Deontology and norm in the bioethical debate: interview with Assunta Morresi

We propose an interview with Assunta Morresi, Associate Professor of Physical Chemistry at the Department of Chemistry, Biology and Biotechnology of the University of Perugia, and member of the Italian National Committee for Bioethics. She has been a ministerial consultant in two legislatures, and as an expert took part in ministerial commissions, inter-ministerial tables, and working groups of the Italian Superior Health Council, and takes part in some European Council committees (CD-P-TO and DH-BIO).

Q. The topic of medically assisted suicide is one of the most controversial in the current Italian debate on Bioethics. For which reasons has the Italian National Bioethics Committee (CNB) issued an opinion on the matter, and for which purposes?

AM. For the first time, the Constitutional Court gave a precise time to the parliament – one year – to pronounce on the decriminalization of medically assisted suicide. Regardless of the evaluations concerning this procedure, we could not remain silent, since we are also the advisory board of the Presidency of the Council of Ministers. If we had not talked, we would have failed in our raison d’être, even if – it must be said – the decision to draw up an opinion in this regard was ours: we did not receive any requests.

The aim was not giving indications in favour or against the introduction of medically assisted suicide, but offering clarity to the legislator and public opinion. The opinion, therefore, was a “photograph” of the ongoing discussion’s state of art: an illustration of the leading, different positions present in the public debate, and therefore also within our Committee. The final result changed within the media: they talked of minorities and majorities, as opposed to and favourable to the introduction of medically assisted suicide. But this is not true, because the Committee has expressed itself in a more articulated way: they distorted the very meaning of the opinion.

Q. Which are the most urgent issues that have emerged, and which are the main points of dissent, in your opinion?

AM. The layout of the document meant that the arguments most frequently emerged were re-proposed, starting from the main contrast between self-determination and protection of life. We enucleated the main criticalities in specific paragraphs: the expression of the will of the person, the involvement of the health professionals, the existence or not of a “slippery slope”, the importance of palliative care. We discussed these points at length, and the only one in which we all found ourselves was the last one, that is the importance of palliative care – we need to clarify that, for some, even full access to palliative care does not eliminate the suicide request.

Many problems emerged remained underlying the opinion and not sufficiently explained, also due to the difficulty of reconciling such different positions, starting, for example, from the very definition of euthanasia and suicide: the media have simplified saying that the entire committee made a distinction, but this is not true.

Definitions are purely descriptive and do not correspond to a joint assessment. We decided to agree on the most recurrent ones and underline who formally performs the act giving death: the doctor in euthanasia, the patient in suicide. From my point of view (and not only), there is no difference between making a fatal injection to the patient asking to die, and handing him/her a glass with the lethal drug. And a difference in the definitions reflects a substantial difference in the nature of the deeds that are defined.

We discussed a lot about the role of the doctor and the health personnel, also following the document of the FNOMCEO (National Federation of the Order of Physicians and Dentists) and an audition of the President Anelli: if the death becomes a medical act, the profession itself it is upset because it was born to fight death, and not to procure it. Indeed, the refusal of the federation to legalize any form of euthanasia is clear and firm.

On the contrary, there is also the position of those thinking that helping to die is an act of solidarity: these are two irreconcilable positions, which presuppose radically different visions of life and its meaning. This irreconcilability emerged clearly talking about the inevitable clash between deontology and the norm, especially if of high rank: if the deontological medical code (which forbids the procurement of death) conflicts with a constitutional provision (which provides that in some cases it is possible, with the help of a doctor), who prevails? And who decides who prevails? An important issue, which however has not emerged in the final text.

Q. Which are, in your opinion, the priority issues regarding the attempt to reconcile the principle of safeguarding life and that of self-determination of the subject?

AM. From my point of view, we must seriously reflect on self-determination, interpreted in an increasingly exaggerated way. In summary, today self-determination means that the maximum expression of freedom, dignity and personal fulfilment consists in the full realization of the individual will, regardless of relationships with others and provided there is no harm to others. But if this is the hypothesis, we must draw logical consequences. For example, we should review a series of rules that we now accept to protect the most vulnerable: why stop people from selling organs, if they do so in full awareness? Why force motorcyclists of age to wear a helmet? Why force employees to take holidays if they want to give it up freely? And we could continue. In this perspective, the examples just listed are not protections, but limits.

Even the legalization of the procured death is seen as a form of self-determination, through the implementation of a clearly expressed will, motivated by suffering perceived as unbearable. But who can establish the limit of suffering, deny the suicide witnessed to some and allow it to others? Can a parliament, or a court, establish that the suffering of a mother for the death of a child is more bearable than that of a seriously disabled quadriplegic and blind (as was Fabiano Antoniani), and therefore deny the former what is permitted to the second? And again: why prevent suicide, if the will and suffering are clear, as is the case for prisoners? The reflection on this is very complex; in my opinion, we should begin to deal with the contradictions brought by this conception of self-determination.

Q. Which challenges does this debate pose to healthcare professionals, in your opinion?

AM. The nature of the medical profession itself is at stake. A doctor who procures death is not a doctor, by definition: you need to find another name and another profession. And it is not possible to solve the problem with the conscientious objection: if death becomes a medical act, we need, first of all, to foresee a cost corresponding to the service provided, to quantify hours of work, means and personnel employed. Provision should be made for the training of those who carry it out, in the university or specialized courses – and here, the difference with abortion, which concerns only gynaecologists and anesthesiologists, should be emphasized: to administer a lethal product, or suspend vital supports with the intention to procure death could be oncologists, geriatricians, neurologists, cardiologists, psychiatrists, paediatricians, and so on. And if death is considered a gesture of solidarity, then a positive and effective medical act, why deny access to children and the mentally ill?

Our mentality changes over time: legalizing euthanasia means that killing someone is not a crime, in some cases, if a doctor who follows specific procedures does so. It means that life should not always be protected, but sometimes it is good to take it off. Once the principle has been established, moving the borders is only a matter of time: not surprisingly, in all the countries where these laws are approved, the number of deaths is continually increasing. It is a radical anthropological change: the medical class bears its main burden and is called upon to ask its meaning and nature.

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