Medicine and Morals
MEDICINE AND MORALS
A Study-course on "Medicine and Morals" was held in the Auditorium of the Hospital of St. Camillus from October 14th to 18th. We give below a resume of some of the papers read.
The Ecclesiastical Magisterium in the Evolution of Medico-Moral Problems
Fr. Marcello Zalba, S.J., Professor of Moral Theology at the Pontifical Gregorian University, took as his subject: "The Ecclesiastical Magisterium in the Evolution of Medico-moral Problems". He prefaced his remarks by observing that the Church had never presumed to interfere with scientific research, but simply to guide it towards correct applications. He then proceeded to indicate the criterion with regard to medical intervention upon the human person, as explicitly and uninterruptedly laid down by the Magisterium. In the first part he dealt with operations with regard to the body, and specifically with the following: generation (referring to the impediment of consanguinity, to the marriage of congenital defectives and to the prematrimonial medical certificate); birth, stressing the constant and determined opposition to abortion, bodilyintegrity, which was resolutely upheld until the principles of the double effect and of totality, as also advanced techniques, had brought to maturity the present teaching with regard to lawful and even obligatory operations. He proceeded to speak of direct sterilization, always strongly condemned by the Church, and about the use of the sex-faculty, referring to the defense of continence in general, the lawfulness of periodic abstinence, opposition to various forms of castration and to what was strangely regarded as artificial insemination. He then spoke at some length of the respect due to the corpse, emphasizing the lawfulness of utilizing it for study purposes, but always paying attention to the principles of justice. He adduced documentary evidence to prove that, from earliest times, the Church had allowed biopsies to be made for the same objective. For each aspect of his subject, the speaker outlined the development of the present teaching, settled or solved in such masterly fashion by Pius XII and followed with an easy mind by moralists and medical men.
In the second part, Fr. Zalba examined the criteria for lawful operations on the human person without injury to either dignity or freedom. He paid special attention to the use of anaesthetics and analgesics, to painless childbirth, to experiments upon living persons, to interference with the psyche, to euthanasia and resuscitation. Regarding anaesthetics, he recalled that they were forbidden if there was an intention of using them to shorten life deliberately for the purpose of avoiding pain, or if they could cause damage, such as a reduction of will-power or the (stimulation) of dangerous pleasure. Speaking
on painless childbirth, he emphasized that in this connection there was no fault whatever from the moral point of view, because it was lawful to avail of scientific means and to apply them in a reasonable way for the relief of pain. This is not opposed to Holy Scripture which affirms only the travail inseparable from maternity and does not forbid the use of lawful means to make the birth easier and less painful.
Amongst operations dealing with the psyche he mentioned psycho-surgery which, though not given full treatment in church documents, is nonetheless lawful like other operations and on the basis of the principle of totality. With regard to hypnosis, analysis with the aid of drugs and psychoanalysis, he spoke of the possibility of abuse and therefore the validity of papal warnings about it. He repeated that euthanasia was absolutely unlawful; at most, one could be allowed to ease the suffering of the dying, even to the point of unconsciousness.
As may be easily understood, the conference, besides clearly expressing the principal aspects of medical morality, also clearly re-affirmed the Catholic criterion for promoting medical science and ethics, always however within the bounds of law and justice insofar as they concern the person and the sacred rights of the sick. And if the Church in the past and even to-day takes up a position of reserve with regard to some particular operations, she does so to restrain the danger of haste, to avoid damage to the social order and to promote safer techniques.
The Principle of the act with the double effect and its Application in the Medical Field
Fr. Zalba was followed by Fr. D. Capone, C.SSR., a member of the Alphonsianum Academy, on The Principle of the double effect and its application in the medical field. The wide range of cases offered not just to doctors but to every man by the application of this principle inspired the speaker to make a direct investigation of the principle in question. To-day more than ever before, this was required by the contrast between the simple course of nature and the growing demands of a culture which, in supplying new possibilities, tends also to impose both in theory and in practice, new obligations, which are often required by political needs, by particular activities, by public opinion, etc.
Herein lies the dilemma of the medical man, or more often of the moralist: should he let nature run its course without hindrance or should he intervene to mutilate it on the plea of cultural well-being? This disturbing question is almost like the one about squaring a circle. The lecturer endeavoured to solve it by clarifying and defending the concept of
person, a concrete and definite reality which should be subjected to examination both in its original circumstances and in its particular situation according to the demands of prudence. This virtue which directs right action does not permit one to follow in all circumstances the laws of science but detects and gives authority to an inner morality, often necessary in a concrete case.
He next explained the principle in question by a reference to its essential components (its formulation dates from 1600 but its intuition is part of man's birthright). Aided by profound philosophical and ascetical considerations, the speaker went on to deal with the co-existence of good and evil in the dimension of earthly reality, and showed the existential necessity of often having to choose a good, no matter how limited it may be, side by side with a lesser evil, since it is impossible to have an unmixed good. At this point, Fr. Capone's lecture turned into a real meditation upon the co-existence of good and evil, based upon the Gospel parable of the cockle; he thus logically repudiated a rigoristic morality in favour of a morality of co-existence, which is basically the doctrine of Divine Providence and Christian realism.
The non-Christian doctor who follows only so-called "medical morality", and who ignores the higher reality of man, will run the risk of allowing evil to prevail over good, the part over the whole. Seeing only the earthly life of a patient, ignoring its divine dimensions and horizons, he will deliberately take his stand upon a hedonist and temporal morality; he will choose, even though he may not actually intend, the greater evil instead of the greater good; he will take care of one aspect of life but not of the whole life.
The Catholic doctor, on the other hand, while quite resigned to perform an operation with a double effect, one good, the other evil, will strongly refuse to operate except when faced with a choice between a greater and lesser evil, he operates to remove the greater evil and thereby promotes the over-all good of the patient. This is but the fruit of Christian prudence, of the mind enlightened by science and by faith. By this means the doctor will refrain from useless attempts to eliminate every vestige of sacrifice from human life, as the hedonist-technological culture pretends to do. He will also identify cases of heroic endurance, to which the patient is not indeed normally bound; when faced with such cases the doctor may with a safe conscience apply the principle of the two-fold effect.
Situation Ethics and its modern Postulates
Fr. Louis Bertrand Gillon, O.P., Dean of the Faculty of Theology at the Pontifical University of St. Thomas of Aquin, took as his subject: "Situation ethics and its modern postulates".
Having clarified the meaning and the range of the expression "situation morality" according to the latest existentialist philosophy of Heidegger, the speaker recalled the view expressed by Pius XII in a discourse delivered to the World Federation of Young Catholic Women. The Pontiff affirmed that in decisions of conscience a man found himself face to face with God; he makes his decision without the intervention of any law or of any authority, not even that of the Church.
Fr., Gillon next, gave his attention to the atheist idea of situation morality (Sartre), and also to that which claimed a Christian inspiration, which originated in the thought of S. Kierkegaard and was more recently developed in the work Honest to God by A. T. Robinson, an Anglican bishop.
The speaker further referred to some Catholic writers who, although making some use of situation morality in Catholic theology, still do not deny the moral law or objective morality. Some particularly difficult cases were dealt with by Pius XII in the above-mentioned discourse; he gave a few examples and pronounced a rather negative verdict when it was a question of prohibiting precepts of the divine law which necessarily required obedience.
After a close scrutiny of the reality of the human conscience, of its value in judgements and in decisions, Fr. Gillon concluded his lecture by drawing a contrast between badly-understood situation ethics and a sane Christian personalism, capable of accepting responsibility and making decisions.
This account by Fr. Gillon, particularly meaningful for its many insights in the practical sphere and not simply in the medical field, was followed with close attention by all present.
The alleged Application of Situation Ethics in Medical Practice
The next speaker was Mons. G. Geraud, Professor of Pastoral Medicine at the Pontifical Lateran University. He took as his subject "The alleged applications of situation ethics in medical practice". He first fully illustrated the whole concept of situation morality. He then showed how this fitted in very well with the psychology of the doctor because it emphasized the incommunicable character of the object of medical knowledge, namely, that there are no two patients who are exactly alike. But "situation ethics", continued the speaker, also wants to provide a moral attitude which, at the very moment when a determined case arises, will make provision for it and take decisions about it over and above the law. It is indeed very true that the doctor often finds himself dealing with cases which surpass the limits of the strict application of the law; his conscience therefore cannot act unless it is enlightened.
Recalling a meeting with Pius XII, Mons. Geraud quoted the penetrating thought of the Pontiff when speaking of situation ethics. It may thus be summarised. "Over and above the law, the directives which ensure rectitude of conscience for the doctor are: 1) In all circumstances, all the good must necessarily be foreseen beforehand; 2) a concrete case must never be separated from its ecclesial context; 3) the strides of the intellect must keep in step with the mystery". Mons. Geraud, using some concrete examples, illustrated the value of these directives.
After this account, it was again made very clear that the thought of Pius XII was the fundamental and almost unique code summarizing the various doctrines which had been under discussion. A request was made for some practical remembrance of his lively interest in medical problems. This could take the form of some suitable commemoration of his great work to coincide with the tenth anniversary of his death. The proposal received unanimous approval and Mons. Angelini promised that such a commemoration would be held in due course on October 18th at the conclusion of the Study Course.
Respect for human life and Moral Principles
On October 17th three subjects came up for discussion: "Respect for one's own life and others' and moral principles" by Fr. Visser, C.SS.R., Dean of the Theological Faculty of the Pontifical Urban University; "The principle of totality and its applications in medical practice" by P. A. Gunthor, Professor of Moral Theology at St. Anselmo; and "Resuscitation and its moral problems" by P. C. Nadalet, Professor of Moral Theology in the theological faculty of the Marianum.
Fr. Visser began by recalling theological principles: human life, a most precious gift, makes man unto the likeness of God (Gen. 1: God breathed the breath of life into man formed from the slime of the earth); every new human life requires not alone the cooperation of the parents but a creative act of God; the human soul is immortal although the integral life of man requires the body with which it came into being; and therefore at the end of time, the resurrection of the dead.
He then went on to show how respect for life demands absolute prohibition of any direct attempt upon human life. But since a doubt remains as to when truly human life begins, the practical rule must be followed: probable life is certain life. It is therefore necessary to adopt a course of action which will avoid the danger of destroying a human life. In case of a clash between certain life (e.g. a mother) and doubtful life, the former prevails, on condition however that no direct attempt is made upon either the one or the other.
In the second part, the lecturer spoke of the obligation of preserving human life insofar as it is in our power to do so; power in this context means both material power and moral power, i.e. without disproportionate sacrifice. Whilst it is never lawful to make any attempt upon human life, no matter how weak or minimal it may be, it is not necessary to adopt extraordinary means; it is enough to use ordinary means, proportionate to the value and condition of the human life in question. The decision is difficult in certain concrete cases; hence the praiseworthy tendency to preserve every life to the greatest extent possible. Care however must be taken to see that this supremely humane principle does not degenerate into supreme cruelty, as would happen for example by the use of all possible means to prevent a man from dying in peace.
At the end of this lecture there were numerous lively objections; all were dealt with in a clear and satisfactory fashion by the lecturer.
The Principle of Totality and its application in Medicine
The second speaker, Fr. Gunthor, began by explaining how the principle of totality could be understood in. different ways. Vatican Council II in the Pastoral Constitution, for example, stressed the unity and totality of man in body and soul. This had wide repercussions in medical practice which could no longer concentrate only on the diseased organ but must take into account the whole person. The principle of totality, in the specific sense of the word, states that the part of the totality of a human being exists for the whole, consequently it is subordinated to the whole; and that the whole holds a pre. dominant power over the part and may dispose of it in its own interest. (Pius XII)
Although this principle is evident, its application is not always easy. The principle itself has undergone undeniable development. Whilst Pius XI spoke rather of the body in which the parts are disposed, Pius XII always paid more consideration to the whole person, to whom the parts have a relationship of finality. In this perspective, justification may be found, for example for psychosurgery, for proper aesthetic medical care, etc. From this point of view, the solution is also found for the problem of transplanting an organ from one living human body to another. A transplant is not simply in favour of the recipient of the organ but also favours the donor who in this way under certain conditions realizes the ontological social structure of the human person.
In the Encyclical Humanae Vitae, the Pope does not allow certain applications of the principle of totality to matrimonial problems; for example, the single act cannot be considered as a part of the totality of matrimonial life, for if it were, the single act could no longer be a total dedication. Furthermore, the principle of totality, even from another point of view, cannot be applied to marriage, in the sense that a man could interfere with his nature for the benefit of his personal good or that of his wife. Anyone who reasons in this way fails to see that the concept of nature is analogous. It may in fact refer to certain physical data, more or less contingent, which may and in some cases ought to be dealt with within the limits of the principle of totality. But nature may also mean a series of attitudes and human acts, richly and deeply meaningful and of sublime significance. And in this sense nature cannot be trifled with; it can only be fulfilled or destroyed.
Resuscitation and its Moral Problems
Fr. Nadalet, the third of the evening's speakers, first spoke of the idea of resuscitation which included all techniques and methods used to re-establish and maintain the vital functions of an organism which are either greatly weakened or gravely insufficient. He next described the interval that exists between clinical death and biological death.
Medicine, he said, has succeeded in establishing the fact that death no longer appears as a single event: we die by degrees.
However the new therapeutic methods of resuscitation have shown the radical insufficiency of the hitherto classic signs of death, such as the failure of respiration and of blood circulation. With the complex technical apparatus of resuscitation, people who are apparently dead can be kept alive.
But, continued the speaker, this raises an infinite number of problems: when is a person really dead? How can we deal with increasing requirements when the centres of resuscitation are increasingly less? What criteria should the doctor follow in resuscitation? And what if the person should remain permanently incapacitated after resuscitation?
Morality answers all these questions by indicating the tasks of medical practice. Medicine helps people to remain alive; it fights against disease and death; it can delay death but it cannot eliminate it. In the final analysis, medicine helps men to draw maximum value from their lives so that they can make a better preparation for death.
Moral Aspects of Transplants of human organs
The final day of the course began with a lecture by Fr. Giovanni Perico, S.J. on "Moral aspects of the transplants of human organs".
After a rather confused initial period, the scientific debate on human transplants has entered a new phase of greater precision; this offers increased possibilities for rewarding research in the context of moral laws.
In the first place, morality does not fear medical progress; it realizes that man's very intellectual structure urges him to advance, for it is a structure intended for research. If it sometimes puts on the brake, it is only to dissuade the research-worker from putting progress on too high a pedestal, like an idol to which everything must be sacrificed.
As regards transplants from corpses there are no big moral problems. Whilst the subject was still alive, they were "personal goods"; now they belong to him only in an indirect way. Therefore no right and no precept of indisposability suffers injury if, to aid a brother in distress, some part is removed from the lifeless body, always, of course with due consent, or at least presumed, from the next of kin.
On the other hand, as regards removal from a living person, we must reconcile and integrate two principles. One is the principle of indisposability of whatever may be considered part of the substantial integrity of the subject; the other is the principle of solidarity, in virtue of which we may, whenever necessary, dispose of our organs for the benefit of a third party. This may be regarded as a payment of our "social debt" to make up for what we have received from the social group.
Corning down to the concrete case of a kidney transplant from a living donor, undoubtedly the greater technical perfection of the operation, the methodology used in the choice of eventual donors, the use of immuno-depressive techniques, have all greatly diminished the risk both to donor and to recipient. On this account, whenever it may be necessary to save a patient suffering from grave uremia, and there are no other alternatives, a kidney transplant from a living donor is certainly lawful. For one thing, more perhaps than any other social measure, this gesture enriches the community with new sources of love and solidarity which supply an antidote to the devastating social effects of egoism. It is a gesture which responds to the Gospel invitation to love one another to the point of self-sacrifice.
Heart transplants presuppose that the corresponding problem of the donor's death has already been solved. In practice, both theology and morals have adopted as their own the definition of death which science is gradually determining on the grounds of very recent discoveries. Going further, they have asked scientists to try for even greater precision in their ideas. Within the last fifty years we have learned a lot more about death, but we need not wait longer before taking action. We do not, for example, blame the doctors of fifty years ago for using unsuitable remedies they were not compelled to wait for us. Consequently, a subject who is declared clinically dead, and who is morally irrevocably dead, may be regarded as a possible donor. This is so even if it requires the suspension of resuscitation actually in progress but definitely known to be absolutely useless when real life has ended.
As regards the recipient, if he has been properly informed of the risk he will run in submitting to the operation, of the possibilities of survival with his diseased heart, of the possibilities arising from the transplant, and if, having made a complete survey of his present situation, he decides to submit to the risk of operative surgery, then his decision is lawful. The impossibility of continuing in his present condition is a sufficient reason for this decision. Correspondingly, the surgeon who has been invited to operate may intervene for the same reasons if he entertains at least some slender hope of success.
All the most fascinating stages of science began in this fashion. At first, results were limited and sometimes unfortunate; then by degrees results were better and more decisive.
Fr. Perico's lecture was followed by a lively discussion in which several well known doctors and some hospital chaplains took part.
"Humanae Vitae" and Medical Morality
The last lecture of the course was given by Fr. Lio Ermenegildo, O.F.M., who dealt with the recent Encyclical Humanae Vitae in respect of medical morality. In a documented account, he produced evidence in support of the following points: The Encyclical was intended to reply to doubts which had arisen in the field of medical morality, especially after the discovery and diffusion of the progesterone pills. But the Encyclical did not go into the medicoscientific aspect of the problem. Instead it took pains to enunciate once again, and to clarify in accord with recent medical discoveries, the moral principles which should direct the proper regulation of births. In this connection, reference was made to doctors and medical personnel (n. 27) who are called upon to promote "conviction and respect" for the papal pronouncement. To secure this objective, those mentioned should devote some thought to the permanent and immutable validity of the teaching on the intrinsic malice of contraception. On this particular point, it is of considerable help to recall the very ancient sources, always the same in sense and sentiment, upon which the papal teaching is based. This is very appropriate when it is remembered what attempts were made, especially during the last century, to change the teaching of the Magisterium. This latter in turn, always recognised its obligation to propound again the same teaching and to declare clearly, as the Encyclical in fact does, that the Church can "never declare lawful what is not so on account of its intimate and immutable antagonism to the true good of man". (n. 18)
In the second part, Fr. Lio offered a synthesis of the practical and theoretical conclusions which medical morality ought to take into account. He made particular reference to nn. 14, 15 and 16 of the Encyclical which enunciate the principles and various methods which may be con. sidered lawful or unlawful in the regulation of births. The reasons upon which the papal pronouncement is based are deduced from the nature of conjugal love and of responsible parenthood according to the divine order established by God. According to this divine order made manifest by right reason supported by the Magisterium of the Church, respect must be shown for the limitations imposed upon man with regard to human life, even so far as they have direct reference to the faculties and generative functions (cf n. 17). Respect must also be shown for the intrinsic ordering of conjugal love for procreation, as the Ecumenical Council has stated. This also holds good for the individual acts, at least in the sense that the couple may not artificially prevent the natural possibility of procreation (cfr. n. 11). This moral order is based upon the ontological order, or as the Encyclical says, "on the laws inscribed in the very being of man and of woman". (n. 12)
Thus medical morality should promote this divine order so as to join forces in
fostering the divine vocation of the married couple to goodness and sanctity; this is the primary value of earthly life in an eternal context. The same Encyclical invites modern science to advance in such a way as to offer help in solving the difficulties of couples by using suitable means which conform to the order willed by God. In this way, medical science, although aggrieved by the papal pronouncement is encouraged to new research and greater victories. It thus makes its own contribution to the salvation of souls; this is the end towards which the Magisterium of the Church ever looks, and never more so than in the historic Encyclical, Humanae Vitae, of Paul VI.
Recalling Pope Pius XII
When the lecture was over, H. E. Mons. Fiorenzo Angelini spoke on Pius XII to commemorate, as had been requested, the tenth anniversary of his death. Mgr. Angelini movingly recalled the work of the immortal Pontiff in favour of doctors and medical-surgical science. In particular, he spoke of his masterly grasp of the new principles and directives of medical morality, and of the results obtained in Christian formation in such a delicate and complex sector in every part of the world. This commemorative function, inspired by repeated references to the teaching of Pius XII and to its particular application in various fields of medical science, was welcomed with loud, prolonged and rapturous applause. It was clear that the pastoral talents of the deceased Pontiff were still a living memory in the minds of those doctors who had had him as their teacher.
Weekly Edition in English
14 November 1968, page 6
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