International Catholic University
The general principles of the Catholic tradition that inform and give shape to Catholic medical ethics and to medical practice are rooted in the Scriptures. The meaning of the Scriptures has been developed by the philosophical and theological study that attempts to understand the wisdom of the scriptures in a manner that allows that wisdom to be brought forward to apply to the advances within the horizon of the contemporary world. This is the task of the magisterium. This lecture will proceed with a summary of the essential elements of the tradition, then the Natural Law foundation of the tradition will be made explicit, and finally the more specific principles -- some material and some formal -- will be presented. The Scriptures reveal that human beings are created in the image and likeness of God. Human beings are called upon to exercise power in the world in a manner that manifests human dignity as the image of God. Human creative power is limited. Human creative power is to be providential as God is providential. It is to be stewardship, not control. God as a loving Father continues His guidance over human affairs. God entered into history with Divine Law, for example the Ten Commandments, the Eight Beatitudes, and the great commandments of love, to assist humans so that they might reach the end for which they were created. In addition, God created human beings in such a way that they have a share in God's eternal reason through Natural Law. Natural Law, as described by Thomas Aquinas, is the subjection of human beings to God's providence in a most excellent way -- "in so far as it partakes of a share of providence by being provident for itself and for others" (ST, I-II Q.91. a.2).
The covenant of God with humanity is the model for human beings to relate to each other. The covenant is faithful -- hesed; it is patient; it is merciful; it is compassionate. Each human life inasmuch as every human being is created by God in God's image is equal in dignity. Human life is finite. It comes from God and is drawn back to God. Every human being receives life from God and from their parents -- to receive life; to share in the joy of life; to experience suffering; and, finally to die. Life and sickness are to be patiently endured in faith and hope. The source of that faith and hope is centered in a firm grasp that our incarnate God took upon Himself our human nature, lived, suffered, and died in expiation for our sins. So death marks the end of the earthly pilgrimage for each and every human being. But, as did Jesus go to His Father, so shall we to be united to a loving Father who now awaits us.
The Natural Law tradition, which is foundational for the Catholic tradition, is found in the Summa theologiae of Thomas Aquinas. Thomas displays here the synthesis of the religious tradition with a philosophical tradition that developed out of Roman Stoicism. In Thomas's treatment, he presents the self-evident principles of practical reason and he provides a mechanism for the generation of more specific precepts to guide prudential decision making for ethics generally. This mechanism assists in the formulation and in the application of the principles in medical ethics. Natural Law theory makes these fundamental claims: (1) there is a natural order or rule in the universe and (2) this natural order or rule is accessible to human reason as (a) known by reason and (b) as directed by reason.
It is essential to the understanding of the Natural Law tradition to locate and to understand its remote source and its proximate source. The remote source of Natural Law is Eternal Law -- the plan of God for the created world. The proximate source of Natural Law is human reason as human reason comes to understand human nature. Human reason experiences the inclinations which manifest human nature; human reason apprehends the inclinations of human nature as good; and commands that these goods be accomplished under the command of human reason.
Because the remote source of Natural Law is the mind of God, the tradition remains confident in its claim that there is truth to be achieved Because the things in the universe, inasmuch as they have being, have their ultimate source in the mind of God they have specific natures which are open to be understood by human beings over time. Nonetheless, because the proximate source of understanding the Natural Law lies in the activity of human reason and its grasp of nature, including human nature, the tradition recognizes this grasp as limited and open to revision of the more specific precepts in the advance of knowledge. The general principles and the general precepts are, of course, not open to revision.
A closer examination of this theory as explicated by Thomas Aquinas in the Summa theologiae illustrates the principles and the generation of the precepts of Natural Law. Thomas maintains that good is apprehended by human reason and that the first precept of Natural Law, based on the principle that all things seek good, is "good is to be done and pursued and evil is to be avoided" (ST I-II, q.94, a 2). In the derivation of the several more specific precepts, Thomas working from within a metaphysical context, holds that practical reason apprehends the natural inclinations or tendencies of human beings as good. These inclinations or tendencies are dynamic principles which press for actualization and which are ordered to the flourishing and conservation of human life. Thomas lists a methodical ordering of the inclinations identified as moving from more extensive instantiation to more specific. The first more specific precept developed by Thomas is the precept: preserve human life. It is derived from the inclination in human beings to continue in existence -- to live. This inclination is one that is common to all living substances, for example trees put down roots which seek water and trees turn their leaves to the sun to receive energy necessary for photosynthesis. Practical reason apprehends the inclination to continue in existence as good and orders the preservation of existence and the pursuit of the means of preserving human life. The application of this precept is central to the medical ethics in the tradition. It is controlling in issues at the beginning and the end of life such as abortion, euthanasia, appropriate care for the dying, and medically assisted suicide. The second set of inclinations identified by Thomas is the set of those that are common to human beings and to animals. They include the inclination to sexual intercourse and to the nurturing of offspring. Reason grasps the inclinations; apprehends them as good; and commands that they be fulfilled under the rule of reason. The Natural Law precepts, which have their foundation in these inclinations, are controlling in the theology of marriage as the institution within which it is reasonable to actualize these inclinations. In addition, these Natural Law precepts are controlling in such medical ethical issues as the governance of the reproductive finality. The third set of inclinations includes those that are proper to human beings. Among them Thomas lists the pursuit of truth and the pursuit of life in community.
In summary, the principles of Natural Law and the precepts of Natural Law identify objects (ends) of human flourishing. The ordering of the Natural Law precepts moves from more essential -- from sustaining life -- to more excellent -- to knowledge of God.
Human living is, of course, complicated and its goods are multiple. Some other distinctions are helpful to order the pursuit of goods. The first is the realization that the move made from the general principles to the command of a specific act is fraught with difficulty because of the complexity of human action. Thomas Aquinas reminds us that practical reason is concerned with contingent matters and as we descend from universal truth to the rightness of action in contingent matters it may be the case that because of some peculiarity of detail the more general principle does not apply in this situation. For example, the Natural Law precept to have sexual intercourse does not apply to those who have been called to a vocation which embraces celibacy and it applies to those who are married within certain limits and it applies to those who are unmarried by informing them to refrain from intercourse. In addition, the Natural Law precept to preserve human life applies in a different manner to the soldier than it does to the ordinary citizen. Furthermore, it is to be noted that the general principles of Natural Law may fail to be operative in human beings because of the lack of rectitude or because of the lack of knowledge. In regard to rectitude, the passions may have been trained in such a way as to pervert rectitude. An example of this may be seen in the lives of those who abuse alcohol or drugs or sex. It is very difficult for these human beings not to be blinded by these disordered passions. In regard to knowledge, it is clearly understood that the achievement of knowledge is a long process and when achieved at all is achieved only late in life. An example of a development in knowledge is found in the transition in understanding of human reproduction from the preformationist perspective to the understanding found in the two germ cell theory.
Another helpful distinction that assists in the ordering of the human pursuit of goods is the recognition that the specification of an act alone or of an intention alone is not sufficient for the moral determination of an act. The moral goodness of act requires that the object, the intention, and the circumstances all be good for an act to be good and hence morally permissible. If the either circumstance or the intention is not good, then the integral goodness of the act is lost. An example in regard to circumstances is the following. It is good for married couples to have children, however if the circumstances of their marriage are not conducive to the nurturing of children, then they ought to refrain from having children. An example in regard to object is the following. If one of the partners of the marriage is infertile, they cannot, even for the good of procreation, use material from outside the marriage to accomplish the procreative end. Procreation is limited to the marital union. An example in regard to intention is the following. It is good for married couple to engage in marital intercourse. However, if one of the partners engages in intercourse as an act of power over the other, then the act loses its integral goodness. Another example in regard to intention, one that is very powerful in the contemporary culture, is the intention of compassion. It has been suggested, out of compassion, that the stem cells of one human being be used to serve the well-being of another human being or out of compassion the life of the dying be terminated.
Among the more specific principles operative in medical ethics in the Catholic tradition, the most important are the principle of sanctity of human life, the principle of double effect, the ordinary/extraordinary distinction, and the principle of totality. The principle of sanctity of human life is the fundamental principle in medical ethics. It recognizes that other goods may be secured only in virtue of having life. It is not, however, an absolute value. The principle of the sanctity of human life has its source in the acknowledgement of God as the author of life and in recognition of the reality that human life is finite. In addition it has a foundation in common sense . . . how can autonomy or choice or any good be exercised without life . . . and in Natural Law where the precept "preserve human life" is the first of the more specific Natural Law precepts enunciated.
In contemporary medical ethical literature there are several renderings of the principle. Among them are the following: (1) human life has absolute value and may never be taken; (2) innocent human life may never be directly taken; (3) human life has relative value and may be taken for other significant values; and (4) conflict of life situations are inevitable; whenever conflict occurs minimize the taking of human life. The Catholic tradition aspires to the first of these understandings. Such affirmation is found in the seamless garment of Cardinal Bernadin and in the great Gospel of Life of Pope John Paul II. However, for most of its history the Catholic tradition has affirmed the second of these principles. In this affirmation there is special emphasis on the qualifying terms "innocent" and "direct" and in the acknowledgment that in a fallen and broken world -- in a world in which there is evil -- human aspirations fall short of the ideal. Self-defense, just war, capital punishment -- when no other remedy is available -- are instances of the application of the second understanding. This principle is operative in medical decision making in instances of the use of particular medications at the end of life and in certain types of abortion decisions. The third interpretation of the principle is operative in those philosophical positions that do not recognize human life as having fundamental value or do not distinguish human life and its particular dignity from other forms of life, or tend to ignore the human life issue in the pursuit of other goods. This understanding of the principle is operative in the claims of some feminists who rank the choice of a woman to have a career, or education, or financial well-being over the continued existence of nascent human life. The fourth interpretation has been put forward to account for the claim that some action which directly takes innocent human life may be permissible in some extraordinary circumstance beyond those permitted in (2).
The Principle of Double Effect is a purely methodical principle. It rests on the common sense perception that the human agent is responsible for acts and omissions and also, to some degree, for the consequences of action. It recognizes also that in this imperfect and complicated world, an action may have more than one effect. The foreseen effects of an action may be good effects and bad effects. The principle states the conditions under which it is permissible to engage in an act which has two foreseen effects -- one good and one bad. The conditions are (1) the act itself must be good or indifferent; (2) the good effect is not produced by means of the bad effect; (3) only the good effect and not the bad effect is directly intended; and (4) there is a proportionate reason for placing the action and permitting the bad effect. Among the most recent application of this principle is the use of particular medications at the end of life. In order to relieve pain in the dying patient, medications are morally permitted which have as the intended effect the mitigation of the pain of the patient and the bad, although not intended, effect of depressing the respiratory system of the patient. The good of the mitigation of the pain is permissible, even though death may be the foreseen result.
The extraordinary and ordinary means distinction is a critical distinction for with this distinction comes obligation. Human beings in the exercise of stewardship of their lives are morally obliged to take ordinary means in the care of life. Ordinary means are all medicines, treatment, and operations which offer a reasonable hope of benefit for the patient and which can be obtained and used without excessive expense, pain or other inconvenience. Extraordinary means are all medicines, treatments and operations which cannot be obtained without excessive expense, pain, or other inconvenience or if used would not offer a reasonable hope of benefit. The distinction between ordinary and extraordinary means shifts generally as technology advances as well as specifically and individually depending on the prognosis of a patient and the invasiveness of the treatment. What in the past might have been extraordinary means such as almost any surgery, has, because of medical advances such as antibiotics, heart and lung machines, immuno-supressant drugs, become ordinary means. What might be ordinary means for one person might be extraordinary means for another. The hinge element here is benefit to the person. It might be appropriate, hence ordinary care, to use a ventilator to support, temporarily, the respiration of a patient recovering from an injury or illness and it might be inappropriate, hence extraordinary care, to use the same ventilator modality for a patient actively in the dying process.
The principle of totality recognizes that the individual person is the steward of body and soul. In exercising stewardship, the person is permitted the use of the faculties and powers of the body and soul in accord with the immanent finality of the faculties or the powers in the service of the whole. The person may not destroy the faculties or powers or limbs or organs unless their destruction is required for the good of continued existence or that of mending or avoiding serious injury. The principle states simply that the part is subordinate to the good of the whole. This principle, aided by the distinction between ordinary and extraordinary means and the principle of double effect governs treatment decisions which requires that function or powers be rendered useless or that body parts be amputated. In applying this principle, however, there is an important distinction to be made. The distinction depends upon a determination of the nature of the organism to which the principle is to be applied. The distinction is between a physical organism and a moral organism and there is a corresponding limitation of the application of the principle. An organism, e.g. a human body, is a physical whole if it has a unity subsisting in itself. It has a unity on the level of essence. The relationship of part to whole exists if the part is an integral part of the physical unity, that is, the part by its very nature has no finality outside the whole. "It is wholly absorbed by the totality of the organism to which it is attached." (Pius XII, 44,786) A moral organism, for example a community, is a whole which is not a physical unity subsisting in itself but a union of individuals bound together for the realization of some common good or action. The persons who are members of a moral whole have meaning in themselves and outside that determined by their role as collaborators in the common enterprise that unites the group. A moral organism has a unity on the level of action. From the distinction of organisms as either physical or moral wholes there follows the corresponding limitation of action in the application of the principle of totality. In the case of a physical whole, such as an individual human being, the person seeking the good of the person, may dispose directly of the parts and organs within the scope of their natural finality. The person may "intervene, as often as and to the extent that the good of the whole demands to paralyze, destroy, mutilate and separate the members" (ibid.) of the body. On the other hand, if the organism is a moral whole, the application of the principle is limited to the activities of the members in the service of the whole. This understanding of the principle of totality as it applies to moral organisms clarifies the limits of the application of the principle of sociality. The application of the principle of totality exercises a limiting function in medical ethical issues such as limits on human subject use in medical research and medical therapies such as the use of human embryonic stem cells.
Because medical ethics is developed at the intersection of medicine, ethics, and law a few notes on the move from morality to law, the limits of each, and the functions of law are appropriate to bring this lecture to a close. It is often claimed that the assertions of a moral tradition are binding only on those in the moral tradition and ought not to cross over into law. Now that claim is partly right and partly wrong. There are some claims of the tradition that are binding only on those who accept the tradition, but there are some claims that are universal in their application. An example of the former is the form of liturgical celebration within the tradition. An example of the latter is the prohibition of the taking of life. The protection of human life is one of the most important functions of the law. Here the moral standards of the tradition and civil law overlap. Another example of appropriate overlap is the treatment of marriage. If marriage as a natural institution is foundational for the good of society as well as for the good of the individual, then law ought to recognize this pivotal function of marriage and put into place protections for this institution. Only those elements of the tradition, which are necessary for the survival and functioning of the good community, are to be embodied in the law.
It is important to note in any treatment of law that law has more than one function. Law functions to coerce, to forbid, to permit, and to instruct. One of law's most important functions is its teaching function. Law instructs those in the civil community of the standards of right and wrong and of the rights and responsibilities of citizens. Furthermore, if it is the case that the moral development level of most people never rises above the level of concordance to the law, the essential role of law in maintaining order and well as in facilitating human flourishing must be acknowledged.