Bio Ethics

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CHAPTER 3 THE INTEGRITY OF THE HUMAN PERSON THE PURPOSE OF THIS CHAPTER is to explore, in the context of health care, two contrasting approaches to a theological understanding of the human person and of the relationship between God and humankind. These contrasting approaches are dualism and holism. The chapter has two parts. The first will develop in general the issues involved in the problem of dualism. The second will explore how dualism and holism yield different directions in our understanding of how God works in the world of women and men. That is, the second part of this chapter discusses the theological question of the relationship of divine and human causality. Who causes what? How do God and humans interact in causing change? Does human healing contradict or cooperate with divine healing? Dualism and Holism We have already alluded to dualism and holism in discussing the theological basis for human dignity. For the Hebrew there was little if any idea that the human person was split into two more or less separable parts: body and soul. But this integrated view of the human person was not the only one influencing Christian theology. For many centuries a second, more dualistic understanding of the human person was dominant, and its dominance affected our understanding of ourselves as embodied creatures. The terms “dualism” and “holism” are important ones in contemporary theological anthropology, but they are not easy to define. A number of different sorts of dualisms can be described. There is “anthropological dualism,” which designates a split in the human person between bodily and spiritual aspects. Inevitably in this kind of dualism there is the judgment that the spiritual aspect, or soul, is the good part, or at least the more important part, and that the material aspect, the body, is the evil or less good part, or at least the less significant aspect of the human person. Instead of seeing human beings as animated bodies or embodied spirits, dualists see us as imprisoned souls. For the anthropological dualist, the human soul is reduced to its present diminished or sin-filled state largely because of its imprisonment in material flesh. It strives to return to its original pure state of spirituality. Other forms of dualism may be connected in various ways to this body–soul dualism. “Original dualists” hold that the split in human persons between soul and body is explained by the fact that there are two equally powerful creator gods, one good who creates spirit, and the other evil who creates matter. Thus, for the Manichaeans, salvation is the return of the good soul from the evil body to the good god of light. Similarly, sexist dualists, who hold for the inherent superiority of man to woman, often identify man with soul, spirit, and intellect, and woman with body. Woman is inferior to man as body is inferior to spirit. Sexism pervades human social and economic systems, including systems of health care. The large discrepancy in income between doctors, who until recently have been mostly men, and nurses, who have been mostly women; the unnecessary surgery sometimes performed on women; and the tendency in some approaches to medical ethics for men to tell women what they may and may not morally do with their bodies are examples of practices where sexism is apparent. Then there is the kind of dualism that so separates humankind from the rest of creation as to reject any notion of interdependency and interaction. This is the dualism that is often charged against the biblical idea that humankind has a “dominion” over nature. It arises when dominion becomes exploitive domination. Like all dualisms, it implies that the mind and the technology it creates should take precedence over material creation, the “body” of our universe. This destructive form of anthropocentrism is also often coupled with sexism. Men are said to be the ones capable of changing nature with their minds and technology; women are seen to be more like the body of nature. Feminist ethics correctly criticizes this form of patriarchy. Finally, there is a dualism in our theological understanding of divine and human causality where these are seen as two separate and even opposing principles. Theologies that oppose grace to human freedom are examples of this. This dualism is treated later in this chapter. The opposite of dualism is holism. This emphasizes the integrity of the human person and opposes any attempt at those kinds of dichotomies that would diminish the dignity of human persons by splitting us up into superior and inferior parts. It is true that the term “holism” is sometimes used to avoid the complex analyses necessary for an adequate theology and ethics of health care. “Holism” can become a modern and rather pedantic word for everything good, noble, true, and beautiful. It rejects criticism and questioning because it is “whole.” When used this way, the term “holistic” is applied to ethics or to medicine in a way that covers up sloppiness and hinders good ethics and good health care. Nonetheless, as an antidote to the truly destructive forms of dualism that so often arise in theology and in health care, the contemporary emphasis on human integrity is essential. We have already seen that the Hebrew Scriptures present a generally holistic view of the human person. There is little anthropological dualism and no original dualism in the main Hebrew tradition, although sexism is apparent in the patriarchal system of the Hebrews, and some later Old Testament books show the influence of body–soul dualism. It is the whole person who is created in the image of God, not just the soul or spirit. The Hebrews did not think in terms of distinctions or separations within the human person. There are no words in biblical Hebrew that can correspond correctly to later notions of “body” and “soul.” Indeed, most of the Old Testament does not include with any real clarity the idea of an afterlife. There is no notion of an individual “immortal soul.” Human life is here and now embodied as God wants it to be. The nephesh, or human person, is animated by God’s ruah, the Spirit or divine force of God that returns to God when the nephesh dies. Pauline anthropology is generally similar. Paul thought primarily in Hebrew terms. His basic understanding of the person is holistic. His famous discourse on the struggle between the spirit and the flesh in his letter to the Romans does not refer to the soul and body of the human person but, in keeping with the Hebrew practice of using terms to apply to the whole person under differing perspectives, refers to the whole human person because that person is or is not empowered by Christ’s Spirit and grace. It is not the soul that wars against the body but the cosmic order of God’s grace that wars against the cosmic order of evil and death. Greek philosophy, with its emphasis on distinction and analysis, brought along with its great contribution to Western thought a tendency to reduce the bodily aspects of men and women to second-class status. Platonic, neo-Platonic, and Stoic schools were especially influential in this. Whereas in Hebrew thought almost any “part” of the human person could represent the whole, in Greek thought the human being was indeed split up for analysis. And in many schools of Greek thought, the body was considered ontologically or essentially inferior to the spirit. For Plato, for

example, the real world was not this world, with its material reality, but the world of ideas of which this world was merely an imperfect image. Body and matter were inferior to mind and idea (Plato 1991, bk VII, 514a–521b). It is interesting to note that this dualism led to two opposite extremes concerning an ethic of the body. For both hedonists and Stoics, the body was unimportant, insignificant when compared to the spirit. The hedonists concluded from this dualism that people ought to pursue pleasure with abandon, since whatever they did with their bodies counted not in the least, whereas the Stoics argued for an ascetic life, since the body ought to be suppressed and disciplined in the service of the soul. This dualistic emphasis entered Christian theology early in its development. To reject all Greek influence as if Christian theology would have been better without it is too simplistic. It is in any case quite impossible to determine what Christian theology would have been like without Hellenism, since its influence has been central and not peripheral. But it is possible, and indeed necessary, to point out and to counteract the inadequate theologies that have resulted from this influence. The dignity of the human person is a dignity based on God’s plan that humans be created in the divine image with a destiny to live with God. But what is it of the human person that images God, and what is it of the human person that has such a destiny? Unfortunately, many Christians have been apt to answer that it is our souls or our minds or spirits that image God, and that only they have an ultimate destiny. Bodies are of no ultimate importance. Early in the development of the theology of the human person, church authors (the fathers of the church) began to develop the idea that the human person was created in God’s image. They asked what it was about the human person that imaged God. They even asked what aspect of God the human being resembled. Varying answers to these questions showed varying implications concerning the integrity of the human person (O’Grady 1975, 16–18). For Irenaeus of Lyon, the entire human person was created in the image of Jesus of Nazareth, who was the image of God the Father. There is here no sense of dualism. For Origen (who castrated himself to remove sexual temptations) and for Clement of Alexandria, on the other hand, our spirits were created in the image not of the incarnate Jesus but of the preexisting Word of God, the Platonic Logos, the Son as he was in the perfect world of ideas, the spiritual world. And for Augustine, who emphasized the depravity of human nature resulting from original sin, it was our minds that imaged the eternal Trinity. Thus, in much of Christian theology, the soul took precedence and the body became diminished. Though no orthodox Catholic theologian has ever held that the body was created evil by God—Augustine himself was adamant in rejecting the Manichaean heresy that thought so—there has been a general tendency in Catholic theology to downplay the body’s goodness and importance. Scholastic theology included tendencies toward a separation of body and soul, and of natural and supernatural orders. Thus, the Catholic religion was seen as “saving souls.” In comparison, other tasks were secondary. Contemporary theologians are in the process of counteracting this trend. Drawing on contemporary philosophy with its “turn to the subject,” today’s theologians are more apt to stress the integrated mystery that is the human person. Because the body is a human, enspirited body, and because the soul is a human, enfleshed soul, the human person in his or her totality is worthy of respect. We are free and noble not because of our souls but because of our created humanity. Even the idea of our eschatological destiny has shifted with the realization that it is not so much our “immortal souls” that are saved in a spiritual afterlife as it is our total human selves in a future that is here and now as well as in a more definitive state where God and we will fulfill our created destiny. The Christian dogma of the resurrection of the body takes on greater meaning in this context. Heaven becomes less an unhuman place where souls float around and more the realization of human hope as revealed to us by God. Implications for health care are apparent. Health care practitioners are not performing secondary functions as they heal bodies instead of souls. The integrity of the human person means that it is indeed impossible merely to heal a body, as if that body belonged to a person who existed somehow apart from it. Sensitive and ethical health care professionals learn this from their experience with those whom they serve. Theology agrees. As God has created us, and as God has predestined us, we are whole beings who deserve to be treated and healed as such. The alien dignity of the human being is the dignity of an integrated person. Divine and Human Causality One sort of theological dualism needs further exploration. Throughout the history of the development of Christian theology, one of the most difficult theological issues has been the relationship between divine and human or “natural” causality. We have already discussed aspects of this. Sometimes the issue has been framed in the context of the relationship of grace and nature or of grace and human freedom; here the central issue becomes whether grace and nature are two separate or even opposing forces or whether they are two interconnected dynamics in God’s original creating will, a question we have already briefly explored. Or the issue can be seen in the context of original sin, with its effects on human nature and on the world; here the issues become the relationship of sin to natural causality and created finitude, the degree to which sin has altered or destroyed God’s original plan, and the problem of how much of what we experience as growth and as decay is due to sin rather than to the inherent limits of creation. We have also briefly developed these areas. We need now to turn more directly to the issue of causality itself.

The problem is easy enough to describe, though the theological and human mystery it presents is unfathomable in its richness and depth. What is the relationship between divine and human causality? What does God do and what does “nature,” including human nature, do? How actually does God work in human affairs? Does God directly create disease? Is disease a divine punishment for sin? Is the healing of disease cooperation with God’s creative plan, or is it rather a contradiction of that plan, a usurpation of God’s sovereignty, a removing of what God has sent? If God causes and wills cancer, then are we contradicting the divine will when we try to cure it? Does God heal disease or do we? Has God established a “nature” that God wills to be closed to human transformation? Or is human causality, transforming the world and even humanity itself, acting in cooperation with God’s will? It is easy to see how a dualistic answer to the problem of divine and natural causality gets us into trouble. The very way we ask the question causes problems, if we see divine and natural causality as separated from each other. Some of the questions in the previous paragraph may appear bizarre to us, but they are questions demanded by a dualistic approach to this issue of causality. If God’s acting is seen as intrusive, as an opposition to the created causalities of the world and of human beings, then this kind of problem emerges. We can easily enough reject two extremes that fall outside any acceptable Christian theological spectrum: the extremes of a reductionist naturalism and of a reductionist supernaturalism. The former extreme is an atheistic denial of all divine causing; it allows only for natural causality and denies altogether the existence and relevance of God’s creative activity and providence. It has seldom been a temptation for Christianity. The latter extreme has at times found its way into Christian theology and piety. It is a supernaturalistic rejection of all natural processes of causality. It tends to lead to a rejection of science and medicine, to insist on “faith” as the only acceptable process for healing, and to see God’s immediate choice in each and every event. Natural disasters are seen as God’s punishments for the sins of those hurt in them, and disease is seen as an immediate punishment for the sins of the person who is sick.1 Yet if it is easy to reject the extremes of the spectrum, it is harder to develop an adequate theology of the relationship of divine and natural causality. It is hard to remember that these causal dynamics are in fact not separate, and so we are tempted to identify certain events as “God’s will” while we stress the human or natural causality in other events. Nonetheless, a correct theology will continue to emphasize the inseparability of these aspects of creative causality, refusing to allow either to eliminate the other. The Old Testament includes various approaches to the relationship of divine and natural causality. At times the Bible tends to see God’s direct hand in events that we would be less likely to describe as directly caused by God. Thus, the prophets often see natural disasters and sickness as God’s punishment. Wars that afflict the Israelites are seen as God’s wrath against their infidelity, and the prophets often reject any attempt the people make to form alliances to protect themselves against their attackers. Jahweh himself will destroy their enemies; they are not to trust in natural alliances. Thus, the prophet Hanani criticizes King Asa for his alliance with Aram; Isaiah and Jeremiah both reject alliances with Egypt. God himself has caused the war; God alone can save the people from its devastation (2 Chr 16:7–9). Medical help may also be rejected. For example, King Asa is criticized for turning to doctors and not to Jahweh in his final illness (2 Chr 16:12). And Deuteronomic theology rejects Israel’s attempts to develop a kingdom with secular rulers, insisting that God alone rules in Israel. But there is also a different theme in the Old Testament, a theme in which human or natural causality cooperates with the divine will. The Jahwist tradition, in its theology, accepts Israel’s attempts at establishing a kingdom. This approach emphasizes God’s trust in the people of Israel; the king rules with God’s confidence and is God’s representative who transforms the land in accordance with God’s will. Here the people continue the task entrusted to them in the beginning. Within the limits of creatureliness, women and men carry on God’s work. It is in this line that the book of Sirach (Ecclesiasticus) praises the physician and his skill: “The skill of the physician shall lift up his head; and in the sight of great men he shall be admired. The Lord created medicines out of the earth; and a prudent man will have no disgust at them” (Ecclus 38:1–3). The same two approaches to the relationship of divine and human or natural causality continued into Christian theology. Sometimes the emphasis was placed on a more immediate divine causality, at other times on natural causality. Those who stressed the latter might be accused of secularizing Christianity, of neglecting the immediate importance of God’s presence, while those who stressed the former might be charged with denying the goodness of God’s creation or with hindering scientific and social progress. It is probably impossible to avoid an overemphasis on one or the other aspect as long as we see these two modes of causality as separate. When we do, we are likely to reject divine causality altogether if we are not believers, or to reject human causality if we are. Thus, for example, the early Christians Tatian and Tertullian argued against the use of medical care, as did the tenth-century ascetic Nilus, who insisted on trusting in God and not in doctors (Entralgo 1969, 79). Bernard of Clairvaux, in his twelfthcentury letter to the monastery of Anastasius, rejects at least some use of medical treatment for monks, since “those who live the life of nature cannot be acceptable to God…. The proper medicine is humility and [prayer to be purged of guilt] … because vain is the help of man” (Bernard of Clairvaux 1953, 458–59, letter 388). One further example is the nineteenth-century condemnation of inoculation against poxes, which were explained as God’s punishment (Schillebeeckx 1982, 117–18). But the central tradition of Catholic theology has not been opposed to medical care. Indeed, even in some of the examples just cited, it is hard to be sure whether the opposition was based on bad theology or on a correct avoidance of ineffectual and even harmful medical treatment. Catholic theology has generally supported health care as a properly Christian task, and even as a special Christian vocation. Catholic theology has developed the necessary basis for allowing the possibility of health care as pursued by human art without seeing it as contradicting God’s own purpose. In the process of doing this, various theological stages have been important. We have already mentioned the work of Hippocrates, the Greek physician and philosopher of the fifth century BC who contributed to the advance of medicine by pointing out the patterns in nature, patterns that would enable the student of anatomy to understand disease and its cure through a process of analysis, diagnosis, and prescription. Modern medicine is based on this process. But Hippocrates did not really secularize medicine, as so many have believed (Entralgo 1969, 60–62; Pompey 1968, 17–20). Rather, the advance he made in the understanding of nature was as much theological as scientific. Instead of seeing in disease and its cure the more or less whimsical decisions of supernatural beings (the Greek gods and goddesses), he saw in these things the workings of nature. He did not, however, reject the supernatural aspects of causality, since for him nature was a sacred, not a secular, reality.

Philosophers and theologians recovered the tradition of Greek medicine in the High Middle Ages. Here Thomas Aquinas was of particular importance. Basing his theology on the philosophy of Aristotle, Thomas stressed nature in a way somewhat similar to that proposed by Hippocrates. Nature is not opposed to grace. Rather, grace builds on nature. Similarly, divine and natural causality need not be seen in opposition to one another but are instead compatible. It is easy for us to underestimate the importance of Thomas’s claim that “the perfection of divine providence requires intermediary causes for its fulfillment” (Thomas Aquinas 1945, II, 144, Summa contra gentiles, bk 3, ch 77). Thomas distinguished primary and secondary causality (ibid., ch 72). Though God is the ultimate or primary cause, God works through created secondary causes that we can study and learn to manipulate. These are patterns embedded by God in creation, patterns that God expects us to learn about and to work with. Processes such as disease and healing are not the immediate result of God’s free choice but are rather mediated by the patterns of causality placed by God in the created world (Entralgo 1969, 87). “Just as the divine providence does not altogether banish evil from the world, so neither does it exclude contingency, nor impose necessity on things” (Thomas Aquinas 1945, II, 133, Summa contra gentiles, bk 3, ch 72). Similarly, Aquinas’s notion of “conditioned necessity” helped in the process of integrating divine and natural causality. Certain realities, events, and processes were to be seen as only conditionally necessary and not as absolutely necessary. Although caused by God as primary or ultimate cause, these events need not be seen as absolutely willed by God but only as conditionally willed. We may rightly alter them by learning to use the patterns God has embedded in creation (Entralgo 1969, 87–94; Thomas Aquinas 1945, I, 198–200, Summa Theologica I, q. 19, a.3). Thomas was interested in medicine. He writes about the causality that moves the human heart, and, more important, he spends a great deal of effort to determine the kind of human endeavor medicine is. For Thomas, medicine is not a science like physics as much as it is an art. Yet it is an art that must use the knowledge of physics and of other sciences, “for the practices used in the art must be based on the properties of natural things” (Thomas Aquinas 1986, q. 5, art. 1, ad 5, p. 22). That is, medicine is an art in the sense of a skilled art, a techne in the Aristotelian sense. It draws on knowledge of the patterns of natural causality that God has embedded in creation to do God’s work in transforming creation according to God’s plan (Larkin 1960). Thomas’s development for Christian theology of the complex relationship between divine and natural causality was thus an important step forward toward providing an adequate theological basis for health care and for health care ethics. Divine and natural causality could be seen as cooperating. Medicine could be accepted as an art in its own right, without any sense of conflict with God’s active providence. Contemporary Catholic theologians have furthered this process by insisting even more on the inseparability of divine and human causality. Despite the advances he made in stressing their compatibility, Thomas still tended to think in terms of two more or less separate levels or orders, one human and the other divine, one natural and the other supernatural, one of nature and the other of grace. Today Catholic theology has moved toward a rejection of this separation. The mystery of the meaning of human life is such that it is impossible to separate what is human and what is divine. This inseparability does not mean that we can act as if either causality had been eliminated by the other. This is often a danger in “holism”—we keep only the part we like and we call it the whole. The history of the Christian tradition may have wrongly separated the two kinds of causality, and it may sometimes have seen them in opposition to one another, but it is important not to lose sight of the insights gained when these “two” causalities are seen in creative tension with one another. Though it is true that they can never be separated, never even known apart from one another, it nevertheless remains helpful for us to allow these two aspects of creative causality to teach us their “separate” lessons. From human or natural causality we learn our nobility, our freedom, our creative energies, our capacities to transform the universe. Thus, if we stress only divine causality as if it were a rigid and confining thing that we dare not challenge by any effort at creative