Contemporary Catholic Health Care Ethics

Second Edition

David F. Kelly, Gerard Magill, Henk ten Have

• Publisher: Georgetown University Press
• Year: 2013
• ISBN:
  9781589019614
• Edition: 2
• Topic: Medicina
• Subtopic: Etica in medicina

Contemporary Catholic Health Care Ethics, Second Edition, integrates theology, methodology, and practical application into a detailed and practical examination of the bioethical issues that confront students, scholars, and practitioners. Noted bioethicists Gerard Magill, Henk ten Have, and David F. Kelly contribute diverse backgrounds and experience that inform the richness of new material covered in this second edition.

The book is organized into three sections: theology (basic issues underlying Catholic thought), methodology (how Catholic theology approaches moral issues, including birth control), and applications to current issues. New chapters discuss controversial end-of-life issues such as forgoing treatment, killing versus allowing patients to die, ways to handle decisions for incompetent patients, advance directives, and physician-assisted suicide. Unlike anthologies, the coherent text offers a consistent method in order to provide students, scholars, and practitioners with an understanding of ethical dilemmas as well as concrete examples to assist in the difficult decisions they must make on an everyday basis.

PART I
Theological Basis

CHAPTER 1
RELIGION AND HEALTH CARE

Introduction

IN THE UNITED STATES in the late 1960s a new development occurred in a longstanding area of inquiry. What had been the largely intrareligious study of the morality or ethics of medical practice became “bioethics.”¹ Displaying perhaps a combination of arrogance and ignorance, American bioethicists often claim, or at least imply, that this field of study was created brand new by the philosophers who coined the term. Without question what happened in the last four decades of the twentieth century was a major development, essential to the emergence of what the discipline has become. Secular philosophers (those who speak from no religious tradition) began in the 1960s to show interest in a field they had for a long time ignored, and this interest and excitement made bioethics a far more influential endeavor than it had previously been. New research centers and professional groups were established. Governmental oversight bodies were appointed. Scores of new journals appeared. And the religion-based approaches that had preceded this new development have been influenced and to some extent eclipsed by it.

It is nonetheless entirely inaccurate to suggest that the new American bioethics of the late twentieth century owes little to its religious forebears. As the second and third parts of this book make clear, much of what bioethicists claim, many of the judgments they make, are based on conclusions reached by religion-based approaches to medical ethics.²

From the American perspective—indeed, from the perspective of the West in general—the Roman Catholic tradition has been most influential. Catholics developed over many centuries a highly specified approach to medical ethics. The Jewish tradition also created a detailed and centuries-long tradition of medical ethics, but it had less influence largely because Catholic immigrants to the United States outnumbered Jews and because, as discussed in detail in part II, Catholics adopted a natural law approach to morality, claiming that moral judgments were based on reason and, hence, applicable to all humans, whereas Jewish scholars were less apt to insist on this, basing moral claims at least in significant measure on rabbinic interpretations of scripture (Mackler 2000, 2–12).

In any case, religion has been of major significance in shaping health care ethics as we know it today. Religion develops an understanding of the human person on which an ethic of health care can be based. Thus, the first part of this book is directly theological. Readers who work on health care ethics from a religious perspective will find this part especially useful and perhaps in some sense normative. But even readers who do not find religious anthropology persuasive may want to discover what Christianity has to say on these issues. Bioethics, after all, even in its secular garb, deals with patients and health care providers who are religious and whose faith affects their approach to health care. It is clear that American bioethicists need at least a decent knowledge of the Catholic and Jewish traditions if they are to practice well. Bioethics has emerged from religious roots and cannot be understood apart from them.

Nor is it true, as is often stated by those who reject the role of religion in public bioethics discourse, that religions are not helpful because they disagree with one another. It is true that they do often disagree. But so do secular thinkers and secular approaches. Somehow it is thought valid to ask both liberals and conservatives about stem cell research despite the fact that they usually disagree, but it is invalid to ask both Catholics and Jews because they may also disagree. The richness of religious language often adds an essential dimension otherwise missing from the discussion.

Religion is concerned with the meaning of human life in its ultimate dimensions. Religious faith is the human person’s response to God’s revelation as God discloses to us who we are in the divine plan. Theology is our search for a greater understanding of this revelation and of our response to it. Thus, religion, revelation, faith, and theology are all centrally interested in the meaning of human life. Why do we exist? When and how do we live at our human best? What kind of respect do we owe our own human lives and those of others?

Sometimes religion has tended to understand human life from an overly spiritualized or angelicized perspective. This has occurred from time to time in certain movements in Christian and Catholic theology. When this occurs, religion tends to reject the importance of the body, of human health, and of the processes of health care. These aspects of human life are then considered irrelevant to spiritual growth or are even seen as hindrances to it. The human person is turned into a kind of inferior angel whose true home is the world of the spirit. Religion is reduced to the otherworldly.

More often religion has included in its searching and its theologizing these essential aspects of human living. Human health and health care have been of central importance to much of Christian theology and Christian practice. Religious women and men, clergy and laity alike, have dedicated their lives to human healing, both of the body and of the spirit. Theologians and health care professionals have worked together in developing theologies and anthropologies of health care and of health care ethics. Health care and religion have something to offer one another.

The aim of part I is to explore the idea of a theological basis for health care and health care ethics. What can Christian theology bring to our understanding of human health, of human health care, and of bioethics? We explore the topic in several stages. The first chapter is an overview of the history of the relationship of religion and medicine, suggesting some of the main lines in the Christian theology of health care. The second and longest chapter develops the theological basis for human dignity, exploring the theological themes that serve as the fundamental basis for health care. The third chapter speaks of the integrity of the human person and explores both dualistic and holistic approaches to Christian anthropology. Here we also try to deepen our understanding of how God works through human actions, of the relationship of divine and human (natural) causality in health care. Chapter 4 speaks of the sanctity and quality of life, two concepts often seen in opposition to one another as principles for health care ethics, and also discusses the problems of individualism and corporatism in health care. Finally, chapter 5 is a methodological analysis of how theological principles have worked and ought to work in the actual practice of health care ethics. It deals especially with divine sovereignty over human life and with the meaning of human suffering as principles in medical ethics.

The scope of these first five chapters includes themes common to all religions, but the focus is on Christian theology generally and on the Roman Catholic tradition specifically. This focus reflects the historical influence of Catholic medical ethics.

Religion and Health Care

Until the last forty years or so, Roman Catholic theologians and philosophers, together with Jewish scholars, were virtually alone in the field of medical ethics. Although other philosophers and theologians studied ethics and moral theology in general, and although they applied moral principles to sexual and social issues, they never developed in depth the science and art of health care ethics. Professional associations of physicians such as the American Medical Association did promulgate and interpret codes of medical ethics, but these were more likely to be codes of etiquette for members of the profession intended to enhance the prestige of physicians than they were actual moral analysis of health care procedures and structures. As has already been noted, this situation has changed radically in recent decades as bioethics has become a rapidly growing field of study for philosophers, health care professionals, lawyers, historians, sociologists, theologians, and religionists of various backgrounds and religious affiliations.³

The fact that, until recently, only Catholics and Jews developed detailed studies of health care ethics does not mean that only they were interested in the larger relationships of religion and medicine. Even though the Roman Catholic tradition was the most detailed and the most influential, and even though only this tradition produced a truly systematic and extensive literature in health care ethics, the relationship of medicine and religion is significant within the larger Christian tradition and generally in the religions of our world. Religion deals with the core questions of human existence and is thus interested in issues of healing. The human person is an embodied spirit, an animated body, and so human health involves spiritual and physical aspects in inseparable interaction. Although one or the other of these may rightly be emphasized for certain purposes, the complete separation of the human person into spiritual and physical parts is detrimental. Until the Enlightenment of the eighteenth century, the radical separation of medicine from religion was not attempted, and religions generally included physical healing in their ministry to whole people.

A number of world cultures have combined the two arts of healing in the same person. Egyptians and other Near Eastern peoples, Asians, and some of the Celtic and Germanic tribes did this. The “holy man” was the physical healer as well as the religious leader. What we know today as modern medicine, of course, was not available, and these healers combined a trial-and-error approach (empirical medicine) with religious practices of a supernatural or magical kind. Westerners are starting to find out that, although some of what “primitive” peoples do and did to heal themselves is ineffective, many of their techniques do work, and we are adding this “alternative and complementary medicine” to our own medical repertory (Callahan 1999). Perhaps more important, we are discovering anew what “primitives” were never tempted to forget, that healing concerns whole people and is most effective and most ethical when it addresses the needs of whole people. Physicians who forget this and see only parts of a body, and clergy who forget it and see only angels or souls, run the risk of doing a great deal of harm (Kelly 1979, 47; Agnew 1967, 581–82; Pompey 1968, 14).

Historians often refer to the Greek physician Hippocrates of the fifth century BC as the founder of scientific or rational medicine. He introduced a rational approach to medicine, insisting on the process of diagnostic analysis. For Greek medicine—and for Roman medicine, which followed it—this replaced the previous combination of “empiricism” (trial and error) and magic (Kelly 1979, 47; Entralgo 1969, 15; Agnew 1967, 582; Pompey 1968, 15). But it did not separate religion and medicine. Hippocrates saw medicine not as something secular but as a part of his religion. The changes he introduced were as much religious as medical. Nature was sacred, not secular, and to study it and heal it was to act religiously. For Hippocrates, disease and health followed laws of “natural” causality, but these laws were nonetheless sacred, not secular (Kelly 1979, 48; Entralgo 1969, 42–44).

Following the time of Hippocrates, most Greek and Roman doctors were not official religious leaders, and this practice continued during the first centuries of Christian Rome. Physicians of the time recognized, however, that their vocation was of religious significance. They were to serve as Christ had served, to heal as he had healed, even to save as he had saved. The Christian concept of agape (love or charity to others in imitation of Christ’s love of humankind) entered their understanding of the Christian medical vocation, and with it came an insistence that doctors must treat the poor for free, must care even for incurable patients, and must consider spiritual as well as physical needs. Patients were more than objects to be treated if curable and otherwise ignored (Kelly 1979, 49; Entralgo 1969, 54).

As the structures of the Roman Empire collapsed, so did the approach to medicine the Romans had inherited from the Greeks. But in accord with the importance Christianity gave to healing and to caring for the poor and the suffering, specifically religious Christian institutions began to take up the work of the “lay” doctors. Monks in their monasteries cared for the sick, and some bishops built hospices for travelers and indigents. Thus, priests and religious women and men began to take over the work of the physician (Kelly 1979, 49–50; Entralgo 1969, 56–57, 60–62; Pompey 1968, 17–20). It is interesting to note that the results were at best mixed. At first, these monks and nuns studied and followed the medical practices of the best of the Greek and Roman doctors, and they added to this what they discovered in their missionary wanderings among the pagan tribes of Europe. Gradually this learning was rejected, and the same combination of trial-and-error with specifically religious remedies that we noted in pre-Hippocratic medicine replaced it. It seems as if there was little interest in exploring how to be a better doctor or in trying to understand disease and its cure (Kelly 1979, 50; Entralgo 1969, 65–70; Pompey 1968, 18–19). For the monks, medicine was not so much an art to be studied and wondered about as it was an added responsibility. Their primary desire was to be monks, not physicians. In this context, and in the general social disintegration of the time, medical care diminished in quality. But once again the Christian religion and its institutions had given evidence of the importance of health and health care to religion.

In the High Middle Ages of the twelfth and subsequent centuries, medicine again came alive as a discipline in its own right. Educational centers appeared in the great cities of Europe, and these universities began to teach medicine to interested students. Fewer and fewer physicians now were priests or monks (Kelly 1979, 50–51; Entralgo 1969, 62, 74). In fact, church synods and councils began to forbid the clergy to practice medicine, probably because they did not want them to earn their living at it and thus fail to carry out their religious duties, and because the primitive state of medicine at the time often meant that physicians would be involved in useless or harmful procedures that could bring notoriety and even criminal charges (Kelly 1979, 51; Pompey 1968, 23, 25–26). Of more lasting importance in the reemergence of medicine was scholastic theology, especially that of Thomas Aquinas and his followers, which rediscovered the philosophy of Aristotle with its insistence on nature and on natural laws. Medicine could emerge again as an art to be studied and explored. But in this revival medicine was still religious. The intellectual context of the time was theocentric, and the study of medicine was perceived to be a part of the study of God’s creation as God willed it to be (Entralgo 1969, 78–79, 83–90). For many of the lay doctors of the Middle Ages, and of the Renaissance and Baroque eras that followed, the care of the sick was a specifically Christian vocation (Entralgo 1969, 91–100; Pompey 1968, 30). Sir Thomas Browne’s 1642 book is a classic example of how one physician viewed his vocation (Browne [1642] 1963).

This started to change in the eighteenth century, when European intellectual patterns came to be dominated more and more by the Enlightenment. Enlightenment philosophers such as Voltaire, Kant, Newton, Locke, and Hume began to stress the importance of human reason and of scientific analysis for human progress in isolation from and even in opposition to religion (Kelly 1979, 61–62). They saw that the preceding centuries had often been engulfed in interreligious disputes that had caused turmoil and considerable suffering for the people. They thought that a freedom from this kind of darkness would release humanity from the shackles that kept it bound to reactionary authoritarianism. They thus rejected much of religious authority, especially when they perceived it as hindering human development, which they tended to identify with scientific and technological progress. Human reason could achieve a better society. Religion was accepted only, or at least primarily, for its utilitarian function of teaching people how to behave morally for the establishment of a better society.

In this intellectual environment, medicine tended for the first time to separate itself ideologically from religion. In the previous centuries, most doctors had been lay Christians, not priests and religious. But they had seen their vocation as quite clearly a part of their Christian religion and of its worldview. Now medicine was to become secular, unreligious, and sometimes even antireligious (Pompey 1968, 8–11).

It was in the eighteenth century that Christian theologians began to develop a specific field of study and body of literature to explore the interface of religion and medicine. What had previously been sporadic or had been incorporated into larger treatises of systematic or moral theology now found its own expression and a beginning of cohesion in a subdiscipline of pastoral theology known as pastoral medicine. Theologians and some Christian physicians recognized that the complete separation of medicine from religion was harmful to both disciplines, and pastoral medicine emerged as an attempt to correct this. The term “pastoral medicine” is generally unfamiliar today, especially in the United States, but it was the primary prediscipline to the Catholic medical ethics of the twentieth century. As pastoral medicine arose in the eighteenth century, and as it continued into the nineteenth and twentieth centuries, it tried to bridge the gap between religion and secularized medicine by including all aspects of the interface of these two disciplines (Kelly 1979, 62; Fleckenstein 1963, 160).

Pastoral medicine thus developed two emphases, one medical and the other theological. The first emphasis was to teach the theologians and the parish clergy what they needed to know about medicine. Theologians would need this knowledge in their study of Christian anthropology in order to understand better the meaning of human persons as God created us and intends us to live, the way in which human beings act and react, the theological questions of body–soul interaction and of grace and human freedom, and in order to develop a moral theology of medical practice. The parish clergy would need medical knowledge in their parish ministry as counselors and confessors, and to enable them to provide first aid and basic medical advice to parishioners where doctors were lacking (the tendency of medical personnel to gravitate to the big cities is not new, and rural sections of Europe in the eighteenth century were often without physicians). The second emphasis of pastoral medicine was theological and ethical. Doctors could learn from theologians about the spiritual dimensions of the person and about the application of moral–theological principles to medical practice (Kelly 1979, 60–61).

As pastoral medicine developed, it emphasized first one, then another of the various aspects it included. During the eighteenth century, under the influence of the Enlightenment, much of it was limited to manuals of first aid for rural priests and ministers. Religion was to be useful in some measurable way, and physical healing and hygiene to prevent disease were ways to achieve this goal (Kelly 1979, 63–64; Niedermeyer 1955, 1:15–19, 53–54; Fleckenstein 1963, 160–61; Pompey 1968, 8–12, 33–117, 295–96). In fact, some of the early literature quite clearly argued that this was to be the clergy’s primary task. It transformed the clergy into doctors. At the other extreme were works of pastoral medicine that altogether rejected the Enlightenment search for better medical science and argued for a supernaturalist approach that would change doctors into clergy (Niedermeyer 1955, 1:55–57). In the nineteenth and twentieth centuries pastoral medicine moved more and more in the direction of moral theology or medical ethics, and some books were really medical ethics texts. Yet despite these shifts in emphasis and tendencies to limit the field to one or another aspect, pastoral medicine maintained a dialogue between medicine and religion.

The years since the 1960s have seen a new revival of the study of medicine and religion and of medicine and ethics. Medical ethics, long a Roman Catholic discipline, is now quite ecumenical. Nurses, physicians, lawyers, and other professionals involved in health care and in health care institutions are studying with philosophers and theologians to develop better approaches to the complex individual and structural questions that beset the health care system. Medicine no longer considers itself separate from the wider concerns of the meaning of human existence, traditionally the subject matter for theologians and philosophers.

There are many reasons for this. Some are obvious to all who are involved in health care in any way: the rapid growth in medical technology with its tendency to dominate medical care to the exclusion of personal interaction and...