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Medicine and self-determination in bioethics: interview with Maurizio Mori

We propose an interview with Maurizio Mori, Full Professor of Moral Philosophy and Bioethics at the Department of Philosophy and Sciences of Education, University of Turin, member of the Italian È membro del National Committee for Bioethics and chairman of the association Consulta di Bioetica Onlus.

D. 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?

MM. The purposes of issuing this opinion are declared, that is to present a reflection on assisted suicide. Two assumptions have explicitly emerged: a contrary one, both on a moral and a legal level, and a favourable one on both plans, obviously within certain guarantees. The result of this work is a descriptive opinion of positions, and not of a single view. The preceptive elements remain indirect: they depend on the detection of the ongoing debate. I would say that this aspect is also very important because, on many bioethical issues, there is no agreement even on which are the terms of the question.

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

MM. The element that seems to me most original, in the CNB opinion, is a non-themed observation, which differentiates between suicide as we understand it “traditionally” and the medically assisted one. Here lies the difference: in “traditional” suicide, the person does everything alone, and tendentially in secret; suicide is usually unexpected, there is a concern not to let even the possibility of the extreme gesture leak out, and is seen as a sort of “betrayal” towards the social group. On the contrary, medically assisted suicide is – precisely – assisted, and is socialised: and this changes radically. Socialisation brings out the problems, and these become public once emerged, can be addressed and solved – if they are solvable. I think this is a crucial point to focus on.

The main points of dissent are those linked to two different visions of the world and ways of conceiving ethics. Those who are contrary believe that the act of “taking life” is always forbidden. However, reading between the lines, the principal value of the opposition is not affirmed: there are more extrinsic reasons, for example, saying that there are always palliative treatments, underlying the risks of possible abuses – such as that of the so-called slippery slope, which is totally wrong for those who support the other position. Let’s take a concrete example. When the divorce was introduced in Italy, the separation period was five years, then fell to three, then again was further reduced: the transition from five to three years was not inevitable and necessary because “the slope was slippery “. On the contrary, it was a passage on which the Italian society reflected and saw that five – and then three – years were too many. So it is not the slipperiness of the slope that inevitably leads to the valley, but a reflection on emerging social needs.

In conclusion, even those sustaining the contrary position, seem to do it for practical reasons, linked to contingencies, instead of for purposes of principle, almost as if these principles are no longer proposable in public – and this is an element of some importance, from a historical and cultural point of view.

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?

MM. The “safeguard of life” is a concept challenging to be proposed as a principle because the term “life” appears generic and unsuitable for facing occurring situations. We must introduce a distinction – already present in current literature – between “merely biological life” and “merely biographical life”. The first is the metabolic process, and the second is made up of feelings, memories, expectations, projects, self-awareness. In our world, advances in technology, at the base of the biomedical revolution, have led us to a separation between biological life and biographical life. Sometimes we have biological life without biographical life: this is the case of the permanent vegetative person – let us think about the debate on Eluana Englaro, in which expressions such as “life that is not life” were used.

Therefore, when we face the safeguarding life issue, the problem must be translated: do we safeguard biological life or biographical life? Another underlying problem is that not only humans but also some non-humans have biographies – and this opens up another question, which we do not address here, but which remains essential.

What is paramount is safeguarding biographies, and here self-determination is a determining factor.

We have to consider another point: at the end of life, not only the distinction between biological and biographical life occurs, but sometimes even an infernal situation – that is the condition of remaining in a state of suffering without possibility to get out of it. And here the problem arises, whether voluntary death is right or not.

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

MM. The narrative of the professional is also a significant problem. Here two different conceptions of medicine counterpose, as before two positions on the meaning of suffering, life, and ethics counterposed. In this case, we have to know if the medical profession is necessarily connected to Hippocratic fiction – and we should see how much it corresponds from a historical point of view: the Hippocratic oath does not belong to Hippocrates himself, but the school. I attributed, in my manual on Bioethics, to Hippocrates things from the Hippocratic vulgate, and perhaps we would have to do any actual work of historical exegesis – but this would lead to another discourse.

Two thousand and five hundred years ago, in those historical conditions, there was a ban on giving death, as for much else; we think, also in other historical periods, of the prohibition of contraception and abortion. The question, however, is to ask whether the medicine should continue to respect those criteria, almost as if it were a meta-historical activity, or if the medicine is a practice inscribed in history itself, and that it carries out its service in historical circumstances.

If the medicine is a profession of personal service, I find it hard to think that a doctor – facing situations such as that of in the face of Fabiano Antoniani or others, let us think of Davide Trentini or Eluana Englaro – turns his face away and refuses his help. Denying the existing of infernal situations, and saying that palliative care is the solution, is not seeing reality: facing these situations, helping is an ethical act, as well as a medical one.

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