When All Possible Means Are Too Much

09 Nov 2018

Doctor of medicine, priest and university professor of moral theology and bioethics, Pablo Requena has tackled thorny end-of-life issues in his latest book, ¡Doctor no haga todo lo posible! (Doctor, Don’t Do Everything Possible!). 

STI Experts

The provocative title reflects Dr. Requena’s assertion that “it is not always appropriate to use the entire therapeutic arsenal at one’s disposal.” Limitation is in line with the Hippocratic Oath, “first, do no harm,” he explains, as sometimes lengthening someone’s life only increases or prolongs his suffering. 

Treatment possibilities have expanded to the point where limitations on them must be considered ethically, says Requena. The book specifies some of these: ECMO (Extra-corporeal membrane oxygenation, which is a cardiac and respiratory life support technique); CPR (cardio-pulmonary resuscitation); chemotherapy; ICU (intensive care unit) care; dialysis; feeding tubes. This is not to say that these treatments should always be limited, rather that they are sometimes appropriate and sometimes less so, and each case should be weighed separately.

He stresses that while technological advances are positive insofar as they have improved diagnoses and treatment possibilities, they must be used as part of the doctor-patient relationship, keeping in mind always that “we are applying the technologies to the person.”

The doctor-patient relationship is fundamental for keeping at the forefront the real needs and wishes of the individual patient. Guidelines and protocols are helpful, he says, but should not supplant individualized treatment. “Undoubtedly, protocols are a big help. But we can’t pretend they will give us every solution to the individual problems of each of our patients. They function as guides, but we can’t look to them for all the answers.”

The book attempts to respond to the question of where the appropriate limits to therapeutic efforts lie. Requena suggests applying the principle of proportionality, as well as bioethics concepts of autonomy and quality of life, rather than falling back in simplistic “ethical recipes.”

It also considers moral issues like the difference between “not beginning” and “suspending” certain therapeutic treatments, and one’s moral responsibility for desired versus merely foreseen consequences as well as for failure to act.

Dr. Requena wrote the book for everyone involved in making these delicate decisions - for health professionals and for patients and their loved ones - and to inform the discussion about end-of-life issues generally. 

Euthanasia, as Requena sees is, is not part of medicine. However, he adds, “the request for euthanasia is part of it, because it’s always an alarm signal that something is not being dealt with properly.”

The author devotes a good portion of the work to considering how decisions should be made. He favors shared decision-making between medical professionals and patients or the family members designated to decide for incapacitated patients. He stresses that it is the doctor who should establish clinical good practice, and communicate with the patient about the treatment options he prefers. Requena rejects the extremes of old-fashioned paternalism that treated patients like children and the concept of patient autonomy that reduces the doctor to a mere technician there to carry out patient wishes. Only extreme cases of disaccord should involve a judge, and doctors should make all possible efforts to avoid those circumstances, which rupture the vital health-care relationship.

So important is the doctor-patient relationship in itself that formal steps have been taken to propose that UNESCO consider it Intangible Cultural Heritage. Dr. Requena, who is the WMA’s (World Medical Association) Vatican delegate, would like to see the Vatican support that initiative.

¡Doctor, no haga todo lo posible! De la limitación a la prudencia terapéutica. (Comares, 2017)

Buy it here.