Any medicine to die without pain

Endless suffering - preservation of life at any cost? - or: When is a person allowed to die?

Media vita in morte sumus - In the middle of life we ​​are surrounded by death. Death is the sure lot of all living and omnipresent: In the news worldwide, also in our personal environment, when people close to us die.

We can be happy and grateful for the medical possibilities with which lives can be saved and suffering alleviated today. But some cases have shockingly shown us the dangers involved. It is all too easy for doctors, nurses, relatives or judges to become masters of life and death. When accompanying a terminally ill person, the aim is always to provide help in dying, but not help in dying, if this means directly bringing about death.

I.

Medical progress has created a difficult situation in the past few decades. On the one hand, modern medical options can cure or at least stop diseases that were considered incurable just a few years ago. On the other hand, the use of all medical-technical means of today's intensive care medicine can lead to a significant prolongation of the suffering and death of people. Everything must be aimed at making it possible to live and die in dignity right up to the end. For this it may be necessary to use the intensive medicine in full or to do without it. The final decision should be made on the basis of the specific situation of the dying person, with his wishes and needs in the foreground. I will go into more detail later on the “living will” and its problems, which I will only mention here.

We all know the opportunities also and especially in medicine. But limits? Anyone who practices science as a profession may even be shocked at first by such a term. Science seems to be and remain science precisely because no one simply sets limits to it from outside. Its efficiency lies precisely in the fact that it repeatedly questions and exceeds previous limits. This is what makes the claim to an objective-free theory worthy of the name and to autonomy thrive. Of course, we all know that there are such limits. This thought is not easy for modern man. Because science has advanced almost uninterruptedly over the centuries. Every new discovery has led to new questions and new solution methods. Science has repeatedly created new fields of exploration and repeatedly broken new ground. Today we are more likely to come up against the limits associated with our finiteness, including when it comes to resources. We also have limits due to the possibility of error: the scientific mind gets lost in its own inadequacies. There are also hard economic limits because here and there scientific progress becomes priceless. These are at least practical limits. But is it so easy to separate theory and practice in modern science today?

Knowledge is power. This is an old statement. Science has always had a profound impact on the world by continuously changing it. While in the past, however, the growing abundance of results from science served life and promoted civilization, here - at least in our consciousness - a change has occurred. Admittedly, adverse consequences were recognized earlier, but they appeared to be minor. In recent decades, the scientific and technical development has increasingly raised awareness of the problem: In addition to the indisputable blessings for the continued existence and further development of human culture, it cannot be overlooked that advances can also lead to irreversible damage to our world all human life on her is profoundly endangered.

Intensive care medicine helps people to survive in an astonishing way and at the same time poses the difficult question of whether doctors are obliged to take all therapeutic measures, even if there is a likelihood that only vegetative survival is preserved. Is it allowed to "artificially" end a life that is suffering hopelessly? Is it even allowed to refuse help to prolong life? Finally, think of all types of transplants. A basic difficulty of the problem is that the tension between what is technically feasible and what is morally responsible is usually not noticed at all. For a long time there is a lack of sensitivity for the moral implications of modern control of nature. It often appears to be justified by itself: by its successes, by its ever increasing tendency, by its possibilities for change, by its general acceptance. The dominance of neoliberal thinking increases this attitude. This gives an almost invulnerable immunity to important technical processes from ethical inquiries. Where are these lacking sensitivities justified and how can they be detected at all?

First of all, the momentum of the technical feasibility has to be mentioned. Much of what could be produced, technologically achievable in terms of process, has gained such a suggestive power up to our time that it almost assumed normative power. The higher the level of development of technology in individual areas, the more radically the further development seems to be accelerating. The impetus for "progress" happens almost automatically. It is no coincidence that in this context the images of a wacky, increasingly accelerating train that can no longer be braked and an avalanche that brings its irresistible strength and movement are used. In the course of the modern control of nature, the change is legitimized from the start and thus appears again and again as a necessary "optimization".

Another reason for the receding awareness of the moral responsibility of technological processes is not infrequently the anonymity of what is happening. This is not only related to the momentum of this process and the division of labor or teamwork of those involved, but many processes run in their inevitability almost without a clearly recognizable and responsible subject. Nobody has an individual control option for the whole, even if everyone contributes to the "functioning" of a system. It is not always easy to invoke the popular “polluter pays principle”, since in many areas converging effects that subliminally complement each other accumulate, add up to harmfulness and exceed a tolerable threshold value. These structures increase the relative uncontrollability and thus also reduce the moral responsibility. We experience this especially with questions of biomedicine at the beginning of life and its ethical implications.

There is a certain chance that a new ethical view of what is technically feasible will almost automatically impose itself in spite of these tendencies. "Prometheus, finally unleashed, to whom science gives unprecedented forces and the economy gives the restless drive, calls for an ethic that, by voluntary reins, holds back his power from becoming a calamity for people." (H. Jonas, The principle of responsibility , Frankfurt 1985, 7)

II.

The basis for our discussion is the anthropological approach. We can medically discuss man's life, its beginning and earthly end, we can clarify legal details or demand legislative action. In all of these perspectives, however, the decisive factor is what image of man we start from. The question of how to justify human dignity as an “absolute value” becomes all the more urgent. Some wonder how human dignity can be justified in our thoroughly secular age with declining religiosity.

In the theological area, but also beyond that, one quickly arrives at the image of God in man in the sense of the first creation story on the first page of the Bible. But you can't make it too easy for yourself here. There are still many sources for this human dignity from ancient times to the Enlightenment. In the realm of our churches, too, it has sometimes been difficult to grant all people this dignity with their rights. Think of the slaves, for example. The inviolable human dignity is specified in inviolable human rights. It is about a fundamental legal equality.

But the question remains: How should this general human dignity be justified? The reference to the first page of the Bible is quite appropriate for this: “And God said: Let us make people in our image, like us ... So God created man in his image; in the image of God he created him. "(standard translation), or:" ... an image that is equal to us ... And God created man in his image, in the image of God he created him. "(Revised Luther translation) or: "Let us make man in our image according to our likeness ... God created man in his image, in the image of God he created him" (Buber-Rosenzweig).

One has to consider this word carefully. The human being is determined as the representative of God for the living next to him. The submission of the earth and the rule over the animals are also clearly emphasized as basic tasks. Today we know that the expression “image of God” is rooted in statements about kings and that people really have a sovereign, ruling, central position in the whole of the world of creation. One must not defuse the words, because there is really very specific talk of "subjugating" and "trampling down". But neither should we tacitly use a modern concept of domination that would be identical to exploitation. Because the meaning of the "ruling" at that time is no less part of caring for the creatures to live together according to creation. So cherishing and caring is also part of this service. Only in this way is man a governor and representative of God; he is not absolute master. He has this domain of the earth as a fief, as a mandate, as a dowry, which he should receive and keep. This applies to the entire entrusted earth: for all creatures, yes, ultimately also for the fellow human being who needs care in his weakest moments.

Man is distinguished by the fact that he has this ability to rule and care. It assumes that the person gets an overview of the area entrusted to him and its possibilities, recognizes the situation and can enforce his will. So this distinction of man consists in reason, in the power of judgment and in the will. Tradition has repeatedly interpreted the image of God in this way, for example Thomas Aquinas: “Man surpasses all other living beings with his understanding and reason. So he is the image of God according to his reason and understanding. "(S.th I, qu.3, art. L)

It should not be overlooked that the text addresses a double meaning. Man has this distinction of the royal governor of God on earth. It belongs to his equipment from creation, thus to his human existence. But it is also a mission that has yet to be fulfilled. It is therefore an ethical task that requires respect precisely in the performance of this creative mission. Man cannot rage on earth and consume it as he wants. It is his first duty to ensure the security of life in the world subject to him and thus to ensure inner and outer peace. And this commission belongs from God to the inner structure of creation. One has to pay attention to the word "dignity". It is human by creation. We don't give it to him. That is why it must not be touched. Otherwise the one who does this also loses his own dignity.

These insights are not limited to the Bible and theology. You also started thinking in other areas. I would just like to refer to two brief examples in this context. This is the case with Kant, whose 200th anniversary of his death we celebrated two years ago: “What has a price, something else can be put in its place ... that, on the other hand, is above all price ... that has a dignity. The human being and every reasonable being in general exists as an end in itself, not just as a means for arbitrary use for this or that will are never used merely as a "means". Hegel means nothing else when he speaks of the fact that this idea of ​​the person is “of infinite importance” (Basic Lines of the Philosophy of Law, § 209). So it is not the case that human dignity is just an undigested biblical residue that one can ultimately do without. But then we should also use the full potential of meaning that is in the Bible.

This is also the reason why this ultimate depth of human dignity and thus also of human rights against all temptations of human beings to pretend to be lord of life in a wrong way comes from God and finds protection in him, which he also demands respect. This is one of the reasons why the preamble to our Basic Law begins: "Aware of his responsibility to God and to people ..."

 

Only in this way do we have the right spirit not to fall into omnipotence in the face of man's greatness, but to preserve both: the astonishment of his greatness and the humility of ruling. We can only do this in front of God, because God leaves us unabridged the greatness of man, but also grants us forgiveness again and again if we stumble in our hubris. Let us remember the words of PS 8: “Lord our rulers, how mighty is your name in all the earth; you spread your highness across the sky. What is a person that you think of him, the child of a person that you take care of him? You made him little less than God, crowned him with glory and honor. You made him ruler over the work of your hands, laid everything at his feet. ”This is especially true for the extremely precious gift of life in all its phases - from the first beginning to its natural end. But what if man himself becomes dependent on other people; when the power of one makes it possible to rise above the other, even seemingly to become a judge of his life and death?

III.

While the service of accompaniment and help in the dying process has often been carried out naturally by individuals, families, neighbors and the closer community over the centuries, the willingness to do so has significantly decreased in the past decades. For some years now, however, many people have no longer wanted to accept the taboo and anonymization of dying, death and mourning. They strive to provide intensive support for all those affected at their location: in the family, in old people's and nursing homes, in hospitals or in the community. Many of them received suggestions from the rapidly growing "hospice movement". The Council of the Evangelical Church in Germany and the German Bishops' Conference have taken up, continued and supported these efforts since 1989.

Not to be overlooked is the increasing number of people who are dying without relatives or penniless. The number of people of all ages living alone is increasing. Their life path, which also includes dying, is also different from life together in partnership, marriage and family. The average age of death has moved upwards more and more. Dying at home with family and relatives and neighbors has become rather rare. Funeral culture provides a mirror of the various attitudes changes toward death. The way life is shaped also determines how we deal with death. The demand for active euthanasia (killing on demand) is repeated again and again. In our society, prosperity, a rising standard of living and vitality into old age are proclaimed as programmatic goals. Many people can hardly imagine hardships and borderline situations for their own lives. The impressive successes of medicine led to the sometimes immeasurable hope of restoring health, of eliminating pain or of a life with a "new organ". Today many see the goal in a long and fulfilling life. Some also expect reincarnation to compensate for the privations they have experienced and the hopes that have not been fulfilled. The belief in a life after death in the sense of a one-time personal perfection (eternal life) tends to recede.

Precisely because private and social taboos have proven to be detrimental to our lives, dying, death and mourning are once again becoming topics that are socially and conversationally open to the public in a new way. To a certain extent, the public suffering and death of Pope John Paul II also contributed to this.which, despite the media interest, has retained intimacy and dignity in the end.

In a nutshell, I would like to address the following principles from the point of view of the Catholic faith, which also largely sees the Christian churches in consensus here. They result from what has been said so far and lead this further to the concrete.

1. Everyone wants to live and develop fully in life. Those who are sick come up against limits, which are particularly evident in frailty and helplessness, hardship and suffering, pain and misery. Anyone who is so sick is looking for help. This need for help is fundamental. Hope relates first to the neighbor, but especially to the doctor.

2. The inevitable natural limit of the still fundamentally finite life could be extended again and again. This creates a peculiar ambivalence in the borderline experience: On the one hand - at least there is a tendency - to believe that medical-technical progress is almost unlimited, so that death is increasingly distant or appears to be a taboo; on the other hand, in the face of the overwhelming power of death, which without exception affects every poignant death, the entire impotence of man becomes evident like hardly anywhere else.

3. The experience of the limit in illness and especially in death is a real sign that points to the finiteness and limitation of human existence. This can lead to people being assessed as absurd or as a faulty construction. There are very different reactions to it: almost titanic standing up, but also self-forgotten surrender to "fate". The riddle of death does not disappear where one believes that one can leave behind all claims of the unconditional. That is why the attitude towards death remains the touchstone of every image of man and of every view of life. The experience of the border cannot be denied, but neither can it be covered up. The ancient human struggle against death has developed undreamt-of possibilities and achieved fascinating successes in our time. In the end it turns out that death is more powerful. This is difficult for humans, especially for today's humans, to endure. At the same time, there is a growing temptation to significantly influence the process of dying from the outside. "We regulate the entry into life, it is time that we also regulate the exit." (Max Frisch, Diary 1966-1971)

4. Biblical faith understands finitude and limit in terms of creatureliness. The creature knows that it doesn't have to be, but it is. The creature borders on nothing without being simply void. The creature already has its own reality through its existence and its work. But this has always been lent to him. The creature does not encapsulate itself. Although the creature is positive in itself, it is not simply self-sufficient. It reaches its perfection more when it accepts its “poverty” to receive everything from another and to complete itself in him. Relation to God is not a defect, but the highest possibility. The moment the creature fails to recognize this humility in terms of being and stands absolutely on itself, it becomes presumptuous because it does not accept the measure intended for it. In this refusal to accept creaturely poverty lies something like the root of what is called original wrongdoing and original sin.

In doing so, of course, man is not trapped in the fate of his individual or collective natural endowment, but he should also use reason. This is what sets his human dignity apart. He does this not only to heal the defects of factual human nature, but to make the inevitable limit of life bearable. But these attempts to overcome the “limit” must not secretly start from an expectation that the creaturality of being human could fundamentally be abolished. There are certainly many such and similar basic attitudes here, from the simple suppression of death to dreams of a life without aging and dying.

5. The experience of this creaturality also affects the understanding of “self-determination”. Among other things, it should also determine the relationship between doctor and patient, between the patient and the nursing staff. All partners are connected to one another through the acceptance of common humanity and the experience of its limits. This creates an elementary fraternal solidarity that is somewhat independent of the specific situation of the individual who is healthy or sick. In this way, the patient's need and need for help can find better consideration, but the human dignity of life and death also has a common foundation, which should prevent the patient from simply becoming an "object" or from the patient only demanding services. This should also facilitate the quality of trust between doctor and patient.

IV.

The whole topic is increasingly guided by the concept of autonomy or self-determination. This is a signal word for the characterization of modern times and modern thinking. Moral action should not be determined by any impulses or external authorities, but by human freedom and reason. No claim should be regarded as morally binding that has not been recognized and recognized as such by reason. The idea that it is the visibility through reason through which all liability must be conveyed, and that this mediation alone removes a norm of subjective arbitrariness and arbitrariness, is the core of the concept of autonomy. It is understandable that it is precisely in medical ethics that the principle of self-determination is invoked, namely in order to save human freedom and personal dignity with the power of today's medical possibilities. There is a risk of forfeiting one's own responsibility towards this superiority. The principle of self-determination must be understood and understood precisely with this intention in mind.

The point is that the human subject, in situations of being dependent on the help of others, does not reveal the scope for personal decision-making and personal design to those who carry out professional roles, e.g. doctors or nursing staff, but also to other authorities. Due to the high density of networks and the complexity of a large part of human activity, self-determination has a high priority today and is considered an urgent goal of ethical education.

However, it cannot be overlooked that in this concept of autonomy, individual elements are combined that must first of all be recognized and carefully assessed. Initially, autonomy does not mean that human reason and freedom are the only sources for the standards of action. Autonomy and self-determination must also not simulate a complete self-sufficiency, which is basically only God's own. A concept of omnipotence of the human subject easily creeps into this category, which is also anthropologically inappropriate. For example, a person is not an autonomous being who lives in complete independence. In spite of all freedom and self-determination, it is referred to others, certainly different in the individual phases of life, so that being dependent on the help and care of others is not a priori foreign determination. The finiteness of an autonomous being cannot be overlooked either. Man does not own himself completely. That is why he is not simply the master of his life. This is a decisive reason why there cannot and should not be any active euthanasia. This becomes particularly evident when one thinks about the fact that the finite human being is not only mortal, but can also still live, if he has lost the current possibility of decision and also the recognizable consciousness. But there is no doubt that he does not lose his human dignity in the process, and that he has a special right to it. Autonomy does not only apply to the healthy, strong, decision-making person, but also to the sick, weak and incapable of decision-making patients. But there is no doubt that an exaggerated concept of autonomy also becomes incapable of really addressing the patient's situation. Basically, a rigorous concept of autonomy offers no protection for the really weak. At first it is logically logical, but from a differentiated point of view it is wrong to subordinate the “ethics of autonomy” entirely to an “ethics of care”. This is also not without problems, because there is no one-sided asymmetry between doctor and patient, because the patient in particular still has certain rights. So the doctor has to be instructed. Medical care is an answer to the patient's request for help, who entrusts himself to the doctor for as long as he can decide.

In this situation, wishes and tendencies arise for a so-called living will. Since the late 1970s, this has also attracted more attention in Germany. A living will documents a person's will in the event that they can no longer express themselves and effectively exercise their right to self-determination in health matters. Taking a closer look, a living will is a generic term that includes all expressions of will by a person capable of making decisions in the run-up to illness or death, who is to become legally binding in the event that he is unable to articulate his current will in a binding manner due to his illness or injury. In general, one would have to differentiate more between a patient's will, a care directive and a power of attorney. We'll come back to that later.

V.

The demand for active euthanasia is very often based on the understandable, primeval human fear of dying that is burdened with suffering, hopelessly drawn out or even medically and technically prolonged. But this does not have to be the case. It is certainly not the case that the seriously ill are left with senseless torture and extradition to the medical apparatus in the name of a life support at any cost. The conviction that no sick person may be killed directly and deliberately does not mean that the sick person or the doctor are morally obliged to use whatever means they can to prolong the life of a dying person. So there is a limit to the obligation to prolong life at any cost. The use of pain relievers - medicine speaks of the positive experiences of palliative sedation at the end of life - is therefore qualitatively different from the administration of agents whose effect is aimed at ending life. The qualitative ethical difference between killing and letting die must not be leveled. The decisive factor is the renunciation of an unauthorized, definitive and total disposal of human life, which e.g. decides on the meaning or value of human life and on the type and time of death. Every premature, direct and deliberate termination of life is a violation of the inviolable right of human beings to exist. The requirement that such an intervention may only be carried out with the knowledge and will of the seriously ill person does not change anything. An unauthorized manipulation is also the prolongation of life, which is forced by all means, medicinal or technical, but which has become humanly pointless. Technically delayed death must not triumph over human death. Here we move in a highly explosive area of ​​ethical standards and human judgment. We see the tension between the patient's self-determination, protection of life and human dignity. This is where the other actors come into play: relatives, friends - and last but not least, the nursing staff and doctors.

Often the motive for active euthanasia is given as human compassion for the “senselessly suffering”. The compassion that is not ready to go the way with the dying can of course also turn out to be not very humane. Behind this is a questionable image of man, which is possibly only determined by progress and the idea of ​​a perfect wholeness. The ability to suffer belongs to the human being. According to its own information, palliative medicine cannot achieve real pain relief in only about 1 percent of dying situations. (Prof. Dr. G. L. N. Radbruch, Aachen). The fight against this pain is today of course the prerequisite for a human overcoming of suffering. The nearness of death gives the person - not necessarily and not in every case - one last chance: It shows him the wholeness of his life and asks him whether he has sounded out the possibility of his life and examined its sustainability. In this hour, which thanks to palliative medicine does not erase insight and understanding, many dying people have reconciled themselves with their family members, cleared up some rifts and found a new reconciled relationship with their fellow world. True compassion goes along such a path as a brother and sister, carries with it such a process of dying and suffers from the purification of a human life. It would be inhuman to completely prevent this human possibility. Of course, these considerations presuppose a thorough human reflection on pain and suffering and its significance for humans. In the cases discussed so far, this is only possible if the patient is able to express his or her will. However, it becomes problematic in the case of a loss of consciousness, for example in the case of a coma, in patients with progressive dementia or in repeated strokes with the result that the inability to articulate one's own will.

VI.

Overall, it makes sense and is understandable why living wills make sense in the face of a changing doctor-patient relationship. Some speak of a requirement. The patient wants to be understood, he wants the communicative connection to a doctor, especially his doctor, to be maintained even if he can currently no longer communicate with him. One way to secure this goal in the case of illness and / or age-related decision-making ability in the interests of the patient is the so-called living will.

In the course of time there have been a large number of drafts and forms for advance directives, which differ considerably in terms of form, content and level of detail. In this context I would only like to refer to the "Christian living will" of the German Bishops' Conference and the Council of the Evangelical Church in Germany in conjunction with the other member and guest churches of the Working Group of Christian Churches in Germany, the first edition in 1999 and a revised version in 2003 Version is available.

Essentially, it is about the following orientations that relate to the dying situation. I quote: “In the event that I can no longer form or express my will, I have the following: no life-prolonging measures should be taken on me if, to the best of medical knowledge and belief, it is established that every life-sustaining measure has no prospect of improvement and would only prolong my dying. ”So this decree does not apply if death is not imminent, for example in the case of persistent coma or advanced dementia. The churches did not want to portray the lives of coma patients or other handicapped people in general as unworthy of life. The misunderstanding should be averted as if there were blanket situations before the dying process in which, for example, a human life could be declared from the perspective of a third party and generally as no longer worth preserving.

In the second edition, space has been created for your own formulations in order to give space so that people can declare their will to medical treatment for diseases which as such do not lead directly to death. This primarily refers to patients who are not yet in the dying phase, but who have an "irreversible, fatal underlying disease". Despite medical treatment, this irreversibly leads to death at an indefinite point in time. There are special explanations for this that I have to refer to.

This is of course a problem. We are still moving here in a certain legal uncertainty, in an area that is not legally and legally conclusively regulated: On June 10, 2004, the Federal Minister of Justice Brigitte Zypries presented the results of a working group “Patient Autonomy at the End of Life”, which she set up in September of the previous year had been. The task of the working group was to check the binding nature and scope of advance directives, to name important building blocks for the creation of advance directives and to make suggestions as to the extent to which statutory regulations could promote patient autonomy. In autumn 2004, the Federal Ministry of Justice submitted a draft bill for the 3rd Amending Act on Care Rights, on which comments could be submitted by January 31, 2005. The German Bishops' Conference and the EKD have drawn up detailed statements.After the coalition was formed, the federal government continued to work hard on a new draft, which is now likely to be voted on among the governing parties and which will soon be introduced into the parliamentary discussion.

Especially recently, the statements of important bodies have been increasing. The National Ethics Council published a more extensive declaration “Self-determination and care at the end of life” on July 13, 2006 (see our statement of July 13, 2006). Now the decisions of the German Lawyers' Day last week are added. All in all, these statements, together with the position of the German Medical Association, will certainly have a strong impact on the discussion of the immediate future. I will come back to a few aspects at the end.

Living wills can be of great help to relatives, carers and doctors. Further education about the possibilities of human and medical help as well as about the forms of ethically and legally permitted medical end-of-life care is sensible and necessary. Not every will - even in writing - expressed will for treatment in the event of illness assesses the full scope of the decision. The will that is written down does not have to be identical to an actual will when an emergency occurs, which can sometimes only become concrete years later. Here, too, it becomes problematic with the phase mentioned, in which the patient can no longer express himself. What is the presumed will? We need legal clarity - not least with a view to the responsible doctors and nursing staff. We must, however, be careful not to further bureaucratize human life and, especially in the last phase of its life, to replace the usual and sensible approaches with inadequate juridification.

I would therefore like to remind you of some principles by which the churches are guided in the question of terminal care. With the doctors in Germany, the churches know that they are united in their concern for dignified care for the dying. The recently revised and published in May 2004 principles of the German Medical Association for medical terminal care speak out in favor of alleviation of suffering, affection and care and clearly reject any form of so-called active euthanasia, which is killing. At the same time, this is a clear rejection of any form of approximation to the euthanasia regulations that have been introduced as current law in some of our neighboring countries. The prohibition of killing, i.e. the inviolability of another person's life, also strictly opposes killing on request and assisted suicide. A patient who is fully conscious can and may refuse medical interventions per se. However, he is not allowed to demand certain medical actions, such as the administration of drugs that cause death.

Seriously ill and dying people must not be put under any pressure or get the impression that one wants to get rid of them. Especially in the weakest phases of their lives, they should be able to be certain that they will remain valuable as a person and that they will receive support. Self-determined care for patients and respect for the wishes and ideas of the specific person can be reflected in advance directives. If it is precisely in one of the weakest phases of life - at the end of it - self-determination is confronted by outside determination, the living will should enable the minimum level of co-determination that is necessary for a decent death. Patients, doctors, relatives and nursing staff are all challenged here. But I would also like to remind you of the pastoral care of the clinic, which certainly plays an important role here.

If we demand that human life is unconditionally worthy of protection, especially at the end of life, we are well aware that recourse to human dignity is in danger of being used in a downright inflationary manner. Many people think of human dignity as an empty shell or a bad check. Even in the technical discussion among constitutional lawyers, the unconditional validity of human dignity is called into question. Therefore, anyone who speaks of human dignity would do well to explain what they mean by that. I have tried this above with a view to man's creatureliness and his likeness to God.

In our talk of human dignity, we expressly value the fundamental and indispensable statement that human dignity belongs to human beings, regardless of any external situation. It's not about the question of how much dignity a person exudes. Nor is it about the question of how dignified and “worth living” a person's life appears to others. A person's dignity cannot be assessed. It cannot be measured. Human dignity is inviolable and means an unconditional right to respect and protection. This claim to validity precedes any positive state legislation. Whoever gives it up can no longer stop the dynamic by which human dignity is increasingly restricted. It then comes increasingly under the control of prevailing social opinions. This has nothing to do with “dam rhetoric”, as some believe. Anyone who follows the discussion at various levels clearly sees that the risk of a dam breaking is extremely real.

When we talk about the dignity of people at the end of their lives, the question is: How can each individual be given the respect and protection that corresponds to his or her dignity until the end of his life and when he dies? This question cannot be confined to the days or hours of a person's death. It is closely related to how we, as individuals and as a society as a whole, deal with the transience and frailty of human life. Protestant and Catholic churches have repeatedly expressed themselves on this in the last few years together and individually. For example, reference should be made to the joint declaration “God is a friend of life” (1989), the joint collection of texts “Dying companionship instead of active euthanasia” (2003) and corresponding declarations by the German bishops, summarized in “The German Bishops No. 47 ".

The youth cult of a fun and adventure society makes it difficult to grapple with the transience of life and one's own death. We oppose it with a “culture of the whole person”: a culture that sees the meaning of each age and also keeps an eye on the dignity of a frail person. People who are at the end of their lives must not be pushed aside as "obsolete models" and "contaminated sites". Dying should not be suppressed and made taboo. The last phase of human life can also be seen as a significant lifetime.

Legal regulations and social conventions that pave the way for active euthanasia are a mistake that we firmly reject. Such a practice cannot bring about the promotion of humanity that it is sometimes hoped for. Rather, it puts old, handicapped, seriously ill and dying people under enormous pressure not to be a burden to society and to bow to its demands. Alleged voluntariness and factual coercion can hardly be separated in such a practice. The experiences from Belgium and the Netherlands speak a clear language: The spokesman for the CDU / CSU parliamentary group in the inquiry commission "Ethics and Law of Modern Medicine" of the German Bundestag, Thomas Rachel, speaks of around 3000 people annually who are active there on request Receiving euthanasia from doctors. Active euthanasia is performed in around 1,000 patients without asking for it. Only about half of the cases are reported to the supervisory authorities. These numbers are alarming.

We take the fear of many people of a painful, excruciating and lonely death very seriously. This fear leads many people to ask for “active euthanasia”. Especially when surveys in connection with a painful end of life ask about the acceptance of “active euthanasia”, 70% of respondents in Germany speak out in favor of this option (Allensbach survey 2001). If, however, the alternative between “active euthanasia” on the one hand and pain therapy and hospice work on the other hand is addressed, the acceptance drops to - at least - 35.4%. This acceptance is significantly lower for women than for men (figures from the German Hospice Foundation). Despite all caution, the trend is clearly recognizable: the less people have to fear a painful death, the less they urge the active killing of the dying. Dealing with the dying respectfully requires personal support and care, respectful care, but also medical care that alleviates pain and accompanies the process of dying without unnecessarily prolonging it.

Palliative medicine has established itself in recent years as an important instrument for the medical care of the seriously ill and the dying. The findings in this area today enable a very individual approach to the respective situation of a person who is dying. In this way, medical care is possible, which actually means a considerable relief of pain and agony, but without being allowed to cause death itself - even in the final stage. The development of its own profile for “Palliative Care” reflects this development in the science and practice of care. It remains a challenge to expand and promote this provision of palliative care and palliative medical care to the population, especially at the end of life in our country. We warmly welcome the development and ever broader implementation of the hospice idea. Many people get involved here in the sense of a “culture of the whole person”.

Whether in hospice work, in the clinic, in outpatient or inpatient care, in the visiting service or in the family - everyone who attentively accompanies people in their death does an irreplaceable service to human dignity. Among other things, this is the aim of the ecumenical “Week for Life”, which in May each year takes on changing main themes from the area of ​​human life in all its phases from beginning to end. In 2004 we paid particular attention to the end of life. We call on not to leave the companions of the dying alone in their difficult and often stressful task. They should be able to feel that their service is valuable not only to the dying but also to the living. Offers of support and advice are in demand, but also spiritual offers that convey a feeling that the last escort of the dying may be placed in God's hands. Many parishes and groups do an exemplary job here with their visitor services.

And there is one last thing I would like to mention briefly. It absolutely belongs in this subject area: Human dignity is also expressed in our farewell and remembrance culture. Burial forms, rituals and symbols can give the grief of relatives, the radical seriousness of death and the personal memory of the deceased an appropriate expression. If they do not do this, they fall short of the claim that human dignity makes beyond death. For us Christians, funeral culture combines grief with hope: grief over parting with an irreplaceable person and hope for a life in God's all-embracing love that overcomes death. A Christian burial, mourning and remembrance culture is therefore a clear and unmistakable expression of Christian resurrection hope. It is part of life and death. Only in this comprehensive view can we ultimately do justice to human beings in their dignity.

There are serious problems here which have not been fully discussed and which still require further discussion. In recent times, this has been conducted in an extraordinarily differentiated manner from very different quarters. It is impossible to do justice to the positions in a single paper. This is also not necessary, as it is often reported and discussed in this forum for intensive care medicine. But I want to at least name the problems that are at stake, which of course would have to be developed again in a separate lecture:

- Binding nature of advance directives (our position: They are not a full surrogate of a current expression of will, but an essential point of reference for the determination of the patient's will by the caregiver or authorized representative). Advance directives should be binding. But one should not suppress its indicative character. There are certainly cases where they do not have a full binding effect.

- Reach of advance directives (our position: We are in favor of limiting the range of advance directives, specifically to diseases that lead to death, in the sense outlined earlier).

- Discontinuation of treatment in vegetative coma patients (our position: life-sustaining measures must not be discontinued in vegetative coma patients; vegetative coma patients are living may be decreed).

- Written form (our position: We recommend the written form of living wills, but we would not strictly require it in every case).

- Guardianship court approval: You can vote for or against the involvement of the guardianship court. There are certainly reasons for requiring a permit. The court must particularly examine whether the will of the person concerned is complied with by the decision of the supervisor or authorized representative. In this respect, it protects the patient's self-determination against errors and misuse.

- I do not want to go back in detail here to a topic that is not the subject of this paper. It plays a role in the aforementioned text of the National Ethics Council "Self-determination for care at the end of life" and also in the resolutions of the German Lawyers' Association. It is about the involvement of doctors in suicide. Both statements seem to me to go far here, if, for example, in the future "knowing that suicide is not prevented and a subsequent rescue is omitted" in the knowledge that suicide is freely responsible, it should not become a criminal offense. I have fundamental doubts about a formulation such as “free responsibility for suicide”. I have doubts whether one is doing the doctor a service by allowing a medically assisted suicide that is no longer frowned upon.

This touches on difficult questions that have probably not yet found a solution. But I have sketched the common statements of both churches. Difficult questions remain. I just want to mention the behavior in the vegetative coma patient facilities that I occasionally visit again, insofar as they are located in the Diocese of Mainz. In doing so, I have to say again and again with great gratitude to what extent women and men in these stations make an extremely impressive commitment to life, in case of doubt for life, which they also understand as a service in the name of the Church. If we take the protection of life seriously, we must not give up this service. For this we must also ask medicine and doctors to give this area full protection of life. This also applies analogously to the cash registers, so that they do not endanger this highly impressive commitment to life in the future as well. It depends on the general conditions under which we are. A nurse in our Giessen vegetative coma patient station said to me as I said goodbye, when I thanked her for the nine years of working with the vegetative coma patients: "I can't help it, I love them all as they are." who bears responsibility at this point and wants to restrict the protection of life for these sick people - not infrequently they are innocent victims of traffic accidents - should first visit such facilities. Then, if he seriously wants to, he will think differently afterwards.

I am convinced that we need advance directives to be binding, albeit more in the sense of indicative character. If we do not make differentiated terminal care mandatory, we will hardly be able to curb the approval of forms of “active terminal support”. But with the same clarity, a distinction must be made unmistakably between those actions that actively bring about death and are therefore to be rejected ethically, and those that assist the dying person in a dignified death without bringing about death in any way.

The whole discussion shows us once again how true the old wisdom is that every person dies his or her death.That is why, despite the need for framework regulations, it is not possible to legally stipulate everything down to the last detail. It is good if the person concerned has thought about a threatening situation in his life and has expressed himself accordingly. But I think that time and again it takes time-honored virtues to alleviate this human situation. It takes the cooperation and interaction of all people in the vicinity of a seriously ill person. This includes the doctors and nurses, relatives and friends, pastors and psychologists. A human “compassion” really has to prevail, a feeling of being affected by a person's suffering. After all, especially with regard to the doctor, one should never lose confidence that he decides in his possibilities in the way that is best for the well-being of the person. All the necessary paper norms can never replace this trust and its fulfillment.

(c) Karl Cardinal Lehmann

The spoken word is valid

Intended cuts in the lecture in some parts