International Catholic University
Foundations: The work of the first two lectures will be spent putting into place the foundations of medical ethics in the Catholic tradition. Consideration of the foundations is essential, if the discussion is not to be reduced to bare casuistry or situation ethics and if the tradition is to serve as a guide for issues not yet within the contemporary horizon. So the starting point will be the background out of which the Catholic Medical Ethics grew. Once the background of the tradition, which originated in the ancient world, is in place, the modern situation and its failure will be described and the contemporaneous need for the religious traditions to exercise their appropriate influence will be affirmed.
The tradition is a rich one whose material elements are drawn from revelation, from the teaching magisterium, and from sound medical practice and scientific research and whose formal elements are derived from ethical principles, from the Natural Law tradition, and from legal theory, as all of these interact to serve the human good and the human pilgrimage through life and by death into eternal life. After the delineation of the tradition, the second lecture will present the general principles, followed by a listing of some of the more specific principles that guide reasoning in this field.
First the historical background: Thinking about the appropriateness or the inappropriateness -- the morality -- of medical intervention is as old as the human race. For centuries these discussions of medical intervention were carried on as embedded within a religious tradition. In the world of classical antiquity -- in Greece and Egypt and Rome -- medicine was practiced under the guidance of the Gods and they were invoked to heal and to assist in healing. Judaism and later Christianity, and even later Islam -- the religions that revere the Scriptures -- found in those books the wisdom to guide human life and the practices which serve human life. The traditions of the Book share an important set of truths including life as the gift of God, of human living as life lived in covenant with God, and of a people called to exercise stewardship in the image of God -- creative stewardship -- in the created world. While there are some important differences within these traditions, there are important truths they hold in common.
In ancient Greece and ancient Rome the practice of medicine was a priestly art connected with respectively Asclepius or Aesculapius. The symbol of Aesculapius became and continues to be the symbol of the practice of medicine. The code of Hippocrates, which dates from the 5th Century B.C., has long associated healing with priestly office. In it the physician prays, acknowledges debt to those who transmitted the art of medicine, and swears to use treatment
[T]o help the sick according to my ability and judgment, and never with a view to injury and wrongdoing. Neither will I administer a poison to anybody when asked to do so . similarly I will not give a woman a pessary for abortion . I will keep pure and holy both my life and my art . I will enter [a house] to help the sick and I will abstain from all wrong doing and harm, especially from abusing the bodies of man or woman, bond or free . . . And whatever I shall see or hear in the course of my profession . . . in my intercourse with men, if it be what should not be published abroad, I will never divulge it holding such things to be holy secrets.
While the oath itself contains much more and the Hippocratic corpus contains more than the oath, there may be noted at least the inchoate form of the ends and limits of medicine. Among them are the following: the positive goal to help the sick and the negative limit to cause no injury; the separation of killing from curing in the role of the physician; the universality of the application of the practice to men and women whether free or slave; and the obligation to confidentiality.
In the Jewish tradition medicine was practiced and still is practiced out of the steadfast fidelity to the covenant with God and to the covenant of life -- L'Chaim. In both Moses of Mount Sinai and in Moses Maimonides, who are often referred to as the temporal poles of the golden age of Judaism, there is to be found the combination of healing power and priestly office. The staff of Moses -- the staff with the single snake coiled around the shaft of the staff -- is recorded to have had healing power. Moses Maimonides (the Jewish philosopher-physician who practiced medicine in the regnant Muslim society from Cordova in Spain to Morocco and finally in the Sultan's Court at Cairo) wrote, in the Twelfth Century, a prayer that is often considered to contain a moral code for the practice of medicine. Hear the words of an excerpt from the prayer of Maimonides.
Inspire me with love for my art and with love for Thy creatures. Do not allow thirst for profit, ambition for renown and admiration, to interfere with my profession, for those are the enemies of truth and of love for mankind and they can lead astray in the great task of attending to the welfare of Thy creatures. Preserve the strength of my body and of my soul that they may be ever ready cheerfully to help and support rich and poor, good and bad, enemy as well as friend. In the sufferer let me see only the human being. Illumine my mind that it recognize what presents itself and that it may comprehend what is absent or hidden. Let it not fail to see what is visible, but do not permit it (the mind) to arrogate to itself the power to see what cannot be seen, for delicate and indefinite are the bounds of the great art of caring for the lives and health of Thy creatures. Let me never be absentminded. May no strange thoughts divert my attention at the bedside of the sick, or disturb my mind in its silent labors, for great and sacred are the thoughtful deliberations required to preserve the lives and health of Thy creatures.
Note carefully in the prayer of Maimonides the following: the acknowledgment by the physician of dependence on God; the practice of medicine as informed by love of God; the practice directed to the good of the patient and practices described as care for life and health and the preservation of life and health; the universal application of the art of medicine to rich and poor, to friend and foe; the recognition of the distinction between the physical and the spiritual; the tie of the practice to truth and love; and the warning against those things such as desire for profit and ambition for renown which detract from the practice of medicine.
Of the material elements that inform the Christian tradition the most important are those rooted in the Scriptures, especially in the New Testament accounts of the ministry of Jesus, and in the teaching magisterium which is entrusted with presenting the meaning of the Scriptures in each age. Among the most frequently recurring stories in the New Testament are those of the healing miracles of Jesus. That healing ministry of Christ is part of the identity of the Catholic physician, the Catholic health care provider, and Catholic health care institutions. They cite rightly, as an apothegm "to heal as Jesus healed" and they ought to appropriate that apothegm into practice. Examples of the healing by Jesus abound in the scriptures . . . the healing of the leper, the servant of the centurion, and the mother-in-law of Peter, the restoration of sight, the restoration of bodily integrity, the restoration of life, and of speech and of mobility. It is said in the gospel of Matthew that in this healing mission Jesus fulfilled the prophecy of Isaiah, "He took away our infirmities and bore our diseases" (Is 53:4).
Yet, Jesus as healer of physical illness is just one dimension of His healing ministry. His radical healing ministry extended beyond the healing of bodily infirmity. He healed those who suffer from sin as well as those who suffer from physical infirmity. He drove out demons and forgave sinners and condemned hypocrisy. Medical practice worthy of the name Catholic would, through appropriate partnering with clergy, keep alive the multidimensional healing that our fallen human nature requires. The Muslim tradition of medicine which flourished in the Middle Ages was renowned for its technical skills and its intellectual advances. Medicine was practiced within an ethical code derived from Islamic teaching and philosophy. God was acknowledged as the author of life and death. Physicians were admonished that they did not control life or death. Those who were physicians had grave obligations -- to be expert in their art, to be humanitarian in the distribution of their practices, to respect human life, to keep confidences, to do no harm. The physician/philosopher Avicenna (980-1037) is among the most famous of the Eastern Islamic Scholars of the medieval period. He integrated religion and science and philosophy, especially the philosophy of Aristotle, in his works. His Canon of Medicine was considered a standard medical text in Europe and Asia until the seventeenth century. In the Canon, he described medicine as the art whereby health is conserved and the art whereby health is restored after being lost. The Islamic Code of Medical Professional Ethics continues this tradition and calls for Muslim physicians to practice medicine within the framework of belief in God and belief in Islamic teaching. They look to the Qur'an to inspire the Muslim physician in practice and to keep before the physician the obligations and limits of the practice of the medical art. In an oath which bears some similarity to the Oath Of Hippocrates, the Muslim physician makes these commitments: to acknowledge his faith and his dependence upon God; to be grateful to his teachers and parents; to be competent in his field; to remember that human life -- which begins at conception -- is a gift from God; to refrain from administering anything harmful to a patient; to respect his patients by appropriate communication with the patient and by keeping in confidence information about the patient; to be modest in his practice; and to seek wisdom in decisions.
Contemporary Medical Ethics: Catholic physicians readily embraced, with appropriate modifications, the commitments articulated in the Code of Hippocrates. And the Catholic tradition continues to keep its tradition alive through the careful examination, in the light of the tradition, of the practices of medicine and the gains of science, and through the timely publication of the results of that study. The Pontifical Institute of Science which was established in 1936 and which traces its ancestry to the Academia Lincei established in 1603, and whose international membership includes renowned scientists -- Catholic and non-Catholic -- among them many Nobel laureates, is committed to the study of the advances of science so that science and religion may advance together to serve human good. In recent years the academy has addressed such issues as the environment, neurological research, human fertility, the origins and the evolution of life, the formation of galaxies in the young universe, the beginning of life, the implications of genetics, and the food needs of the developing world.
In addition to the Pontifical Academy, the bishops of various national conferences study, through commissions created for just that purpose, issues in the practice of medicine and put forth guidelines to assist in the formation of the individual conscience and of institutional conscience. The Religious and Ethical Directives for Catholic Health Care Institutions, prepared by the National Conference of Catholic Bishops in the United States, provide one example of the ongoing efforts of the tradition to interact with and transform the contemporary world. The document presents seventy directives to guide the Catholic community in respect to appropriate health care. The directives are ordered around the six themes of social responsibility, pastoral and spiritual responsibility, the health care professional and patient relationship, care at the beginning of life, care at the end of life, and the formation of health care alliances.
Each of those religious traditions continues to inform the practices and institutions of those who claim the tradition. Nonetheless, the informing role of the religious traditions in the practice of medicine does not continue without challenge. In the last quarter of the twentieth century a deliberate effort was made to separate bioethics from religious commitment and to develop a more general and, hence, more universal set of ethical principles to guide bioethics. The more general universal principles included such sets of principles as beneficence, nonmaleficence, autonomy, informed consent, and justice -- made famous as the Georgetown mantra. These principles were thought sufficient to direct a value-free science and a value-free medicine for a pluralistic polity. Furthermore, these principles were wedded to a particular enlightenment and western liberal account of human life that has, at its core, an inadequate philosophy of person -- a philosophy which values an excessive individualism fueled by the will, unfettered by truth, of the autonomous rights-bearing individual and which respects only those individuals who are capable of exercising autonomous rights.
The principles are so general as to be empty. The myth of a value-free science and medicine collapses in the wake of the revelation and subsequent scrutiny of the findings of the Nuremberg Trial, of the Japanese Biological Warfare Unit 731 experiments, and of Tuskegee. The underlying philosophy of person is a form of elitism which denies protection to those who are not like those in power. A more adequate philosophy of person reveals that we live our lives more often as related dependent human beings. Autonomy is always a limited accomplishment achieved over time, if at all, and achieved only after a long period of dependency and often followed by another period of dependency. Autonomy is always limited -- constrained by the relationships which define one's life and these relationships oftentimes require that the powerful accept disadvantage for the sake of the dependent other. Human beings are dependent in the most absolute and radical way first upon God and then upon each other. Living a rich human life places us in different relationships to each other throughout life. Some of these relationships are symmetrical and some are asymmetrical. The symmetrical relationships have their source in our being related to each other in fundamental equality as human beings.
The asymmetrical relationships have their source in the fundamental inequality that we have on account of the obligations and duties that arise in our different vocations whereby we serve one another. In those relationships which are asymmetrical, such as physician/patient, professor/student, attorney/client, parent/child, the model is God's relation to God's creatures. They are asymmetrical because one party to the relationship has knowledge, which is the source of power and authority, and the other party to the relationship is in need of the authority and power. These relations have definition and give content to duties and rights. The physician, professor, attorney, parent exercises authority over the patient, student, client, child; on the other hand, the patient, student, client, child has the right to the appropriate competence of the authority. Out of that competence and within the limits of the role, the physician serves the good of the patient; the professor serves the good of the student; the attorney serves the good of the client, and the parent serves the good of the child. The patient, student, client, child submits to that authority until that authority is no longer needed. The exercise of power and authority is to be merciful, compassionate, and just as God is merciful, compassionate, and just.
So in failure of the bioethics of the twentieth century, in the twenty-first century the religious traditions are called upon to recover their role as informing practices and institutions they claim as their own. Dr. Edmund Pellegrino -- for many years a leader among Catholic physicians and in Catholic medical care -- speaking to and of the tradition of Catholic medicine and health care often cites the words of Kierkegaard to remind medical practitioners of their calling to imitate Christ. Kierkegaard said, "Without imitation of Christ, the fruit of Catholic faith, Christianity becomes mere mythology or poetry or an abstract idea." The Catholic physician then is called to imitate Christ -- to heal as Christ healed.
Moreover, the tradition as Catholic is reminded of its limits. Healing of physical illness is not always possible. The bodies of this temporal life are mortal and corruptible. Hence, an exclusive focus on healing is too narrow and too exclusive a center. It is to buy into what Stanley Hauerwas calls the Promethean myth of modern medicine that offers the promise of human salvation in more and better medicine. Jesus healed but he also suffered and died. Here Catholic medical practices and Catholic health care institutions and Catholic patients have special obligations because of the Jesus revealed in Scripture. Catholic practices and institutions must embrace methods and be places of caring for the dying that is inevitable. And they must offer visible witness to both the truth of the finitude and to the truth of the promise of human existence. In His suffering and dying, Jesus, from the depths of His humanity, called out for consolation. In Gethsemane, He asked to be rescued, "My Father . take this cup of suffering from me." He revealed to His friends His grief and anguish. He said, "The sorrow in my heart is so great that it almost crushes me." He asked them to stay with Him and He is sorely disappointed by their failure to remain with Him. He experienced abandonment and, close to the end, He cried out to His heavenly Father, "Eli, Eli, lema sabachthani (Father, Father, why have you forsaken me?)." And, at last, He placed Himself into His Father's care. Catholic health care institutions have to be places and have to provide services and spaces within which human beings who are experiencing crushing sorrow, anguish, and abandonment will find in attendance caring people to touch, and to wash and to anoint their bodies, attentive people who do not turn away from them, loving people whose simple presence sustains them, and faithful people who do not abandon them in their dying. And Catholic people who are dying must come to terms, finally, with human nature as created, accept their dying in the hope of eternal life, and in the end reach out to God's infinite power.
Limits of Medicine and Science: The tradition values the contributions of medicine and science and law, but it does not turn over its moral authority in medical ethics to the success of medical practice, to the advances in the science, and to current renderings in the law. Technologies honed by medicine and science and public policies crafted within the law must serve the dignity and vocation of the human person. There is a very long history of scientific and medical research, propelled by the research imperative, that treated human beings as means to ends of progress and therapy. And religious authorities must respond appropriately and respectfully to the scientific and medical advances when they present opportunities for genuine human flourishing. Church leaders have on more than one occasion stepped inappropriately into the domain of science; and scientists have more than once sought refuge in the claim that its pursuits are value-free. History has witnessed, on both sides of the science-theology debate, incredible hubris and authoritarianism. Both sides, in careful application of the canons appropriate to their respective fields, must accept the limitation of their expertise. Authority exercised rightly recognizes the power of the dialectical tension between fields and disciplines and between theory and practice in the pursuit of truth. Moreover, authority is not exercised for its own sake or for the sake of power but for the sake of truth. Recent history has also witnessed from both sides the incredible results of appropriate collaboration and cooperation. One particular example of such cooperation is to be found in Directive fifty-eight in the Religious and Ethical Directives for Catholic Health Care. Directive fifty-eight asserts a presumption in favor of providing food and water to patients as long as the food and water provides a benefit to the patient, that is, as ordinary care. The advance in the directive was accomplished by careful testimony of physicians, theologians, and philosophers. The physicians offered their medical judgment that there are some conditions of illness and decline in which food and water no longer benefit the person. Philosophers and theologians offered their expertise in the careful application of the distinction between ordinary and extraordinary means of preserving human life, in their affirmation of life as a fundamental value, and in the distinguishing of continuation of biological existence from the continuation of human existence.
With the background in place, the next lecture will develop the general and specific principles.