Bio Ethics

CHAPTER 4 THE IMPLICATIONS FOR HEALTH CARE WHEREAS THE PRECEDING CHAPTERS have developed a basis in theological anthropology for health care, this chapter and the next explore the implications of this anthropological basis more specifically for ethics. Here we ask in somewhat more practical terms how what we have learned in theological anthropology is and ought to be applied to health care ethics. Sanctity and Quality of Life The anthropological themes discussed thus far support the unique dignity, destiny, and integrity of human life. In a word, human life is sacred; it is holy because it participates in God’s own holiness. Human life is characterized by its sanctity. But when ethicists talk about the sanctity of human life, they may use this term to imply something a bit different from what we have thus far discovered theologically. For some moralists, the term “sanctity of life” designates one pole of an axiological spectrum used in ethical analysis. At the other end of the spectrum is “quality of life.” Ethicists use these concepts to ask whether human life is to be judged and evaluated on the basis of its quality, or whether its intrinsic sanctity means that quality or lack of it is irrelevant to ethical decisions about health care. While it is often difficult to make these decisions in individual cases, an adequate ethical application of theology can help us eliminate the two extremes of the spectrum. One end is an absolute sanctity-of-life position, which requires that all possible actions be taken to save a human life. No cost is too great if there is even a remote chance of prolonging or saving a person’s life. Men and women may never be allowed to die if they might live on, despite the lack of quality that their lives would have or the brevity of time that might remain to them. Even if they are unable “to pursue life’s goals and purposes, understood as the values that transcend physical life,” their lives must be prolonged (Shannon and Walter 1988, 636). Those who hold for this absolute sanctity of human life are often called “vitalists,” since for them a person’s physical life is itself of ultimate value. Thus, no other value, however important, can ever justify the taking, or the giving up, of a human life. Very few moralists adopt this extreme position. But some approach so closely this end of the spectrum as to refuse cessation of treatment in cases where further medical invasion seems useless and even harmful. Human life must be sustained at virtually all costs. Catholic moral theology has not accepted this approach, though some Orthodox Jewish scholars tend to do so (Dorff 2000a, 313), and surveys have indicated that physicians sometimes find this emphasis compatible with what they perceive as their medical role, though this is far from universal among doctors and has clearly changed in the last few decades. The other extreme end of the spectrum is a totally lax quality-of-life position. Here the argument is that human life loses all value when certain qualities are lacking. This position permits cessation of treatment, or active killing, for trivial and even hedonistic reasons. The qualities considered may be those connected with efficiency and material productivity. Only the strongest and the fittest have sufficient quality of life to merit health care. Attempts have been made to list a number of indicators of human personhood, some of which are overly quantitative while others are not sufficiently well defined. They lend themselves easily to abuse. Joseph Fletcher has made attempts in this direction, but it is not always clear whether his indicators—an IQ of at least 20, self-awareness, self-control, a sense of time, a sense of the future and the past, the capacity for relationship, concern for others, control of nature, curiosity, idiosyncrasy, and upper-brain function—are intended to mean that if any are lacking there is no person at all, or that such a being is a person but need not be cared for, or that a person should strive for the optimal development of these human dimensions (Fletcher 1975). Again, very few moralists argue for the most extreme position. But there are some who come close enough as to allow for cessation of treatment or active killing even in cases where there is a likelihood that a meaningful and dignified human life can be sustained by reasonable medical effort. The reductionist argument that the morality of abortion depends on the woman’s choice, the argument that infants with virtually any handicap should be allowed to die if the parents so choose, the approach to suffering that denies it human value, and the position that the morality of suicide is purely a personal matter are typical of this view, where nearly any reduction in the quality of our lives is seen as a morally valid reason for ending them. Although it is easy to reject these more extreme approaches, it is far harder to try to determine ahead of time what exactly the theological principle of the dignity of human life requires in this context. Both the sanctity of life and the quality of life are important. Each emphasis brings necessary warning and witness. Each corrects the excesses of the other. The Roman Catholic tradition has recognized both the sanctity of life—life is indeed sacred—and the ethical import of at least some degree of quality of life—at some point, a lack of quality means that life can be let go. This humane application of the theology of human life to health care ethics is clearly found in the distinction between ordinary and extraordinary means of preserving life. The distinction goes back several centuries, though it is most often attributed to Pope Pius XII, who repeated it and stressed it during his pontificate in the 1940s and 1950s (Pius XII 1957, 1958). According to this tradition, it is never obligatory to make use of medical measures that are morally “extraordinary” in order to preserve life. This principle will be examined in detail in chapter 13. For now, it is enough to note that it is based on both sanctity and quality of life. In the words of the Catechism of the Catholic Church, “If morality requires respect for the life of the body, it does not make it an absolute value” (1994, 2289, p. 551). It is true there is a danger that the distinction between ordinary and extraordinary means of preserving life may tend toward too lax a quality-of-life position. This is especially problematic when social and economic factors are included in the decision-making process. It is far too easy a temptation for health care providers and institutions, and for politicians and voters, to decide to eliminate health care opportunities for the poor and the powerless as a means of “solving” the problem of scarce resources. On the other hand, resources are not infinite, and the Catholic tradition has been wise in its insistence that a variety of factors must be considered in the attempt to determine what is ordinary and what is extraordinary. Quality of life must be considered (Ashley 1988). This Catholic approach, which has insisted on sanctity of life and quality of life, is based on the theology of the meaning of human life in its dignity, its destiny, and its integrity. Human life is sacred, yet its sacredness resides not in the mere prolongation of physical or even of psychic or spiritual activity. The very freedom of the human person—our created destiny to move beyond ourselves, our unique status in God’s creative providence, and the existential unity of ourselves as body–soul—calls for more than mere continuance in life.But this same theology of the human person condemns the attitude that human life consists in a quantitative accumulation of easily defined and measured characteristics, the absence of which would be reason to deny life’s meaning and goodness. We return to this more explicitly in the next chapter, but it is becoming clear that the theological concepts and symbols of the Christian understanding of human life do not give simple unidirectional answers to specific issues of health care ethics. What they do is require us to avoid simplistic answers because they unfold to us more adequately, but never completely, the mystery of human life as God creates it. In a similar way, theology provides no easy answers to the question of exactly when human personal life begins or ends. We have stressed the integrity of the human person as a unity of body–soul. Even when earlier approaches to theology tended at times to separate these into two distinct aspects, there was no complete agreement on when precisely the being we have come to call a human person began or ceased to be in this life. The Catholic Church has never officially decided when the soul “enters” or “leaves” the body. In its Declaration on Procured Abortion, the Vatican Congregation for the Doctrine of the Faith says this explicitly: “This declaration expressly leaves aside the question of the moment when the spiritual soul is infused. There is not a unanimous tradition on this point and authors are in disagreement” (CDF [1974] 1999, n19). Nor can contemporary theology answer the question of when full human life with full basic human rights begins or ends. Both the more dualistic and the more holistic approaches to the human person have recognized that the human being, in this life at least, needs both body and soul to be alive. Each must be apt for the other. Each must be sufficient for the other. Some of Catholic tradition speaks from a Thomistic-Aristotelian base and argues that there must be enough matter for there to be a form. Contemporary theology prefers to avoid phrases that imply separation but agrees that the human person is neither soul nor body but a unity where the body is enspirited and the spirit enfleshed. For neither approach is it easy to determine when human personal life begins or ends. This theological tradition ought to make us more hesitant than we sometimes are in coming to easy judgments about abortion or euthanasia. But this does not make theology useless. Quite the contrary. Adequate theological principles allow us to reject easy solutions to difficult mysteries. They argue against a too simplistic identification of the completeness of human life with the moment of conception, an identification that ignores the complexity and the uniqueness of the human person along with other human values. They argue equally against the attempt to deny the value of early human life altogether, to make it automatically secondary to other considerations, or to make it depend extrinsically on social or parental choice. Human Life as Individual and Social Another set of concepts that, like sanctity and quality of life, are sometimes seen by ethicists as being in opposition to one another are those of individuality and collectivity or social corporateness. An adequate theological basis for health care and health care ethics must recognize and support the human significance of both society and individual. We have already briefly noted the shift in emphasis in contemporary moral theology from an excessive and sometimes restrictive focus on individual sin to an emphasis on social and structural sin. Unlike Protestant ethics, Catholic ethics developed in the context of individual confession. This practice began in the sixth and seventh centuries among the Celtic monks in Ireland, who then spread it in their missionary journeys to continental Europe. Until then, reception of the sacrament of reconciliation had been public and usually limited to one time per person. The penitent would confess to the bishop and then enter a period of public penance followed by public reconciliation before the Christian community. For various reasons the practice had fallen into disuse. Often Christians would put it off until just before death, since then the penance could not be imposed and there was less chance of their falling back into sin when the sacrament would not again be permitted (Mahoney 1987, 4–5). The Irish development had its advantages and symbolized well that the forgiveness of God in Jesus and the Church was always available to the contrite. But its effects on the developing discipline of moral theology were

not all benign. Priests now needed to be told, or so it was believed, how to judge individual penitents and individual sins. The penitential books were lists of sins with their penances, and from them developed later the summas for confessors and the manuals of moral theology. Emphasis turned more to individual actions of individual persons (Mahoney 1987, 5–17). This occurred even more in medical ethics than in other areas. The wider array of topics discussed in pastoral medicine was largely neglected, and the individual daily professional practices of medical personnel were more and more stressed. Catholic medical ethics was interested in what individual patients and individual doctors and nurses did medically. This restricted emphasis has been challenged in the decades since Vatican II, a challenge that correctly rejects the individualist bias in the definition of the earlier tradition. And the challenge is itself part of a wider recognition in contemporary ethics (and, indeed, in other disciplines such as sociology, psychology, philosophy, and political science) of the inadequacy of trying to understand the human person, and the meaning of human life, from a purely individualist perspective. This has been the temptation in Western medicine and in Western philosophy since the Enlightenment. Many of the Enlightenment thinkers saw “man” essentially as an individual whose rights and aspirations were open to abuse by others and by society. The human person was seen more or less as a separate atom, a little world apart from others. True, most individualists recognized the need for some kind of social interaction, but there was the sense that such interaction, and the structures needed for it, were secondary to the individual and were morally subordinate to the individual’s needs, priorities, and goals. Sociologists argue that this trend has been most pervasive in the United States, where the development of the individual’s personhood is seen to require the removal or the overcoming of social influences. Church, family, and state are thus privatized, leaving the individual free to choose among them, to accept or reject their influence as he or she thinks right. Commitment is treated with suspicion, and the larger society is neglected for the sake of the individual, resulting in personal loneliness and in structural injustice (Bellah et al. 1986). Nothing of what we have discovered from the Christian understanding of the human person leads in this direction. God created not so much an individual man, Adam the individual, as ha-adam, humankind, in the divine image and likeness. God chooses us as a people, a society, a chosen race, a royal priesthood. Grace is not a thing acquired by individuals, but God’s own communication to his human creation through which we become symbols of God to one another, sacraments of God’s presence in humankind itself. Just as the “supernatural existential”—the order of grace in creation—has a social dimension, so does the order of sin. We are born into a dynamic of sin that transcends the individual, just as we are born into a dynamic of grace that transcends the individual. Christianity, like Judaism, proposes a people of God, not just a loose and private collection of individuals. This means that we have responsibilities to one another that are based on essential human solidarity and not just on individual agreement. Society is not ontologically (metaphysically, essentially, in its real nature) a free agreement among individuals who might just as well have decided to stay separate. In a real way, this kind of individualism is another kind of dualism, a dualism that separates what cannot be separated, that divides individuals from one another and from the larger whole that includes them all. The recent reemphasis in Catholic moral theology on questions of social justice is but one example of how contemporary theology is aware in a renewed way of this social dynamic at the heart of the human mystery. But there are dangers present in this emphasis if the importance of the individual person is neglected. Reductionist individualism, both ontological and ethical, is rightly rejected. But this rejection is sometimes done too easily, without the proper nuance, as if it could rightly be replaced by its opposite, by a kind of reductionist collectivism or corporatism. While it is true that the individual cannot live in isolation and may not rightly neglect the common good, it is also true that the corporate whole of society—the collective, the state—may not rightly trample on individuals. Again we have an example of how a dualism can cut both ways. The separation of individuals from society, so that individuals are led to neglect social commitment and the common good, can bring with it the equally devastating separation of society from the individual so that the collective neglects the persons that constitute it. It was this insight that led to the admittedly one-sided individualism of the Enlightenment. Enlightenment philosophers saw the destruction done by the social structures of the time, including the church. “Coherence,” “solidarity,” and “community” can be oppressive, and both church and state have brought tyranny in their name. Individualist philosophy reacted against that by emphasizing the potential of the individual and by trying to create structures where the individual could not only survive but could thrive. Sociologists are right when they decry the alienation and the rootlessness that follows from an individualistic society. Ultimately, no human person can thrive alone. But it is dangerous to react so totally against individualism as to fall into collectivism. Neither the individual nor the collective is ultimately prior. Thus, individualism and corporatism should serve in some sense as correctives to one another, not as synonyms for evil and good, as is often implied in contemporary social ethics. In health care ethics, this is especially important. Too much emphasis on the individual can lead to decisions that neglect the common good; a misplaced emphasis on the corporate whole can lead to unethical decisions. Two areas in medical ethics can serve as examples: organ transplants and the “right to health care.” More is said of each in later

chapters; here I merely make a few points about the individual and corporate whole. For some time, Catholic medical ethics argued against the morality of organ transplants. The argument was based on a restricted interpretation of the principle of totality, according to which a human body might be “mutilated” by the removal of an organ only if such a procedure were for the good of the individual’s own body. Because this condition would not be met if the purpose of the mutilation were for another’s body, most Catholic moralists wrote, for a time, against the procedure. This teaching was changed when Bert Cunningham, a student of moral theology at The Catholic University of America, suggested that the mystical body of Christ might serve as the basis for a wider interpretation of “totality” (Cunningham 1944). The totality would be corporate and not individual. Organ transplantations would be licit. But Cunningham tended in some of his conclusions to neglect the individual donor. He would have permitted the transplant of an eye from a living donor, even from a one-eyed convict sentenced to life in prison, and thus “not needed by anyone” (Cunningham 1944, 106). It is clear that Cunningham’s move toward corporatism entails a lack of respect for the individual person. It is true, of course, that a “valid” corporatism would reject this kind of imbalance. But we need to guard against it precisely by using individualism and corporatism as correctives to each other’s excesses. Contemporary medical ethics does this when it insists on the donor’s rights as well as on the responsibilities each of us has to give, sometimes of our own bodies, to the health of others (Kelly 1988). Another area where questions of the relationship of individual and corporate whole are apparent in health care ethics is the area of the right to health care. Included here are questions of access to care; cost containment; managed care; medical insurance; socialized medicine; economic and budgetary priorities; private, public, and for-profit hospitals; the incomes of health care practitioners; and a host of other questions that seem to defy ethical analysis. To what extent is health care a right? Again, theological principles do not bring us easy answers. The claim that an overemphasis on either the individual or the collective makes for bad health care is true enough, but it does not solve these often excruciatingly complex issues. Christian theology must indeed argue that health care is a human right. Because health in all its manifestations is such an essential part of the dignity and indeed the destiny of human life, we have an obligation, to the extent that this is reasonably possible, of providing each other necessary health care. Health care is not just another commodity that can ethically be left to market forces. Both larger governmental bodies, through their powers of taxation, and smaller voluntary units, have roles to play in this process. Health care practitioners themselves are obliged to contribute to the effort. But the right to health care is not an absolute right; there is no right to an infinite amount of health care. We often hear that no price can be put on the value of even a single human life. This is true, but it means that human life is not measurable in terms of dollars; it does not mean that human life is measurable in terms of an infinity or an indefinite number of dollars. It does not mean that society is obligated to provide unlimited funds for health care. Priorities in these areas are notoriously difficult to establish. Is it morally right to transplant a heart while people starve in Africa? The problem is often phrased this way, or in the context of arguing about military and domestic budgets (how can we train a soldier or build a tank while people die from lack of medical care?). Though questions like these may help with their shock value, they are not ultimately helpful in leading to answers. We might also ask if it is morally right to spend money on symphony orchestras, or televisions, or on the education of chaplains, instead of on starving peoples. Economies are more complicated than that, and health care does not exhaust the morally right expenditure of society’s wealth. But health care is a human right, and even if the more specific questions of resource allocation defy simple ethical analysis, Christian health care ethics must insist that wealthy societies meet their obligations to provide medical care to those who need it. The ability to pay cannot be the basic criterion for health care. Economies generally and health care institutions specifically exist to serve the common good and must not make efficiency or profit the ultimate priority.