The Physician's Relationship With Morality
From President of World Federation of Catholic Medical Associations
ROME, DEC. 2, 2006 (Zenit) - Here is the text of a document released by the World Federation of the Catholic Medical Associations.
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Letter to Catholic Physicians Worldwide on
"The Physician's Relationship With Morality"
By Dr. José María Simón
World Federation of the Catholic Medical Associations (FIAMC)
Relations between the physician and the moralist have not always been easy. Numerous colleagues from different countries are asking for reflections to help them to practice the medical profession with moral security. One of the requirements of this moral security is frequent consultation with experts to enlighten the professional conscience. In order to be truly human, it must be well trained and correctly informed and must be frequently refined in its permanent search for the truth. In recent times, given the nature of the answers of the experts, it is worth offering certain clarifications on the quality and scope of these answers.
The natural law exists
The natural law is the ability of straightforward human reason to know and to stick to the truth. There is no other profession that appreciates the existence of this law as much as physicians.
Although the natural law does not coincide with biological law, we are perfectly aware that if we underestimate human physiology, for example, our patients will be sick. No one can, for example, eat stones without transgressing the laws of our body and, therefore, falling ill. This can help us to understand that there is also a law which helps us to value human dignity. We all "know" that it is bad to kill an innocent human being. Or that it is bad to steal. We know that if we do not consider the human being also as a psychological, spiritual, family and social being, our duty to transform suffering into well-being (as physicians we are like Nazarenes, like Cyrenaics, who help to withstand the weight of the disease and the pain) will never fully attain its objectives.
Although the absolute majority of the inhabitants of planet Earth believe in a Supreme Being, in many Western societies many thinkers and opinion creators do not. We can also give them natural reasons for what is good or bad for the human being. Furthermore, it will sometimes be with these reasons that they will perceive how sublime our thinking is.
In view of the existence of the "natural law," given its complexity (although some rules are very simple), and as it is obvious that we human beings have suffered from serious limitations since the times of Adam, we can wonder whether there is some ultimate authority which can interpret this law correctly. Numerous intermediate jurisdictional levels help or hinder the perception of this law.
Our ultimate personal authority is our personal professional conscience, which will trigger the decisions on medical acts. Indeed, each of us just with our own reason can go far in the search for the truth. But there is a safe, genuine and objective, and therefore useful and good authority for a general interpretation of the law, something which prevents us from making glaring errors with the human being and which moreover seeks the transcendental happiness of people.
God is the Creator of the universe and of man. And, as some political constitutions say, God made man free. Free to choose the truth and good. But also free to choose evil. Experience tells us that good and evil are entwined in countless shades inside our health-care structures. If evil exists, confusion and error also exist. Both blameworthy and blameless error (we must fight against both!). Moreover, it is possible that some people are particularly determined to spread the confusion. And evil can establish real "sin structures," places, establishments or laws which do not serve the human being.
The Church interprets the natural law
Our Creator stipulated that it is the Church that should interpret the "natural law" in an authentic manner. It moreover looks after everything that he revealed and which is not in nature. As human beings we are only passing through this world as a test, to a certain extent isolated from God but not at all forsaken. In the Lord's Prayer we say "Our Father, who art in heaven," which already shows that we are on another level, not in Heaven. "Thy kingdom come" and "deliver us from evil" clearly show us that there is a better condition which can come and which has not yet fully come and that the Creator can do everything. The teachings of the Catholic Church can help us on not leaving us alone. The Church speaks with human language (and in different languages) about everything that happens to man.
Another truth that our own and historical experience perceives is the reality of the progress of medicine, irrespective of the fact that there have also been advances, backward movements and asymmetries in different countries and cultures. As human beings we have numerous surprises to discover in nature itself and we are capable of inventing and of building no end of things, which makes living a passionate and never complete experience.
Progress should be made using both sides of the coin: science and ethics. In recent years the name and contents of a supposed new discipline, bioethics, have made a fortune. Personally, I believe that many years ago as physicians we already had equivalent disciplines. I recently read books on medical morals and on professional ethics from the beginning of the last century and they are treatises on bioethics ...
The teachings accompany the progress of medicine
The progress of medicine is also accompanied by a deployment of the teachings of the Catholic Church. New techniques, new discoveries, call out to physicians, who find support in the teachings. Support is security. Moral security is necessary in order to practice our profession. The [Church] teachings enlighten the professional conscience in order to practice with good, adapting to the times and moments of progress. The teachings intervene after considering the data obtained by the experimental sciences. They do not save us from the effort of studying the world by ourselves. On the contrary, they impel us to do this de facto and de iure.
Ecclesiastic common sense tells us that, although all of us who are baptized are the Church and we all do our bit for it, it is the Pope and the bishops in communion with him who exercise the teachings of the Catholic Church. It could not be otherwise. The Almighty became one of us and left representatives, acting as they want and how they want, but adapting to the logic written by himself. It is not reasonable for anyone, in any way, to produce teachings or to try to interpret the "natural law" authentically.
Therefore, when a papal or episcopal document appears on a subject of interest to the profession, the Catholic physician should be critical with the legion of moralist theologians who interpret and reinterpret it in the media. As if the Pope did not write clearly. As if as Catholic physicians we could not understand it by ourselves! They should not offend the intelligence of professionals or of the population in general. I know that some theologians have the backing of numerous publications, have been prestigious university lecturers for years or are linked to us by friendship. Emotivity can turn heads that are well screwed on and, on the other hand, also make people understand by other means what they do not understand through reason.
Any ordinary person understands the saying "What the boss says goes." This should be enough to silence anyone who shamelessly takes over someone else's duties.
It is essential to take into account that, as in the case of personal appearances or revelations, the public aspect of the Catholic Church takes precedence over private teachings. The public teachings of the Catholic Church on the subjects which affect us thus always have priority and truth. The private teachings of theologians must always be rejected if they contradict the teachings of the Catholic Church. And even if they appear to contradict them.
One of the principles of communication in the Catholic Church is that of clarity and non-contradiction. There are no secrets in the Catholic Church. The major truths are public and are clear (they can be found in the Catechism of the Catholic Church). When a mystery is proclaimed, it is clear and it is classified as such.
The life of people on this Earth is aimed at their eternal destiny. Man cannot be measured in just two dimensions. The third dimension, the one that points upward, is the one that gives our lives volume.
An exemplary case
This is a case of a declaration of experts on the possible legality of the transfer of an altered nucleus to an egg to obtain stem cells. The genetic material from one cell would be altered in such a way that the product resulting from the insertion of this material into an egg and its activation would not give rise to a human being. It would be something like the hydatidiform mole, which also comes from an altered egg and spermatozoid, although in this case naturally.
The exemplariness of the case comes from the intelligence of considering the possibility, from the way of prudently expressing opinions, from the sincerity of the signatories admitting that each is an expert only in one area and that they are not speaking in the name of their Church or work institution, and from the fact that they propose beginning the research with animals.
When making decisions the problem should be framed
On many occasions as Catholic physicians we come across moral dilemmas and have to make decisions. It is therefore important to know how to distinguish between good and evil, which it is impossible to do on the fringes of the Church (this is the way things are).
When making decisions, it would be good to take into account the ancient principle of "primum non nocere" (first, do no harm) and the evangelical principle "no more burdens than necessary." Also, that of working with an overabundance of good. This allows us to go much further on facing problems with humanity.
Although we are not usually responsible for the evil that third parties do or for finding ourselves working within sinful structures, we should never lose the strength of the ideals of youth, the freshness of wanting to change things, however deeply rooted they appear to be, or the conviction that we are never alone.
Before making decisions, the physician takes stock of the situation on facing a specific problem. It is good to fit things into the big picture (the frame) and from a healthy anthropology. I remember the time I was invited to one of the mass media for a debate on artificial insemination in lesbian couples. The different opinions were supposed to be balanced. The guests, however, were a gay activist, a lesbian, a bisexual, a libertine and a heterosexual. Moreover, the presenter and the supporting reports were light-years from the thought of the heterosexual minority. On asking the program editors about such a coarse manipulation, I had to hear that everything had been designed to ensure the strictest equality of opinions ...
In this case, the frame of the issue is not whether or not this kind of couple has a right to insemination or whether there are heterosexual couples who ill-treat their children. The broader perspective can help the fertility professional to be a conscientious objector. Because what is ideal, with the millions of couples and children who are and have been happy, is for children to be born naturally in the family, to a man and a women. This is where we should take the debate because this is where it really lies.
Can you do harm to do good?
Although in general the problems in medical decisions do not tend to be presented as harm which does good, the truth is that this is the key to the issue on many occasions. And the principle of never doing harm to do good (the end does not justify the means) is essential.
Medical decisions are moral acts. Life's routine often means that we do not see them as such. Maybe one day we considered the morality of a procedure or protocol, we decided that it was fair, and we applied it to our different patients without thinking any more about it. Automatisms form part of nature and help us to live without wasting huge quantities of mental energy. However, on some occasions -- not just in extraordinary cases -- the moral act should be studied with care.
The traditional dissection of the moral act into object, aims and circumstances is useful. A good act requires the simultaneous goodness of these three elements which constitute the morality of human acts. Sometimes we have to sharpen our wits to put everything in its place and to clearly detect what object we are assessing. In short, what we are really talking about.
For example, can you get drunk (an evil act) in order to have decayed teeth removed (a laudable aim) in the absence of medicines (a setting favoring the act)? Is this not accepting that the end justifies the means or that harm can be done (getting drunk) in order to do good (health)? The answer to this apparent dilemma, which can be applied to many other cases but not to all, is that we have classified the act as "getting drunk" whereas really it is an "anaesthetic" act. Alcohol is an anaesthetic, although of a secondary category. Our practical reason, with a little training and practice, will help us to classify the moral act correctly.
There are behaviors whose choice, because of their nature, is always wrong. For example, in the case of abortion, it cannot be stated that sacrificing the child to supposedly favor the mother is a good act. However you look at it.
The double effect
The double effect theory has a bad reputation in Europe due to the discredit of the so-called collateral damage in recent wars. You bomb the enemy and, unintentionally, your action injures innocent civilians. This is terrible.
However, medicine holds firm because we accept the theory. Chemotherapy is intended to eliminate cancerous cells while also damaging healthy cells. We remove a sick uterus despite the fact that the woman will be infertile forever. We vaccinate thousands of children despite the fact that some will die from the side effects.
Obviously we must do everything possible to minimize side effects, just as we should do everything possible to prevent a war. With the double effect, it is not a question of doing bad to achieve good. The bad is not wanted. It appears like an unwelcome and persistent guest.
With so-called therapeutic or eugenic abortion, to make it clear that here there is no double effect and that what is being fought first here is the embryo, John Paul II himself stated that the death of an innocent can never be legitimized.
With indirect abortion, although it is right to treat a mother even if we expect the side effect to be the death of the embryo or fetus, some people have given us a solution to moral problems with an excess of good. This is the case of Dr. Gianna Beretta, who refused treatment so as not to harm her pregnancy. She died and her son lives.
The lesser evil
It has become fashionable to talk about the lesser evil as if it were something desirable. But no. You can never do bad, however little it may be or you may consider it to be. Bad is always bad. The theory of the lesser evil does not refer to doing but rather to tolerating. The lesser evil is decided by one or more third parties without us intervening. We have to tolerate certain evils because we are not Quixotes who must fight against everything and moreover the human being is free even to use this freedom badly. Our obligation is never to do bad. Always to do the most good possible. What we should not get used to is to tolerating the bad inflicted on innocents. These are never lesser evils!
Collaboration with evil
With the current state of the world, we often have to consider whether to avoid collaborating with those people and structures which go against the dignity of the human being. Although they may find others who will collaborate with evil, they will not find us. It should not be attributable to us, and, if possible, we should try to lead these situations down the correct paths.
On some occasions we have doubts, especially if the collaboration is remote. Remote collaboration, although effective, is not attributable to us if we do not want it to be. It is good to avoid scandal and not to become contaminated by it. But we cannot isolate ourselves in a glass bubble and stop being a good substance in the world around us.
Freedom and moral security
The Catholic physician has broad freedom to practice the profession. We have intelligence and we need to make it perform to the maximum. Moreover, the security that we are acting correctly (moral security) can be achieved with a minimum ethical training, accepting the [Church's] teachings and consulting certain cases with senior colleagues or with a priest who knows the correct doctrine. Thousands of physicians worldwide practice daily with the peace of mind that they are acting correctly.
As Catholic physicians we have great models on which to base our actions. They have simply identified themselves perfectly with the principle of ethics: "Christus medicus." St. Luke, St. Cosme, St. Damian, St. Joseph Moscati, St. Gianna Beretta, St. Richard Pampuri, Father Pere Tarrés, Dr. László Batthyány-Strattmann, and many more, have preceded us and have become the giants of medicine. Curiously, patients often venerate them more than us, the physicians ...
Some reflections on specific issues
The "affaire" of using condoms to prevent infection with AIDS or unwanted pregnancies is another of the things that drives activist Catholic physicians mad. But we should not let ourselves be led to territories which are not ours. Sexuality is one of the gifts of marriage and within marriage it is expressed to the maximum. As Catholics, and in marriage, we live sexuality to the full. Sexuality outside marriage, between males or polygamous sexuality, does not form part of our anthropology. The Church cannot be accused of spreading AIDS (the other 29 sexually transmitted diseases are almost always forgotten) when it preaches abstinence, faithfulness and patience. This is useful to prevent diseases or teenage pregnancies. But the main purpose of chastity is not to prevent an epidemic but rather to promote virtue and to provide happiness.
It is obvious that Catholic physicians, who work in a world in which there is a bit of everything and in which the same health structures are often perverted, will come across people who will want to continue practicing sequential polygamy or homosexuality. It will not be ingenuous, in an environment of good physician-patient relations, to present them with our proposals. If the person insists implicitly or explicitly on continuing with their practices, the physician will talk to them about the condom as the more or less imperfect "barrier," without presenting it, and especially not recommending it, as something good. And, finally, if the person is infected, they will treat them with affection and professionalism.
It is important to take into account that the Catholic Church's mission is not to promote solutions so that the human being can continue to carry out improper behavior. And as far as possible we should prevent the media from using us to promote unworthy conduct.
There is scientific knowledge which is not obtained from reading the science sections of the media. Thus, knowing that hermaphrodites exist, that post-abortion syndrome is frequent and painful, or that homosexuals can often change, is learned in specialized journals or from experienced teachers.
It is good to always bear healthy anthropology in mind and to think that the mass media understand what is simple better, that they are obliged to have striking headlines and that they can rarely hold a good moral debate.
Euthanasia: dying is not the same as being killed
We cannot abandon a terminal patient, we cannot be cruel to them and we cannot kill them. The only decent thing that we can do is to provide them with quality palliative health care. This should take into account the biopsychosocial, spiritual and family dimensions of the person. This is the path that we should take.
Euthanasia kills freedom. It is a supposed free decision which means that the person will not ever again make free decisions. Not even the very human decision of rectifying. Euthanasia, its popularization or legalization, are on the dark side of the profession, whoever promotes it.
Cases of consultations on whether or not the treatments for the terminally ill are proportional are extremely frequent. Medicine can never refuse hydration, nutrition, hygiene, oxygenation, basic medicines. Recently, an elderly man presented cardiac insufficiency and the ethical committee of his hospital recommended only a treatment with morphinic drugs, while awaiting his death. But the physician dealing with the case solved it with a diuretic, oxygen and digoxin. The true sage was the ordinary physician.
As human beings we were deliberately created incomplete by God. Man needs woman to be fulfilled and woman needs man to be happy. Furthermore, man and woman also need children to complete their plenitude as a family. Husband and wife have all the children that they can maintain and bring up. The number of children depends on many factors and should be decided on with generosity. Large families are a joy for society and for the Church. In my personal opinion, it would be unnatural for the mature human to do without the other sex, unless it becomes a supernatural good, as with celibacy for the Kingdom. There are of course causes of "force majeure" [greater force] or imponderable causes which mean that a person cannot be fulfilled with a partner.
The sex act holds such a sway that it leaves no one indifferent and always has consequences. It unites man and woman in an incomparable manner. It should take place in a context of maturity, commitment and exclusivity: marriage. Man and woman give each other everything, including the ability to generate new human lives. This is good.
There are times when, objectively, for medical, social or family reasons, the responsibility of the parents leads them to avoid a new birth. This possibility is already foreseen in the "natural law." Women are only fertile for a few days a month. Natural fertility regulation methods (Billings, sympto-thermal, etc.) allow these infertile periods to be used for man and wife to remain in communion with sexual relations and thus overcome the unhealthy attraction of other flesh.
Pope Paul VI, in the encyclical "Humanae Vitae," warns that physicians and health care personnel should consider it their professional duty to obtain all the science necessary in this field in order to be able to give the married couples which consult us wise advice and healthy guidelines which they are fully entitled to expect from us.
Contraceptives infringe several human rights: the right to life (in the case of the abortion or morning-after pill), the right to health (they have side effects, unlike natural methods), the right to education (people are entitled to know about their own fertility) and the right to equality between the sexes (the contraceptive burden always tends to fall on the woman).
In July 2005, the International Agency for Research on Cancer (Lyons, France), of the World Health Organization, reported on the carcinogenicity of oral contraceptives with combined estrogen and progestogen, based on the conclusions of an "ad hoc" international work group. They were classified as Group 1 carcinogens.
Regrettably, dear colleagues, at present we are unable to provide natural methods for all those who need them. The low fertility rates in countries with a Catholic majority (Spain, Italy), together with the low knowledge of these methods, means that many married couples use artificial methods. If we take into account that they are relatively rich countries, it cannot be said either that they are especially generous with the number of children. We have an immense challenge here. We should never put out the torch that has been lit in favor of natural methods.
Unfortunately, contraception is not the only challenge of Medicine and of society. Also, we are unable (us and nations in general) to provide means against malnutrition, malaria and the vertical transmission of AIDS. We have the knowledge and some means but we cannot make them available to the needy. There is therefore no lack of work.
Without judging married couples who use artificial contraceptives -- our job is not to judge -- we should never forget this professional duty to offer natural means and to dissuade from using artificial means. It is a sign of progress to understand nature well and to help it as far as possible. The world is incomplete. We have work to do. And, when we do it, the progress can be seen.
Is there anything worse than dragging a child out of its mother's womb? Can abortion be explained to a 5-year-old child? Does a woman who loses a child through miscarriage not weep as if she had lost a child? Do we as physicians do everything possible to transform the suffering of parents with problems in pregnancy into happiness and joy? The Catholic physician practices the preferential option for mothers. Not sole or exclusive but preferential.
We know very little about the physical beginning of the human race. Without falling into scientism, we will need to wait decades until science enlightens us more on this subject. It is not known how or when one species changes into another, if this occurs at all. A large part of what has been written on this subject is provisional and incomplete.
As you know, except in extremely exceptional cases, amniocentesis is performed to provoke abortion if a fetal malformation is suspected. Therefore, as this practice is not carried out for the good of the fetus and the mother, it cannot be considered as a correct medical procedure.
The physician can and must help infertile couples, but cannot substitute them. This principle is very useful to understand that, despite the popularity of so-called assisted reproduction techniques, we cannot give in to easy, profitable, temptations. All efforts should concentrate on improving the fertility studies for couples and on treating what can be treated, which is a lot. Given the obsession that many clinics have with in vitro fertilization, it would be good to explain to couples that the medical function is not to replace them, that amniocentesis is almost always performed to abort defective children, that surplus embryos are often eliminated, that children are frozen.
Catholic gynecologists are the heroes of present-day medicine. Their care and promotion are a top priority for the associations of Catholic physicians and for the FIAMC. General practitioners and other specialists can also contribute wise advice on matters of fertility.
Respect for the embryo: stem cells
I sincerely believe that the most coherent position with the knowledge that we have on the embryo is scrupulous respect from the moment of conception. And that this is the position that avoids the most problems. Our coherence is highlighted when defenders of whales and seals, death penalty detractors, human rights activists and different sorts of philanthropists accept the destruction of an embryo without batting an eyelid (always with therapeutic aims, of course).
Conception lasts for some time, but the process has already been triggered and respect for the wholeness of the embryo starts much earlier: it starts with respect for the union of a man and a woman, avoiding in vitro conceptions. Human beings should not introduce chaos into the bios.
To make a comparison with the beginning of the Gospel according to St. John, we can say that in the beginning is the genetic message, and the genetic message is in life and the genetic message is life. When there is a complete genetic message, which can be expressed and which is expressed in a continuous, coordinated and gradual manner, unstoppable if it were not for adverse external factors, then there is a unique and unrepeatable human being which must be respected. It comes to us and its family (us) must accept it and welcome it.
It is understood that, although any cell, for example from our skin, contains the complete human genetic message, it is not a human being in itself. The expression of this message, which is partial, means that it is not a human being. It is the fertilized egg which is already acting like a human! In the beginning, we are a single and unrepeatable message surrounded by some membranes, RNA, energy reserves and other services. To date, no researcher has "created" life. Human beings are only capable of transmitting it, correctly or incorrectly.
Embryonic stem cells exist to give rise to the embryo. And adult stem cells exist to regenerate tissues. It is that simple.
Strictly speaking, the human being does not have any right to life. Life is a gift that we receive. Before existing we were nothing and we were not therefore subject to rights. What we are entitled to is to not having our life taken away by another human being!
Our profession is perhaps the most admired profession in the world and the one that people expect the most from. I would recommend that you never stop studying, that you bear in mind the physician's promise and prayer (www.fiamc.org), that you do not fall into the temptation of venerating the god Mammon (money) and that you consider the possibility of bringing colleagues to the already existing associations of Catholic physicians.
José María Simón
December 1, 2006
P.S. I am grateful to Monsignor Maurizio Calipari, ecclesiastic assistant of the FIAMC, for the advice that he has given me for the final version of this letter. Although under the supervision of the hierarchy, the Code of Canon Law gives widespread autonomy to the international Catholic organizations such as the one that I chair. The FIAMC is a public-law organization in the universal Church, and therefore "speaks and acts in the name of the Church." This is a clear sign of ecclesiastic trust in lay people.
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