Healthcare Ethics--Theological
And Papal Perspectives
By Thomas Lederer, M.A.
(Includes an Analysis of Evangelium Vitae)
Home Page for the Theological Works of Thomas G. Lederer
"Modern medicine has unprecedented power to heal human beings of physical and mental disease, to keep them healthy, and even to improve the human race. This power can be used to humanize life or to dehumanize and destroy it. It can be used justly to benefit all, or it can be used to benefit the few at the expense of many. How to use such power is a question of values, and therefore, of individual and group decisions that are not merely technical but ethical." (Ashley-O'Rourke page xii)
In their medical ethics textbook Healthcare Ethics--A Theological Analysis, Benedict M. Ashley OP, PhD. STL and Kevin O'Rourke, OP, JCD, STL, place considerable emphasis on the dignity of the human being. They cite the Universal Declaration of Human Rights as written by the United Nations in 1948 to reinforce the notion that "human beings are born free and equal in dignity and rights." (Ashley and O'Rourke, page 13)
However, the authors also take very specific aim on those who place concerns for human freedom and personal sovereignty as the sole criteria for determining the righteous path for medical issues. They see the ethical humanists, and perhaps even the liberation theologians, who have sought to take life choices out of the realm of religious eschatology as having gone too far, and as having abandoned the very foundations of Christian concern for the human condition. Ashley and O'Rourke seek a "via media" between the hubris of human self -importance and deference to eschatological neglect.
TWELVE PRINCIPLES
Central to the Ashley-O'Rourke argument are twelve principles which they espouse, restate, and emphasize repeatedly throughout their work as essential to unlocking the elusive truths of ethical considerations in health care. Behind these principles is a basic respect for the dignity of a human person as well the precepts of Christ's work here on earth: as a lover of humankind, a healer of the sick, and a supporter of those who today we might refer as the "underserved" among us, the anowin--"the little ones," the outcasts, the poor.
The Principle of Well-Formed Conscience indicates that people are obligated to inform themselves about ethical norms, incorporate that knowledge into their daily lives, act according to that knowledge, and take responsibility for those actions.
The Principle of Free and Informed Consent states that people must have knowledge about and give consent before physical or psychological therapy may be administered. The principle also puts forth the notion that those in authority cannot ask for consent unless it is clear that the patient is indeed informed.
The Principle of Moral Discrimination suggests that being morally discriminating is a way of life that we must adopt and utilize in all aspects of our lives as a commitment to God and to the dignity of other human beings.
The Principle of the Double Effect presents an interesting exercise in quasi-syllogistic logic which serves as a system of checks and balances to insure against harm inflicted by rationalized actions.
The Principle of Legitimate Cooperation portrays the Principle of the Double Effect in a scenario in which more than one person participates in the actions being evaluated.
Principle of Professional Communication puts forth the need for trust, informed contact, clear articulation, and continuous update and feedback when it comes to moral issues.
The Principle of Dignity in Community is a foundational statement of the necessity of health care serving human persons; how health care must be at once a gentle balance of ethical, communal, and political considerations; how all ethical decisions must satisfy both the innate and cultural needs of every human person; and also expresses the specific Christian contribution as a vision of authentic human dignity as revealed in Jesus Christ.
The Principle of Common Good, Subsidarity, and Functionalism
can best be summarized by the expression, "from each according to ability, to each according to need, as indicated by Jesus and his concern for the 'little ones.'"
The Principle of Totality and Integrity makes reference to 1Col:
Principle of Growth Through Suffering makes implied references to the Christian theological concept of "already but not yet," points us in the direction of a life beyond this, yet makes clear the need to endure and make as perfect as possible the road to that next life, a road that will indeed be laden with potholes and detours.
The Principle of Personalized Sexuality takes note of a humanized sexuality, one that represents the fulfillment of physical and sensual need but also evidenced with love and sacramental mystery.
The Principle of Stewardship and Creativity sculpts an image of our gifts as humans and the horizons that such gifts offer us as multidimensional creatures of God. At the same time, a limit and a responsibility are placed upon just how far beyond God's intentions we should take those gifts.
The authors coordinate the twelve principles for easier synthesis by pointing to Totality and Growth Through Suffering as part of the preservation of life; Personalized Sexuality as part of procreation; Well-Formed Conscience, Discrimination, Double Effect, Cooperation, Consent, and Communication all as means to help humans learn the truth; and Human Dignity, Common Good, Subsidarity, Functionalism, Stewardship, and Creativity all part of directives for living in our society.
FAITH, HOPE, AND CHARITY
It is crucial to the overall comprehension of the authors' perspective to see that they are saying that faith is required for persons to act as an informed conscience; that hope requires humans to accept growth through suffering, to continue the human community through family, to creatively serve as stewards in God's world; and love (ie, charity) requires profound respect for human dignity, regardless of a person's condition, requires love of oneself through proper health care, and love as responsibility for the well-being of all.
Faith, hope, and love, the three essential ingredients included in the Christian message, the Gospel preachings of Christ. Yet, in the same spirit as The Second Vatican Council and Lumen Gentium, the authors do not contend that Christians have a monopoly on wisdom and on the true God and his grace. They suggest merely that God has made himself most fully and explicitly known to humanity through the work, words, and deeds of Jesus Christ.
PRUDENTIAL PERSONALISM
Much as Beethoven in the final movement of his ninth symphony reviews previous themes, abridges them, and then rejects them in favor of the "Ode to Joy," Ashley and O'Rourke take great pains to review various branches of deontological and teleological reasoning before embracing what they refer to as "prudential personalism." Prudential personalism proposes that the rightness or wrongness of human actions can best be judged by considering the indefinite yet teleological goal we know as "life" by asking, "How does this action in its context contribute to the growth of persons in the community?" We answer this question with help from our informed consciences which the great 20th century theologian Karl Rahner saw as our direct contact with the voice of God.
CHRISTIAN HEALTHCARE MODEL
With their twelve principles and a derived theological perspective as a foundation, the authors construct a model for the ideal healthcare plan which includes:
1-healthcare as a fundamental right
2-comprehensive coverage
3-positive, preventative health care
4-emphasis on quality care
5-emphasis on humanistic education of healthcare professionals
6-a global funding plan
7-and participation of both consumers and health care professional in the administration and planning of the system.
In addition, it is stated that Christians, by the very definition of their moral and theological heritage, must support such healthcare issues along with giving priority to the powerless, the poorly informed, and the least able to pay as well as not leaving important decisions to autonomous professional groups or governmental dictates.
ONE LONG ISLANDTOWN'S COMMUNITY MODEL
It is interesting to point out that, within our community such a model has been nurtured and developed over the past eight years and is soon to see realization when the
Although the convoluted journey from Millie Willan's front porch to
Back in 1968, when the municipal government of Suffolk County decided to build eight health clinics throughout its vast jurisdiction, the final result was seven health clinics due to Huntington Hospital "north-of-25A, let them eat cake" mentality and ultimate refusal to sanction such an entity. Some eighteen years later, in the summer of 1986, living legends from the realm of local social activism gathered to discuss a game plan for building a long-overdue health center for Huntington residents, a facility that would provide primary medical attention for anyone who was in need, regardless of their ability to pay.
Jill Winter from the Huntington Coalition for the Homeless, Fran Leek head of outreach for St. Hugh's Church in
In 1993, shortly after Huntington Hospital spent $1.4 million on a building in which to house a health center, I was asked by Arthur Goldstein to chair the Roundtable Task Force, with a special mission of insuring that the needs of the community were presented to the Hospital, while also looking to see that the Hospital's best interests were never compromised. It was a challenge I accepted and, as the assignment evolved into the chairmanship of a permanent advisory board for the health center and a seat on the Hospital Board of Trustees, it became one of the most inspirational and pivotal experiences of my lifetime.
Referring back to the aforementioned model for healthcare enveloped in Christian ideals, the new health center reinforces such philosophical beliefs:
1-at the very core of its creation and inception is the notion of healthcare as a fundamental right.
2-the health center will provide comprehensive coverage for all types of health problems, physical and mental, ranging from primary care, OBGYN, pediatrics and family medicine, sociological screening and referral, with the anticipated addition of on-sight dental and mental health counseling.
3-the overall facility and the professional staff have been structured with the very important consideration of being able to provide extensive instruction for young, old, male, female, of all ethnic backgrounds in the importance of preventative care and positive health education.
4-despite some traditionalists who originally envisioned a storefront setting or a facility buried deep within troubled, impoverished neighborhoods, Huntington Hospital made it clear that they would not proceed with its health center unless it could offer first-class, state-of-the-art care for all of its clients.
5-a primary consideration in the hiring of healthcare professionals for the facility was that the applicants were experienced in working in settings that required humanistic dedication and an openness to grow and develop their own special calling.
6- while the model developed and endorsed by Ashley and O'Rourke made references to taxation plans on a much grander scope than the microcosm represented by the new community health center, one could not get much more eclectic and communal than the means via which it was funded. It is the first community health center established and managed by a
7-the Huntington Hospital Dolan Family Health Center Advisory Board closely follows the Ashley-O'Rourke stipulation for systematic planning involving "both consumers and health care professionals." With all humility, I must contend that I developed a painstaking process for putting together an advisory board that fairly represented numerous factions of our community so that initial planning and subsequent evolution and development would speak with the voices of the multitudes. The twenty seats of the advisory board allotted to community members (five additional seats are filled by hospital employees and/or trustees) include members of the Hispanic, Afro-American, and Haitian populations. There is a doctor, a professor of nursing, a retired registered nurse, two physically challenged individuals, a lawyer, a managed care facilitator, and a businessman who fancies himself as a theological student, et.al.
In addressing, the postscripts to the Christian healthcare model offered by the authors in which priority is given to the "powerless, the poorly informed, and the least able to pay," I can offer prima facie testimony that the major focus of the advisory board is serving as a perpetual, ever-present conscience to the Hospital lest it ever forget the people whom were being discussed that summer evening on Millie Willan's porch nearly a decade ago.
As a new member of
CHRISTIAN HEALTHCARE ETHICS: ABORTION
A significant portion of the textbook by Benedict Ashley and Kevin O'Rourke is devoted to discussion and examination of the Christian criteria for formulating ethical decisions in healthcare, as the title of the book strongly suggests. The authors utilized abortion as a representative issue as will I.
Abortion has become an explosive issue in our time. Abortion is no longer just a "Right to Life," Catholics vs. the-rest-of-the -world debate. Many new factions have embraced abortion as a focal issue, and the violence and zealous activism that has become associated with an anti-abortion stance speaks for itself.
The text traces anti-abortion theological sentiment back to the Torah, the Didache, and early Christians who opposed the Greco-Roman propensity toward infanticide and abortion for population control.
The authors define abortion as the "termination of a pregnancy with the resulting death of the human fetus." ( ibid, page 218) They describe two types of abortion: "direct" in which the sole intention is to stop the pregnancy and "indirect" in which a fetus will be put at grave risk by medically treating the mother.
The authors state that direct abortion is "contrary to the will of God who creates each person." (ibid, page 218) They stipulate that indirect abortion is only permissible in a "conflict situation:" if its passes the litmus testing provided by the Principle of the Double Effect.
A female contention is that abortion is their choice as women and as sovereign humans is dealt with extensively and fairly by the authors. However, they come back to their unwavering conviction that life begins with the formation of the zygote, that life in any form represents the potential for growth, and that the intentional destruction of that life is unconscionable in the eyes of God and in the Catholic faith.
The authors cite numerous magisterium documents in support of their anti-abortion stance. They also invoke the Principle of Legitimate Cooperation in reference to the participation of healthcare professionals in an indirect medical abortion. The professionals are prohibited from participating in a direct abortion but are permitted--and perhaps morally required--to partake in the after-care of an abortion patient.
The text indicates that excommunication is the ultimate and normative punishment for violation of the Catholic anti-abortion mandate. Just as they define excommunication of a Catholic as the ultimate in estrangement from God, so too do they say that excommunication can be lifted when this estrangement is reconciled. The authors also caution Christians not to pass judgment upon those who are faced with medical decisions about abortion, decisions that do not fit easily in it any one model or any one theological syllogism.
"Instead of judgment, Christians must seek ways to assist women to escape such anguishing dilemmas, while at the same time showing an equal compassion for the helpless child." (ibid, page 221)
THE GOSPEL OF LIFE
Earlier this year, Pope John Paul II published a thesis entitled, "The Gospel of Life," (Evangelium Vitae.) Its subtitle is "The encyclical letter on abortion, euthanasia, and the death penalty in today's world."
In this work, the Pope takes strong and unequivocal stances against what he perceives to be "new forms of attacks on the dignity of the human being." (Pope John Paul II, page 7)
John Paul II quotes Vatican II as emphasis for his proclamation of human dignity:
"By his carnation, the son of God has united himself in some fashion with every human being. This saving event reveals to humanity not only the boundless love of God but also the incomparable value of every human person (ibid, page 5, quoted by the author from Gaudium et Spec,22)
Regarding abortion specifically, there is no ambivalence in the Pope's words or intent when he states:
"I declare that direct abortion that is willed as an end or as a means always constitutes a grave moral disorder, since it is a deliberate killing of an innocent human being. (ibid, page 112)
The Pope's sentiment regarding the establishment of when life begins is also in line with the views of Benedict Ashley and Kevin O'Rourke:
"The Church has always taught and continues to teach that the results of human procreation, from the first moment of its existence, must be guaranteed that unconditional respect which is morally due to the human being in his or her totality and unity as body and soul: 'The human being is to be respected and treated as a person from the moment of conception.'" (ibid, page 108, the author quoting from the Congregation for the Doctrine of Faith, Donum Vitae, February 22, 1987.)
The Pope's book also traces back to the same theological opposition to abortion as utilized by Ashley and O'Rourke, and quotes a nearly 2000 year old thesis from the theologian Tertullian who stated: "He who will one day be a man is a man already." (ibid, page 110, with the author quoting from a work entitled "Apologeticum")
CONTEXTUAL COMPARISON
The authors of the text also treat the teleological process theories from the secular vision of Alfred North Whitehead and from the theological perspective of Pierre Teilhard de Chardin. Both of these gentlemen were pioneers and proponents of process philosophy. Teilhard de Chardin, a priest/anthropologist not always in
Both Whitehead and Teilhard's perspective of evolution as a process support the metaphorical view that process begins at the earliest stage of human development. Thus, it can be deduced, that the process starts with the zygote in Teilhard's biosphere and will one day end with the fully evolved human in the Christosphere. Along the way, all forms of human life are evolving, growing, and deserving of the nurturing, dignity, and respect as taught to us by Jesus Christ as he walked upon the earth.
Once again, the text authors and the Pope speak in similarly regarding excommunication as the penalty for abortion.
"The purpose of the penalty of excommunication is to make an individual fully aware of the gravity of certain sin and then foster genuine conversion and repentance." (ibid page 112)
There are similar parallels between the arguments against euthanasia in the Ashley-O'Rourke text and Evangelium Vitae. Both draw a distinction between: a) a decision to realistically limit care in light of a hopeless prognosis and b) medical professionals inducing death to cease human suffering. The text calls these "passive" and "active" euthanasia, respectively, with the latter being considered immoral, while there being certain moral justification for the former.
"...the mercy killer is simply a murderer putting to death someone no longer able to protect himself or herself." ( Ashley-O'Rourke, page 379, with the authors quoting from Richard Gula, "Euthanasia: a Catholic Perspective.")
"I confirm that euthanasia is a grave violation of the law of God, since it is the deliberate and morally unacceptable killing of a human person," said Pope John Paul II (ibid, page 119.)
OTHER ISSUES
While the Pope's work limits itself generally to abortion, euthanasia, and the death penalty, Ashley and O'Rourke touch upon many controversial contemporary medical ethics issue, some of which include:
1. Contraception--"every (marital) act must be open to the transmission of life." (Ashley-O'Rourke, page 264, with the authors quoting from Humanae Vitae.)
2. Sterilization--"Because direct sterilization is a form of contraception, it is intrinsically unethical and contrary to the Principle of Totality and Integrity because it sacrifices a basic human function without the necessity of preserving life. (ibid, page 272)
3. Surrogate motherhood--"Surrogate motherhood represents an objective failure to meet the obligations of the maternal love, of conjugal fidelity, and of responsible motherhood." (ibid page 283, with the authors quoting from Sacred Congregation for the Doctrine of Faith, "Instruction on Respect for Human Life in its Origin and the Dignity of Procreation.")
4. Transplants--moderation is needed where God wants us to utilize our skills and intelligence to better his universe but not to alter it beyond recognition (ibid, page 302.)
5. Sex Change--the psychological implications and the realization that such operations are radical and irreversible suggest that persons with sexual identity problems should learn to live with them, through efforts at self-acceptance, through counseling, through celibacy.
Throughout their text, the authors present a logically balanced and consistent argument based on their twelve principles, the dignity of the human person, but also blending in theological perspectives. Factoring God into the debate pulls it back from being completely based on the human identity and unwisely excluding the concept of our relationship with God.
POPE JOHN PAUL II AND HIS MORAL
Pope John Paul's work is adamant in its stipulations about the need for Catholics to reach out and grab hold of a "gospel of life," and to categorically reject the modern "culture of death." There was some sporadic criticism directed toward the Pope when this work came out, a considerable amount aimed at his stance on capital punishment. There was less negative commentary about his stance on other issues because much of what he had stated was a re-statement of previous encyclical pronouncements, especially from Veritatus Splendor from 1993.
Some took issue with the Pope's unwavering stance on abortion and on euthanasia, somewhat similar to some of the criticism toward Jesus when it not so much what he said as with what authority he said it.
"Since there is little new in moral teaching is this encyclical, the newness here (beginning with Veritatis Splendor)is the Pope's insistence on being the singular vehicle for proclaiming truth...The human family desperately needs moral guidance. The Catholic Church must offer that guidance. The human family needs encouragement and hope (note: this editorial had earlier criticized the book for being too dour and pessimistic) Without these, it won't be receptive to a moral message..." ("National Catholic Reporter" editorial, page 24,
Why did the Pope issue such a strong encyclical following so closely on the heel of Veritatis Splendor? Speculation about preset publication dates and recent communication with the Holy Spirit would be based on speculation; so, I will look elsewhere. At the risk of self-indulgence, I wish to re-state a moral perspective with which I opened a moral theology paper written last year:
Murder triggered by unrequited love or jealous rage;
political misdeeds out of greed and expediency; white lies, black
lies, grey areas as pathological means for survival; abortion
justified by convenience; substance abuse to anaesthetize the
unbearable pain of consciousness; careless decisions and
alternative lifestyles destroying the nurturance of a nuclear
family; human starvation allowed to exist by way of ignorance and
the sin of omission; the systematic defamation and destruction
of a human being in the name of a free press; humanity playing
deity with artificial insemination, genetic engineering, and
euthanasia; leaks, lies, larceny, and pay-offs as standard
operating procedure in government; interpersonal relationships
based on a primitive pleasure principle; an overall lack of
respect for the gift of life. (Lederer Page 2)
Indeed, these are troubled times. Perhaps no more immoral than past civilizations, although advances in science, technology, and communication certainly seem to have intensified the human sense of self-righteousness and hubris.
Pope John Paul II, with his global responsibilities, has a much wider perspective on immorality than the one I put forth in the aforestated diatribe. He has more reason for concern because he sees sin on such a grander scale. I am certain that Pope John Paul II has a sense of urgency because he knows his time with us is limited. He also must sense and appreciate his position of power, and his ability to publish books, poems, videos, CD's, et.al. to reach out to anyone and everyone regarding how concerned he is about dangerously close to the garden we linger on Teilhard's scale. In response to NCR, the Pope is offering moral counseling with his encyclicals, with his books, and with the new catechism. It is just that not very many people are listening to what he is saying.
When Humanae Vitae was issued, there was an understandably negative reaction among those who wanted to "keep the Pope out of their bedrooms." It was a different time. But today, the Pope's condemnation of abortion and his refusal to succumb to pressure and to sanction contraception even in an age of rampant sexually transmitted disease and population problems is consistent with a message from which he cannot comfortably back away.
I believe that the Pope sees the problem not just unwanted pregnancies or the spread of AIDS, but rather the inability of the human species to cognitively grasp the concept that these sexually related problems are surmountable. A "personalized" sexuality that includes some moderation, some abstinence, and something beyond just the need for gratification is called for.
As someone who helped raise two teenage daughters and somehow, with the help of God and some wonderful Christian counselors, saw them grow into their twenties, I can attest to the pain that young people endure as part of their late-20th century sexual evolution. I have seen the psychological scars left by abortion; I have seen the panic call to a doctor or an AIDS hotline on a morning after; I have seen the confusion between hormonal surges and an underlying desire to settle down and raise a family.
Sexuality can be an albatross if not viewed with some "personalized" maturity, just as medical ethics can be baffling if not viewed within a theological context.
tgl
BIBLIOGRAPHY
Ashley, Benedict M. and O'Rourke, Kevin D. Healthcare Ethics--A Theological Analysis.
Keane, Philip S. Health Care Reform: A Catholic View.
National Catholic Reporter.
Lederer, Thomas. “Catholic Moral Theology:Whose Sin Is This Anyway?” Seminary of the Immaculate Conception,
Pope John Paul II. The Gospel of Life (Evangelium Vitae).
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