You, Me, Us and Medical Ethics

Baby Joseph died this week. his family is Canadian, and the medical community there refused to provide a tracheotomy and long-term ventilator so that he could go home until he died. His medical team felt it was "too risky and invasive for a terminally ill child," and indeed wanted to take him off life support at the hospital. A "pro-life" group then flew him with his father to St. Louis, where the Roman Catholic-sponsored Cardinal Glennon Children's Hospital stepped up and said they'd see he got this opportunity. Sounds great, care for the most vulnerable and all that. It was, and remains, however, "extraordinary" treatment because it could at best only extend his dying. Now, some six months later, the child's suffering is over. The St. Louis doctor insisted that religion played no part in the decision to do the surgery, and that they were simply trying to do the best they could for the baby. He said that he has made a different decision, to end life support, in other cases with the family's consent.

Now, I may feel that the Canadian medical team took a wise stand - but Baby Joseph is only a name to me and I'm wise enough to know that if he were my child, nephew, cousin, or the child of a friend I might feel differently. As the doctor in St. Louis said, these cases must be dealt with individually. However, and it's a significant however, he did come across as just a bit disingenuous since - besides his position at a Roman Catholic hospital - he authored an article against the use of "brain death" to determine death. Since we can't see the soul leave the body, physical determinants are our only option. Now, the autonomous nervous system - the part that keeps the heart beating and the blood pumping - can continue to show activity after all other brain activity has ceased. But since "human" designates a being with more than instinct and autonomous systems it seems to me that we can't consider a patient with only autonomous activity to be alive - at least, not as a human being. Hmmm...I feel a debate coming on. Hope it starts in this blog's "comments" area!

The main point here is that medical treatments and technology have come a long, long way and people today survive illness and injury that would most certainly have meant death even a decade ago. These advances, though, come with a price - and it can be a harsh price for the patient, family and society as a whole. Medical ethics must grow in sensitivity and the ability to face honestly (many doctors still can't) the fact that human beings die. All the treatments and pills in the world can't change that.

Extreme treatments cost money. Nasty idea, to bring money into a discussion on human life. We are, however, social beings; we do not live in isolation from other human beings. Public money spent to keep "me" alive - if hooked up to a phalanx of machines and able to move or communicate little if at all, or to provide extreme treatments - say, a heart/lung transplant for a patient with Cystic Fibrosis - is money not available for treating a number of other, less extreme medical needs - say, a tracheotomy and long-term ventilator. Bill Gates may have more money than God (does God have money?) but even after he and an insurance company have paid the bill for an extreme treatment, some of the cost is absorbed by a hospital and/or medical group getting state and federal funding. There is a point at which the cost to society must be considered. For instance, consider two children needing that heart/lung transplant.* One family is "middle class," with all members having a high school diploma, and some a college education; the other is deeply impoverished with few members having a high school diploma. Before surgery, there is significant medication and treatment that must be attended to strictly, along with doctor appointments that are essential. Equally essential today, such families are given cell phones which must be charged regularly, left on 24/7 in case a match is found, and never used for anything else. These families must be ready and able to get to their hospital immediately after that all-important call. After surgery, there is a laundry list of "musts" for patient and family including doctor visits, physical therapy and medication. As with every transplant, medication to prevent rejection is required every day of that person's life - one year, or sixty years, or something in between. If a heart/lung match is made to our two "sample children," who should receive the transplant call? The unpleasant, harsh - heart-wrenching - reality is that the impoverished patient is less likely to be successful after transplant. The family may well have no access to immediate transport to the transplant hospital, be unable or unwilling to keep the phone charged and working 24/7, may not have the understanding and determination to keep the child's medication filled and administered on schedule, and in fact may well have missed required doctor appointments beforehand.** The family with more education is going to have a better grasp of the need to medicate properly and daily - whatever it takes to do that, and are likely to have better access to the transplant hospital; they are more likely to have made all those doctor appointments before surgery, and willing to make the appointments with doctor and physical therapist afterwards. They are in a position (money for the electric bill) to keep the phone charged and at hand, and to deal with the myriad complexities of transplant recovery.

Society has a real and necessary interest in protecting and providing for all its members - including both children in my example. Surely we must allow that society - with its diversity of religious voices - to have a place in decisions regarding who gets what care?

Okay, companion Renegades...put on your ethics/moral theology caps and let me know what you think about all this!

*Heart/lung transplants do not cure Cystic Fibrosis. The disease will attack the transplant in time, and eventually - if the patient has survived - a second transplant will be needed.

**One of my brothers is a specialist in infants with pulmonary problems and/or Cystic Fibrosis. The scenario given reflects a reality he has experienced personally.

Of Morals and Conscience, and Absolute Certainty, Pt. 2

My hero, Thomas Aquinas, tells a story early in Part 2 of his short book On Kingship: A Letter to the King of Cyprus. A man is unable to get work; he and his family are starving so he steals some food for them. The man, says my hero, is guilty of neither sin (stealing) nor crime (theft). Rather, the community has sinned in not seeing the family's need and providing for it, and finding employment for the man so that he might provide for them in the future, and be a full and productive member of the community.

Stealing is not sin; theft is not a crime; failing to see need and provide for that need is a communal sin. See? "Rules are rules" isn't quite a foolproof as we like to think. Put the "general norm" into context, and it gets messy. Philosophizing about absolute certainty and such isn't a waste of time - when, and only when, it leads us to the "messy," to the "down and dirty" of real life.

A somewhat more obvious example is killing in self defense. Both civil law and the commandments say "Do not kill." After all, life is the highest value in our world. But in the presence of imminent danger of being killed, we are allowed to kill our attacker. ("Allow" suggests that we have the means to do so.) Aquinas goes further, saying we are required to preserve our own lives whenever possible, even if that means killing another person. Our life is as high a value as that of our attacker, not greater - but not less valuable. Even our legal system takes context seriously. Murder is a killing "with malice" for the other person, self defense is without malice. Killing another person in sudden, overwhelming anger or fear - a crime of passion - is treated differently from a deliberate, coldly planned murder. Context counts.

And sin certainly can be personal, but it can be more than personal - a society, a community, can sin as well. Racism on the part of a neighborhood, for instance, isn't just a crime (illegal, against the law - the "rules"), it's both a personal and communal sin. Institutionalize sexism on the part of a church, rules which exclude a person on the basis of gender, is not only a crime, it's a communal sin.

So, in terms of conscience, "obeying the rules" isn't sufficient. We need to inform our conscience with all the context possible - the rules/law, teachings of our faith community (all of this in terms of the intellective component of reason), our imagination, intuition - even, when possible and appropriate, the input of professionals int he area of our dilemma. I wouldn't try to offer a prognosis on my relative's illness - I'd go to an expert if possible. In a medical issue, say, death and dying questions, I'm not capable of projecting elements like timeline, quality of life and pain for the dying person. As part of informing my conscience, of dealing honestly with my context (situation), I need the input of medical doctors, and perhaps psychologists.

As a Christian people, we probably need to revisit an address given by Pius XII to a group of Italian doctors back in 1948. These physicians in post-World War II Italy - a fundamentally and overwhelmingly Catholic country, faced life and death decisions almost daily. The indicator of death at the time was simply that the patient stops breathing. But how long, and by what means, they wanted to know, must we work to keep the patient breathing? Pius XII - no liberal relativist certainly! - told the doctors that all ordinary means of treatment must be used always; extraordinary means, however, were at the discretion of the patient and family. Extraordinary means are those which carry great physical, emotional (hmmm, did the ground shake?) or (this rocked the docs!) financial hardship for the patient or (this would rock the world) the patient's family! Now, at that time, extraordinary means were in short supply. One could try artificial respiration, some heart-stimulating drugs were available in 1948, today there are defibrillators in many high schools and colleges. Today the technology, medical knowledge, drugs and machinery are available to keep patients "alive" - hooked up to machines that breathe for them, feed them, medicate them - indefinitely in many cases. If this causes extreme hardship, however, for the patient - and/or for the family, it becomes extraordinary treatment; the family can release the patient with a clear conscience.

Now, our younger daughter and her infant son arrive tomorrow for a week's stay, so no blog until September 29th or 30th. So why not do some "musing" of your own - and leave comments on that musing here, please! - on issues involving the value of human life and conscience. One example might be this: A human fetus certainly is human life, and that life has a high value - not absolute, but high. However, the value of the fetal life is equal to the value of those persons already born, not greater or less. A woman is living in poverty, with 3 children she can't feed because her husband takes his pay check and gets drunk on it. Can she justify an abortion in order to care better for the children she already has? (And yes - this is an actual case. The man and woman were both Roman Catholic, so he forbade using birth control, but demanded - to the point of physical violence - that she be ready and available for him whenever he wanted sex.)

If you don't feel brave enough for that one, you can certainly come up with others. :)

Have fun, and see you in 2 weeks.

Of Morals and Conscience, and Absolute Certainty, Pt. 1

Nearly 200 Roman Catholic priests throughout the U.S. recently signed a letter to Maryknoll's superior, asking that he and the community support Fr. Roy Bourgeois, despite Vatican orders, on the basis that he was simply following his conscience - as is required of everyone. Now, despite the fudging on why Maryknoll should support him (nothing was of his support for women's ordination being good, just, etc.), this was a heroic act on their part. The Vatican is losing patience more and more quickly with "recalcitrant" priests. It does, however, provide some solid "musing" for this Renegade Theologian.

We aren't required to follow "any old conscience," but a properly informed one. The Vatican would say (and has said) that "properly informed" means learning what the Church [i.e., the Pope] teaches, and following it without question. That, however, presents a number of problems for the student (however casual)of moral theology/ethics: absolute certainty in moral questions; restricting information to one source, suggesting (if not outright requiring!) acceptance of that source without question; no distinction between the "right" and the "good" - which equates the legal with the moral, perhaps making them interchangeable; and making the "moral" universal - impersonal, as it is without reference to the person making a decision.

We are required, as Christians -not just as Catholics, Roman or otherwise - to follow our conscience, insofar as it is properly informed. This isn't an option, it's a requirement! To come to an informed decision, then chicken out because it's tough or scary or might endanger our income is sinful. But what does the phrase "properly informed conscience" mean?

Following that can be scary! It's a whole lot easier, and safer, to "follow the rules," without question - probably the biggest reason people run for the safety of reactionary parishes where "Father knows, and I can't do anything wrong by doing what he [sic] says." It takes awareness, time and effort, and sometimes a giant leap of faith to inform our conscience well, and then follow its direction without the comfort of absolute certainty.

Absolute certainty, however, is impossible for human beings. As Thomas Aquinas points out, we are finite beings, with finite knowledge. (He uses the term "knowledge" broadly, it isn't strictly "intellective" - knowledge we get from a book, but I'll get into that later.) God alone is Absolute, to God alone can "absolute" knowledge - or any other attribute - be assigned. For us mortals, the properly informed question brings us, at best, to "moral certainty," the point at which we have done all we can to inform our decision, and must make it in good faith, and act on it.

That decision, all moral decisions, is made by a specific person. "I" have a specific history, skills, gifts, possibilities and real impossibilities in a given situation, access to ability to understand helpful information. "I" am making "my" decision in a very specific personal context. "General norms"and universal statements/teachings can and often should be a part of my information gathering - but these are not sufficient; they ignore the moral context in which "I" find "myself." This is when it gets scary at times, and where the reactionaries start screaming "Relativism!"

It's only Relativism, however, if we ignore all sources outside ourselves - at least, those which don't agree with what we want to do!

While "I" am a specific person, a specific moral agent in a specific moral dilemma (no dilemma = easy decision) and in a specific moral situation/context, "I" am, as a Christian, equally part of a faith community. "I" have the ability to gather information from outside "myself," as well as from within "myself." (Even those with intellective limitations are responsible to the extent those limitations permit.) In order to make a moral decision and act on it from an informed conscience, "I" must gather information from both outside and inside of "myself." "I" must seek out what my church teaches on the subject of "my" dilemma and consider that seriously, and prayerfully. "I" can search out other sources from "my" particular church - theological writings past and present, homilies, even articles in "my" church's newspapers and/or magazines. "I" must apply the intellect which is God's tremendous gift entrusted to us. That's not enough, thought. Reason isn't restricted to intellective knowledge, says Aquinas (and me). Our human design helps us, informs us, also through imagination - imaging ourselves doing or not doing something, imagining the consequences - good as well as bad - of a particular decision. Then there is that nebulous but inescapable quality call "intuition." There is within us, in every decision - moral or not, that something deep within us, that urges us to go ahead, stop, think it through, etc. It's even been called "the voice of God" - and this particular theologian calls it just that. Intellective knowledge, imagination and intuition are the powerful, trinitarian form for "the gift of reason." All three should be utilized as sources of moral knowledge if we struggle to make a moral decision...and act on that decision.

Okay, getting way too long for one post. Can you tell this particular theological area is a passion? More next week.

musing on morals...

while on vacation. Next week I'll be back with the results. Morals...conscience...certainty...