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Which Medical Ethics for the 21st Century?
Dianne N. Irving
Everyday we read and hear about the constant onslaught of controversial medical issues, e.g., euthanasia, physician-assisted suicide, test-tube babies, cloning and stem cell research, creating monsters in the lab, etc. — it is all coming down very fast and we will all have to make decisions about these and many other issues not even imagined yet in the 21st Century. But what will be the basis of our decisions, of our choices?
Everyday we read and hear about the constant onslaught of controversial medical issues, e.g., euthanasia, physician-assisted suicide, test-tube babies, cloning and stem cell research, creating monsters in the lab, etc. — it is all coming down very fast! This is not just business as usual! Yes, we will all have to make decisions about these and many other issues not even imagined yet in the 21st Century. But what will be the basis of our decisions, of our choices? Perhaps it is time to stop and seriously reconsider which medical ethics should be used as the basis of these choices — while we still can! This choice will be critical to the well-being of each of us individually, as well as to the well-being of our society at large. I cannot help but recall a favorite caution of St. Thomas (paraphrased): “A small error in the beginning leads to a multitude of errors at the end”! Indeed, the ethical theory we choose will be the starting point for these complicated decisions. As such it can cause us to reach conclusions and perform actions that are harmful and destructive — or those, which will enrich, fortify, and strengthen all of us. The choice, of course, is yours.
Abstracting from all the possible academic ethical theories which will be vying for your patronage, I will focus narrowly instead on two theories of medical ethics — secular bioethics and Roman Catholic medical ethics, pointing out briefly what they are, comparing their conclusions about what is right or wrong, and indicating where they have already lead us. Frankly, I am convinced that secular bioethics can only lead us — individually and collectively — to profound destruction, and should in no way be confused with Roman Catholic medical ethics. In fact, I would encourage Catholics to stop using the term “bioethics” with reference to the Church’s moral positions. I want to end by touching briefly on how the John Carroll Society itself embodies the very heart and soul of Roman Catholic medical ethics — and as such serves as a working role model for the rest of us.
To begin with, consider that ideas do have consequences — especially ideas about ethics when they are applied. Fundamentally different ethics lead to fundamentally different conclusions about what is right or wrong. Nowhere is this more obvious than in medical ethics. A quick comparison of the different conclusions already reached by secular bioethics and Roman Catholic medical ethics should make this graphically clear.
Consider for a moment the strikingly different conclusions they reach. Secular bioethics considers the following as ethical: contraception; the use of abortifacients; prenatal diagnosis with the intent to abort defective babies; human embryo and human fetal research; abortion; human cloning; the formation of human chimeras (cross-breeding with other species); “brain birth”; “brain death”; purely experimental high risk research with the mentally ill; euthanasia; physician-assisted suicide; living wills documenting consent to just about anything; and, withholding and withdrawing food and hydration as extraordinary means. In contrast, Roman Catholic medical ethics, as expressed in the National Conference of Catholic Bishops’ Ethical and Religious Directives for Catholic Health Care Services,1 considers all of these unethical — with the possible exception of the use of “brain death” criteria (and some Catholic theologians are now becoming concerned about that as well). Probably the only issues on which they both agree is that the use of extraordinary means, e.g., a ventilator, is not morally required if a treatment is medically futile, and that even high doses of pain medication may be given if medically appropriate. How is it that these two ethical systems lead to such opposite and contradictory conclusions? It is because their conclusions flow necessarily from very different ethical principles, or premises.
Secular bioethics is an academic ethical theory that was made up in 1979 by a group called the National Commission, and documented in their Belmont Report.2 They were attempting to identify “neutral” ethical principles that could be used in a pluralistic, multi-cultural society — where no one’s ethics should be imposed on others. The Belmont Report identified three ethical principles — respect for persons (which rapidly evolved to mean pure autonomy), justice and beneficence — otherwise known as “the Georgetown Mantra.”3 These principles were supposedly drawn from the systems of various philosophers — e.g., Kant, John Stuart Mill, and John Rawls. In effect, they took bits and pieces from different ethical theories and rolled them up into one ball. Each of these principles they referred to as prima facie — i.e., no one principle could over-rule any of the others. The way we come to know these ethical principles is by taking courses, attending conferences, and listening to bioethicists lecture.
However, eventually and inevitably cracks began to form in the very foundation of this brand new ethical theory. For example, because bioethics was derived from bits and pieces of fundamentally different and even contradictory theoretical systems, the result was theoretical chaos, rendering it academically indefensible. More problematic, when people tried to apply the theory it didn’t work because practically speaking there was no way to resolve the inherent conflicts among these three principles.
While the Commissioners of the Belmont Report gave a nod to the traditional Hippocratic understanding of Beneficence as “doing good for the patient”, their definition is essentially and predominantly utilitarian, with particular emphasis placed in that Report on the “good” for society at large — or roughly, “the greatest good for the greatest number of people”. Utilitarianism has always had a serious problem with defining in practice what “good” is, but it is generally reduced to some sort of lack of pain, or pleasure. It is clear, however, that their formula leaves minorities and the vulnerable out in the cold. There are no moral absolutes here — only “rules” or risk/benefit ratios, which are by definition relative. As utilitarian, the general norm or standard against which one determines if an individual action is right or wrong is “utility”; i.e., if that action is useful to achieving good consequences, those being defined as “the greatest good for the greatest number”. The principle of Justice, too, is ultimately defined along utilitarian lines. Even the principle of Autonomy eventually ends up serving “the greatest good” — as I will indicate in a moment. At any rate, after all is said and done, bioethics is reduced to some form of utilitarianism or relativism, where “consequences” are the only morally relevant condition and the “good” of the individual person is clearly not top priority.
There are several misconceptions about bioethics I would like to clarify. First, bioethics is not really just the “general moral consensus of the people”, but rather it is an idiosyncratic systematic academic theory of ethics alongside many other such academic ethical theories or systems vying for recognition in the universities — bioethics simply being the one that was made up by the National Commission. Second, bioethics should not be equated with the entire field of “ethics” per se, as often seems to be the implication today, but again, it is only a sub-field of ethics. Third, bioethics is not a “neutral” ethical theory at all, but defines itself as “normative” — i.e., it takes a stand on what is right or wrong.4 In fact, there is no such thing as a “neutral” ethics — and that includes utilitarianism, consensus ethics, Kantianism, cultural relativism, emotivism, casuistry, and communitarianism as well.
Eventually, as with most made up theories, bioethics is now in fact dysfunctional — it doesn’t work, as admitted in publications by even many of the founders themselves — the best kept secret in bioethics! For example, Daniel Callahan (one of the founders of the bioethics “think tank”, The Hastings Center, and former Director of the American Eugenics Society)5 conceded in the 25th anniversary issue of The Hastings Center Report celebrating the “birth of bioethics”, that the principles of bioethics simply had not worked. But not to worry, he said, we’ll try communitarianism now: “The range of questions that a communitarian bioethics would pose could keep the field of bioethics well and richly occupied for at least another 25 years”!6 Al Jonsen, one of the original members of the National Commission, admitted in his “Preface” to the first serious book confronting the myriad inadequacies of “bioethics principlism”, that there were really only two real ethicists on that Commission, that they had essentially made the principles up, and agrees with the premise of the book that bioethics should now be regarded somewhat as a sick patient in need of a thorough diagnosis and prognosis:
A fairly widespread perception exists, both within and without the bioethics community, that the prevailing U.S. approach to the ethical problems raised by modern medicine is ailing. Principlism is the patient. The diagnosis is complex, but many believe that the patient is seriously, if not terminally, ill. The prognosis is uncertain. Some observers have proposed a variety of therapies to restore it to health. Others expect its demise and propose ways to go on without it.7
Gilbert Meilaender’s early and incisive suspicions about the consequences of the
several “mind/body splits” inherent in bioethics theory emerged in yet another
important book, in which he explains “how easily the ‘soul’ — attention to the
meaning of being human, a meaning often illuminated by religious and
metaphysical insight — can be lost in bioethics.”
Equally problematic is the fact that only a very tiny percentage of “professional bioethics experts” have any academic degrees in bioethics at all, and even for those few that do there is no uniform or standardized curriculum, most teachers don’t really know the subject matter themselves, the courses vary from institution to institution, there are no local, state or national boards of examinations, and no standardized professional responsibilities are required. There is not even a code of ethics for bioethicists. Most “bioethicists” by far have never taken even one course in bioethics.10
Regardless, these bioethics principles of autonomy, justice and beneficence were made the explicit basis for many major governmental regulations, private sector and industry guidelines, even international guidelines still in use today — e.g., the federal OPRR regulations on the use of human subjects in medical research, The Common Rule, Institutional Review Board Guidebooks, Hospital Ethics Committee Guidebooks, most policies for hospitals and other health care facilities, the international CIOMS/WHO Guidelines for the use of human subjects in Third World countries, etc.11 The bioethics principles now literally redefined the “ethics” of other disciplines, e.g., business ethics, and ethics in engineering. Even our country’s military schools have restructured their ethics courses and essentially reduced them to courses in bioethics. Many colleges and universities already require a course in bioethics in order to graduate.
More recently, the proposed statute concerning the use of “decisionally incapacitated” human subjects in medical research, introduced in the State of Maryland legislature in early March 1999, is grounded on these same three bioethics principles, as its first drafts explicitly states. This proposed statute purports to”respect the autonomy” of mentally ill human subjects to such an extreme that it would allow them to give informed consent to choose “research agents” who would then “substitute their judgments” as to whether or not these mentally ill persons would have wanted to participate in even high risk, no direct benefit medical research for “the greater good of society”, were they competent12 — an absurd and dangerous interpretation of autonomy and altruism, indeed.
Although bioethics wants to claim that it does not embody any anthropology — or definition of a “person” — it obviously does. One of the most popular by far comes from one of bioethics’ most infamous practitioners. Australian animal rights philosopher/bioethicist Peter Singer, President of the International Institute of Bioethics under the United Nations, and the newly appointed director of Princeton University’s Center for Human Values, defines a “person” as something actively expressing “rational attributes” (autonomy, choosing, loving, self-consciousness, relating to the world around one, etc.), and “sentience” (feeling pain and pleasure). Therefore, he enthusiastically advocates infanticide of even normal healthy newborn human beings — in fact, even older children. Why? Because they do not actively express “rational attributes” or “sentience”, and therefore they may be human beings, but not “persons”. On the other hand, he claims that the higher primates, e.g., apes, monkeys, dogs, pigs, chickens — even prawns — are persons because they do actively exercise “rational attributes” and “sentience”:
... For on any fair comparison of morally relevant characteristics, like rationality, self-consciousness, awareness, autonomy, pleasure and pain, and so on, the calf, the pig and the much derided chicken come out well ahead of the fetus at any stage of pregnancy — which if we make the comparison with a fetus of less than three months, a fish or even a prawn would show more signs of consciousness. Since no fetus is a person, no fetus has the same claim to life as a person.13
... Now it must be admitted that these arguments apply to the newborn baby as much as to the fetus. A week-old baby is not a rational and self-conscious being; and there are many nonhuman animals whose rationality, self-consciousness, awareness, capacity to feel, and so on, exceed that of a human baby a week, a month, or even a year old. If the fetus does not have the same claim to life as a person, it appears that the newborn baby does not either, and the life of a newborn baby is of less value that the life of a pig, a dog, or a chimpanzee. ... In thinking about this matter we should put aside feelings based on the small, helpless and — sometimes — cute appearance of human infants. To think that the lives of infants are of special value because infants are small and cute is on a par with thinking that a baby seal, with its soft white fur coat and large round eyes deserves greater protection than a whale which lacks these attributes. Nor can the helplessness or the innocence of the infant homo sapiens be a ground for preferring it to the equally helpless and innocent fetal homo sapiens.14
But if it is true that a “person” is defined only in terms of the actual exercising of “rational attributes” and “sentience”, then the following list of human beings are also not human persons, and therefore not due the same ethical and legal rights and protections as persons: the mentally ill, mentally retarded, patients with Alzheimer’s or Parkinson’s disease, the comatose, alcoholics, drug addicts, the frail elderly, paraplegics and all other disabled human beings, patients with nerve damage or disease, etc.
Philosopher/bioethicist R.G. Frey15 correctly pushes Singers logic to its inevitable conclusion: the mentally ill, etc., who are not “persons” should be substituted for the higher primates, who are “persons”, in purely destructive experimental research. This is ethical — even morally required for “the greater good”. Similarly, Norman Fost defines cognitively impaired human beings as “brain dead”. Singer, who also enthusiastically promotes eugenics, uses all three bioethics principles at will, depending on which one gets him where he wants to go. Thus adroitly he appeals to our autonomy — e.g., if the parents of a defective newborn, or even a normal newborn, autonomously “choose” to kill their child, then that is ethical and we must respect their autonomous rights. However, if the parents won’t do this on their own accord if it is for “the greater good”, then the government has the duty to force them to do it, particularly if the child is defective! So much for rights; in fact, Singer does not even believe in rights at all!16 His colleague R.M. Hare is just as articulate when he discusses the role of the government in such issues. For Hare, the maximum duty that is to be imposed by the government is to do the best impartially for all the “possible people” there might be by having an optimal family planning or population policy, which means necessarily excluding some possible people. Indeed, he argues, the best policy will be the one which produces that set of people, of all “possible sets” of people which will have in sum the best life, i.e., the best possible set of future possible people!17
No wonder Singer has been run out of Germany, Austria, and France, and is picketed just about every place he lectures. I worry how Singer will define “human” values at his new Princeton post — will it include the values of only some human beings and not others? Isn’t this establishing a category of sub-human human beings? Haven’t we been there before?
At any rate this explains in essence what bioethics is, what its ethical principles are, and why it comes to the conclusions it does in these medical ethics issues. Given that secular bioethics comes to so many conclusions opposite from those of Roman Catholic medical ethics, I would suggest that we reconsider using the term “bioethics” to refer to Roman Catholic medical ethics. One is definitely not the other.
The moral law
By contrast, the Church bases its ethical decisions on the moral law — and the moral law itself is composed of two basic laws — the natural law, or what we can know is right or wrong through the aid of reason alone, and Divine Law as interpreted (not made up) by the Magisterium.18
The natural law does not mean the “laws of Nature” or the “laws of the Cosmos” — as many New Age gnostic versions of natural law advance, nor does it refer to the “laws of society”, but is grounded instead on the objective and objectively knowable nature of human beings. It is not something made up. Because it is based on our common humanity, natural law transends different cultures, times, ethnic backgrounds, etc. — and is therefore truly applicable to all people at all times — including the 21st century.
Here the common good is not defined as “the greatest good for the greatest number of people”, but rather as those goods which all human beings, simply as human beings, have in common — e.g., food, water, shelter, clothing, friendship, etc. Maritain captures the stark difference between these two concepts of “the common good”:
The end of society is the good of the community, of the social body. But if the good of the social body is not understood to be a common good of human persons, just as the social body itself is a whole of human person, this conception also would lead to other errors of a totalitarian type. The common good of the city is neither the mere collection of private goods, nor the proper good of a whole which ... relates the parts to itself alone and sacrifices them to itself. It is the good human life of the multitude, of a multitude of persons; it is their communion in good living. It is therefore common to both the whole and the parts into which it flows back and which, in turn, must benefit from it. ... It presupposes the persons and flows back upon them, and, in this sense, is achieved in them. ... It is a fundamental thesis of Thomism that the person as such is a whole. The concept of part is opposed to that of person. To say, then, that society is a whole composed of persons is to say that society is a whole composed of wholes. ...[I]f the person of itself requires “to be part of” society, or “to be a member of society”, this in no wise means that it must be in society in the way in which a part is in a whole and treated in society as a part in a whole. On the contrary, the person, as person, requires to be treated as a whole in society.
As human beings we are always persons. “Personhood” is coextensive with human nature. By virtue of possessing intellect and will, we are “beings of a rational nature”, or “rational animals” — and therefore by definition we are also persons simply by possessing this human nature19 — whether we happen to be exercising it or not. Nor is “person” the same as the common understanding of “personality.”20
It is because we are persons who knowingly and willingly choose to perform certain actions that those actions are called “moral” or “immoral”. Since our human natures always strive toward our human good or perfection — our “end” — we know empirically that those actions are morally right which lead us to our natural end, and those actions are morally wrong which lead us to harm instead, or go against the good of our human nature. For example, taking crack cocaine is wrong because it harms us, hurts us, prevents us from reaching our human ends or goods — not because God said so. A human act, then, derives its moral goodness from its conformity with human nature. And human nature cannot be changed (and still remain human).
The first ethical principle of the natural law, from which several other principles are drawn, is familiar to us all: “Do good and avoid evil.”21 Natural law also includes three (not one) general norms against which we determine what is right or wrong: (1) the subjective norm — not just “conscience”, but a well-formed conscience; (2) the objective proximate norm — right reason, a very rich understanding of reason which embraces the harmony, interrelationship and good within any single individual, as well as among individuals within a society. Here the “common goods” must flow back upon the backs of each and every member of that society, and the institutions are there to ensure that;22 and, (3) the ultimate norm — the Divine Nature itself, the ultimate measure of right and wrong, and of goodness. Of course, the Divine Nature is not the subject matter of natural law philosophical ethics, but of theology (which I will address in a moment).
In applying these general norms to concrete situations we decide what particular actions are right or wrong based on three (not one) conditions: the kind of action, the intention for doing the action; and the circumstances under which the action is done. All three conditions must be met for an action to be ethical; and although the intention and the circumstances are mostly determinative, there are some — not many, but some — kinds of actions that are absolutely morally right or wrong. For example, kinds of actions such as using human beings in research with the intention of helping to cure diseases is not inherently wrong, in fact it is laudable, as long as certain circumstances prevail, e.g., the person has given informed consent, and any harm sustained is proportionate to the medical good that can be derived. However, this does not mean that we can volunteer to mutilate or otherwise seriously harm ourselves. Nor does it mean that even early human embryos, who are scientifically human beings and therefore human persons, may be destroyed in order to help others in need.23 It is inherently wrong to intentionally kill an innocent human being — regardless of the intention, or the circumstances — or her size. Evil may not be done that good may come of it.24
Natural law theory may seem at first a bit complicated, but then life is complicated, isn’t it? So shouldn’t the theory reflect this reality? All in all, this is a very objective, realistic, interrelated, rich ethical theory — grounded on our very natures as human, and known deep in the heart of every human being.25 It is itself a part of the eternal law, which includes both the physical laws of nature and the moral law.
You might ask though, if the natural law is naturally known, why is it that so many people don’t seem to know it, act against it, even deny it? This is a good question, and does indeed point to the limits of using just the natural law as a moral guide in the 21st century. Many people have lost their sense of the natural law within them by habitually acting against their true good, by seeking only things that feel good, or by succumbing to the myriad of temptations constantly surrounding us that seem good.
Can ethics, then, be built on man alone? If a human act derives its moral goodness from its conformity with human nature, from where does human nature get its goodness? To really answer these questions we need also look further at the other part of the moral law — the Divine Law, as interpreted by the Magisterium.
The Divine Law is essentially what we learn through Divine Revelation, as interpreted by the Magisterium — the Bible, the Word of God (not, by the way, to be equated with theological theories). We accept it on faith, and faith of course is a gift. It is roughly summarized for us in the 10 commandments — commandments which are definitely not emblematic of some dictatorship, but rather are there to help us, to guide our human actions toward an even higher good than natural ones — eternal life with God — our ultimate end or GOOD. It is from the Divine Goodness of the Nature of God Himself that the natural goodness of our own human nature is derived. And so it is this whole moral law, taken in its entirety, which grounds the Church’s positions on the list of medical ethics issues I compared earlier.
Now which of these ethical systems would you choose to guide you in considering the complicated ethical issues in the 21st century — many of which are already here? The choice is yours. Should we enter the 21st century embracing the relativistic and utilitarian bioethics of the National Commission — an ethics which in no way really reflects the consensus of the majority of human beings, an ethics which is artificial, not neutral, is theoretically indefensible and practically unworkable, and therefore already defunct? An ethics which absolutizes autonomy in the extreme, but where eventually even autonomy is rendered useless and absorbed into an absolute utilitarian ethics which abandons the good of the individual human being and eliminates any good of any minority?26 A theory where many human beings have less worth than a chicken or even a prawn — and so therefore they can be killed by “choice” or used as “biological materials” in research to further “the greater good” of perfect people?
Or will you choose an ethics which is objectively grounded on our very human natures, on what we know empirically is either harmful or good for us as human beings? One which defines the “common good” as those goods which we hold in common simply as human beings? A rich consistent ethics that is cognizant of and matches the complexities of daily living in the real world? One grounded on the immutable laws of man’s nature but which is capable of being drawn to immeasurable heights by its perfection in the Divine Law, the Word of God?
The individual members of the John Carroll Society
It is indeed this moral law, I would suggest, which is embodied in the many good works of the John Carroll Society. How? Well, according to the moral law, among all other creatures, rational creatures (that’s us!) are subject to and participate in Divine Providence in a more excellent way (if they so choose) insofar as they are provident— by trying to take care of, do good for, themselves and others:
... Now among all others, the rational creature is subject to divine providence in a more excellent way, in so far as it itself partakes of a share of providence, by being provident both for itself and for others.27 (emphasis mine)
And in a very special way you, the members of this Society, do precisely that. Through the kinds of actions such as sharing your gifts, your talents, your time and efforts, through your gifts of knowledge of medicine and law and all the other important professions, you have already produced enormous concrete good for our suffering and vulnerable brothers and sisters here in Washington. You have knowingly and willingly chosen to care for the sick, the troubled, the lonely, the forgotten, the abandoned, the disabled, the vulnerable. (We are all vulnerable, aren’t we?).
By thus being provident for others you in fact do participate in the Divine Providence of God. Like Mother Teresa, your actions also help to fortify us all against our own deep dark unspoken fears of our earthly mortality, of the incontinence and dependency of aging, of the inevitable weakening of our bodies and our minds. In our vulnerable sisters and brothers we see ourselves, and we know that for the grace of God there go I! You have heard, “seen” through the light of understanding elevated by faith, and heeded the Word of God, instructing us that “As you did it to one of the least of these my brethren, you did it to Me.”28 Somehow you understand that the reason why you do this is, your intentions, are ultimately because you love God — the ultimate reason for all of our actions. You know that there is more to life than this life!
So which ethics will you choose to guide us through the turbulent 21st century before us — secular bioethics, or the moral law? The choice is yours — though it might be prudent to remember that it is not just that we have a choice. Of course we each have a choice, or there would be no ethics at all! The real issue is whether or not that choice is good or bad. A small error in the choice of an ethics will lead to multiple — indeed — massive harm and destruction in the 21st century — for ourselves, as well as for our culture and society.29 Choose well, my friends.
Irving, Dianne N. “Which Medical Ethics for the 21st Century?” Presented at the Eighth Annual Rose Mass Brunch, sponsored by the John Carroll Society, The Grand Hyatt Hotel, Washington, D.C., (March 14, 1999).
Published with permission of the author.
Dr. Irving is Professor of Philosophy and Medical Ethics at The Pontifical Faculty, The Dominican House of Studies, Washington, D.C. She has also taught at the De Sales School of Theology, The Catholic University of America and Georgetown University. She is a former career-appointed bench research biochemist at the National Institutes of Health, Bethesda, MD. Her doctoral dissertation at Georgetown University was, A Philosophical and Scientific Analysis of the Nature of the Early Human Embryo (1991). She has written and lectured extensively on the ethics of human embryo research, human cloning, research with the mentally ill, abortion, natural law and “personhood”. The second edition (1997) of her book, The Human Development Hoax: Time To Tell The Truth!, co-authored with human embryologist Dr. C. Ward Kischer, is distributed by the American Life League, Stafford, VA. or can be purchased through Amazon.com.
Copyright © 1999 Dianne N. Irving, Ph.D.