1953, with the greatest trust. Thus it and hospital departments. Don Luigi Monza summarised is necessary to become mothers During this period the activi- the activities of the association for these children who bring ties of the works founded by that he had founded in the fol- with them the finest blessings Don Monza and inspired by lowing way: ‘Now by choice of the Lord’. him further developed, even af- we welcome disabled and re- Don Luigi Monza and the ter the premature death of their tarded children with the aim: 1) two works founded by him (the founder. As a result of the or- of removing from them what is ‘Our Family’ Association and ganisational capacities of the injurious to them and other the lay institute of the ‘Little guiding group led by Zaira people; 2) of reintegrating them Apostles of Charity’) began to Spreafico (1920-2004), the sec- into society, able and self-re- deal with the neuro-psychic ond Mother Superior after liant. To do this it is necessary disabilities of children in 1946 Clara Cucchi (1897-1950), the to provide them with effective when the director of the Neuro- Little Apostles of Charity con- means so that they can achieve logical Institute of Milan pro- tinued their care for children their goal; and hence the spe- posed the re-education of chil- and young people afflicted by 85 cialist doctors [external consul- dren who were abnormal in neuro-mental disturbance by tants]… hence our graduates mental terms as a possible field opening new homes and creat- and specialists who look after of activity. Subsequently, the ing new services. To the three the children with an individual two institutions that were led homes that were active at the method’. At the same time he by Don Monza extended their time of the death of Don Mon- addressed to the ‘Little Apos- work from the medical-peda- za (in Vedano Olona, Ponte tles of Charity’ who belonged gogic field to the rehabilitative- Lambro and Varazze) many to the lay institute that he had motorial field by receiving into others were added in a few founded, the following sugges- their homes children afflicted decades in various regions of tions: ‘It is essential that the by the results of cerebral paral- Italy (the first homes were in children in contact with you ysis as well. Over the years Ostuni, S.Vito al Tagliamento must never feel their limita- such activity was progressively and Bosisio Parini). To these tions. The Little Apostle must strengthened above all at a sci- have been added in recent take on not only their trials entific level as a result of the decades also homes abroad (for (and they have these even specific training of the Little example in the Sudan, in Brazil though they are little, but for Apostles and the action of ex- and in Ecuador). In 1985 the them these acquire a dispropor- ternal workers and consultants, ‘Eugenio Medea’ Institute for tionate size), but equally she with the creation of an ap- Admission and Treatment of a must feel and bear with them proach to disability that envis- Scientific Character (IRCCS), their burdens, including learn- aged the interaction of various with its headquarters in Bosisio ing. She must make this in- disciplines (from physiothera- Parini but organised into re- creasingly easy for them with py to psycho-movement, from gional poles and outlying cen- all the instruments that modern pharmacology to the study of tres, whose principal concern technology makes available. epilepsy, from game therapy to was the scientific dimension of Here, too, you have to excel, psychotherapy, and from neu- neuro-psychic rehabilitation, discovering and multiplying ro-psychological rehabilitation was created. The following those talents that you have re- to neuro-visual rehabilitation, lines of research have stood out ceived from the Lord. You etc.) The ‘Our Family’Associa- in the scientific activity of this must show great love to the tion thus came to acquire the institute, which was named af- children; draw near to them definition of an medical-men- ter the neuro-psychiatrist Prof. with great sensitivity, softness, tal-pedagogic institute by plac- Medea (1873-1967) who was a delicacy, with a capacity for ing itself within a framework of supporter of the ‘Our Family’ sharing pain in a way that has treatment and care for abnor- Association: 1. neuropatholo- never been done with them be- mal children which in Italy had gy; 2. neuro-motorial rehabili- fore’. On another occasion, had such distinguished practi- tation and functional neuro- when speaking about the natur- tioners during the first decades psychology; 3. the psy- al aptitude to deal with such of the twentieth century as chopathology of the develop- children he expressed himself Sante De Santis, Giuseppe ment of language and learning; in the following way: ‘This is a Montesano and Giuseppe Cor- 4. neuro-physiopathology and very beautiful inclination beri. It was, however, only in neuro-radiology; 5. neurobiolo- which wonderfully helps our the second part of the twentieth gy, 6. bioengineering; and 7. institution with the first apos- century that child neuro-psy- the organisation of health ser- tleship of the dear children that chiatry acquired its own auton- vices. This IRCCS is spe- the Lord has given us and omy through the establishment cialised in biomedical research

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but also specialises in the pro- classes of evening school in his twice for conscription, he had vision of capillary care through town. to leave on military service, its residential and clinical When he was fifteen years and this was entirely spent be- structures, places of admission, old his family was struck by a hind the lines because of his by and centres of work placement. terrible misfortune – his father no means perfect physical At the present time the ‘Our was paralysed after an accident state. In December of the same Family’ Association is a chari- at work and this had grave con- year his older brother also died. table work strongly charac- sequences for the already After being taken prisoner, his terised by the use of the most stretched family budget. In the brother had been sent back to modern resources that medi- meantime Luigi, who was an Italy by the Austrians in a bad cine and biotechnologies allow assiduous attendant of the state of health at the end of the to be used in the treatment of, parish oratory, had already war. In February 1919 Luigi and care for, neuro-psychic dis- thought about embarking on was discharged and could thus abilities. But it is also charac- the road of the priesthood. De- take up again his studies at the terised by a commitment al- spite the changed family condi- Archbishop’s College of ways to have an approach of tions, with the consent of his Saronno where he finished his care and empathy towards the mother, in the same year, 1913, middle school and during the little patients and their family he was sent to the parish priest summer months passed the ex- relatives. In addition, the lay Don Vismara at the Salesian amination to enter high school. institute of the Little Apostles Missionary Institute at Penango During his high-school years of Charity has in time been he continued to be a prefect at flanked by other institutions the College of Saranno and (such as the ‘The Group of during the summer months he 86 Friends of Don Luigi Monza’, helped his mother with work in the ‘National Association of the fields, without, however, Parents of Our Family’, and the neglecting to attend the oratory. ‘Association of Volunteers for In October 1922 the seminar- International Co-operation’). ian Luigi Monza began to at- These have broadened their tend courses in theology at the work beyond the initial specific Rotondi College of Gorla Mi- field of re-educational and re- nore, which was not very dis- habilitative activities. For that tant from Cislago. At this insti- matter, the initiator and inspira- tution he continued to hold the tion of all these works did not office of prefect. In October immediately think of dedicat- 1924 he began the third course ing himself to the questions and in theology at the seminary in issues connected with the dis- Corso Venezia in Milan. Dur- abilities of children but had ing the school year he had ‘simply’ sought to express in problems of health which did the society of his times ‘the Monferrato (AT) where he re- not, however, prevent him from charity of the apostles and the mained for three years attend- being promoted to the next first Christians’, wherever this ing the middle school. In the course. Like other seminarians was needed. summer of 1916 Luigi, after re- who had been held up in their Don Luigi Monza was born alising the dramatic situation in studies by the events of war, he in Cislago (VA) on 22 June which his family found itself followed the fourth course dur- 1898 to Giuseppe and Luigia (his older brother had left for ing the summer of 1925 and Monza. He was the fifth child the front, a sister had joined a obtained a sub-deaconate on 28 of a numerous peasant family convent, and his mother was June of the same year and the and two of his brothers died the only support that his invalid deaconate on 15 August. Final- when they were still very father could rely on), decided ly, he was ordained priest on 19 young. Luigi as a boy was not not to go back to the institute. September 1925 by Archbishop very strong and he was thus However, the parish priest Cardinal Tosi and he celebrated baptised a few days after his came to his aid and managed to his first Mass the next day in birth and confirmed at the age get him accepted by the Colle- Cislago. of only thirteen months. How- gio Villoresi in Monza where After his ordination as a ever, as he grew older he he began the fourth stage of priest, Don Luigi Monza was gained better health. At the age middle school as a prefect (in sent as a helper to Vedano of six he went to elementary addition to his studies he also Olona (VA), to the parish of St. school and at the age of seven had to watch over and help the Maurice which was in the he had his first communion. other seminarians), and in this hands of Don Pietro De Mad- After finishing the three years way there was no burden on the dalena. He reached the town- of compulsory schooling (how- family budget. ship at the end of September, ever he had to take the exams In January 1917 he was accompanied by his mother for his second class twice) he called back to his home be- and his younger brother (who was set to the trade of a cobbler cause of the deterioration in the at that time was sixteen years in a shop where his older broth- condition of his father, who old) and he immediately began er already worked. At the same died the same month. In April to deal with parish matters. In time, however, he attended the 1918, after being examined particular he was responsible

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for pastoral care for young peo- pre-date some of the character- Blessed Virgin of Miracles, to- ple. In large measure intended istics of modern pedagogy, for gether with the parish annex, for young people, such care example when he approached was entrusted to the Congrega- was largely made up of initia- the maladjusted in a way that tion of the Oblates. Don Monza tives promoted by Don Luigi: banished any form of rigidity thought that he would not re- the ‘schola cantorum’, theatre, or authoritarianism, trying, in- main for long at Saronno and in the football team and a course stead, to appreciate them by en- addition he already had funds of French for those who were trusting them with jobs that re- to begin his work. He thus thinking of looking for work quired trust. When in 1931, as a managed to purchase land at abroad. The period spent at result of a decree issued by the Vedano Olona on the hill Vedano Olona was, however, new Archbishop, Cardinal Ilde- known as ‘Lazzaretto’, thanks marred by certain episodes fonso Schuster (1880-1954), in part to the good offices of linked to the political climate the sanctuary was raised to the the new parish priest, Don Am- of the time which was marked status of a parish, Don Monza brogio Trezzi (1881-1972). In by the rise of the Fascist Party continued to be responsible for October 1936 Don Monza was and the fall of democracy. After the oratory, which received an sent as a parish priest to a certain offences against the increasing inflow of young neighbourhood of Lecco, to the parish priest (who for some people who were now attracted Church of S. Giovanni alla time had been opposed to the by the film projector which was Castagna, where he arrived of- local Fascists) and certain located in a suitable hall. As an ficially in January 1937. As provocations received by the alternative to the cinema, he al- soon as he had arrived he began young people of the oratory, so organised football games in to dedicate himself to the vari- and after an attack on the vice- the field which he had made ous duties connected with his commander of the town, Don out of the orchard owned by his new role (celebrations of the 87 De Maddalena and Don Monza mother, and he always tried to Eucharist, processions, preach- were suspected of being the in- ensure that footballs were al- ing, confessions, doctrine, vis- stigators of the episode and ways available. its to the sick, etc.), and he paid were put in prison on the During his stay in Saronno especial attention to the various charge of attempted murder. Don Monza began to think Catholic associations (Catholic After four months of prison about the creation of a secular Action, St. Vincent, brother- Don Monza was acquitted (al- association which would en- hoods, etc.). In the meantime though obliged to never return gage in work of apostleship in a the house in Vedano Olona had to Vedano Olona), and Don De society that was increasingly been built and it was officially Maddalena (acquitted of the deChristianised as a result of opened on 30 September 1937 specific charge but adjudged Marxist and Fascist doctrines. after a period of retreat by the dangerous to the regime), was These aspirations could be ful- first three followers (Clara sent to the frontiers of Italy in filled when, in the early 1930s, Cucchi was appointed ‘Superi- Sicily). he became the spiritual director or’ in March 1937) in the com- In November 1928 Don Lui- of two young women (first pany of Don Monza. In Octo- gi Monza, after about a year Clara Cucchi and then Teresa ber the work was called by its spent as an assistant in the ora- Pitteri) who, because for vari- founder the ‘Our Family’ Insti- tory of the Milanese parish of ous reasons that had not been tute in order to express how ‘as Santa Maria del Rosario, was able to consecrate themselves children of the same father all transferred to Saronno to the entirely to God, wanted to de- men make up one family, and Sanctuary of Our Lady of Mir- vote themselves to apostleship how all the members of the as- acles where he could once and charity. Starting in 1933, sociation will be fathers and again be near his mother. The these two women and other mothers, brothers and sisters, sanctuary was in the hands of ‘young ladies’ used to go to the for all those who draw near to two elderly priests but was not home of Clara Cucchi for them, in the same way as all the a parish and up to that time had meetings on spirituality at homes of the association must not had a real oratory even which Don Monza often re- be a family for all those who though it was surrounded by a ferred to the examples of the stay in them’. Subsequently, he numerous population whose Apostles and the first Chris- drew up various general indica- young people did not have any tians who were characterised tions to regulate the life of the place to meet or gather. The above all else by their love for ‘Little Apostles of Charity’ hew helper immediately began their neighbours. He expressed who were termed such to indi- his apostleship by welcoming himself on the subject once cate that the members of the as- children and young people, at with the following words: ‘if sociation had to give them- first in his modest flat which at they were to say to you: “I want selves to other people in humil- that time he shared with his to write the life of Christianity ity so as to bring the Gospel mother, then in the courtyard in a fine volume, that volume message to society. annex, and finally in a field in a page, and that page in a At the outset the home at which up to that time had been line, and that line in one word”, Vedano Olona was used as a used as an orchard. In addition, we would answer him by say- place for spiritual exercises and he was involved in creating a ing “write Love”’. to welcome people who needed choir for the religious cere- In 1935, given that in the shelter. Thus it was that during monies. In his relationship with meanwhile the parish priest had the Second World War it took the young people he seemed to died, the Sanctuary of the in a significant number of peo-

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ple who had fled from the de- Apostles of Charity’ received Ponte Lambro, becoming the populated cities because of the the juridical recognition in object of veneration by the frequent bombings. ‘Our Fami- diocesan law of being a ‘lay in- faithful and numerous admirers ly’ had in the meantime been stitute’, and the next year in of the works that he inspired enlarged with the entrance of front of Don Monzaa the first for children with neuro-psychic other young women and once two sisters professed their disabilities. the war had ended it began to vows – Zaira Spreafico and Don Luigi Monza was the be involved again in various Pasquina Sormani. In the expression of an ideal of holi- activities in the area (assistance meantime Zaira Spreafico, be- ness pursued in the ordinary di- at nurseries, summer schools, ginning in 1948, had acted as mension of life (he himself de- spiritual retreats). Despite his Superior because of the bad clared that ‘holiness does not heavy commitments connected state of health of Clara Cucchi, consist in doing extraordinary with his activities as the parish who later died in February things but in doing ordinary priest, Don Monza found the 1950. The institute of Ponte things extraordinarily well’) time to visit the sisters of his Lambro became the Mother and was proclaimed blessed in work and supported them spiri- House of the ‘Little Apostles of the Duomo of Milan on 30 tually at times of difficulty. In Charity’ and the headquarters April 2006. November 1945 some ‘Little of the ‘Our Family’ Associa- Apostles’ were entrusted with tion. Prof. MASSIMO ALIVERTI, the running of a ‘Centre for the Don Luigi Monza continued Professor of the History of Medicine, Admission of Children and in the meanwhile to run the the Faculty of Medicine and Surgery, the University of Milan-Bicocca, Young People, the Sons and parish of S. Giovanni alla Lecturer in the History of Psychiatry, Daughters of Prisoners and Po- Castagna (with all the problems the Psychiatric Clinic, 88 litical Victims’ in Cugliate in connected with the difficult so- the University of Milan, upper Varesotto. This activity, cial situation of the post-war Italy. which was moved to Campo period), despite the advice of This article is partly based on the dei fiori in Varese in October the Archbishop to devote him- memories and testimony of family rela- 1947, was continued until April self to only one of his two jobs tives of the author who knew Don Monza 1949. (given, as well, his by no during his period in Vedano Olona. The author expresses his gratitude to the man- As was observed at the be- means excellent state of agement of the Lay Institute of the Little ginning of this paper, from health). In April 1954 his moth- Apostles of Charity in Ponte Lambro and 1946 onwards the work of Don er died. She had been suffering the Rector of the Sanctuary of the Blessed Monza began to deal with as- for some time from cerebral ar- Virgin of Miracles in Saronno. sistance and care for children teriosclerosis. At the end of Au- with disabilities with the ad- gust Don Monza, who for a Bibliographical References mission to the home in Vedano number of years had com- Olona of the first two children plained of heart trouble with- A.A.V.V., La beatificazione di don Luigi Monza, special edition of La Nostra who were afflicted by mental out, however, undergoing med- Famiglia. Notiziario d’informazione del retardation and behaviour dis- ical tests, had an acute heart at- Gruppo Amici di don Luigi Monza, XLVII, n. 1, January-March 2006. orders in May of the same year. tack which led on 29 Septem- A.A.V.V., ‘Speciale don Luigi Mon- Over subsequent years these ber 1950 to the end of his earth- za’, in Vedano Aperta. Informatore di vita new activities ended up by util- ly existence in the parish house parrocchiale, XVII, n. 1, Easter 2006. A.A.V.V., ‘Il ministero sacerdotale del ising all the human and finan- of S. Giovanni alla Castagna. beato don Luigi Monza nel Santuario del- cial resources of ‘Our Family’, Before dying he had words of la Beata Vergine dei Miracoli di Saron- which at the end of 1949 sus- comfort for the ‘Little Apos- no’, Quaderni del Santuario, n. 21, Sep- tember 2006. pended in definitive fashion its tles’ who were looking after E. APECITI, Dare la vita. Biografia del other activities. In addition, the him and assured them that the Servo di Dio don Luigi Monza (ITL spa, home at Ponte Lambro (CO) in work would continues to exist Milan, 1998). M. BOFFI, L. MEZZADRI, and F. ONNIS, January 1949, and the home at and would grow and develop Don Luigi Monza. Un profeta della carità Varazze (SV) in May 1952, further after his death. (Edizioni San Paolo, Cinisello Balsamo were inaugurated and directed His coffin was first laid to (MI), 1996). M. BOFFI, L. MEZZADRI, and F. ONNIS, towards the new needs of the rest in the cemetery of S. Gio- Il beato Luigi Monza. La vita, la spiritu- association. vanni but in 1968 it was moved alità, le opere (Edizioni San Paolo, In January 1950 the ‘Little to the chapel of the institute of Cinisello Balsamo (MI), 2006).

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