Bioethics: An Orphan Discipline
For many years, in Catholic seminaries, nursing schools, and colleges, systematic courses were given on what was called medical ethics. These courses were included in moral theology and philosophical ethics curricula, and were used in Catholic hospitals.
Between 1949 and 1955, Father Gerald Kelly, S.J. wrote a series of five booklets entitled Medico-Moral Problems, which were published by the Catholic Hospital Association of the United States and Canada. Father Kelly then revised the booklets and used them as the basis for his book, also entitled Medico-Moral Problems, which was published in 1957.1 The volume was arranged according to the second edition of Ethical and Religious Directives for Catholic Hospitals, issued by the Bishops of the United States. Father Kelly was probably the greatest moral theologian of the twentieth century. He was a careful worker who consulted a number of moral theologians before he published anything, and because of this his solutions were considered to have a high degree of probability. Other authors such as Charles J. McFadden2 and Thomas J. O’Donnell3 put out text books on medical ethics which were used by many priests. Catholic Hospitals stayed very close to the Bishops' Ethical and Religious Directives.
In the 1960s, the development of the birth control pill presented a new set of problems for the teachers of medical ethics. For the first time, Catholic moral theologians in the United States dissented from the authentic teaching of the Catholic Church. In anticipation of a change in the Church's teaching on contraception, some professors did not wait for the papal decision, but they began to teach that contraception was permitted. When the encyclical Humanae Vitae was issued by Pope Paul VI in 1968, for the first time in the history of the Church a large group of Catholic teachers signed a public statement which openly rejected the teaching of the Church. The revolt was organized masterfully. The leaders obviously had advance copies of the encyclical, obtained through corruption in Rome. The protest appeared in newspapers, such as the New York Times, in the same issue in which the publication of the encyclical was reported. This public protest presented a serious problem for many of these teachers. After they had expressed their dissent from the authentic teachings of the Church, they quickly had to realize that their dissent could not be defended on the basis of the traditional fundamental moral theology and ethics. Many of these writers then abandoned the traditional moral theology. Many of these attempted to create a new fundamental moral theology or ethics. When they presented these new creations to their scientific peers, however, they found that they couldn't convince one another. They all agreed on the answer, that people could practice contraception, but they could not agree why this was permissible. All of a sudden, Catholic moral theology was in a shambles. in 1993, Pope John Paul II had to provide them help in reconstructing moral theology with his great encyclical Veritatis Splendor (The Splendor of Truth).
Most non-Catholic moralists had accepted the legitimacy of contraception since 1930, when the Anglican Lambeth conference accepted it. Their attempts to justify the practice, however, were not cogent for most Catholic theologians. The resulting gap between theory and practice characterizes most Protestant theologians and many Catholic moral theologians. Nevertheless, both Catholics and Protestants tried to constitute fundamental moral theologies with principles drawn from Sacred Scripture and Church Fathers and Doctors.
Within the more specialized field of medical ethics, as Verhey and Lammers point out, a period followed, in the 1970s and afterwards, when interest in the religious traditions moved from the center to the margins of scholarly attention in medical ethics.4
One new feature of medical technology had a significant influence on the development of medical ethics. In the 1960s, Dr. Belding Scribner was using the medical technique called dialysis. In this technique the blood of a person whose kidneys have failed is passed out of the body, through a filtering machine, and back into the body. This technique was invented in the 1940s, but it could be applied only for temporary relief of critical kidney failure.
Patients with irreversible and complete kidney failure inevitably died. Dr. Scribner had a patient, Clyde Shields, whom he hoped to keep alive for a long time. After a previous patient had died, Dr. Scribner awoke in the middle of the night with a marvelous idea. He would insert into a vein and an artery a permanent arteriovenous access, "a tube that could be fixed into a vein and an artery, so that the patient could be hooked to and taken off the machine as often as necessary. The tube was made of Teflon tubing. The shunt worked, and Clyde Shields lived, with dialysis twice a week, for another twelve years.
Albert Jonsen has called this "an appropriate moment to signal the start of bioethics."5 The reason for this judgment is not the use of the new technique. The reason is that the Seattle Artificial Kidney Center had many more patients than it could treat. "A committee of laypersons was asked to choose, from the many medically qualified patients, the few who would receive life-saving treatment." Jonsen recalls the famous article in Life magazine by Shana Alexander, who described how the committee of laypersons decided who lives, who dies.6 The Seattle Kidney Center committee was forced to answer the question of life and death in a practical way, and without the application of traditional moral principles.7 It is this process, removed from the traditional solutions of moral problems in medicine, by the application of moral principles to particular cases, that Jonsen sees as the beginning of a new discipline of "Bioethics," distinct from both Moral Philosophy and Moral Theology.8
A new discipline or science deserves a new name. Jonsen mentions several people who were among the first to use the term “bioethics”: R. Sargent Shriver, Van Rensaleer Potter, Dr. Andre Hellegers, and Warren Reich.9
This new discipline of Bioethics began to be organized the 1960s through several important conferences. In 1960 a conference was held at Dartmouth College on "Great Issues of Conscience in Modern Medicine." The CIBA Foundation sponsored a conference in London in 1962. Gustavus Adolphus College in Minnesota held conferences in 1965 and 1967, and Reed College, in Portland, held one in 1966.10 Several centers were established, including The Hastings Center (in 1969), and The Kennedy Institute at Georgetown University (in 1970).11
The net result of these conferences and institutes was to move bioethics away from the authorities and institutions of the Catholic Church.
In the late 1960s, the development of the new discipline of bioethics was furthered by concerns about the ethics of research with human subjects. Senator Walter Mondale called for the establishment of a governmental commission to deal with the ethics of research with human subjects, as well as scientific advances in genetic engineering and heart transplantation. This initiative ultimately led to the National Commission for the Protection of Human Subjects of Biomedical and Behavioral Research (1974). Albert Jonsen was one of the eleven members of the National Commission, who were sworn in on December 3, 1974.12
One of the mandates given to the Commission was "to identify the ethical principles which should underlie the conduct of biomedical and behavioral research with human subjects, and to develop guidelines that should be followed in such research.".13 In order to carry out this mandate, they decided to have a closed retreat to explore the nature and role of ethical principles for human research. The retreat was held at Belmont House, a conference center in Maryland, in February 1976. The resulting report was known as The Belmont Report.14 The report, which was printed in 1979 by the United States Government Printing Office, is available in Source Book in Bioethics.15 The report set forth three basic principles particularly relevant to the ethics of research involving human subjects: the principles of respect for persons, beneficence, and justice. The application of these three general principles led to the three requirements of informed consent, risk-benefit assessment, and a just selection of the subjects for research.16
The National Commission was generally considered a success, according to Albert Jonsen. When the report was criticized by Professor George Annas because it merely endorsed the status quo, Jonsen and Michael Yesley responded to the critique. The Commission chairman, Kenneth Ryan, also replied, saying that the success of the Commission "depended on ideal commissioners who were academic, experienced and non-ideological, . . . and taking a pragmatic approach."17 These words of praise, however, point out the principal defect of the Report. By describing the work of the Commission as non-ideological and pragmatist, Dr. Ryan indicated that ethics in the Catholic tradition, with clear moral principles concerning death and mutilation, was neglected. The rules in the Belmont Report are admittedly "inadequate to cover complex situations. At times they come into conflict, and they are frequently difficult to interpret or apply."18 The principles are stated at such a high level that they may be said to be vague enough to be true. Reviewers of research of disparate ethical viewpoints may well agree on lofty generalizations, which provide little help in principled decisions.
The Ethics Advisory Board
The National Commission had suggested that certain kinds of research with the fetus and with children be submitted to a "National Ethics Advisory Board" to be established within the Department of Health, Education and Welfare. Secretary Califano chartered the "Ethics Advisory Board" (EAB). The EAB had two ethicians, Father Richard McCormick, S.J. and Sissela Bok, along with six physicians, several lawyers and lay members.19 The EAB took up one problem concerning research on the fetus, regarding the new procedure of fetoscopy, and a second problem, whether federal funds should support research on in vitro fertilization. With regard to the latter subject, the report favored support of research. No action was taken on the report. The report on fetoscopy, however, won approval, and became the first and only fetal research protocol to receive federal approval.20 The EAB was disbanded by the Department in 1980. Jonsen comments that the non-existence of the EAB allowed the Reagan and Bush administrations to avoid politically embarrassing decisions about funding of research with human embryos, or fetal tissues, between 1981 and 1992. By this comment, Jonsen seems to reduce ethical decisions to political correctness.21
The President's Commission
The next step in federal involvement in the study of ethical problems was the establishment of the President's Commission. President Carter signed the bill in 1978, and issued an executive order chartering the Commission in December 1979. Albert Jonsen was again appointed to serve on the Commission. Jonsen, by this time a laicized priest, was apparently the only Catholic appointed. The President's Commission's first assignment was to consider the advisability of a uniform, legal definition of death. Jonsen reports how he and one other commissioner, Patricia King, said that they could not fulfill the congressional mandate to find a uniform legal definition of death, and leave untouched the issues concerning the discontinuance of life support. The Commission agreed to undertake a distinct study of this latter problem — a study which led to the report entitled Deciding to Forego Life Sustaining Treatment. After some discussion, the President’s Commission issued a definition of death. In reaching their position, they tried to avoid confusion between permanent coma and total organic death. The report, entitled Defining Death, recommended for a model statute: "Death is the irreversible cessation of cardio-respiratory functions or the irreversible cessation of all functions of the brain, including the brain stem."22 No position was taken on the ethical implications of permanent coma or persistent vegetative state, from which total brain death had been distinguished.
The next important area of study was on the termination of life support. The word "forego" was chosen to cover both withholding life support and withdrawing it. Cases discussed included those of Karen Ann Quinlan, Abe Perlmutter, Joseph Saikewicz, In the Matter of Dinnerstein, and In the Matter of Spring. Classical ethics had used certain distinctions, including "ordinary versus extraordinary" treatment, "acting vs. refraining from action," "omission vs. commission," "direct vs. indirect killing." Jonsen reports how he did not object to the logical critique of the distinctions but to the implied suggestion that almost nothing of analytic usefulness could be salvaged from these distinctions. However, Jonsen seemed to be satisfied with the position formulated after the discussion. The wording accepted included this principle: "Nevertheless, the difference between acts and omissions — which is hard to draw in any case — never by itself determines what is morally acceptable. Rather, the acceptability of particular actions or omissions turns on other morally significant considerations, such as the balance of harms and benefits likely to be achieved, the duties owed by others to a dying person, the risks imposed on others in acting or refraining, and the certainty of outcome."23 This use of proportionalism is unacceptable for Catholics and Catholic institutions.
The Commission then reached the conclusion, that "A decision to forego treatment is ethically acceptable when it has been made by suitable qualified decision-makers who have found the risk of death to be justified in the light of all circumstances."24 Jonsen notes that the report includes a footnote reference to the 1980 Vatican Declaration on Euthanasia, that the terms "proportionate" and "disproportionate" be substituted for the more traditional, but outmoded, "extraordinary" and "ordinary." It is strange that the Vatican position was misused to defend direct killing.25
Jonsen criticizes the report for its insistence "that the current interpretation of the legal prohibition of active killing should be sustained." In taking this position, Jonsen moved another step away from acceptable Catholic teaching on direct killing.
This report, Deciding to Forego, while it endorses the idea that the competent patient is the best-qualified decision-maker, supplements this with various forms of proxy decision-making for the incompetent. It stresses, for the first time, the value of a durable power of attorney. It also deals with cardio-pulmonary resuscitation policy.26 Here a presumption is established in favor of resuscitation in the event of unexpected cardiac arrest. A competent and informed patient, or an incompetent patient's surrogate, is entitled to make the decision with the attending physician that an order against resuscitation should be written on the chart. When a patient will not benefit from resuscitation, a decision not to resuscitate, with the consent of the patient or surrogate, is justified27 With regard to patients with permanent loss of consciousness, the decisions of patients' families, following appropriate decision-making procedures, should be followed. In this case the patient requires "basic nursing care that is needed to ensure dignified and respectful treatment of the patient."28 This formulation leaves open the question of whether artificial nutrition and hydration ought to be included in basic nursing care. It seems clear that ANH should be provided in most cases.29 This report is described by Albert Jonsen as the most successful of the Commission's reports.
The discussion about securing health care to all Americans moved the work of the President's Commission away from ethical problems to the area of social ethics disputed between major political parties.
The work of the National Commission and the President's Commission involved the federal government in establishing policy based on ethical decisions. For the most part, these decisions were made by doctors, lawyers, and philosophers. The few Catholic theologians involved did not seem to have been concerned about the moral teachings of the Catholic Church, and the reports issued, of varying values, represent a secularized ethics, more influenced by the decisions of the civil courts than by Catholic ethical tradition.
Secularized Ethics
Albert Jonsen has written The Birth of Bioethics which has provided a good deal of the information about the growth of a secular bioethics independent of the principles drawn from ethical philosophy, moral theology, and the teaching authority of the Catholic Church. Jonsen is also the co-author with Stephen Toulmin of an earlier book The Abuse of Casuistry.30
Jonsen and Toulmin begin their book with a prologue stating the problem. They begin with the 1984 Presidential campaign in which Geraldine Ferraro, a Catholic, was challenged to state her position on abortion. Toulmin and Jonsen say, "She declined to endorse a simple, still less extreme position on either side of the dispute about the morality of abortion. She repeatedly stated that she was personally opposed to abortion, but believed that it should be a matter of choice and supported the rights of women to make their own decision." It is significant that Jonsen and Toulmin do not consider Ferraro's pro-abortion position as "an extreme position." After reporting statements of several 'Bishops attacking this position, the authors try to neutralize that response by referring to a full-page advertisement in the New York Times stating that "A diversity of opinion regarding abortion exists among committed Catholics."31 Right from the beginning, then, it is clear that Jonsen and Toulmin have moved out of the precincts of Catholic moral theology and traditional ethics. The attempt to justify this by these authors and the people represented in the New York Times ad by referring to the principles of moral theology such as probabilism, religious liberty, and the centrality of informed conscience is a completely erroneous use of Catholic theology.
Going further, Jonsen and Toulmin try to reduce the dispute over abortion to a political debate. They see a deeper intellectual conflict between two very different accounts of ethics and morality: "One that seeks eternal, invariable principles, the practical implication of which can be free of exceptions or qualifications, and another that pays closest attention to the specific details of particular moral cases and circumstances. The second position, which they try to dignify by the name casuistry, should more properly be called relativism. And it is inconscionable to hint that authentic Catholic thinkers pay no attention to "specific details of particular moral cases and circumstances." Reputable Catholic moralists know that morality is judged on the basis of the object, the end, and the circumstances of human acts, which then must be evaluated by the appropriate moral principles. In addition, the reference in the advertisement to "the centrality of informed conscience" is a complete misunderstanding of what is meant by an informed conscience in Catholic theology, as is clear from the encyclical letter of Pope John Paul II, Veritatis Splendor (August 6, 1993), quoting the Second Vatican Council's Declaration on Religious Freedom, which states that in "Informing their consciences the Christian faithful must give careful attention to the sacred and certain teaching of the Church. For the Catholic Church is by the will of Christ the teacher of truth. Her charge is to announce and teach authentically that truth which is Christ, and, at the same time, with her authority to declare and confirm the principles of the moral order which derive from human nature itself. It follows that the authority of the Church, when she pronounces on moral questions, in no way undermines the freedom of conscience of Christians. This is so because freedom of conscience is never freedom from the truth but always and only freedom in the truth."32
Jonsen and Toulmin further confuse the issues by bringing in the moral system of probabilism. But probabilism was not and could not be involved. As Vermeersch notes, "every divine precept is either certainly evident or uncertain. But a certain precept, even if the certitude is moral certitude, is binding."33 Thus probabilism only becomes operative in the absence of moral certitude. Probabilism as a moral system cannot be used when the probability of an opinion has been taken away by a later law, decree, or declaration of the Holy See.34 In the matter of abortion, as Pope John Paul points out in his great encyclical letter Evangelium Vitae (The Gospel of Life), the Christian tradition is clear and unanimous from the beginning up to our own day in describing abortion as a particularly grave moral disorder. That tradition begins with the Didache, one of the earliest Christian writings, which puts the matter clearly: "You shall not kill a child by abortion. "35 That same tradition was included in the documents of the Second Vatican Council, which declared that abortion and infanticide were unspeakable crimes. This teaching on abortion is one of three de fide teachings of this great encyclical of Pope John Paul II. The invocation of probabilism is completely without foundation.
Since abortion is the preeminent moral issue of our times, the ethical judgments about it provide a paradigm for judging the various moral positions. Jonsen and Toulmin say that people on both sides of the abortion debate have looked for universal laws and principles, and this has done much to make the whole debate unresolvable. They look instead for discussions about the morality of abortion which would be "temperate, and with discrimination, and with the acknowledgement that conflicting considerations are involved." They look for a just, if somewhat painful, balance between rights, claims, and responsibilities. In this way Jonsen and Toulmin reject the absolute value of fundamental moral principles and the paramount value of human life. Surprisingly, they even praise the approach of the United States Supreme Court in the infamous case of Roe v. Wade.36 It is also surprising that they try to approach difficult moral questions from the viewpoint of sociology. They cite an author who gave a course on the abortion debate by relating the positions of pro-life and pro-choice writers to their respective life styles, personal commitments, and levels of education. Jonsen and Toulmin note that sociologists paid special attention to the "zealots," and state that "zealots are the people least open to reason." They take this position because they hold that the "zealots" are committed to universal and invariable principles. This of course means that they could not accept a least common denominator morality by consensus. Jonsen and Toulmin describe people who accept absolute moral principles as dogmatists, and those who reject binding ethical principles as relativists and they try to position themselves in the middle. Unfortunately they do not see that there is no room for a tertium quid. Those who reject absolute moral principles are relativists.
Some Themes Of Catholic Moral Teaching
Here we enter the basic philosophical and theological distinction between traditional ethics, especially as it is found in the teachings of the Catholic Church, and the ethical position of the new bioethicists. On the one hand, the traditional ethics is based on the acceptance of the reality of God and the subordination of all human activity to God. There is a relationship between the moral good of human acts and the meaning of human life. The moral life is a life of Christian discipleship, which opens up before us the perspective of perfect love.
The Church has a long history of reflection on morality. In this reflection, Sacred Scripture remains the living and fruitful source of the Church's moral doctrine. The Second Vatican Council reminds us that the Gospel is the source of all saving truth and moral teaching.37
This traditional teaching is based on human freedom. Human beings are certainly free, but this freedom is not unlimited. It is called to accept the moral law given by God. Human truth itself is not a creation of human freedom. There cannot be a moral autonomy which would amount to an absolute sovereignty for human beings.
Modern thinkers often claim for their ethics an autonomy which disregards the dependency of human reason on divine wisdom. Many of these thinkers neglect the effects of original sin, and the consequent need for divine revelation as an effective means for knowing moral truths, even those of the natural order.38
An autonomy from God also involves the denial of specific doctrinal competence on the part of the Church and her magisterium with regard to particular moral norms which deal with the so-called "human good." There is an autonomy of earthly realities, in which created things have their own laws and values, which are to be gradually discovered, utilized, or ordered by man. Nevertheless, a false concept of the autonomy of earthly realities maintains that created things are not dependent on God, and that man can use them without reference to their Creator.39 Such a concept of autonomy is incompatible with the existence of God as Creator.
The Church's morality based on the natural law can provide for the universality of some moral rules. Since the natural law expresses the dignity of the human person, it is universal in its precepts, and its authority extends to all mankind. The positive precepts are universally binding, and they are applied to particular acts through judgments of conscience. On the other hand, the negative precepts of the natural law bind always and without exception. They oblige everyone, regardless of the cost, so as never to offend the personal dignity of any human being. These negative precepts from time to time create situations in which we must be prepared to die rather than to do evil. There are, then, moral absolutes which must be observed in any and all circumstances.
This brief summary of central themes of moral teaching is drawn mainly from the work of Pope John Paul II. It is this kind of moral teaching which, we must insist, should govern the ethical discussions in our Catholic health care facilities. It is the kind of moral teaching which is being rejected by many writers and ethicians in the discipline of bioethics. To the extent that these new bioethicians cut themselves off from sound philosophical and theological ethics, to that extent they have become an orphan discipline.
Notes
1. Gerald Kelly, S.J., Medico-Moral Problems (St. Louis, Missouri: The Catholic Hospital Association of the United States and Canada), 1958.
2. Charles J. McFadden, O.S.A. Medical Ethics (Philadelphia: F. A. Davis Company), 1955.
3. Thomas J. O'Donnell, S.J. Medicine and Christian Morality (New York: Alba House), 1975.
4. Allen Verhey and Stephen E. Lammers, Theological Voices in Medical Ethics (Grand Rapids, Michigan: William B. Eerdmans Publishing Company, 1993), p. 3.
5. Albert R. Jonsen, The New Medicine and the Old Ethics (Cambridge, Mass., and London, England: Harvard University Press, 1990), p. 18.
6. Shana Alexander "They Decide Who Lives, Who Dies," Life, November 9, 1962, p. 102.
7. Jonsen, New Medicine, p. 18.
8. Ibid.
9. Jonsen, Birth of Bioethics, 26ff.
10. Ibid., 13-17.
11. Ibid., 20-24, 99.
12. Ibid., 90-109, esp. 99.
13. Ibid., 102.
14. Ibid.
15. Source Book in Bioethics, ed., by Albert Jonsen, Robert M. Veatch, and Leroy Walters (Washington, D.C.: Georgetown University Press, 1998), pp. 22-28.
16. Jonsen, Bioethics, p. 104.
17. Ibid., p. 102.
18. The Belmont Report, Source Book, p. 22.
19. Bioethics p. 106.
20. Ibid., p. 107.
21. Ibid., p. 107.
22. Ibid., p. 110.
23. Birth of Bioethics, p. 112; Source Book, p. 169.
24. Bioethics, p. 113.
25. Ibid., p. 113
26. Ibid.
27. Sourcebook, p. 162.
28. Ibid., p. 161.
29. See George P. Graham, Homiletic and Pastoral Review, 1998.
30. Albert Jonsen and Stephen Toulmin, The Abuse of Casuistry: A History of Moral Reasoning (Berkeley, Los Angeles, London: University of California Press, 1988).
31. Abuse, p. 1.
32. Veritatis Splendor, no. 64.
33. Arthur Vermeersch, S.J. Theologiae Moralis: Principia-Responsa-Consilia, Tomus I (Romae: Gregorian University Press, 1947) p. 284, para. 340.
34. E. F. Regatillo and M. Zalba, Theologiae Moralis Summa (Madrid: Biblioteca De Autores Cristianos, 1952), p. 305, par. 275.
35. Pope John Paul II, The Gospel of Life, no. 61.
36. Jonsen and Toulmin, p. 4.
37. Pope John Paul II, Encyclical letter Veritatis Splendor, (The Splendor of Truth) (August 6, 1993).
38. The Splendor of Truth, No. 35, 36.
39. Pope John Paul II, Splendor of Truth, no. 39, quoting the Second Vatican Council's Pastoral Constitution on the Church in the Modern World, no. 36.
Monsignor George P. Graham received a J.C.D. degree from the Catholic University of America and a Ph.D. degree from New York University. He served the Diocese of Rockville Center in New York as Vice-Chancellor, Vice-Officialis, and Officialis. He has been pastor of St. Bernard's Parish in Levittown since 1981. He is the author of William James and the Affirmation of God (New York: Peter Lang, 1992) and articles and book reviews in The Jurist, The Proceedings of the Canon Law Society of America and Homiletic & Pastoral Review.
© 2001 Ignatius Press
This item 4126 digitally provided courtesy of CatholicCulture.org
