Bio Ethics

CATHOLIC MORAL THEOLOGY has traditionally argued that ethics (what we ought to do) must be based on anthropology (who we are). Contemporary theologians have drawn from both the tradition of Catholic theology and the developments of modern philosophy to explore anew the meaning of human life as God intends it. This chapter suggests a theological basis for the dignity of the human person. Health care and health care ethics presuppose at their very core that the human person is of special worth, and the Christian understanding of the human person supports this concept of human dignity. Catholic theology has traditionally argued for the dignity of the human person from two theological bases: creation and redemption. It was God’s original purpose to create the human person with a special status within creation. But sin tainted the original goodness of humankind, and, though we never entirely lost our position as specially valued images of God, we were found to need a savior, a redeemer to restore us to God’s grace and favor. Thus God decided to send Jesus as savior, to return to us the capacity of life according to God’s original design. This approach to the theological foundation of human dignity is of value, and its emphases on creation and redemption are essential to the Christian story of God’s loving care for human beings. But contemporary theologians are apt to point out that this approach suggests too much that Jesus Christ is an afterthought in God’s plan for human destiny. The God who creates is the same God as the God who saves from sin, say such theologians as Karl Rahner and Edward Schillebeeckx, and it was God’s will from the beginning that all of humankind should share in the divine life in and through Jesus Christ. God did not “decide to send Jesus” only as an answer to sin. The tradition of the felix culpa (“happy fault”), for all its beauty, is inadequate. It was not sin that caused the incarnation of God in Jesus Christ; it was God’s original creation of human dignity and destiny that laid the basis for the divine communication of God’s self to humankind in the God-Man Jesus Christ. For Schillebeeckx, “ ‘Christology’ is concentrated creation: belief in creation as God wills it to be. It is not a new divine plan for a creation which has gone wrong…. Belief in creation is essentially bound up with belief in the person of Jesus as God’s definitive salvation for men and women” (Schillebeeckx 1982, 118). Human dignity, created by God and revealed in Jesus, the human face of God, is at the center of the Christian message. It serves as a basis for the theological anthropology that grounds health care and health care ethics. Christian theology has often referred to our human dignity as an “alien dignity” (Thielicke 1975, 231). Sometimes this implies that it is not really we who are special but rather that our dignity is only borrowed temporarily from God, as if God might at any moment decide to eliminate it. In this scenario God becomes something of an uncaring experimenter. God grants us a temporary set of attributes to see what we might do with them, to see if we will jump the hurdles. God may be intrigued but does not ultimately care. The entire Christian message of the incarnation rejects this interpretation of alien dignity. Alien dignity means something quite different. Having freely chosen to create human beings, God has also freely chosen to involve God’s very self with us, with our plans and our sufferings, our virtues and our sinfulness. That is what the cross and resurrection of Jesus mean. Our dignity is indeed “alien.” Properly understood, however, the alien nature of human dignity means not that human dignity is a fiction, nor that it is extrinsic to ourselves, but that it is established by God. That God keeps us in existence does not reduce who we are but ennobles us. Alien dignity means that our worth is not found in any mere usefulness granted us by other women and men. We are of worth. That worth is from God, not from the individual or social agreement of other humans. We are of more than utilitarian value. Our worth remains even when sin-filled persons or sin-filled structures ignore it. It is alien because it transcends us and our possibilities of rejecting it. It is this approach to human dignity that best serves as foundation for health care and health care ethics. The Christian message, when properly understood, adds a theological, religious dimension that reinforces the basis for health care and health care ethics. Humans are inintrinsically worthy. God has said yes to human life. The concept of human dignity as developed in Christian theology can be explored through various themes. Following the outline of John F. O’Grady, in Christian Anthropology: A Meaning for Human Life (1975), this chapter treats four such themes: the human person as image of God, chosen by God, ordered to God in grace, and alienated from God by sin.1 The Human Person as the Image of God The Christian understanding of the human person considers men and women to be the pinnacle of God’s creation. We are made in the image of God (O’Grady 1975, 10–11). The very beginning of the Bible makes this clear. The Jewish and the Christian understanding of the meaning of human personhood as created by God in the beginning is one of total goodness and of almost divine stature. In the stylized poem of the first chapter of Genesis, the author waits until the sixth and last day of God’s creative activity to create the land animals and man and woman. God has prepared for this moment. First came light; then land and water; then the plants; then the sun, moon, and stars; and, on the fifth day, the fish and the birds. These last receive a blessing to go forth and multiply. At the end of each day, “God saw that it was good” (Gn 1:1–25). Finally, on day six, “God said ‘Let us make humankind in our image and likeness.’ … God created humankind in God’s image. In the divine image God created it. Male and female God created them” (Gn 1:26–27). Men and women receive the same blessing as the other animals to go forth and multiply, but to them is also given “dominion” or authority over the rest of creation. At the end of the sixth day, God saw that what had been created was “very good.” Two of the key words here are the Hebrew words “selem” and “demuth,” usually translated “image” and “likeness,” respectively. The first word suggests an actual physical resemblance. People look like God. The second word corrects that impression while adding to the impact by repeating that God creates us to be of almost divine stature. We are not photocopies of God, but in a very concrete way we resemble God and are God-like (O’Grady 1975, 10–11). Much of the tradition of Christian theology, influenced by Greek philosophy, has tended to interpret this theological theme of creation in God’s image in a very spiritualized and dehumanized way. Since much of Catholic theology has depicted God as pure and perfect spirit, unchanging, and completely indivisible, theologians have tended to emphasize only the spirits, souls, or minds of women and men in the context of our created imaging of God. Only our souls are created in God’s image, according to this approach, not our bodies. But a human soul is not a human person. The book of Genesis tells us that humankind is created in God’s image. There is no implication in most of the Hebrew Scriptures that men and women are split into two parts. That is, there is little or no anthropological dualism. Nor is there an “original dualism” (O’Grady 1975, 11). Unlike some other religions contemporaneous to Jahwism, the Hebrews rejected the idea of two creative forces or gods—one good creating spirit and light, the other evil creating matter, darkness, and sin. It was not just a part of the human person that was created in the image of the one God. Rather, the human being, the body–soul complex, the existing person is like God. Why? What is it about the human person that makes her or him like God? The answer is complex, but it is at least partly because humans, like God, have dominion over the rest of creation (O’Grady 1975, 11–14). We exercise authority in God’s name over the earth and the animals. Adam names the animals, a sign of authority over them. Unlike the rest of creation, in the language of contemporary theology we can be said to transcend who we are. We are open to self-creation in and through history. We can hope for a future and act to bring it about. Alone in creation—at least the creation we have so far come to know—women and men can reflect on who they are, can be aware of what they are not, and can decide, within the limitations of created finitude, to change themselves and their society. The very enterprise of health care depends on this kind of understanding of the human person, even if the understanding is not explicitly theological. Scientific knowledge requires both a faith in the ongoing coherence of nature and the possibility of making leaps into the unknown, of hypothesizing about the future, and of making that future real. Thus, the biblical teaching on the human being as created in God’s image, or a secular equivalent of it, is in some ways essential to the ongoing task of health care. In biblical times, this notion that human beings were the image of God was very different from the idea of humanity prevalent in some other religions. In many of these, humans were subservient to the forces of nature. Humans were to worship these forces and in some cases actually sacrificed themselves or their conquered enemies to them. For the Hebrews, in contrast, human beings were not set below the rest of creation, but above it. Nature was not divine. It was created, like humans, by God. This was the natural order of things: God the creator in dominion over all of creation, including human beings, and humans acting for the Lord in dominion over the rest of creation, constituted the original harmony desired by God (O’Grady 1975, 12). This emphasis on the created goodness of human persons and on our almost divine stature does not require a literalist belief in the details of the Genesis story as if this work were scientifically or historically “accurate.” If time travelers could go back with video cameras, they would see something quite different from the idyllic garden pictured in the book of Genesis. The goodness of God’s creation is not that of a created infinity, of a created perfection, were such a thing logically possible. We are not God. This is symbolized for us even before the fall in the fact that God gave a command that separated humanity from Godhood. Humankind was not to eat of the fruit of the tree that only God could digest. This has important implications for an anthropology that proposes to found a health care ethic. It means, first, that human beings are created in a dignity that makes them both creatures and cocreators with God. We are not merely equal to the rest of creation. We are to some extent cocreators, or at least coagents with God in bringing God’s plan for creation to fulfillment. Yet we are not God; we are creatures. Our creative powers are limited, both by our creaturely finitude and by sin. Not only can we make mistakes but we can also sinfully break up the fabric of God’s creation and of our own society. I will return to the ethical implications of this theological principle of creaturely cocreator in chapter 5. The understanding that Genesis is not meant to present a historically accurate idyllic picture of a perfect garden is important for a second reason as well. It is important to know that there never was a time when creation was not finite. Sometimes we get the idea from certain interpretations of Genesis that in the beginning life was totally without struggle, without work—indeed, without growth and maturation. Education was instant, love easy, healing unnecessary. This approach can lead us to see our life and work mostly as the unfortunate consequences of that “original sin.” Had there been no sin, there would have been no work, no reading, no art, no struggle to create, no medicine, no progress or regress, no tripping and falling. Admittedly, it is very difficult to distinguish, in this real world of ours, between sin, which God did not want, and human finitude, which was part of the divine plan. But a more nuanced understanding of the theology of creation at least tries to grasp more adequately the built-in finitude of our creation, understanding it not essentially as a sin-caused obstacle but as the very possibility of creation in the first place. God never intended to make us God. What God did was create a “good creation.” And in that creation, the creature ha adam—humankind—was of very special worth. This more nuanced approach to the notion of creation in God’s image is also helpful in understanding and responding to some recent criticisms of Christian anthropology that have emphasized its potential dangers. Some have argued that it is precisely because we think we have dominion over the earth that we have caused such human and ecological havoc. Those who take this view argue for an anthropology that sees the human being as merely one more kind of animal, more complex, perhaps, but differing only in degree and not in quality from the beasts. They charge Christianity with “humanocentrism,” or with “speciesism,” with forgetting the rest of nature in its rush to depict men and women as God-like. Although there is much truth to these charges, at least in their practical ethical implications, it is unhelpful to reduce the stature of the human person to that of nonhuman nature. The human person, as created by God, experiences herself or himself as transcendent. This is a phenomenon of human life. It is not evil humanocentrism to recognize and make theologically explicit the vast difference in freedom and dignity between human beings and the other creatures with which we are familiar. To fail to do so is perhaps to hate oneself by rejecting one’s own nature. But this does not give us a license to run roughshod over the rest of creation. God’s universe is good in itself, even prior to the arrival of our species. God’s purpose in creating cannot be restricted to what is good for humanity. The Jewish and Christian notion of human dominion over creation is not intended to be absolute. It is a created and limited dominion. There are two reasons why this is so. The first requires no real theological sophistication and can be supported simply from human self-interest. An absolute dominion would lead to devastating results for the human species itself were we to act on it in an unlimited fashion. Human beings are part of the ecosystem and depend on it. Our selftranscendence does not change this. The second reason is theological. Humankind is called to exercise its authority in creation not as God but as cocreative creature. Though we are created with special dignity and preeminence, and with special authority and “dominion,” we are nonetheless created along with the rest of God’s work. God’s will is not that we undo what God presents for both divine and human honor and glory but that we transform creation and ourselves as caretakers of what God has made. People are called to exercise stewardship, not total domination.

The theme of the human person as the image of God continues in a particular way when Christian theology proposes Christ as the perfect image of God. If all women and men are created in God’s image, Christ is the perfect image of the Father. For the rest of us, the image is tarnished, but not for Jesus. Thus, Paul tells us that “Christ is the likeness of God” (2 Cor 4:4) and “the image of the invisible God” (Col 1:15). Jesus exercises his dominion as God does, and as God wants us to exercise it. What women and men are called to be in creation is realized in Jesus. The Human Person Chosen by God The theme of the human being as image of God is one of the core creational themes of Christian anthropology. As we turn now to the theme of divine election, and when we later discuss the theme of the ordering of humanity to God in grace, we should remember that these are not added to the first theme in any separable way. That is, God’s election and the gift of God’s grace are not decisions added later or superimposed by God as afterthoughts. Rather, they reflect from different theological perspectives the very same intrinsic dignity of human life that we have already discovered. God created human beings with a destiny to be chosen. The best of Christian theology does not see that destiny, and its actual achievement in grace, as another layer added to ungraced, undestined natural humanity. The human person is special, according to Christian theology, because we are created at the start with a graced destiny of self-transcendence. That human beings have a destiny in God’s original creating will can properly be called a kind of “predestination” (O’Grady 1975, 25). Human dignity arises in large measure from the fact that God has created us with this predestiny to transcend ourselves, to move beyond our own horizons and that of our surroundings to share God’s life. Even those of us who do not accept this belief in its specifically Christian form experience the phenomenon of human freedom with its call to move beyond who we are, to seek the infinite, to share in the spirit of God. The term “predestination” has, of course, another meaning as well—a meaning that, in its more extreme and simplistic forms, contradicts and undermines the very possibility of true self-transcendence and thus destroys in large measure the theological basis for human dignity. This second meaning is unfortunately the more common one. Here predestination means not the creating will of God that all humans be ordered to God through grace, but a kind of arbitrary divine decision whereby only some are given the real possibility of salvation, while others, comprising most of humankind, are left inevitably without God’s power and life, condemned to endless death. God decides ahead of time who will be saved and who will be damned. Human freedom has little or nothing to do with it. God’s grace, when it is offered, overwhelms freedom totally; the saved have no choice, since this kind of grace cannot be rejected. Nordo the damned, since God withholds grace from them and leaves them to the power of sin and death. The theological problems of the relationship of grace and freedom, or of “nature and grace,” are complex, and even such theologians as Karl Rahner have not “solved” them. The divine–human relationship is a mystery.2 But it is at least clear that God’s creating desire and plan for human beings includes a destiny that respects the human freedom and capacity for transcendence that God has given men and women. Thus, it is in this more theologically precise sense that the term “predestination” is best used. God has planned, in creation, that human persons should live full human lives with God in Christ. God has predestined all women and men to live with God’s own self (O’Grady 1975, 24–25). The Jewish and the Christian teachings on election make more specific certain historical and symbolic events through which God is seen to work the divine salvific plan. Christians specify three principal events or stages in the unfolding of God’s plan for human salvation: creation, election, and incarnation. We have already discussed at some length the first principal stage, the creation of men and women in the image of God with a special blessing and a special task. Humans are to share in God’s work of transforming the world and themselves in accordance with God’s plan. This creative alliance is continued in an ongoing covenant between God and all humanity, a covenant symbolized in events that the Bible narrates as having preceded the more important covenant with the people of Israel that would follow later. Two examples here can give us an indication of how God continues this creating alliance with all people. The first occurs after Cain kills Abel in the fourth chapter of Genesis. God punishes Cain for this act of murder, but even here God agrees to give Cain a token that will be a sign to others who might harm him that God still holds Cain in his favor and protection. This event is a symbol of God’s ongoing relationship to created humanity. The second example is better known, and it, too, symbolizes the universality of God’s covenant with the human person. The eighth and ninth chapters of Genesis narrate the story of Noah and his family, saved by God from the flood. After the flood ends, God repeats to Noah and his family the same blessing given to Adam and Eve at the moment of their creation. God adds a covenant with them, an alliance with all of humanity that pledges God’s fidelity and sets in the sky a token of that pledge: the rainbow, a sign that God would never again in wrath destroy the world by water. All of humankind is special to God. The second principal stage in the unfolding of the history of salvation is, of course, the election of the chosen people of Israel. This event is seen first in the call to Abraham and is then repeated over and over again throughout the Old Testament. God calls Abraham out of his own land to a new land that God will give him. Abraham will be the father of a new and special people. God symbolizes the degreeof commitment to Abraham and to the people of Israel by agreeing that if God should ever reject the people, which will never happen, it will be right for God to be destroyed. The oath ritual in Genesis 15 is a kind of early and solemn “cross my heart and hope to die.” The ritual was used to solemnize treaties between persons or peoples. The parties to the treaty would kill a number of animals, cut them in half, and then walk between the pieces. The idea was that if they violated the treaty, they would deserve death and dismemberment. Here it is God (a fiery oven) who walks between the pieces of the animals. God is committed to the chosen people. “You will be my people and I will be your God.” The election enters a new and advanced stage with Moses, when God leads the people out of Egypt, symbolizing a release from bondage and oppression. God gives them the law, which they receive not as a new burden of impossible tasks but as a gift from God establishing anew the covenant God continues to make with the specially chosen people. The alliance is again renewed through the kings, who will rule the people in God’s name. The covenant does not always work out well. The prophets constantly remonstrate with the people about their failure to fulfill their responsibilities. The people are unfaithful to God. They oppress the poor and the powerless. They refuse to accept their task of transforming self and society in accordance with the divine plan for their destiny. Sin alienates them from the God who has chosen them. Yet the dignity of their lives re

remains. God’s fidelity to the election remains. God punishes and calls them to repentance, and when they repent, God again accepts them and the alliance is renewed and repaired (O’Grady 1975, 29–31). The third stage in the working out of God’s plan for human destiny, as this is seen by Christians, is the incarnation. When the time was right, God came as a human being to reveal God’s own self to women and men. The predestination of humanity is accomplished in the enfleshment of God in Jesus, and through the cross and the resurrection. Here is the new election, the new covenant, the transformation of humanity from the order of Adam to the order of Christ. God gives God’s very self to created humanity in a self-communication. The life, teaching, and death of Jesus reveal how important humans are to God. God is involved in the actual living of a human life and in the actual dying of a human death. The Christian scriptures leave no opening for an idea that has sometimes invaded our theology and our piety: that Jesus was not really human but only a kind of extraterrestrial visitor from a spiritual world. That heresy has been with Christianity throughout much of its history. Perhaps it is because we are unable to accept the idea that, for God, we are worth the incarnation, the humanization of divinity. Perhaps it is because when we reject the possibility of God’s forgiveness we need some kind of excuse to distance ourselves from the challenge Jesus gives us to live life as fully and as lovingly as he did. So we say that the reason he could live that way was because he was God, and not really human. Whatever the reason, the docetic heresy, the idea that Jesus merely appeared to be human, that he was a kind of visiting deity masquerading as one of us, undermines the central Christian basis for the dignity of the human person. If God could become a human being, the dignity of humankind is indeed demonstrated in a new and exciting way. Christians believe that Jesus establishes a covenant, a new development in the alliance of God with the chosen people. Christians are called to make this covenant manifest, to be its sacrament, to sign forth the alliance by their lives and their actions and their very beings. The first letter of Peter states: “You are a chosen race, a royal priesthood, a holy nation, a purchased people; that you may proclaim the perfections of him who has called you out of darkness into his marvelous light” (1 Pt 2:9). Christians have a task to make manifest what has been revealed to them about God’s plan for humankind. They are to strive for peace and justice, for the transformation of self and world in accordance with the dignity and the cocreative challenge given them by God in creation, in election, and in incarnation. Like Israel, Christendom has failed to live up to the covenant. Christians oppress the poor. They violate their own dignity. They are unfaithful to the God who has chosen them and who has shown them the way in Jesus. Yet, as with the people of Israel, God calls them to repentance and is faithful to the alliance (O’Grady 1975, 32).The Human Person Ordered to God by Grace The dignity of the human person as created by God and as destined to divine life is oriented or ordered to this life through grace. We have already noted the complexities of any theological attempt to spell out the relationship of grace and human nature with any precision when treating of the two meanings of predestination. Christian theology has tried, not always successfully, to maintain a balance between the created freedom and dignity of the human person and the gratuitous grace of God. Contemporary theologians, especially Karl Rahner, have furthered this attempt in an important direction by refusing to allow any easy separations between “nature” and “grace.” Though not identical, the natural and supernatural orders in the human person cannot be separated. And while the exact relationship is mysterious, the mystery reflects the complexity of the human person actually existing in the world and is not so much a problem to be solved by theological analysis as a disclosing and unfolding of what it means to be a human being (O’Grady 1975, 52–56; Rahner [1954] 1961; 1963, 3–44; [1959] 1965). All of this, which seems sometimes so abstract, is essential to any attempt at establishing a theological basis for health care and health care ethics. Health care providers develop sensitivity to their patients. Those who approach their work from a specifically Christian perspective will find that this sensitivity is affected by their theology of the human person. In chapters 3, 4, and 5, we deal more specifically with the problems of dualism, with the relationship of divine and natural causality, and with the use of theological principles specifically in health care ethics. But all of this depends on an adequate theology of the meaning of human life. For Christians, this must of necessity include the issues of nature and grace. If these two aspects of human life are seen as antagonistic to one another, so that human “nature” is somehow unworthy of care, then health care can never be a truly Christian vocation. Only grace and the supernatural life of the soul have importance. The mystery of graced nature remains a mystery, but it is important to grasp that in humankind God’s gift of grace does not mean that human “nature” is less worthy but that it is more worthy. That the human person is ordered to God by grace is one further dimension of the dignity of the totality of human life, not a reason for splitting people into matter and spirit and limiting our ministry to the spirit. It is the whole person who is graced. For Catholic theology, at least in its better moments, grace does not overwhelm human freedom, nor is the human being so radically depraved as to be without reception for, or a natural affinity to, grace. Grace reaffirms and enhances the dignity and the nobility of human life (O’Grady 1975, 58–59). Grace is experienced. If it is true that God, in creation, has destined us to share divine life in Jesus, then that divine life ought somehow to be experienced. The actual experience of God’s life through grace has been the subject of analysis by theologians and psychologists

and of poetry and expressive prayer and narration by those we call mystics. For some, the experience of grace, or the religious experience, is a feeling of total dependency on God, or a blind leap into God’s void. Rudolf Otto, in his classic work The Idea of the Holy (Otto [1923] 1950), suggests that true religious experience is the experience in human life of the fascinating and scary mystery who is God. The mystics have tried through narration and symbol to describe their encounters with God’s presence in their lives, but these attempts never capture adequately the experience itself. The fact is that “grace,” or the experience of God’s life in our human lives, can never be adequately defined. There are two reasons for this. The first is the more commonly recognized. Since grace is of God, grace is of its own nature mysterious. It transcends our comprehension. The second is less obvious but perhaps of greater importance for health care. If grace is not something separable from our own humanity, if—although not identical to human nature—grace can never be separated from our humanity or analyzed apart from it, then the mystery of human nature itself, the transcendence of the human person in our actual lived experience, imposes its own mystery on the mystery of grace. Grace, in other words, is mysterious not only because it is supernatural, thus going beyond our comprehension; it is also mysterious because it is human. Human persons, in our unfathomable humanness, are the ones who are graced. Grace does not exist on its own, out there somewhere in a large reservoir waiting for people to turn on the tap. It is human beings who are graced, and grace thus shares in the human mystery. In the scriptures, grace is really any and all gifts of God to women and men. Grace is a free gift. It is not something contractually owed. God does not owe us creation, nor does God owe us salvation or our human destiny—though having created us, God owes us the respect due to his own handiwork. Grace is any and all communication of God to us. It is the process whereby God tells us about herself, calls us closer to divine life. Various theologians in the development of Christian theology have given different emphases to grace and have seen the relationship of grace and human nature differently (Getz 1982). For Augustine, in the fifth century, grace was primarily a medicine that healed a humanity corrupted by original sin. His purpose was to heal; Augustine was no hater of humanity. Yet there is in Augustine a kind of pessimism about human nature, especially in its bodily and sexual aspects. Augustine emphasized the power of grace, and although he usually tried to maintain the tension between this divine power and human freedom (Augustine 1887b, 5–10), there are places in his theology where he lets go of that tension and almost eliminates freedom from the balance. He sometimes argues for the more simplistic forms of predestination where humanity becomes God’s plaything, and the vast majority of humankind is condemned (Augustine 1887f; 1887e; 1887b, 41–46). Nonetheless,

Augustine maintains the biblical notion that God created humankind good, and that God intended men and women to share divine life in Jesus Christ. For Augustine, humankind’s purpose from the very beginning was to share in God’s life. Thomas Aquinas, in the thirteenth century, was considerably more positive about the worth of human nature. Even without grace, human nature in its “pure” state and in its fallen state retains its natural tendency toward God, its desire to see God, its affinity for God’s grace. If Augustine’s starting point was original sin and the need for healing grace, Thomas emphasizes the goodness of human nature as created by God and sees grace as elevating that nature to a new, added, supernatural level with its own new purpose (Thomas Aquinas 1945, II, 997, Summa theologica Ia Ilae, q. 110 in corp., also ST, IIa IIae, q. 171, ad 3). In this way, Thomas better expresses the continued worthiness of the human person and better maintains the dialectic between freedom and grace. Grace builds on nature; it does not oppose it. Grace opposes sin. This was true for Augustine, too, but since for him human nature had been thoroughly and radically depraved by sin, there was little or nothing good left in it for grace to build on. Thus, for Augustine, grace opposed (sinful) human nature, whereas for Thomas, human nature, in its freedom and capacity to receive grace, could work more harmoniously with it. But Thomistic theology, especially as it developed in theologians who followed after Thomas, tended to split nature and grace too much. Grace built on nature, true. But grace was something added to nature, as if nature could exist without it. Thus the danger came of a new kind of dualism, one that split the human person into the merely natural and the newly supernatural. This distorted the mysterious interaction in human life, the dialogue of the divine and the human. In some theologies it also led to the reification of grace. If grace was separated from the human mystery, perhaps “it” could be comprehended as a thing on its own. The various distinctions among kinds of grace, and the tendency to think about amounts of grace earned and lost and kept somewhere in escrow till the next confession, came from this separation. Paradoxically, as grace became more and more supernatural, separated from the human, it became more and more definable and comprehensible. It could become a thing added to human nature, rather than an integral aspect of the alien dignity of human life in its mysterious richness. Contemporary theologians, particularly Karl Rahner, have tried to overcome the dualism inherent in some earlier concepts of grace. Rahner’s approach has been called “transcendental Thomism” because he tries to build on Thomas’s notion that human nature has a built-in capacity for or affinity with grace while he changes the tendency in some older theologies to separate nature and grace. Rahner talks about a “supernatural existential” (Rahner 1963, [1954] 1961). Human beings, as we exist in this world, participate in the supernatural order and are never totally separate from it. Even those who reject God’s grace are, as human beings, related toward it even in its absence. This “supernatural existential” means that saving grace is not limited to those who are explicit believers in Christ. Grace is not added to human nature as an extra. There is only one order of human existence, and it includes our supernatural destiny as God intended in our creation. For Rahner, grace is God’s self-communication to women and men. And it is we, as humans, who are the primary communicators, the sacraments of God’s revelation. We humans are the symbols through whom God’s revelation comes. Among us humans, Jesus Christ is the perfect symbol, the most complete communication, the definitive grace. A definition from another time and context can summarize our brief survey of the dignity of human life as ordered to God in grace. The Council of Trent in the sixteenth century declared that grace is God’s love for us as that love is in us and changes us. God’s gift of grace to human persons is an integral part of the dignity of human life. The Human Person Alienated from God by Sin In exploring the biblical and the theological notion of the dignity of the human person, we have already mentioned the reality of sin. This final brief section on sin in the human condition comes last among the themes for good reason, because for the Christian, the dynamic of sin, important as it is, is secondary to the dynamic of creation-election-grace. God’s plan from the beginning was and is for the supernatural human destiny of all men and women. Human sin opposes that plan, but in God’s power and love sin never really threatens to destroy it. The supernatural existential in God’s graced creation is not just an equal antagonist holding its own against the powers of sin and death. Rather, the order of grace has achieved the ultimate victory over sin. This is the good news of the gospel (O’Grady 1975, 62–92; Mahoney 2003, 724–26). Nonetheless, sin remains an important and often devastating dynamic in human life. Those who are involved in health care know this from experience. First, and more obviously, there are the ethical issues connected with health care—the issues that comprise “medical ethics”—and these issues have to do with right and wrong, with human choice, and often with greed, sloth, deceit, lust, envy, hubris, violence, and waste—in a word, with sin. These dynamics exert their influence not only in the individual acts of sinful people, including both healers (health care providers) and patients (health care recipients), but also in the very structures of the way health care is delivered. Some of these issues are relatively simple; many more are excruciatingly complex. It is not always easy to know precisely where the “sin” is or what the morally right solution is. Yet despite this, we sense the reality of sin, of brokenness, and of the injustice and cruelty that we people do to one another. Second, and less obviously, there is a deeper dynamism of sinfulness inherent in the human condition that can appear in times of sickness. Here distinctions between sinfulness and created human finitude blur. Not all limitations are sin or sin’s results. It is sometimes hard to know what is sin or the effect of sin, what is truly evil, and what is merely part of the necessary processes of growth and decay inherent in creation. We have seen that among the species we know, humans alone are aware of their future and can hope for a true transcendence beyond their present limitations. Yet this very capacity brings with it a loneliness, an anxiety, a recognition of limits, a human confrontation with death. Sensitive health care professionals are aware that the medical enterprise, with its vulnerability and “guilty knowledge” in combination with what is often a life-and-death context, brings out these human encounters at their deepest and most significant level. This can be terrifying. It can also be faith-filled, trusting, and consoling. The Christian belief that God in Jesus Christ has triumphed over sin and death adds a hope and a faith that human life is ultimately meaningful. This does not remove the pain of confronting sin and the ultimate limits of creation. It does not easily answer the challenge that comes to us from the experienced absurdities and evils that plague human living. But it does offer a faith and a hope that God’s plan will be brought to fruition despite the power of sin and alienation. God’s destiny for humankind is prior to and greater than the sin and death that would deny it. The question of how evil can exist in a world created by a good and loving God yields no easy answers. Yet some approaches are more adequate than others, especially in the context of health care and health care ethics. For some Christian theologies and pieties, all human limitation is the result of personal sin. Disease is a sign the sick person has sinned. Natural calamities like droughts and floods are signs of God’s wrath on sinners. The Bible itself often connects calamity and misfortune with the sins of Israel. Often such a connection does indeed exist. Sickness can be the result of abuse or violence. “Natural” calamities can be the result of environmental exploitation or of unjust economic and political systems. But the facile identification of all limitation, of all sickness and suffering and decay, with sin and its results is inadequate and even harmful, especially in the context of health care. More adequate Christian theologies and pieties recognize that God could not create a second God. God could only create something created, and creation has within itself, seemingly of necessity, characteristics of finiteness, characteristics of limitation, characteristics of growth and decay, even characteristics of violence. The alternative to this may not be perfection; it may be nothingness. Then, too, there is human freedom. The human person, in his or her freedom, is given the possibility of rejecting for himself or herself the realization of God’s plan. Contemporary moral theology is far less apt to identify specific ways in which this is done (mortal

sins) than was the moral theology of prior times. But Catholic theology has traditionally upheld the possibility of such a rejection. True freedom, of course, is not the freedom to sin; it is the freedom not to sin that comes with grace. But God gives us grace in a way consonant with our own human freedom. God does not overwhelm our freedom but invites it to an acceptance of the eternal plan for humankind. Thus, in a paradoxical way, human freedom requires the possibility of sin. If it is to have the possibility of saying yes, which is truly freeing, it must also have the possibility of saying no. This is the heart of what many of today’s Catholic moral theologians mean by the term “fundamental option.” The idea is often misunderstood to mean a kind of laxism or even subjectivism. But “fundamental option” does not do away with the possibility of mortal sin, the possibility of choosing death instead of life. Nor does it imply that real sinning is only internal, that those who may cut themselves off from God and from neighbor must do so by some kind of deep introspective decision that has no direct connection with others in the real world. It is true that the Bible, and all of moral theology, is clear that sin is ultimately a violation of God’s holiness. But the same Jewish and Christian tradition proclaims loudly that sins of injustice, greed, and lust against other persons are equally sins against the holiness of God, precisely because God has created humanity in God’s own image and likeness, has predestined it to share divine life, and has established that destiny through grace. A fundamental option for evil, like a fundamental option for good, is symbolized, established, and confirmed through human choices and human acts. The reality of sin in our human world is both individual and structural. There has been a direction lately in Catholic moral theology toward a reemphasis of structural and systematic sin. Structural sin was never really forgotten in the Catholic moral tradition, though it was often underemphasized. Ethicists now recognize the interdependence of structures and individual actions. When structures are unjust, and to the extent that they are sin-filled, their oppressive tyranny often surpasses the evil of individual sinful actions. And individuals who find themselves within such structures are less free to say yes to God’s plan. The reemphasis on structures and systems within Catholic moral theology in general has had important results in health care ethics. Prior to the 1960s, Catholic medical ethics was concerned almost exclusively with topics of immediate concern to medical professionals in their daily practice (Kelly 1979, 221–27). Most of the larger issues of pastoral medicine were ignored. Little attention was paid to the nature and biases of medicine itself, or to the social and economic factors so essential to health care. Topics concentrated on the individual medical actions of physician, nurse, and patient. Many concerned reproduction. The methodology of Catholic medical ethics, the way it analyzed issues of health care, was especially apt for these kinds of topics and stressed specific distinctions of actions in their precise physical or biological components. Chapters 10 through 12 examine this in detail. This has now changed. Many Catholic moralists are interested in the more complex issues concerning structural sin in the health care system (Kelly 1979, 407–16). Unfortunately, as we will see in chapters 28 and 29, there is sometimes a tendency to think that easy answers are available, a tendency similar to the past idea that individual medical procedures were open to simple moral analysis. Some approach structural issues in medicine with the same kind of facile condemnation they now reject when it is applied to individual procedures. Despite these dangers, however, the shift in emphasis toward recognition of the importance of structural sin is beneficial to health care ethics. The dynamic of sin is an important and fundamental dimension of human life. But more important from the Christian perspective than the order and dynamic of sin is the order and dynamic of grace. Sin is not dominant. For the Christian, sin is seen in the context of the prior and more fundamental order of graced creation with its God-given destiny. Sin is relativized by the forgiveness and reconciliation that God offers in Jesus. The alien dignity of the human person is established by God and thus worthy of human respect. Notes 1. Jack Mahoney approaches this using the four doctrinal pillars of Christian faith: creation, sin, salvation, and fulfillment (Mahoney 2003, 721–27). 2. For a typology of the ways in which divinity and humanity are understood to interact, see Getz 1982.