Where Has Catholic Medical Ethic Gone?

Patrick Guinan

Introduction

Catholic medical ethics dominated the discipline until the 1970s. The standard texts were those of Gerald Kelly¹, John Kenny², and Charles McFadden³. Today, of the 84 general bioethical resource texts cited by the Kennedy Institute for Ethics, National Reference Center for Bioethics⁴, only four can be considered Catholic. What happened? This paper will attempt to define Catholic medical ethics, give the reasons for its decline, describe those authors who uphold the Catholic ethical tradition, and, finally, provide reasons for hope for the future.

But first, so that everyone may understand where this essay is coming from, a definition of Catholic. By Catholic is meant the tradition of the Roman Christian Church as expressed in the Second Vatican Council documents and further exegeted by Pope John Paul II rather succinctly in his recent encyclicals Veritatis et Splendor, Evangelium Vi tae and Fides et Ratio. This tradition briefly affirms that God has ordained that faith and reason are compatible, man can know the truth and goodness in reality and he should will good over evil.

Catholic Medical Ethics

Catholic medical ethics is heir to the Judaeo-Greek tradition of religious and philosophical thought perfected by Christian interpretation over the past 3,000 years. There are two medical ethical traditions: clinical and academic. The first is the more general clinical tradition taken from the Hippocratic writings and further developed by physicians. It is basically a virtue ethic based on natural law and as such acknowledges sacred powers superior to man. It affirms the goodness of life and specifically forbids abortion and euthanasia. It promotes the golden rule which in medicine translates into beneficence, nonmalfiance and confidentiality.

The second is the more specific academic tradition that arose from the Church s charge to cure and care for the sick in imitation of Christ. The Church, even in apostolic times, cared for the sick, and later in the middle ages monasteries and monks were the practitioners of medicine. Spiritual and physical care became the discipline of pastoral medicine, which included rules prohibiting abortion and euthanasia. This tradition was developed by theologians: its history is well summarized by David Kelly⁵.

Prior to 1970 Catholic medical ethical texts dominated the field and usually began with an exposition of Aristotelian realist rational psychology which assumed that the acting person could know right from wrong and that they could freely choose one or the other. There then followed methods, such as the principle of the double effect, for determining the hierarchy of goods, and finally chapters on specific types of medical decision making such as abortion and euthanasia. This approach was rather standard and can be seen in such authors as Kelly, Kenny, and McFadden. It would be fair to say that medical ethics prior to 1970 was the Catholic tradition.

Reasons for Change

There are several reasons why Catholic medical ethics declined precipitously in the late l960s. The first and most important was the profound cultural change that coincided with the 1960s. The backlash to the Vietnam war and the civil rights movement were but two of the more visible effects of this profound change which really was the end of the Enlightenment Project with its focus on personal autonomy and the perfectibility of man. The ethic of the Enlightenment has been predominantly utilitarian. The Hippocratic tradition and Catholic medical ethics have been remarkably immune to Enlightenment philosophy and utilitarianism. Second, this cultural shift influenced the church which attempted to adjust to these societal changes with the Vatican II Council. The Council was scripturally based and attempted to evangelize the culture by reconciling divine truth with human freedom. Unfortunately Council "progressives" united to emphasize the latter over the former. Then came Humanae Vitae⁶ in 1968. This is an oversimplification, but in es sence, what happened was that the Catholic academic elite choose freedom over truth, as expressed by the Magisterium. The documents of Vatican II are theologically traditional and valid; however, given the information elite�s bias, the media spin favoured the distorted interpretation of the progressives.

The theologians Charles Curran⁷ and Richard McCormick⁸ are examples. In their medical ethical writings "conscience" trumped the Magisterium, principally in the areas of sexual ethics. This is a red herring because conscience, rightly formed, corresponds to truth and is not autonomous or "self actualizing" as implied by Karl Rahner⁹ and Henri de Lubac¹⁰, heroes of the progressives. The ethic of proportionalism, developed in part by Josef Fuchs¹¹ and Louis Janssens¹², suggested that a proportionately greater good, say a potential career, might justify an abortion in an unwanted pregnancy, and could therefore change the morality of an act. This theory is fundamental utilitarian and is therefore incomparable with exceptionless norms such as abortion and euthanasia.

Third, the discipline of bioethics was first described in 1971 by Potter von Rensselaer¹³ and soon pre empted medical ethics. The distinction between classical "medical ethics" and the more recent "bioethics" must be kept clearly in mind. Medical ethics concerned the rightness or wrongness of acts involving health, particularly in the treatment of disease. It involved physicians and ethical philosophers who specialized in medical matters. It had a Hippocratic component.

Bioethics arose in the past 30 years, in part, because of the need of third parties, usually the federal government, for oversight in healthcare matters and the public�s need for the appearance of ethical control. The predominant methodology of bioethics is "principalism"¹⁴.

Principalism is the regnant medical ethical system in the United States today¹⁵. It is essentially a system made up of mid level principles such as beneficence, nonmalfiance and autonomy, which are conducive to conflict resolution. The moral implications of principalism are neutral although it can be, and usually is, employed in justifying a proportionalist or utilitarian outcome.

Bioethics credentials varied widely from a Ph.D., or D. Min. to a certificate received after a few hours of lectures. Laws mandating institutional review boards to approve research projects, and ethics committees in hospitals, created an instant demand for schools to design programs to expeditiously produce these experts in bioethics. Medical ethics, by default, was diluted in the larger field of bioethics.

Fourth, and finally, medicine has lost the social prestige it enjoyed prior to 1970. This happened for a variety of reasons. The doctor-patient relationship eroded when technology replaced clinical expertise and empathy. Medical research excesses were revealed in the Belmont Report¹⁶. Third party interference in medical decision making weakened the doctor patient relationship. Authority in general, and the physician�s in particular, were no longer respected. Bioethics filled the resultant vacuum.

Catholic Medical Ethics and its Deviants

The Catholic position on medical ethics is rather clearly articulated in the Ethical and Religious Directives¹⁷ of the National Conference of Catholic Bishops. It might be pointed out that this document includes a section on Pastoral Care. It rather prophetically states that ethics includes not only the guidelines for what are not permitted in the medical treatment of disease, but it also provides positively for the spiritual care of the soul of the sick person (Part 2).

The two "life" issues, abortion and euthanasia, overshadow all others in medical ethics. The Catho lic Church, in its defence of the sacredness of life, articulated the natural law condemnation of both. Several encyclicals speak to these issues. Veritatis Splendor¹⁸, in proclaiming the validity of truth and the existence of exceptionless norms, such as the killing of innocents, specifically condemns proportionalism. Evangelium Vitae¹⁹ forcefully argues for the defence of life. Finally, Fides et Ratio²⁰ defends the compatibility of truth and reason.

In discussing Catholic medical ethics we will use as criteria the positions authors take on abortion and euthanasia. These two issues are straightforward and publicly familiar, and make equivocation difficult. We will attempt to limit our discussion to acknowledged Catholic authors.

The Catholic positions on these issues are clear cut. Abortion and euthanasia are not permitted; they are exceptionless norms. Kelly, Kenny and McFadden all considered them ethically objectionable. The Ethical and Religious Directives clearly state the Church�s medical ethical positions. Benedict Ashley and Kevin O�Rourke²¹ are in agreement as are Germain Grisz²², Robert Barry²³, H.P. Dunn²⁴, and William May²⁵. John Haas�s²⁶ Ethics and Medics, published by the National Catholic Bioethics center, is also solidly Catholic.

As mentioned previously, a break in what had been a fairly unified Catholic medical ethical position occurred after the encyclical Humanae Vitae appeared in 1968. The firestorm of dissent against the prohibition of contraception spilled over and involved other life issues such as abortion and euthanasia. In essence, it was argued that, if in his or her conscience a person felt that abortion was permissible, it was therefore morally acceptable. It was assumed that there was a proportionately valid reason to justify this admittedly serious action. The same applied to euthanasia.

While the origins of proportionalism began in Europe as far back as the utilitarians Jeremy Bentham and J.S. Mill, it impacted Catholic medical ethics after Vatican II through the influence of Fuchs and Janssens, as reflected in the writing of Charles Curran²⁷, Bernard Haring²⁸, John Dedek²⁹, and Danie Maguire³⁰. Although proportionalism was applied to many non-medical moral issues, its proponents used the publicity over the publication of Humanae Vitae to successfully promote the proportionalist agenda in areas of medical ethics. They have been remarkably effective in influencing and compromising Catholic medical ethical prac tice.

Two of the principal centres of bioethics: the Hast ings Center and the Kennedy Institute originally had Catholic backgrounds. They are influenced by the ethical methodology of principalism: the employment of this system directly and indirectly promotes proportionalism. It would be difficult to overestimate the influence of these two centres.

Pope John Paul II�s cogent and definitive rebuttal of proportionalism in the encyclical Veritatis et Splendor and the subsequent Evangelium Vitae has somewhat muted the movement among Catholics. However, its disciples are still publishing books, such as Richard Devine�s³¹, as well as journal articles from a proportionalism perspective.

It should be noted that the Hippocratic tradition has been correspondingly eroded by the emphasis on bioethics and principalism. Proportionalism is inherently opposed to a natural law and virtue ethics. The decrease in the use of the Hippocratic oath in medical school graduates is an example of this.

Conclusion

We have attempted to review Catholic medical ethics over the past fifty years. As mentioned previously, prior to 1960 medical ethics was two tiered but related. The Hippocratic tradition of natural law and virtue ethics was subscribed to by Catholic physicians who took the Hippocratic Oath at graduation. Related to this but more formal was the Catholic medical ethics of the moral theologians as reflected in the texts of Kelly, Kenny, and McFadden.

Cultural changes resulted in a disruption of both traditions. The Hippocratic Oath has been replaced by other pledges more congenial to the Zeitgeist. The natural law prohibitions of abortion and euthanasia have been compromised by proportionalism.

If indeed the Enlightenment Project and the modern era are ending, and a postmodern era is emerging, there is hope for a return to a sense of the sacred and a respect for natural law. Veritatis et Splendor may very well light the way. If so, there may be a return of Catholic medical ethics to the prominence it once enjoyed.

References

Kelly, Gerald: Medical, Moral Problems. Catholic Hospital Association, St. Louis, 1958.
Kenny, John: Principles of Medical Ethics. Newman, Westminister MD, 1952.
McFadden, Charles J: Medical Ethics, 6th Ed. Davis, Phil., 1961.
Basic Resources in Bioethics: 1996-1999. Kennedy Institute of Ethics J., 10:81-102,2000.
Kelly, David: The Emergence of Roman Catholic Medical Ethics in North America, The Mellen Press, New York, 1979.
Humanae Vitae: Encyclical on the Regulation of Birth. USCC, Washington, DC, 1968.
Curran, Charles: Medicine and Morals. Corpus, Washington, 1970.
McCormick, Richard: The new medicine and morality. Theologic Digest, 27,301-321, 1973.
Rahner, Karl: Concerning the Relationship Between Nature and Grace. Theological Investigations, 1961.
de Lubac, Henri: The Mystery of the Super natural. Herder and Herder, NY, 1967.
Fuchs, Josef SJ: The Absoluteness of moral terms. Gregorianum, 52:415-455, 1971.
Janssens, Louis: Ontic evil and moral evil. Louvain Studies, 4:115-116, 1972.
Potter, von Rensselaer: Bioethics: Bridges to the Future. Prentice Hall, Englewood Cliffs, NJ, 1971.
Levi B: Four approaches to doing ethics. J.Med. & Phil. 2 1:7-39, 1996.
Evans J: A sociologic account of the growth of principalism. Hastings Center Report Centre. Oct., 2000, pp 3 1-38.
Belmont Report: US National Commission for the Protection of Human Subjects. US GPO, 1978.
Ethical and Religious Directives: United States Catholic Conference, Washington, DC, 1995.
Veritatis et Splendor: Vatican Translation. St. Paul Book and Media, Boston, MA, 1993.
Evangelium Vitae: Inside the Vatican. April 1, Supplement 1995.
Fides et Ratio: Inside the Vatican, Oct., 1998.
Ashley, Benedict and O Rourke, Kevin: Healthcare Ethics, A Theological Analysis. The Catholic Health Association, St. Louis, MO. 1989.
Grisz, Germain, and Shaw, Russell: Beyond the New Morality: The Responsibilities of Freedom. U of Notre Dame Press, Notre Dame, Ind, 1974.
Barry, Robert: Medical Ethics: Essays on Abortion and Euthanasia. Lang, NY, 1989.
Dunn, HP: Ethics for Doctors, Nurses and Patients. Alba House, NY, 1994.
May, William: Human Existence, Medicine and Ethics. Franciscan Herald Press, Chicago, IL, 1977.
Haas, John: Ethics and Medics, National Catholic Bioethics Center, Boston, MA.
Curran, Charles: Politics, Medicine, and Chris tian Ethics. Fortress Press, Philadelphia, PA., 1973.
Haring, Bernard: Medical Ethics. Fides Pub lishing, Notre Dame, IN ,1973.
Dedek, John: Contemporary Medical Ethics. Sheed and Ward. New York, NY, 1975.
Maguire, Daniel: Death by Choice. Doubleday, NY, 1974.
Devine, Richard CM: Good Care, Painful Choices, Paulist Press, NY, 1996.

Dr. Patrick McGuinan MD is Associate Professor in the Dept. of Urology of the College of Medicine in the University of Illinois.

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