The term Bioethics began to be discussed only from 1950s and 1960s however the terms like medical ethics and biomedical ethics were already in fashion. It is the technological advances in the biomedical area like; saving, improving and extending human lives necessitated the entry of bioethics. In biomedicine, 1960s was an era of extraordinary technological progress. It saw the advent of kidney dialysis, organ transplantation, medically safe abortions, the contraceptive pill, prenatal diagnosis, the widespread use of intensive care units, and artificial respirators, a dramatic shift from death at home to death in hospitals or the institutions like old-age home, and the first glimmering of genetic engineering. Medicine is transformed from a diagnostic and palliative (pain killing) discipline into a potent agent able to cure disease and effectively forestall death.
Today bioethics is a field that ranges from the anguished private and individual dilemmas faced by the physicians or other health care workers at the bedside of the dying patient to the terrible public and societal choices faced by citizens and legislators as they try for justice in health care.
Word Bioethics – Potter, Van Rensselaer – USA – Cancer researcher – biologist - 1971. Bioethics: Bridge to the Future (Englewood Cliffs, N.J.: Prentice Hall)– Bios=Life, Ethics= Science of morals, system of moral principles, rules of conduct Bioethics is considered as an independent or new discipline v/s branch of ethics or subdivision or sub discipline or a component of ethics. An intersection of ethics and the life sciences
The object of special moral theology is to concretize man’s response to God’s call in specific areas of life. Moral life is the response to God’s call – Bernard Haering – Call and response - Moral theology in general sketches out to us “what should be our response to God’s call”. Bioethics restricts the area this response and see that how a man can respond to God’s call in the area of concern for our neighbour, and that, in the value incarnated by the 5th commandment: the value of life – from birth to death. So value of life from birth to death is the object or special concern of medical or bioethics. Different terms: Bioethics – Medical Ethics – Biomedical Ethics – Health Care Ethics – Medical humanities
Bioethics is a systematic study of human behaviour or acts (actus humani distinct from actus hominis acts of man) in the field of life sciences and health care, in so far this behaviour is examined in the light of moral values and principles. - Warren T. Reich. Bioethics studies the morality of human conduct in the area of life.
Medical Ethics is the reflection on human experiences in the medical field in its moral dimensions where the principle object is human action in health care decisions. Medical ethics is the code of manners and conduct used by doctors and those in the field of medicine. Medical ethics mainly addresses the physicians. The emphasis is on the moral obligations of physicians and on the doctor-patient relationship.
Health Care Ethics addresses those engaged in serving others in their search for health: doctors, nurses, patients, their families, other health professionals etc.
Life or medicine or health care specifies the area of human action and moral decision. Here the problem of right and wrong or good and bad in the medical care of the patients is the main concern or target.
Sub-divisions of Bioethics
1. Theoretical Bioethics deals with the intellectual foundations of the field. - What are its moral roots – Are there foundations with in the practice and traditions? Whether they theological or philosophical starting points?
2. Clinical Bioethics refers to the day-to-day moral decision making of those caring for patients. Typically focuses on individual case, what is to be done here and now with the patient. – Should a respirator be turned off? Is this patient competent to make such a decision. Should the full truth be disclosed to a fearful cancer patient? – Give rise to great medical and moral uncertainty - What Aristotle and Kant said “practical reason” comes sharply into play here. It is the concreteness of the judgement that is central here: what is to be done for this patient at this time, i.e., here and now?
3. Regulatory and Policy Bioethics The aim of this is to fashion legal or clinical rules and procedures designed to apply to types of cases or general practices; this area of bioethics does not focus on individual cases. – eg. Legal definition of clinical death – from heart-lung to a brain death definition – use of human subjects in medical research – allocation of health care resources –the aim is practical rather than theoretical - - Law and policies are important here –
4. Cultural Bioethics refers to the effort systematically to relate bioethics to the historical, ideological, cultural, and social context in which it is expressed. – How does the trends with in bioethics reflect the larger cultural, social, context of the society? Principle of autonomy – Beneficience – individualism –This means that the bioethics problems will usually have a social history that reflects the influence of the culture of which they are a part. – Countries with strong paternalistic tradition may not consider the issue of patient choice and informed consent!
2. Medical Codes of Ethics
Medical Ethics has been expressed in a variety of ways at different stages of history ranging from prayers, oaths, and deontological codes to directives, guidelines, and declarations issued by medical conferences
a. Prayers of religious inspiration express gratitude to God for blessings received and ask for divine assistance in the correct performance of medical duties.
eg. The Daily Doctor’s Prayer – The Daily Prayer of a Physician – once attributed to Moses Maimonides who lived in (1135-1204) but now it is thought to be the work of Marcus Herz, a German Jewish Physician (Four Jews who dominated the world: Jesus – Everything is Love, Marx – Money, Freud – Sex, Einstein – relative) doctor of the 18the century. Daily prayer asks for courage, determination, and inspiration to enable the physician to develop skills, meet responsibilities and heal patients.
b. Oaths incorporate the notion that an alliance with gods was essential if a patient was to be treated successfully: For centuries, it is the most important formula for passing on bioethics – the common way of expressing the ethical concepts in the ancient world – It sought protection for those treating the patient and punishment for those who broke their word. (Charaka Samhitha, Manuscript of ancient India, contains the medical student’s oath, reference by Menon and Haberman, 1970)
Hippocratic Oath – Most famous of all oaths – most enduring medical oath – known in the name of Hippocrates of 4th Century B.C. lived in Alexandria – Father of medicine – work of many people including Pythagoras of the 4th c. – practiced by Greek doctors but insufficient evidence – Magna Carta of medical Ethics and it commands profound respect. It is appreciated respected by Christian, Muslim, Jewish and civil traditions. – Even magisterial teachings gives support to certain aspects of the ethical traditions of Hippocratic Oath. EV. 89. H.O. has an introduction containing the formula of oath – a conclusion which requests blessings and curses. And two other parts, first referring to relations between doctors, and the second to relations with patients.
The core ethic of the HO is the physician’s pledge to do what he or she thinks will benefit the patient. – repeated twice in the oath – Picked up in the “Declaration of Geneva” where the physician swears “The health of patient will be my first consideration.”
c. Professional Codes of Doctors: Those who were not happy with the spiritually inspired texts, wanted a more complete and systematic codification of how a doctor is supposed to behave towards his patients and other colleagues.
Medical Ethics of Thomas Percival, eminent physician of Manchester, England (1740-1804) was written in 1794 and published in 1803. – prototype of deontological codes – Model for the American Medical Association’s (AMA’s) first code in 1847. – since 1940 – a plethora – overabundance – excess - of national and international medical codes – codes for surgeons, gynaecologists, psychiatrists, cardiologists, health workers
Deontological Codes consist of a variety of texts containing lists of specific duties, which the members of the profession must observe. They are distinct from laws or rules. Duties contain norms of behaviour, etiquette, and good relations and serve the interests of the group directly and of the users indirectly. The rules are essential for the correct performance of a doctor’s duties. Moreover there are skills = Technical goodness or excellence in some particular activity Virtues = virtues are inner dispositions; they are not tied to certain activity but are necessary for ‘the good of the man’. Virtues are not characterized in terms of result and achievements”. All the four - rules, duties, skills and virtues - are essential for the success of the health care ministry.
d. Declarations are put out by various international medical assemblies and other bodies, which are vested with particular authority. They are of interdisciplinary and pluralistic in character.
5. Limitations of Medical Ethics: Every course has its own limitations- both from the moral as well as medical point of view.
1. The moral point of view: Moral theology does not have all the answers to all the questions. This is specifically true in the area of medical ethics and even more so in that of bioethics. This course will probably raise more questions than it will answer. Manuals had all the answers. Today, moral theology reflects on human experience in the light of the salvation history and salvific mission, and formulates tentative answers to individual problems. Certain answers will definitely be re-interpreted. We give general guidelines and the official Church teaching - the Magisterium.
2. The medical point of view: This is not a medical school, nor is this a class in medicine. Hence we will not be able to go into details in the medical side of the problems; nor is this really necessary. Since most of us are not medical students, but are here as theology students, there will be a tendency to oversimplify medical matters and its details. Medicine is progressing fast and the professionals are not able to update on; the latest medical techniques and research; more for the students of moral theology. What is more, the progress of medicine will itself present more problems from the moral point of view. We can only reflect on these theologically if we are familiar with them. Moreover, moral theology may well come to certain conclusions on the morality or immorality of certain medical techniques and researches and procedures. But it is quite a different matter trying to get the scientists and the doctors – Catholic or others - to see the validity and accept these conclusions.
a) Profit motive: Most medical students have to face great expenses through medical schools. This means when a doctor starts work, one of his first pre-occupation is to get rid of the debts he has accumulated through hes studies. Often this engenders a certain thrust and preoccupation with making money. If there is any real idealism left over from medical school, it is quickly lost with the possibility of making large sums of money.
b) Apathy: Doctors and other health professionals are over-exposed –continuoulsy – to suffering, pain and death. And so, they become indifferent – not really indifferent to the needs of the people and their suffering – but it is protective turn-off mechanism – it preserves their sanity and make them continue to work effectively and professionally. Whatever is the cause of it, it does tend to dehumanize the doctor and consequently medicine itself.
c) Technology: Most of modern medicine today is very technological and the doctor has so many equipments at his disposal to render his task more effective that many now consider themselves no longer healers but technicians doing a technical job on a case. Often it happens that the personal ouch is lost and the identity of the patient as a person is lost with it. Some doctors are more concerned with the progress and success of technology.
d) Qualifications: What is the criterion to admit students into medical school? Usually their academic proficiency in science! Not much is really required of the young student as a person who cares for people, that is, for his human qualities. We know that the practice of medicine is no longer regarded as a vocation to serve humanity but often as just a technical job that demands certain knowledge of the sciences. Medical ethics demands for human criteria – in the choice of candidates – a genuine screening process – where medicine is a real service to the people and not to just science and progress. The right people as doctors and nurses would go a long way to reconciliation-humanize medicine and its practice. When we humanize medicine the “practice of medicine” will turn to a “ministry of healing”
All is not negative neither in medicine nor in medical ethics. There are many doctors all over the world who dedicate themselves tirelessly to the cause of humanity. This is good, encouraging and edifying. It is a witness to Christian agape whether the doctors are Christian or not.
Medical ethics deal with some of these problems of medical ethics. We ask? How far can we let medicine go in experimentation with man for the sake of so-called progress!
Let us re-call to our mind! Medicine can cure. Medicine can postpone death, but it cannot eliminate it altogether. This eschatological key must always be before our eyes in all that we say and reflect on in medical ethics.
Bioethical Issues: Christian Perspective
In recent years, modern science has been very successful in the medical-technical sense. The pace of development in the field of life sciences has accelerated; however it has created many unusual situations in bioethics.
Of late in a brief essay for the journal First Things, the University of Chicago medical doctor and philosopher Leon Kass noted that with advances in biomedical science and technology, there are now “new uses for biotechnical power that soar beyond the traditional medical goals of healing disease and relieving suffering.” In Kass’ view, “human nature itself lies on the operating table, ready for alteration, ‘enhancement,’ and wholesale redesign.”
The “New Medicine”’s manipulative possibilities necessarily involve the healing option. However, Nigel Cameron avers: “But there are growing examples in less dramatic areas, not least in the reproductive biology, where in vitro options have no more connection with the healing enterprise than egregious uses of cosmetic plastic surgery. Indeed, they raise more serious ethical problems. The central point is that these are all alike manipulative uses of medical skill to serve ends other than healing. The paradigm has shifted.”
This shift took place in the bioethics agenda in the context of the crumbling of Judeo-Christian anthropology and the Hippocratic commitment in the first half of the twentieth century. I quote Cameron:
“This shift was symbolized, above all, in the one substantive revision that has been made to the Declaration of Geneva, the World Medical Association’s re-statement of what were intended to be Hippocratic principles in the aftermath of the perversion of medicine under the Germany of the 1930s and 1940s. In place of the ‘utmost respect for human life’ pertaining ‘from the time of conception’, abortion becomes an option by the substitution of the studied ambiguity of ‘utmost respect’ for life ‘from its beginning’.”
Biotechnical as well as bioethical issues are mainly focused on two stages of life: The origin and early phases of life vs the final phase of life. Stem cell research, brain research, experimentation with human subjects, genetic engineering, organ transplantation, eugenics, are still some other areas of biotechnology to mention a few. Discussions around the beginning of life issues centre exactly on two theses: Life vs Love. Today, it is possible to have intercourse without reproduction and reproduction without intercourse. While the artificial contraceptive technologies shun life and contemplate love single-handedly, the artificial reproductive technologies shun love and contemplate life alone. On the other hand, the debate about end-of-life issues turns crucially on prolonging life or shunning life abruptly, and on the matter of suffering. “Life is good; but how much extension of life would be good for us?
The central phenomenon or the subject matter in all the bioethical issues is human being at his most vulnerable and dependant as the creature of time and space in the aftermath of Fall. Although seemingly dissimilar, all these great questions in bioethics deal with how far man can shape his bios, his biological endowment. They all address the question of how we treat human beings. The fact that he constantly does shape and reshape his physiological endowment cannot escape our attention. At the same time it is increasingly clear that the scientific world view dominates life, to the extent that it has marginalized the traditional religious understanding of life and the world and has led to a strong concentration on the Hic et Nunc, ie., ‘here and now’.
Modern Bio-medical technology: Modern medicine can be characterized in the following ways:
1. Natural sciences like physics, biochemistry, and molecular biology are considered the basis for the fundamental medical sciences like anatomy, physiology, pathology etc. Human functions and qualities are reduced to measurable biochemical and biophysical processes which are expressed in numbers as much as possible. This means that medical practice is based on and dominated by scientific abstractions.
2. Disease is conceived of as an ontological entity, which exists apart from patient and physician, and is localized to processes in the patient.
3. Medical practice and investigation of the patient’s body reduces the ‘subjectivity’ of patient and physician to a minimum.
In other words, medical practice has increasingly become dominated by an approach in which the machine is the leading metaphor for the human body. The influence of technology on our medicine is so great, that according to Ten Have, “technology is constituent to the type of medicine which prevails today.”
Humans have always seemed to find ways of intervening in nature. The ability to make a fire and the invention of the wheel had profound impacts on the development of human society. Our current technological revolution presents further opportunities and capacities for intervening in life on both the micro and macro levels. The technologies surrounding conception help us to determine when we will be born and what some of our qualities may or may not be. Developments in genetics led to the production of new grains that produce more bushels per acre. An oil eating bacterium has been manufactured to help to clean up oil spills. And the artificial heart is now a reality. Hardly an area of our lives is not touched by technology. To quote the Psalmist: “Thou hast given him dominion over the work of thy hands; thou hast put all things under his feet.” (Ps. 8,6; cf. Gen. 1,28-30)
But the record of technology is a mixed one. Definitely technology has brought benefits. Computers have given us incredible capacities for calculating and information processing. Biomedical technologies provide improved diagnostic capacities. Other technologies have fairly negative consequences. Nuclear weapons have brought us to the brink of annihilation. More sophisticated instruments of “interrogation” continue to be developed. The impact of yet other technologies is diverse. Nuclear power stations provide necessary energy but problems of waste disposal have yet to be satisfactorily resolved. Birth technologies provide children, but are such children reduced to commodities?
Whatever one’s judgment about a particular technology is, it will definitely continue to have far-reaching effects on our lives.
Characteristics of Technology
Let me indicate the features of technology proposed by Norman Faramelli in his Technethics.
a. The empirical or pragmatic spirit. This is certainly close to the American spirit. One wants to get the job done and done quickly. The issue is results.
b. Functionalism. This follows from the pragmatic bent of our culture. The issue is performance.
c. Preoccupation with means not ends.
d. Preference for quantity over quality. An old song has it that if you can’t be with the one you love, then love the one you are with. This attitude reflects - among other things – a preference for that which is at hand, for what is available, rather than that which is better.
e. Efficiency and profit. The concept of standardization led to the development of interchangeable parts, which led to mass production, which led to fewer skilled laborers being needed, which led to lower wages, and which led to higher profits. All the above said factors joined here to promote efficiency in the service of higher profits.
f. Manipulation. For only through manipulation can productivity be increased at cost effective level. But such manipulation may be quite another thing when we begin mass producing people.
The Christian Perspective
“What is specific to Christian ethics (perspective) is the scripturally inspired understanding of man and the world that the Christian brings to concrete issues and that affect his solution to these problems.” The essential difference is in the world view. The Christian world view is theocentric. God has authority, is sovereign, is known by revelation, and operates according to biblical principles. The secular world view is anthropocentric and focuses on the importance of the person. The Christian moral program is not limited to the rational ethics of the secular perspective alone, rather, it is a morality which has its origin in God’s self-revelation. God revealed his ethical program in three stages: (1) when he created the first man and the first woman, (2) and when he reaffirmed it with the Ten Commandments on Mount Sinai. This moral program finds (3) its highest perfection in the moral message taught by Jesus of Nazareth on the Mount of Beatitudes, and in the unique and perfect fashion in which he lived it.
James M. Gustafson, in The Contribution of Theology to Medical Ethics, opines that the contribution that theology can make to medical ethics depends upon what claims are made and defended about God, the ultimate power, and about human beings as moral agents in relation to God.
1. God intends the well-being of the creation.
2. God is both the ordering power that preserves and sustains the well-being of the creation in the events of nature and history.
3. Humans are finite agents whose actions have a large measure of power to determine whether the well-being of creation is sustained and fulfilled. Medical research and practice is an area in which finite and sinful humans have capacities to intervene in the biological processes of life in such a way that God’s intention for the well-being of the creation is furthered or frustrated.
What is the role of theology to medical ethics?
1. The beliefs of theology contribute to medical ethics by providing a moral point of view, i.e., a fundamental moral perspective on medical care and research. eg. Man is created in the image and likeness of God.
2. These beliefs contribute to medical ethics by grounding and informing certain attitudes toward life, which are significant for medical ethics. eg. The dignity of human being is from the fact that he is created in the image of God..
3. These beliefs ground and inform a basic ethical intentionality that gives direction to intervention in the biological processes of life. eg. Surgical sterilization done in the name of economic indications violates the dignity of man
If our point of departure is: Medicine is at the service of human person, it is necessary to explain what man, the recipient of this service, is. For George V. Lobo, “man is a creature, made to the image of God, fallen, but recreated to the likeness of Christ as an active agent in the history of salvation.” Christian perspective is founded on these particular presuppositions about man, on this definite anthropology. Really the anthropology of a Christian is centered around Five doctrines, namely: the glorious doctrine of creation, the sad truth of sin, the happy dogma of incarnation, painful doctrine of passion and the celebrated doctrine of ascension.
Man can know what he is through reason alone. However, the best guarantee of knowing himself is by adhering to what God has revealed: For Sacred Scriptures teaches that man was created “to the image of God”. Certain essential characteristics of Christian anthropology and theology relevant for biomedical ethics are synthesized below; however, it may not exhaust all the points of Christian anthropology:
1. The imago Dei. Man is a creature made according to the image and likeness of God.
The immediate foundation of the moral order is the value and dignity of human person; and this value is seen in its full depth when man is acknowledged as the image and child of God. Since we have ignored this, the whole Christian biomedical ethics has come to a collapse. I quote:
“We have forgotten that highly distinctive understanding of who we are which takes its point of departure from the biblical doctrine of our creation in the imago Dei. This insight has ever since, though increasingly in secular garb, sustained our dignities and freedoms and nourished all that we hold most precious in our understanding of human nature. With the collapse of its intellectual underpinnings in the theological substrate of western thought, the question of human kind has become increasingly moot.”
Although a scriptural discussion of humanity as imago Dei is a subject that goes beyond the scope of this seminar, I bring three general concepts of the term from a quote from Wernow:.
“The first is that of humanity’s shared essence. Since the entire human race was and is created in the image of God, we share that essence. Implications of equality and similarity are associated with this revelation. Second … (is that) Pauline references to the ‘image of God’ seem to associate ‘image of God’ with moral content. Particularly telling is the imperative connecting image with choosing to put on righteousness and holiness, and a behavior compatible with such a choice. A third insight is gained when conjoining the moral characteristic and the characteristic of shared essence. It is the morality conferred on us by the residence of God’s image that provide for the presence of universal fundamental moral norms.” The danger today is that man does not realize the ‘mysterious difference’ in imago Dei and behave accordingly. The eclipse of the sense of man as imago Dei is equal to the eclipse of the sense of God. To John Paul II, this is the root of the ‘culture of death,” and he continues:
“Man is no longer able to see himself as “mysteriously different” from other earthly creatures; he regards himself merely as one more living being. … Enclosed in the narrow horizon of his physical nature , he is some have reduced to being “a thing,” and no longer grasps the “transcendent’ character of his “existence as a man.” He no longer considers life as a splendid gift from God, something “sacred,” entrusted to his responsibility, and thus also to his loving acre and “veneration.” (EV, 22)
2. Life: The Precious Gift of God
The Holy Scripture recognizes life itself as the precious gift of God. For, the greatest possession of natural order is life itself, since it is the necessary condition for the enjoyment of all other blessings, even those that are spiritual. The book of Genesis says that God created all living beings (Gen. 1, 20ff), and that human beings are created in a special way in the image and likeness of God in order to become the crown of creation (Gen. 1, 26). It is by the breath of God that man becomes a living being (Gen. 2, 7). When breath ceases, man dies (cf. Ps. 104, 29). Hence life is a sacred and free gift from God. We find Job ready to give up everything in order to preserve his life (Job 2, 4).
Life is a very precious gift, however, the example of Christ integrates yet another dimension: “Although life is an important, fundamental value, it is not an absolute value in itself. The example of Christ clearly demonstrates to us that respect for life – a vital, ethical demand – must not adopt idolatrous forms that are an end in themselves. The gospel teaches that faith and following Christ, in addition to certain human values, are worthy of any kind of sacrifice. That includes one’s own life.”
3. Life: Ownership vs Stewardship
Man is not the author of his life. The ownership goes to God, the Creator. “God proclaims that he is absolute LORD of the life of man” (EV, 53). All the difficult questions about human reproduction and the final moment of death, involve the question of dominion over life. Human life has its origin in Him and one’s life depends on him. Many philosophies view human beings as dependant only on themselves – absolute masters of their own lives and destinies. But Christianity rejects autonomy, and accepts only theonomy. Such reliance on God is precisely the glory and salvation of humanity. The human person can only find the fullness of being and the guarantee of existence in God.
In bioethics where we admit the sovereignty of God over the entire creation and man only its steward, we can avoid technological calculations and find an answer to the various questions regarding life. Stewardship means one’s duty to respect the body and a responsibility to attend to it, and do everything that is within one’s power to defend its physical and functional integrity. His responsible use of freedom towards his body does not allow him to be merely an onlooker but a good steward. The principle of stewardship “has become even more important in modern times as a guide to the use of modern technology.”
With reference to stewardship in the use of technology Ashley and O’Rourke write:
“Consequently, a technology based on the false principle, “If it can be done, it should be done,” is a misuse of our creative intelligence. Rather, we should ask ourselves. “Should it be done?” and only if the answer is “Yes” develop and use the technology to do it. Thus the God-given gifts of our environment and our humanity are ours in stewardship, but because the greatest of our gifts are intelligence and freedom, the stewardship should be creative. Our creativity should be used as co-creativity with the Creator, not as reckless wasting of his gifts.”
4. Human Life: The Dignity
Man’s dignity is derived from his having been created by God in the image of God. So, man in his entirety has a dignity far surpassing any other creature on earth. Quoting Gaudium et spes, John Paul II speaks in the encyclical Veritatis splendor of the singular dignity of the human person: “The only creature that God has wanted for its own sake.” Man is created for God, although the material world is created for him. Everything on earth should be ordained to man as its centre and summit. Since man’s destination is God, he cannot be used as a means to achieve earthly ends. He is not “something” but “someone”. In sterilization for population control, etc., it is the material needs that cause the deprivation of the human person of a basic human capacity. Whenever such an attempt takes place, it does not tend to be “founded on the inviolable dignity of the human person.”
5. Incarnational vs Eschatological
In Christian thought, there is a tension between the incarnational and the eschatological aspects of life; a tension between “to remain in the world” and “not of the world;” a tension between already and not yet. The first emphasizes the responsibility of the Christian to transform the world through active involvement in its affairs. It is based on the responsibility incurred through the incarnational perspective of biomedical technology the Catholic Church has envisioned certain tools for meddling in the world, i.e., to be in the world. They are the Principle of Double Effect, Principle of Legitimate Material Cooperation, Principle of Totality and the Principle of Lesser Evil thanks to the happy memories of Thomas Aquinas, Alphonus Liguori and Pope Pius XII. The tremendous possibilities open to man to transform reality: eg., in the atomic sphere, in the biological sphere through genetic engineering, and in the psychological sphere through behavioural conditioning. Here, man as co-creator shares the creative mission with the Father. So the above said opportunities are also to be seen as the realization of “the original mandate to “subdue the earth.”” “And God made him master over all earthly creatures that he might govern them and make use of them, while glorifying God” (GS, 12). Teilhardian perspective of the universe also opens the way to a sane appreciation of all scientific achievements, which instead of alienating man from his ultimate goal, become steps in his journeying toward God.
Revelation has an eschatological dimension too. This is based on the fact that the individual human soul is immortal. The eschatological tends to look to the future life for fulfilment and to regard with care and a bit of suspicion earthly realities. This gives not only hope but also demands a certain responsibility for the future. The eschatological destiny of man should be warning against absolutizing any present structures, institutions or ideologies. It should serve as a constant critique of anything other than the demands of the Kingdom. This critical stance should point to the need of constant renewal, while at the same time putting up with the inevitable imperfections and limitations of life. This is the eschatological key with regard to life issues: Medicine can cure, medicine can postpone death, but it cannot eliminate it altogether. .
THEOLOGY OF HEALTH AND THE HEALTH CARE PROFESSIONALS
“What makes a Catholic Christian health care system” is not the hanging of photos, a catholic name, and the loyalty to the bishop. There should take place a reconstruction of the Practice of Medicine into a Ministry of Healing. Nowadays the practice of medicine has turned down into a business, which aims at profit or gain alone; however, the core or the heart of ministry, any ministry, including health care ministry, is loss. For that the technician or the mere humanist in the health care worker must grow into a Christian healer, modeled after the soul or the person of Jesus Christ the Physician par exemplar.
A Theology of Health and Healing
1. A Holistic Vision of Health and the Person
The practice of “healing,” is determined by the vision of health and the person. It certainly influences in the making of the moral decisions in the caring of a patient. The Catholic Church’s declared posture towards sickness, healing and health is reiterated in the Dolentium hominum of John Paul II. The Catholic Church holds that medicine and therapeutic cures be directed not only to the good and the health of the body, but to the person as such who, in his body, is stricken by evil. In fact, illness and suffering are not experiences which concern only man’s physical substance, but man in his entirety and in his somatic-spiritual unity.
Pellegrino, an American philosopher physician, calls illness as “an altered state of existence,” where an “assault on the ontological unity of body and self” takes place. This involves the physical, psychological, moral and spiritual vulnerability which the patient suffers in the attack on his or her very being. These words find perfect consonance with what we read in Dolentium hominum.
According to this idea, sickness is something which affects the whole person and Pellegrino interprets illness as a wanting in “wholeness”. And so, he comprehends healing as the process regaining the lost “wholeness” or “integrity.” “Healing means to make whole again, that is, to reestablish the wholeness that constitutes a healthy existence. … Restoration of the integrity of the person is the moral basis of any genuinely holistic medicine.”
Thus intervention of any biomedical technology, if it has to be moral, it has to help the patient in recovering his “wholeness”. And this holistic medical care by a physician is accomplished through the realization of “a right and good healing action” involving the fourfold meanings of the patient’s good. The patient’s good is not only
1. The patient’s’ “medical or biomedical good
2. His good as the patient perceives it
3. His good as a human person who can make his own life plan
4. And his good as a person with a spiritual destiny.”
The above scan shows that sickness affects the physical, psychological, social as well as the spiritual realms; and only a curing and caring that involves the fourfold good in hierarchical order can restore a healing of lost “wholeness”. As for the Catholic Christians, among the fourfold good, the ultimate good or the summum bonum in the hierarchical order consists in the “accommodation to the will or law of the Creator”.” One may sacrifice all the preceding senses of good for the attainment of this summum bonum. 
This is in consonance with what the renowned moral theologian Bernard Haering has to say: In the past, medical ethics used the principle of totality to a great extent but only in view of the somatic concept of health and somatic medicine. . . . The traditional use of the principle of totality justified intervention in view of physical health and functioning. Medical ethics for the future must rest on an all-embracing concept of ‘totality’: the dignity and well being of man as a person in all his essential relationships to God, to his fellow men, and to the world around him.
So the Christian perspective on health and healing aims at “serving life in its totality”. Jesus’ activity was always directed at the restoration, the redemption of the entire personality. A holistic vision of health includes the integral concept of the person. A person is endowed with physical, psychological, moral and spiritual realms. By virtue of this union of matter and spirit in human being, the human body cannot be reduced to a mere complex of tissues, organs, and functions.
In the encyclical Veritatis splendor, John Paul II is categorical in saying: “Only in reference to the human person in his ‘unified totality’. . . can the specifically human meaning of the body be grasped.” Hence man must be respected in the integrated totality of his spiritual and bodily being. Any biomedical intervention that is to respect the person’s dignity in its entirety should start by respecting first the patient’s physical integrity, because the human body is the matrix of the human person. Only this holistic or integral concept of health and person can positively protect the true dignity and integrity of patients as persons against the commercialization and industrialization of health care. Christian perspective is corrupted if it defects from this obligation to meet the needs of the whole person, body and soul.
The ministry to the whole person, a fundamental moral belief in harmony with the Christian anthropology and theology of medicine, is the surest safeguard against the dangers inherent in the biologization of medicine.  This conviction is indispensable to the richest fulfillment of the moral component of the telos of medicine and it goes to form the core of Christian identity in biomedical interventions.
B. Certain Dispositions of a Physician
B.1. Example Par Excellence - Jesus Christ the Physician
Catholic physician is to be modeled after “an ethic whose model is Christus Medicus. Jesus Christ, the physician, is the archetype of Catholic physicians. No Christian physician can ignore that example and remain authentically Christian. This invitation to physicians to mirror Jesus Christ the healer, as portrayed in the Gospels, is a call to perfection through daily practice; and, it needs to be answered by them daily. Catholic physicians are authentic only if they daily unite their Christianity innately with healing. Charter for Health Care Workers (l995): “Doctors are...called to be the living image of Christ...in loving the sick and the suffering”. Accordingly, the life of Catholic health professionals “is Christocentric through and through. Jesus Christ is the reason they are in health care; the example of this most gentle healer and physician of souls set the standard for Catholic health care from our Lord’s day down to our own.”
The physician is at the moral centre of the whole health care system. Physician becomes the locus of encounter for the healing power of Christ. They are society’s delegated advocates for the sick. So, if he is to follow Christ, he has to take up this healing which is nothing other than a ministry, a ministry of “suffering with” (Cum Patio, Mk 1:32-34). Therefore, according to Catholic theology, based on the example of the healing mission of Jesus, the sick person has a claim on the Catholic physicians.
B.2. A Character to be Acquired
In the moments of clinical decision, when no one is watching, the character of the physician is the patient’s last safeguard. It is the robust physicians, constituted of virtue and character, who can guide us as we face decisions in health care. “No matter to what depths a society may fall, virtuous physicians are the beacons that show way back to moral credibility for the whole profession. Physicians who have been truly virtuous both in intent and act, have been, and remain, the leaven of the profession and the hope of all who are ill”.
Any physician’s virtue consists in attaining the patient’s good, the architectonic principle of medicine, “the ultimate court of appeal for the morality of medical acts”. The telos of medicine or end of medicine is not simply a technically proficient performance but the use of that performance to attain the good of the patient.
B.3. Agape Based Healing Relationship
The essential difference in an agapeistic ethics is that rules, duties, and principles are chosen - shaped - by Charity - Chesed. This means that the ethos of a health professional is modulated in its all manifestations by the ordering principle of charity, which is the distinctive mark of a catholic physician. This would transform healing into an act of grace. Consequently, their life will be “a response to the challenge of Jesus to go and do like wise, thus experiencing a summons to Christian diakonia, with regard to the sick.
A higher degree of self-effacement, a corollary of Christian charity exposed by Jesus Christ, is the most distinctive characteristic of a healing relationship that should exist in physician-patient relations. Christ’s self-effacement on the cross led to the healing of the “wound” in the God-man relationship. Practically speaking, in the life of a physician, self-effacement is the sum degree of suppression of his self-interest, comfort and preferences in order to serve his patient. If one does not fulfill this, it is an antithesis of the Christian perspective, because self-effacement is an obligation in charity towards others. This is the “unavoidable conclusion of the parable of the Good Samaritan that presents a challenge to each and every physician of the Catholic fold.” He is the role model of every Catholic health care worker.
B.4. A Profession to Be Practised and A Vocation to Be lived
Health care is a vocation and apostolate rather than an occupation or profession. Profession is “a self generated declaration of dedication to a certain standard of ethical behaviour.” It is a way of life in which expert knowledge is used not primarily for personal gain but for the benefit of those who need that knowledge. However, “a vocation is the same kind of declaration, but one which has its source in a call from God and a desire to do God’s will, to be a witness of the Gospel message through a specific life activity.” In an occupation self interests come to the fore, in a profession, others’ interests come, but in a vocation, God’s interests get prominence; So the first is more self centred, the second is other centred or altruistic ; however, the third is God centred.
The core of all professions is and ought to be a unique relationship that centres about the activity of caring. And in health profession, the relationship is centred around health caring. “To be a physician is to be committed to a noble ideal. To be a Christian physician is to add dimensions of inspiration and aspiration that elevate the ideal immeasurably. Catholic Church needs a physician who is both scientifically competent, and an authentic Christian healer. “Scientific and professional expertise” is not sufficient; what is needed is “personal empathy” the ethos of the Good Samaritan - the neighbour to the wounded, in charity. So each catholic health care worker is a neighbour to the wounded. There is a distinction between the profession of a doctor as well as that of a nurse. When the profession of doctor is primarily centred around the curing of the patient, the nursing profession is centred around the caring of the patient.
B.5. A Health Care Worker - A Minister of life
Primum non nocere (First do no harm) is the first ethical principle of medical practice. According to John Paul II, Catholic health care ministry should witness to the sanctity of life “from the moment of conception until death”. Kevin D. O’Rourke: “People in the health care ministry, ... because they are involved in the care and cure of people, and because they are involved with protecting and prolonging life, they should become spokesmen for the dignity and sanctity of life”.
C. Certain Special Questions Concerning a Catholic Health Care Worker
C.1. Patient’s Autonomy and the Respect for Conscience
In the past, the physician used to be given more freedom in determining a course of action regarding a patient. But today, as we know, the patient has the first and most basic responsibility to make decisions on his own behalf; he is the key party to make the decisions. So, there is every possibility health care professionals may be persuaded to cooperate with morally distasteful actions under the guise of respecting patient autonomy.”
The teaching of the Second Vatican Council on religious liberty gives a legitimate provision for the rights of the conscience of both, physicians and patients, who do not share the convictions of the Catholic Church. Accordingly, the respect for patients or their conscience is an accompanying virtue of patient autonomy. However the physician’s moral beliefs cannot be simply set aside to satisfy the patient’s demands.”
Consequently, “the patient cannot, in the name of the absoluteness of autonomy, demand that the physician become the unquestioning instrument of the patient’s will.” Of course, Christian physicians have to take into account the values and the conscience of the patient, even when those values are opposed to their own; however, they should “know when they must kindly, respectfully and firmly dissociate themselves from a particular patient whose definitions of what is right and good violate Christian morality.” Also we have to know that “no person is obliged to take part in a medical activity which he judges in conscience to be immoral.”
C.2. Evil Medical Practices out of Respect for the Secular Laws
The Evangelium vitae sounds a note of warning when saying that “the passing of unjust laws often raises difficult problems of conscience for morally upright people. “Whenever such a conflict arises between the law of God and any human law we are held to follow God’s law. Catholics, then, may not obey laws that require then to act in violation of their conscience.” Undoubtedly, “the conscience of the religious physician . . . cannot be overridden even if certain practices . . . are legally sanctioned,” because he has “a right to demand not to be forced to take part in morally evil actions.” The Catholic Church is very much aware of the difficulties of the Catholic physicians and feels with them; however, they are urged to keep God’s law even at “the sacrifice of prestigious professional positions or the relinquishing of reasonable hopes of career advancement.”
C.2.1. Conscientious objection
Legal recognition by the state for the right of the person to object in conscience is called conscientious objection. When someone appeals to conscience in refusing to comply with another’s directive is called conscientious objection. It is necessary in modern times because civil law sometimes permits and even requires morally evil actions. When a person uses his right to object against unjust laws it is called conscientious objection. Under the Christian obligation to avoid evil, if a physician thinks that carrying out a sterilization or an abortion would be immoral, his moral responsibility is to refuse to carry it out. He makes this refusal based on the principle of conscientious objection. A Catholic physician is supposed to make this conscientious objection in such situations, because for a Catholic the first thing, of course, is to live faithfully in accord with one’s own conscience shaped by the truth of Catholic teaching. Why is there a place for conscientious objection in sterilization or abortion? It goes “against the first principle of medical ethics First, do no harm.” Therefore, the physicians should not compromise their principles or convictions according to the compulsions, whims and wishes of the people or the state. There is no obligation in conscience to obey the laws that legitimise sterilization; instead, as the Veritatis splendor reminds us that “there is a grave and clear obligation to oppose them by conscientious objection, . . . [because] “we must obey God rather than men” (Acts 5:29).”
C.3. Performing Evil Medical Practices for Material Gain
In the present world Christian physicians have a positive responsibility to resist, and even to refuse to participate in actions out of motives of fiscal necessity. Admittedly, a physician is obliged to provide for himself and his family, but this cannot be the principal motivation for a Christian apostolate of healing. The material gain that one makes through performing evil medical practices is inconsistent with Christian tradition. Jesus’ own healing acts and the story of the Good Samaritan affirm that “medical knowledge is not simply a means to make a living. It is a means of service to others, a mission and apostolate, a virtual ministry to those who have a special claim on the whole Christian community - the sick, disabled, poor, retarded.” An authentic Catholic Christian medical ethics would be incoherent with health care if it were seen purely as commercial activity, i.e., primarily as a means of livelihood and personal profit. The “idea of the physician as primarily a businessman is inconsistent with the Christian ethic of medicine.” If medicine is reduced to a business, physicians begin acting like business people.
Thus those who cooperate in evil medical procedures out of monetary benefits are morally blameworthy and it is not in keeping with Catholic medical heritage. Therefore, Pellegrino reminds us that no fiscal exigency can exterminate the grounds of a doctor’s moral obligation. Those who profit from what may be harmful practices also share in culpability. Blaming the system, arguing that “every one is doing it this way” or that “it’s legal” will surely will not suffice in the face of the kind of solicitude Christians are expected to show to the sick. The Good Samaritan went out of his way, and paid the innkeeper to care for the man he found at the way side. He did not use the occasion to make profit for himself nor to advance his career.
C.4. Cooperation in Evil Medical Practices as a Sign of Compassion
There are Christians, physicians as well as others, who may be prompted to advocate biomedical technologies out of compassion for the one who requests it in the name of “sufferings.” Compassion means “an intuitive identification with the pain and suffering of another.” Christians and secular humanists frequently use the word compassion to support the actions they assume morally valid in response to human suffering. The Catholic Church urges us to be compassionate as Christ and to relieve suffering but always with respect for the inviolable sanctity and dignity of the person. Instead, for secular humanists, suffering is the greatest evil and the relief of suffering is the greatest good. Their compassion may justify taking the life of the sufferer himself, or the life of another for the sufferer.
The feeling of compassion, for the secularist, has a moral import of its own and thus it is a virtue. But for the Christian tradition sentiment cannot operate as a reason for moral decision; compassion is not a virtue unless it is subject to reason and revelation; moreover, suffering is significant in human lives. “Christian compassion reunites the human sentiment of compassion with its source in Christ in his Incarnation” As Pellegrino forewarns us that if compassion is torn from its roots, it can become an “instrument of death.”
PRINCIPLES OF BIOETHICS
Making moral decisions could be a hazardous affair. This is especially true in the field of medical ethics where in we are faced with certain perplexing situations when it is difficult to know what we should do or act. Values and norms seem to clash with each other. This can happen in reality depending on how “absolute” the norms at stake are. This is what we mean by conflict situations. For example, conjugal love v/s openness to procreation, life of the mother v/s life of the child.
Are we in fact obliged to fulfill all values in our human activity? The fact that I am teaching moral theology means that I cannot be visiting the sick. This means that by performing a value, I am omitting another value.
1.The Principle of Double Effect
There are situations more common to medical ethics when one positive action is going to have two effects: a good one and a bad one. The principle of the double effect points out when an action having a good and bad effect can licitly be placed. The principle rightly understood, responds to the question whether in a given case the causing of evil is justified or not? This principle reached its climax during the pontificate of Pius XII. (Allocution to the participants of the VII International Congress of Haematology Society. (12 Sept. 1958) AAS 50(l958), 732f). It appeared for many centuries that St Thomas had first formulated the principle of the Double Effect.
In general, the following four conditions are usually to be observed in permitting an action having a good and bad effect.
1. The action itself must be good or at least indifferent. It excludes the placing of an intrinsically evil act. In case of a dangerous pregnancy, where the life of the mother were at stake, a doctor would not be permitted to kill the fetus directly as this would be an intrinsically evil act in itself.
2. The good effect should not be produced through the bad effect, i.e. the good effect should come before the bad effect. For the end does not justify the morally bad means, whereas it could justify the pre-morally bad means.
3. Only the good effect is to be intended; the bad effect is only permitted. One’s intention is to be honest. The evil effect can only be permitted or tolerated. Certainly not intended.
4. There has to be proportionate reason for placing the action that is for tolerating or permitting the bad effect. All authors suppose that the evil caused should be reduced as much as possible and if there is any other means available, it should be used.
2. The Principle of Totality
The principle of totality teaches respect for the human person in his or her wholeness. That is, the human person is a union, an integrated reality of body and soul, matter and spirit. The principle of totality calls our moral attention to the good of the whole person and not just to some isolated aspect. Every medical technology and treatment must always be viewed in light of the good of the whole person.
The human body is composed of various organs, which are integral parts destined by their whole being to be a part of one complete organism. All the parts function for the good of the whole organism. Since various parts of organism are related to each other, any illness in a part affects the whole body and may even cause a grave danger to the entire body. It is in this context that the Catholic Church expounds the principle of totality declaring that man can lawfully sacrifice a part of his organism for the good of the whole. As expressed by Pius XII, the principle of totality teaches that
“The part exists for the whole, and that, consequently, the good of the part remains subordinated to the good of the whole: that the whole is that which determines the part and can dispose of it in its own interest”.
The use of this principle for such a wide range of purposes emphasizes the fact that its basis is unusually complex.
a. Situations involving one person
Pius XII unequivocally removed all doubts on the subject when he stated that there is not only subordination of individual organs to the body and the body’s purpose, but also subordination of the body to the person’s spiritual purpose.
b. Situations involving two persons
What we are talking about here is removing a healthy organ from one person and transplanting it into a sick person. It is argued that, if it is allowed in a case of need to sacrifice a particular part of the body (a hand, a foot, an eye, an ear, a kidney or a sexual organ) for the good of the ‘human’s body, it would be equally legitimate to sacrifice a part for ‘humanity’s body (in the person of one of its sick, painful, parts). The Christian message of charity and solidarity, illuminated by the example of Christ, is more than sufficient to justify donating parts of the body to another human being. Catholic moralists only gradually came to realize that these transplants between living people could be perfectly legitimate from a moral perspective.
3. The Principle of Legitimate Material Cooperation
The notion of cooperation in evil is broad. It includes all help given to the evil act of another. It includes different modalities; for example, to command or advice another to commit an illicit for example, to command to advice another to commit an illicit act; to sell a good object which will be used for a evil act. Cooperation with evil is classified according to various criteria. First two divisions are (i) positive and negative (ii) formal and material
a) Positive and Negative cooperation
Positive cooperation signifies a voluntary act, which contributes to the evil act of another (for e.g., an instrument nurse assisting in a sterilization procedure). Negative cooperation consists in an omission (like allowing another person to do an evil one could and ought to have done something about to stop him, either by restraining, warning, denouncing, a thief’s act of stealing)
b) Formal and Material cooperation
Co-operation with an evil act is termed “formal” when one wills or consents to the evil act of another in its ethical malice, whether or not the agent of the evil action knows about it. It is termed “material” when cooperation with the evil act of another is through a physical act, without willing or consenting to it. Therefore in the latter, one cooperates with the evil act but not with the evil intention.
Material Cooperation could be divided into immediate and mediate
c) Immediate (or Direct) material and Mediate (or Indirect) material Cooperation
Coperation is Immediate or direct when it coincides in the same act as the one committing the evil act. For e.g., to assist a robber to load a stolen object, or to act as first assistant to a surgeon performing a sterilization operation.
Cooperation is mediate when one provides the means utilized by another person to evil. However, in itself the means does not have any necessary relation with such act. For e.g., to sell weapons which are later used in committing homicide, or to hand over a syringe, which is used by another to “inject himself”.
Mediate material cooperation could be divided in two modes.
d) Proximate (mediate) material and Remote (mediate) material Cooperation
If the mediate help is very closely connected with the sinful act of the principal agent, it is called proximate material cooperation. If the mediate help is not closely connected with the sinful act of the principal agent, it is called remote material cooperation. So the differentiation between proximate and remote is based on the question, “how closely related” or “how distant” is the mediate action of the cooperator to the performance of the evil.
e) Necessary mediate material and Free mediate material Cooperation
The cooperation is necessary when the cooperator’s aid or supportive action is such that without it the principal agent would not be able to perform the evil deed. The cooperation is free if the evil would be committed even if the cooperator’s aid is refused. So the question “how indispensable” refers to the distinction between necessary and free material cooperation.
St.Alphonsus Liguori is usually credited to have refined the Principle of Legitimate Material Cooperation. He has formulated this principle because, firstly, in the world where we live, man often cannot escape some cooperation in the sins of others in order to avoid still greater evils. For e.g., a clerk in a bank may hand over the money he holds, in order to save his own life. Secondly, to carry out some of our responsibilities we usually have to cooperate with others. If it is formal we must refuse to cooperate, if however, the cooperation is merely material, i.e. our cooperation is with the good that is being done and only indirectly with the evil, which we would prevent if we could, then, such cooperation is permissible and even necessary and obligatory. Ashley and O’Rourke sees the principle of legitimate cooperation as a principle of Christian faith, which enables us to be assisted and guided in making prudent decision, and make us to be down-to-earth in our faith.
Norms for material Cooperation
Material cooperation in sinful deeds of others is in general illicit, since the evil of sin should not be supported by any means, but on the contrary opposed and suppressed. Yet on the other hand, man often cannot escape some cooperation in the sins of others in order to avoid still greater evils. This leads to the following principles.
a) Material cooperation is permissible if two conditions are verified: (l) The act by which cooperation is rendered may not be sinful itself. (2) There should be a sufficient cause for granting assistance, which is to serve an evil purpose. Under these conditions, the principles for actions with double effect apply to the cooperation: An action not sinful in itself which has at the same time a good and an evil effect may be performed if the good effect outweighs the evil one.
b) In estimating the sufficiency of the reason for material cooperation, one must take into consideration (l) the gravity of the other’s sin, a greater reason is demanded for cooperation in homicide than in a theft; cooperation in sinful deeds and undertakings that will do great harm to Church or state is never lawful; (2) the closeness of the cooperation to the sinful act; thus a graver reason is required to unlock the door of a shop to a robber than to lend him a car for his robbery; (3) the indispensability of the cooperation, the more certain the sin will be committed without one’s cooperation the lesser a reason is required for one’s aid; (4) one’s obligation to prevent the wrong-doing; a night-guard in a factory has a greater obligation to safeguard the property of the enterprise than a simple worker.
c) Immediate material cooperation is almost always sinful. These are some general principles to give orientation in the knotty problem of permissible cooperation. The concrete instances of cooperation are very often complicated and therefore inevitably give rise to various opinions. Perhaps there is no more difficult question than this in the whole range of moral theology.
4. The Principle of Lesser evil
a) Advising a lesser sin than the one a sinner is about to commit is ordinarily allowed, provided the sinner cannot otherwise be deterred from committing the greater sin.
b) Placed between two impending evils, a person ought to select the lesser one. This rule is very true, but with regard to moral evil it must be correctly understood.
5. The Two Theories
There are two major categories of theories that have great relevance for the analysis of difficult situations in health care. They are usually referred to as deontological and teleological theories. The first category of theories relies on duties or rights and are commonly called as duty or obligation ethics. “Deontology is a way of thinking about right and wrong on the basis of an action conforming to a moral principle or duty independently of the consequences.” The deontologists would say that the correct way to proceed is to familiarize ourselves with the basic duties and rights of individuals or groups, and to act in accordance with those guidelines. Here principles play a major role as products of natural law. This theory also retains that certain actions are right or wrong in themselves by virtue of intrinsic characteristics so that no set of intentions, circumstances, or consequences could simply reverse the objective morality of those acts.
The strength of this theory is that it preserves consistency in the moral life and holds a pluralistic society together by giving a common point of reference for shared expectations and duties. A weakness is that it gives no guidance on what to do when moral principles appear to be in conflict.
The teleological theories rely on ends or consequences to determine whether one is acting rightly or wrongly. The teleologists would argue that in some instances the adherence to duties or rights might lead to consequences that are contrary to the well-being of a society or the individuals in it. Therefore, they say that only when the potential consequences are taken into account can one determine the right course of action. The strength of this approach is that it challenges us to hold in view a bigger picture. It keeps within its purview also the future implications. Its weakness is that there is no unanimity on the way to order the goods or to choose among competing goods. Since no one is an expert on the future, this method is limited by the human inability to predict what will happen. This shows that both deontology and teleology need to be complemented, one by the other.
The moral teachings of the Catholic Church are understood deontologically, that is, they are based on divine and natural laws; however, the Catholic approach to moral issues does not exclude the possibility to examine possible courses of human action in terms of their teleology. The encyclical Veritatis splendor highlights this by saying that “Christian ethics which pays particular attention to the moral object, does not refuse to consider the inner ‘teleology’ of acting.” In this approach, “the primary and decisive element for moral judgment is the object of the human act, which establishes whether it is capable of being ordered to the good and to the ultimate end, which is God.” Hence the official Catholic moral teaching is “teleological” in character. However, it does not accept “teleologism,” i.e., consequentialism and proportionalism, where the approach is “confused with a utilitarian calculus, totaling up goods and harms and choosing whatever action produces the greatest net balance of good over evil.”
The Catholic Church considers contraceptive sterilization as intrinsically evil. The Church demands the faithful to understand sterilization from the perspective of the magisterium of the Church which bases its teachings of sterilization on divine law as well as natural law. On the contrary, as we have seen in the first chapter, there are theologians who justify sterilization of the couple with a high risk for a congenitally defective child. They also justify sterilization of the woman whose life or life span could be seriously threatened by a pregnancy, and whose life preserving medication would seriously affect any fetus’ health.
Such theologians allow sterilization based on the principle of totality, thus extending the interpretation of the principle to the total well-being of the person, including the social and economic condition of the family. In all such situations, these scholars justify sterilization based on the consequences or sufferings which they foresee. In the face of such approaches based on an all-inclusive vision of totality that excuses an intrinsic evil of sterilization for some pre-moral consequences in the personal, familial, and social level, Paul VI responds:
In truth, if it is sometimes licit to tolerate a lesser [moral] evil in order to avoid a greater evil or to promote a greater good, it is not licit, even for the gravest reasons, to do evil so that good may follow therefrom [cf. Rom 3:8], that is, to make into the object of a positive act of the will something which is intrinsically disorder, and hence unworthy of the human person, even when the intention is to safeguard or promote individual, family or social well-being.
Consequently, the official Catholic position rejects the dissenting views regarding such contraceptive sterilizations since they are based on ‘teleological’ contentions such as consequentialism and proportionalism.
 A. Verhey, “The Doctor’s Oath and a Christian Swearing It” LQ 51 (1984) 139-157.
Nigel M. de S. Cameron, The Christian Stake in Bioethics: the State of the Question, in Bioethics and the Future of Medicine: A Christian Appraisal, ed. John F. Kilner, Nigel M. de S. Cameron and david L. Schiedermayer (Michigan, Grand Rapids, William b. Eerdmans Publishing Company, 1995), 10.
 Besides abortion, there are seven different contraceptive techniques: behavioural methods, barrier and spermicide methods, mechanical and mechanical-hormonal methods, hormonal methods, implants, injectables, and finally surgical methods.
 AI, AIH, AID, IVF-ET, GIFT, SIFT, ZIFT, TOTS, LTOT, Cloning,
 H. Jochemsen, S. Strijbos and J. Hoogland, “The Medical Profession in Modern Society: The Importance of Defining Limits,” in Bioethics and the Future of Medicine: A Christian Appraisal, ed. John F. Kilner, Nigel M. de S. Cameron and david L. Schiedermayer (Michigan, Grand Rapids, William b. Eerdmans Publishing Company, 1995), 15.
 Norman J. Faramelli, Technethics, Friendship Press, 1971, 31ff
George V. Lobo, Guide to Christian Living: A New Compendium of Moral Theology (Westminster, MD: Christian Classics, 1991), 69.
 J. M. Gustafson, The Contribution of Theology to Medical Ethics, Marquette Univ. Marquette, 1975, 18ff.
 Stanley Samuel Harakas, Health and Medicine in the Eastern Orthodox Tradition: Faith, Liturgy and Wholeness (New York: Crossroad, 1990), and Contemporary Moral Issues: Facing the Orthodox Christian. Revised and expanded (Minneapolis, Minnesota: Light and Life Publishing Company, 1982); Pedro Lain, Entralgo, Antropologia medica (Cinisello: Balsamo, 1988).
 Lobo, Guide to Christian Living, 79.
 John F. Kilner, Nigel M. de S. Cameron and David L. Schiedermayer, ed., Bioethics and the Future of Medicine: A Christian Appraisal, (Michigan, Grand Rapids, William b. Eerdmans Publishing Company, 1995), ix.
 Jerome R Wernow, “Saying the Unsaid: Quality of Life Criteria in a sanctity of Life Position,” in Bioethics and the Future of Medicine: A Christian Appraisal, John F. Kilner, Nigel M. de S. Cameron and David L. Schiedermayer, ed., (Michigan, Grand Rapids, William b. Eerdmans Publishing Company, 1995), 102.
 Basterra F.J. Elizari, Bioethics (Middlegreen: St. Pauls, 1994), 40.
 Aurelio Fernades and James Socias, Our Moral Life in Christ (Princeton, NJ: 1997), 246-249.
 Ashely and O’Rourke in Health Care Ethics, 202.
Benedict M. Ashley and Kevin D. O'Rourke, Health Care Ethics: A Theological Analysis, 3rd ed. (St. Louis, MO: CHA, United States, 1989), 51-53, 201-203
 Ashely and O’Rourke in Health Care Ethics, 202.
Ibid, no. 13, AAS 85 (1993): 1143.
John Paul II, Evangelium vitae, no. 20, AAS 87 (1995): 423.
 John Paul II, Dolentium hominum (Apostolic Letter in the form of “Motu Prprio.” This was promulgated to constitute the Pontifical Commission for the Pastoral Assistance of the Health Care Workers, Feb.ll, l985), no.2, AAS 77 (l985): 458
 Edmund D.Pellegrino, “Toward a Reconstruction of Medical Morality: The Primacy of the Act of Profession and the Fact of Illness,” The Journal of Medicine and Philosophy 4 (l979): 44-48.
 Pellegrino and Thomasma, The Virtues in Medical Practice, 130
 Pellegrino, “The Virtuous physician, and the Ethics of Medicine”, 246.
 Pellegrino, “Moral Choice, the Good of the Patient, and the Patient’s Good”, 120.
Häring, Medical Ethics, 58.
 PCPA, Charter for Health Care Workers, no.3
 John Paul II addressed the participants of the 35th General Assembly of the World Medical Association, 29 October 1983. “Every human person, with his irrepeatable and unique singularity, is composed not only of the spirit, but also of the body. And thus in the body and through the body is the person itself reached in its concrete reality. Consequently, respect for the dignity of man, demands the safeguarding of his identity as a man, corpore et anima unus, as affirmed by Vatican Council II” (GS, 14). The fundamental criteria for making decisions should be based on this anthropologic vision.
John Paul II, Veritatis splendor, no. 50, AAS 85 (1993): 1173.
 Edmund D.Pellegrino, “Evangelization and the Catholic Identity of Medical Schools,” Linacre Quarterly 60 (l993): 11.
 W.F.May, The Physician’s Covenant, 138-139
 Pellegrino, “Science and Theology,” 29
 Pellegrino, “Science and Theology,” 19-35. For an anthropology of medicine, see Lain Entralgo, Anthropologia medica; Von Weizsacker, Filosofia della medicina.
 Since physician is the center of health care system we have more concentrated upon him. These qualities could be equally applied to any other health care worker.
Edmund D. Pellegrino, “Health Care: A Vocation to Justice and Love,” 121.
 Pellegrino, “Health Care: A Vocation to Justice and Love,” 121.
 PCPA, Charter for Health Care Workers, nos. 2-3.
 Kevin D. O’Rourke, “Is Your Health Facility Catholic,” Hospital Progress 55 (1974): 41.
Grisez, “How Far May Catholic Hospitals Cooperate with Non-Catholic Providers?” 70.
“Kant grounded autonomy in an a prioristic respect for persons. But for the Christian that respect must be grounded in the worth the Creator has given to each life - a worth only God can judge.” Edmund D. Pellegrino, “Agape and Ethics: Some Reflections on Medical Morals from a Catholic Christian Perspective,” in Catholic Perspectives on Medical Morals: Foundational Issues, ed. Edmund D. Pellegrino, John P. Langan and John Collins Harvey (Boston: Kluwer Academic Publishers, 1989), 292.
Pellegrino, “Intersections of Western Biomedical Ethics and World Culture,” 17-18.
Pellegrino, “Agape and Ethics,” 293.
Pellegrino, “Educating the Christian Physician,” 112-113.
Canadian Catholic Conference, “Medico-Moral Guide” (Apr. 9, 1970), Origins 1 (1971): 427.
NCCB, “Pastoral Guidelines for the Catholic Health Care Personnel,” 39.
Pellegrino, “Agape and Ethics,” 293. As F.J. Elizari Basterra says, “for legislation to be ethically acceptable, it is not enough for it to go through the legally correct process of drafting and approval. Observation of procedures only provides juridical legitimacy; only justification from the point of view of the common good can invest it with moral value.” Bioethics, (Middlegreen: St. Pauls, 1994), 151.
John Paul II, Evangelium vitae, no. 74, AAS 87 (1995): 487.
John Paul II, Evangelium vitae, no. 74, AAS 87 (1995): 487. Pontifical Council for Pastoral Assistance records the same in the Charter for Health Care Workers, no. 143: “It is not always easy to follow one’s conscience in obedience to God’s law. It may entail sacrifice and disadvantages.” It cites from CDF, “Declaration on Procured Abortion” no. 24, AAS 66 (1974): 744.
The refusal to carry out duties happens when one knows when to comply with duties that lack the force of moral responsibilities and when to refuse to comply often requires a subtle discernment which cannot be programmed in advance. Germain Grisez and Russel Shaw, Beyond the New Morality: The Responsibilities of Freedom, 3rd ed. (Notre Dame, IN: University of Notre Dame Press, 1988), 166.
Moloney and Rebard, “Theory and Practice of Proscribing Sterilization,” 24.
“Within a pluralistic society Catholic health care services will encounter requests for medical procedures contrary to the moral teachings of the church. Catholic health care does not offend the rights of individual conscience by refusing to provide or permit medical procedures that are judged morally wrong by the teaching authority of the church.” NCCB, “ERD for Catholic Health Care Services,” 453. In the U.S., several states have statutory provisions ensuring a broadly drawn right to conscientious objections regarding sterilization. In such legislation the most important aspect is to impose upon the objecting physician the duty to refer the patient to another facility where he or she can obtain the requested service.
John Paul II, Evangelium vitae, no. 73, AAS 87 (1995): 486.
Pellegrino, “Agape and Ethics,” 290.
Ibid, 296. See also Grisez, Difficult Moral Questions, 335-339.
Pellegrino, “Ethical Issues in Managed Care,” 67.
Andrew B. Lustig, “Compassion” in Encyclopedia of Bioethics, ed. Warren Thomas Reich (New York: Macmillan, 1995).
Edmund D. Pellegrino, “The Moral Status of Compassion in Bioethics: The Sacred and the Secular,” Ethics & Medics 20 (1995): 3.
Richard Gula, “Deontology,” in Encyclopedia of Catholicism ed. Richard P. McBrien (New York: Harper Collins Publishers, 1995), 409.
The various forms of teleological theories are: situation ethics, utilitarianism, pragmatism, proportionalism, consequentialism and so on. In Catholic moral theology, only the last two are under discussion.
Ruth B. Purtilo and Christine K. Cassel, Ethical Dimensions in Health Professions, (London: W.B. Saunders, 1993), 9.
Gula, “Deontology,” 409.
Ibid; Ashley and O’Rourke, Health Care Ethics, 172.
John Paul II, Veritatis splendor, no. 78, AAS 85 (1993): 1196.
Ibid, no. 79, AAS 85 (1993): 1197.
Ibid, nos. 75-79, AAS 85 (1993): 1193-1197. In no. 75, we read as follows: “The former draws the criteria of the rightness of a given way of acting solely from a calculation of foreseeable consequences deriving from a given choice. The latter, by weighing the various values and goods being sought, focuses rather on the proportion acknowledged between the good and bad effects of that choice, with a view to the “greater good” or “lesser evil” actually possible in a particular situation.”
Gary Atkinson and Albert Moraczewski, A Moral Evaluation of Contraception and Sterilization: A Dialogical Study (St. Louis: Pope John XXIII Medical-Moral Research and Education Center, 1979), 59-60.
Paul VI, Humanae vitae, no. 14, AAS 60 (1968): 490-491.