Health Care Ethics

A Catholic Theological Analysis, Fifth Edition

Benedict M. Ashley

• Editore: Georgetown University Press
• Anno: 2006
• ISBN:
  9781589013377
• Edizione: 5
• Argomento: Medicine
• Categoria: Ethics in Medicine

Health Care Ethics is a comprehensive study of significant issues affecting health care and the ethics of health care from the perspective of Catholic theology. It aims to help Christian, and especially Catholic, health care professionals solve concrete problems in terms of principles rooted in scripture and tested by individual experience; however, its basis in real medical experience makes this book a valuable resource for anyone with a general interest in health care ethics.

This fifth edition, which includes important contributions by Jean deBlois, C.S.J., considers everyday ethical questions and dilemmas in clinical care and deals more deeply with issues of women's health, mental health, sexual orientation, artificial reproduction, and the new social issues in health care. The authors devote special attention to the various ethical theories currently in use in the United States while clearly presenting a method of ethical decision making based in the Catholic tradition. They discuss the needs of the human person, outlining what it means to be human, both as an individual and as part of a community.

This volume has been significantly updated to include new discussions of recent clinical innovations and theoretical issues that have arisen in the field:

• the Human Genome Project• efforts to control sexual selection of infants• efforts to genetically modify the human genotype and phenotype• the development of palliative care as a medical specialty• the acceptance of non-heart beating persons as organ donors• embryo development and stem cell research• reconstructive and cosmetic surgery• nutrition and obesity• medical mistakes• the negative effects of managed care on the patient-physician relationship• recent papal allocution regarding care of patients in a persistent vegetative state and palliative care for dying patients

Part I


HEALTH CARE ETHICS
AND HUMAN NEEDS

Chapter One

BIOETHICS IN A
MULTICULTURAL AGE

OVERVIEW

HEALTH CARE ETHICS ORIGINATED IN THE Christian concern for healing using a medical science developed by the Greeks and advanced by Jews and Muslims. But recently health care has become increasingly secularized, and its ethics is often named more inclusively “bioethics.” Current bioethics, however, is fragmented into a variety of ethical methodologies. Because Catholic medical professionals and health care facilities serve persons of various ethical views, and must work in this multicultural environment, it is imperative that Catholics understand the basis of their own Christian ethics of health care well in order to engage in a constructive way with other points of view. Christian ethics of health care has its foundations both in faith and in human reason.

1.1 THE EMERGENCE OF SECULAR BIOETHICS

The rapid medical advances in the last fifty years have raised a multitude of difficult problems in the field of bioethics and have produced an ever-expanding literature on the subject. To understand why these issues are so controversial and to propose effective strategies for their solution, it is first necessary to recognize that in our multicultural age there is no agreement on a common value system. We confront this problem in part I, chapter 1. In chapter 2 we seek a working solution to this basic question before proceeding, in parts II and III, to discuss in detail the main bioethical questions that are now urgent.

The term bioethics began to replace the term pastoral ethics, or medical ethics, early in 1971, after the biologist Van Rensselaer Potter, in his book Bioethics: The Bridge to the Future, introduced it to include the many new interrelated biological issues arising from life sciences and their social implications (Potter 1971). This terminological change was fostered by the realization that health care decisions are not the monopoly of the medical profession, nor are ethical questions the monopoly of the clergy. New questions are constantly arising, and the media quickly and often sensationally opens them up to public debate. The use of this new term bioethics also signaled that new ethical methodologies were becoming influential in these debates, methodologies that were no longer, as they had been formerly, based on religious traditions (Guinan 2001).

In the United States, Catholic hospitals and medical schools, along with some other religiously sponsored health facilities in the United States, play an important role, although as a minority, in the secularly dominated network of such institutions. Secular medical schools seldom, until recently, gave courses on medical ethics. Percival’s Medical Ethics (Percival 1803), often cited as the first American work on the subject, was hardly more than a treatise on professional etiquette. Although as early as 1847 the American Medical Association (AMA) adopted its Code of Medical Ethics, this too did little more than provide guidelines against malpractice suits.

As the term bioethics came into general use, secular centers for this newly secularized field began to spring up such as The Hastings Center, founded in 1969 at Hastings on Hudson, New York. In 1971 the Kennedy Institute for Ethics was established at Georgetown University. These two institutes were originally under Catholic influences but soon opted for a secularist approach (Stevens 2000). To respond to this situation, The Catholic Bishops of the United States issued its Ethical and Religious Directives for Catholic Health Care Facilities (ERD) in 1971. In 1973 the Catholic Hospital (now Health) Association sponsored the foundation of the John XXIII Medical-Moral Research and Education Center in St. Louis (since 1997, the National Catholic Bioethics Center [NCBC], Philadelphia) that provides consultation and workshops on bioethics for Catholic bishops and others. Today there are numerous such centers and publications, religious or secularist in mission. It was with this widening of the field that controversy about ethical theory and methodology became prominent.

The literature on bioethics is now enormous and in large part purely secular in orientation. In the past, Catholic health care professionals and facilities seldom had to face this division of views, but today the formation of “joint ventures” between Catholic and non-Catholic medical facilities, the education of professionals in secular institutions, the spread of health care plans with general membership, and the promotion of ecumenical openness by Vatican II have forced Catholics to confront this ethical diversity (Hamel 2002; Kenny 1997).

Today’s secular humanism originated in the Age of Enlightenment in the eighteenth century (Ashley 1996a, 2000b). In Europe the religious wars between Catholics and Protestants and among Protestant denominations in the seventeenth century had disillusioned many of the intellectual elite with Christianity and led at first to a widespread skepticism. To replace Christianity, whether Catholic or Protestant, certain thinkers began to propose a “religion of reason” that would replace dogmas of faith. Thus they no longer placed their hopes in God, but in the power of natural science and its technological applications, which had made such remarkable advances in the seventeenth century.

This co-option of science by the Enlightenment, because it is only one perspective on science, can be called “Scientism” and is characterized by its claims that natural science must be “value free,” a conception that was foreign to the founders of modern science such as Galileo, Newton, and Harvey, who always supposed that the ultimate purpose of science is “to manifest the glory of God,” the Creator. John Paul II, in his encyclical Fides et ratio (1998c, no. 88), characterizes this view as follows:

[S]cientism … is the philosophical notion which refuses to admit the validity of forms of knowledge other than those of the positive sciences; and it relegates religious, theological, ethical and aesthetic knowledge to the realm of mere fantasy. … Science would thus be poised to dominate all aspects of human life through technological progress. The undeniable triumphs of scientific research and contemporary technology have helped to propagate a scientistic outlook, which now seems boundless, given its inroads into different cultures and the radical changes it has brought. … And since it leaves no space for the critique offered by ethical judgement, the scientistic mentality has succeeded in leading many to think that if something is technically possible it is therefore morally admissible.

A worldview without a value system, however, would not have satisfied the determination of the Enlightenment to replace religion as a guide to life. Consequently, while one face of secular humanism is value-free Scientism, the other face is Romanticism, a movement that sought to create or construct values aesthetically, much as a work of fine art is created. This dichotomy between the objectivity of value-free Scientism and the subjectivity of value-creative Romanticism is reflected in the modern university by what C. P. Snow (1999) called “the two cultures,” the “hard” sciences versus the “soft” humanities. Thus it is to the humanities that ethics is assigned, and some medical schools are now giving courses in what are called “the medical humanities” that interrelate medicine with history, literature, and ethics. No wonder, then, that our created value systems have become so diverse! To understand this diversity of current secular bioethics, however, it is first necessary to look back at its roots in an older tradition. Only when these roots are understood can these divergent ethical systems be compared and evaluated.

1.2 THE FOUNDATIONS OF THE ETHICS OF HEALTH CARE

The medical profession as we know it today originated in Greco-Roman culture. The first known code of medical ethics is the Hippocratic oath to which most physicians still commit themselves. This oath probably originated with the pagan Pythagorean sect, but was transmitted to our age in Christianized form (Edelstein 1943). Roy Porter, editor of The Cambridge Illustrated History of Medicine, writes, “It is no accident that the triumph of the Christian faith (after Constantine made Christianity legal in 313) brought the rise of nursing and the invention of hospital as an institution of health care” (2001, 213; cf. also Kelly 1979). The Christian religious orders founded the first hospitals, and Christian theologians developed an ethics of health care as a feature of medical traditions to which Jews (Zohar 1997) and Muslims (Daar and Khitamy 2000) had made important contributions.

In the Bible two contrasting yet related ethical methodologies are evident. In the Old Testament the dominant ethics is that of the Torah, or Law, contained in its first five books (Harrelson 1980; Kaiser 1983; Birch 1991; Janzen 1994). It is of the deontological (Greek deontos, duty) type, because it chiefly evaluates behavior ethically as to whether it is dutiful and obedient to the laws of God revealed to Moses. Because, however, in current writing the term deontology is understood in different ways, we will henceforth refer to this ethical methodology as “duty ethics.” It is also called “voluntarism” because it bases moral obligation on the will (the Latin voluntas) of some lawgiver, either God or some legitimate human lawgiver. This type of ethics, still evident in Jewish and Muslim works on bioethics (Feldman 1986; Meier 1986; Rosner 2001; Zohar 1997; Kenny 1997), can be called “divine command ethics.”

In other books of the Old Testament, however, a different type of ethical wisdom is elaborated. In the wisdom literature (Murphy 1990), an ethics is presented that is based largely on ordinary human experience of what kinds of behavior lead to a happy life and what kinds lead to unhappiness. Furthermore, the biblical prophets deepen this experience accessible to human reason by teaching that no merely external practice of laws is truly moral unless motivated by genuine love of God and neighbor. This makes evident that the principal weakness of any legalistic, duty methodology is that it does not give any ultimate reason why the will of the lawgiver is right or wrong, and hence how the laws promulgated by authority are to be reasonably interpreted and applied to special circumstances. Even God, as Job complained, sometimes seems to be unfair. Laws are useful and indeed necessary guides for our ethical decisions, but we must still ask whether a law is really just before we can ethically obey it. If we obey it on trust, as sometimes we need to do, then we must at least know the legislator to be morally trustworthy. Therefore the more profound type of ethics is one that is based not on law made by the will of the legislator but on the motivation of the law and its observance. This is called teleological (the Greek telos, goal) ethics, which judges the morality of a decision in terms of the relation of an action taken as a means to happiness, the true goal of life. Just as we use the term “duty ethics” in preference to “deontology” to avoid certain confusions, we will henceforth speak not of “teleology” but of “ends–means ethics.”

Jesus as Model

As shown in the New Testament, Jesus Christ, who for Christians is not only the wisest of teachers but also the best model of human living, faced these two views of ethics (Schnackenburg 1973; Schrage 1988; Farley and Cahill 1995). During his time and in later Orthodox Judaism, the rabbis, although they certainly understood the importance of ethical motivation, saw themselves primarily as interpreters of the Mosaic Law (Torah) in its complicated provisions. In the Torah, moral and ritual laws tended to be regarded as equally important, because ritual observance was thought to enforce ethical observance. Jesus, however, taught in the line of the prophets. He by no means permitted violation of the Mosaic Law (Mt 5:17–20), but put far more emphasis on its ends–means motivation. God’s purpose in creating human beings was to share his love with them, and he asks us to return that love by loving our neighbor. Thus what is central to ethics is not just obedience to law, but love. Jesus in a special way manifested this by his miraculous healing of the sick. Hence, in the Christian tradition, health care ethics, while not neglecting moral laws or norms, should be principally and profoundly an ends–means, love ethics. This does not mean, however, that it is altruistic in the sense that the moral person must neglect his or her own happiness, as Jesus said, “Love your neighbor as you love yourself” (Mt 22:39). Rather it is a social ethics that teaches that no individual can be truly happy except by sharing that happiness in a truly happy community.

In this book we have preferred the term health care ethics and subtitled it “A Catholic Theological Analysis” precisely because for us the ultimate ethical norm is not a set of ethical rules or values but a historical person, Jesus Christ—God become truly human. Therefore he is our model of what it is to be human and the only source of grace that can empower us to overcome our sinful inhumanity and in him become truly human as God created us to be. Thus, in a search for consensus with all those of goodwill, we join with fellow Christians and with other religious people in prayer, meditation, fraternal dialogue, and cooperation, but we can also honestly join with secular humanists to make the world more truly human. To lose hope in the possibility of this union of heart and mind in Christ (1 Cor 1:10) would be to lose hope in Jesus as savior of all humanity.

In the first millennium of the church, ethical questions were generally treated separately in biblical commentaries, sermons, penitential guides for confessors, or in canon law rather than in systematic treatises. Yet the great Western church doctor, St. Augustine of Hippo (354–430 A.D.), in his many works of different types proposed an organized ethical theory that is of the ends–means type and centered on Christian love (O’Donnell and Fitzgerald 1999). At the same time Augustine, in a way more realistic than previous theologians of the Eastern and Western traditions, addressed the problem of why God’s good creation seems so distorted by sin. Augustine’s writings on the doctrine of original sin and the consequent need of divine grace for the restoration of the creation made it clear why ethical decisions are often so difficult. His teaching had little influence in the Eastern Church, but it became the basis of all subsequent theology in the West. After the division of the Eastern Orthodox Churches from the Catholic Church under the Bishop of Rome in 1054, the further development of moral theology was largely the work of the medieval universities in Western Europe, with their three professional schools for clergy, lawyers, and physicians.

Thus it was in this type of Christian theological ethics that the rising medical profession was first trained. In the thirteenth century this theological ethics received its most systematic treatment by the Dominican, St. Thomas Aquinas (1225–1274; see Weisheipl 1974; Torrell 1996; O’Meara 1997), who used the ethical writings of the ancient Greek Aristotle (384–322 B.C.), a pioneer in scientific biology, embryology, and psychology, to provide a strictly end-means system of ethics. At the same time, he assimilated to this theory elements derived from the ethics of Plato and of the Greek and Roman Stoics. In particular he adopted the Stoic term natural law, meaning accessible to human reason, but gave it an ends–means interpretation. He also made use of both Jewish and Islamic thought. Thus Aquinas synthesized the Greek ethics based on reason with the New Testament ethics based on revelation and pictured Jesus Christ, the Healer, as the perfect historical model of both human and divine virtue.

In the late Middle Ages, however, this synthesis began to fragment as a result of disputes between the university theologians and the university philosophers who were committed to the interpretation of Greek thought given by the Spanish Muslim scholar Averroes (Ibn Rushd, 1126–1198; Rubenstein 2003, 20). The central issue concerned whether God created and governed the world freely or fatalistically, which had major ethical implications, because human freedom and hence human ethical behavior are only a participation in God’s freedom. The theologians of the Franciscan order, beginning with John Duns Scotus (1266–1308) and more radically with the nominalist movement headed by William of Ockham (1280–1344) vigorously defended the freedom of God. Unfortunately, in defending God’s freedom, these writers thought it necessary to adopt an ethical voluntarism according to which morality is simply faithful obedience to God’s freely willed laws, a divine command ethic, or religious legalism (Gilson 1955; Wolter 1997; Maurer 1999). How extreme this could be is shown by Ockham’s assertion that if God were to command us to hate him then to love him would be a sin!

Luther and Calvin

Luther, the father of the Protestant Reformation, who was educated as a nominalist, experienced the Law of God as a crushing imposition that tempted him to rebel against God. Only when he read in St. Paul of justification by “faith alone” was he reassured that Christ had paid the price for our sins (Lohse 1999), and what remains for us is simply to accept that vicarious atonement in faith.

Yet the authentic Catholic doctrine, which nominalism had obscured, is that God’s Law is not an imposed burden but a loving guide on the path toward happiness with him. Jesus has indeed atoned for our sins, but by doing so has also made us a “new creation” (2 Cor 5:17; Gal 6:15), so that we live by a “faith working through love” (Gal 5:6; Jas 2:14–17). Thus by grace we truly cooperate in faith with Christ’s saving work, so that St. Paul can say, “Now I rejoice in my sufferings for your sake, and in my flesh I am filling up what is lacking in the afflictions of Christ on behalf of his body, which is the church” (Col 1:24).

Calvin, by stressing even more than Luther had done the sovereign freedom of God and the corruption of human reason by original sin, pushed voluntarism in ethics still further (Bouwsma 1988). Hence Protestant theologians have seldom attempted to develop an ends–means type of ethics. As the author of the article on “Moral Theology” in The Oxford Dictionary of the Christian Church (Cross and Livingstone 1997, 298), puts it, “Protestants have tended to dissociate themselves from attempt to produce detailed systems of duties binding on all Christians, on the ground that good works are a free and grateful response to the completed work of justification in Christ. Thus for Martin Luther, Christians are freed from self-concern implicit in ‘works-righteousness’ to serve their neighbors in love.” Yet among Protestants the tendency to rely on ethics exclusively on biblical precepts has led to a moral rigorism that leads them to accuse Catholics of moral laxism as a result of their reliance on forgiveness of sins in the confessional.

In reply to such accusations, Catholic theologians in the period after the Council of Trent encouraged the laity to use the sacrament of confession more often and more conscientiously. To facilitate this, many very detailed manuals for confessors were published that included numerous questions about the ethics of health care (Kelly 1979). Members of the new religious Society of Jesus, the Jesuits, wrote the most widely employed of the manuals for confessors. Although committed to the theology of St. Thomas Aquinas, these authors were influenced by the attempt of Francesco Suarez, S.J. (1548–1617), to synthesize Thomism with the thought of John Duns Scotus. Thus their manuals had a markedly voluntaristic and legalist tendency.

Hence arose the long “moral systems controversy” between the Dominicans loyal to Aquinas and the Jesuits loyal to Suarez. The debated issue was how to resolve a difficult moral decision when the application of a moral law was doubtful. The voluntarists based their position on the principle that “a doubtful law does not oblige,” because it is the obligation of the lawmaker to make his will clear. Thus one can conscientiously prefer an easier interpretation of the law if that interpretation can be shown to be at least probably true (probabilism). Dominicans, trained not in a duty ethics but in an ends–means ethics, argued that on the contrary one should follow the interpretation that was the more probable (probabiliorism), as the purpose of law is to guide us in choosing the best means to arrive at our true goal. If you ...