The Consistent Ethic of Life: The Challenge and the Witness of
Catholic Health Care
Catholic Medical Center Jamaica, New
Joseph Cardinal Bernardin
May 18, 1986
The very mention of "Bhopal" or "Chernobyl" sends shudders
through people everywhere. While the tragic deaths and injuries caused by the
Bhopal disaster were confined to a particular area, its repercussions are still
being felt worldwide. The Chernobyl incident, however, affects the planet in a
more direct way through the spread of radioactivity. Its destructive potential
is even more worrisome.
These two disasters highlight an important fact which has enormous
significance for the future of the world community: the growing interdependence
of contemporary life—an interdependence which has been accelerated by the rapid
development of science and technology—and the worldwide competition for limited
natural resources. The problems and challenges of the human family today are
enormously complex, increasingly global, and ominously threatening to human life
and society. Each of them has moral and religious dimensions because they all
impact human life.
It is crucial that we develop a method of moral analysis which will be
comprehensive enough to recognize the linkages among the issues confronting us,
while respecting the individual nature and uniqueness of each. During the past
few years, I have addressed this task through the development of a comprehensive
approach to the broad spectrum of life issues which I have called the
"consistent ethic of life."
I am very grateful to the Catholic Medical Center and St. John's University
for the invitation to address you this evening on "The Consistent Ethic of Life:
The Challenge and the Witness of Catholic Health Care." As you may know, I
applied the consistent ethic concept to health care systems last year in an
address to the Foster McGaw Triennial Conference in Chicago. I wish to follow a
similar format this evening, applying the concept, however, to different, but
More specifically, I will first briefly describe the concept of a consistent
ethic. Then I will explore the challenge it poses to health care systems both in
terms of "classical" medical ethics questions and "contemporary" social justice
I. The Consistent Ethic of Life
The "consistent ethic of life" has become part of our ethical vocabulary in
the past three years. No doubt you are already familiar with it—at least, to
some extent. However, there are many misconceptions about it. That is why I want
to ensure at the outset that the basic concept is correctly understood.
Although the consistent ethic needs to be finely tuned and carefully
structured on the basis of values, principles, rules and applications to
specific cases, this is not my task this evening. I will simply highlight some
of its fundamental components so that I can devote more attention to its
application to health care systems and several of the issues they face today.
Catholic social teaching is based on two truths about the human person: human
life is both sacred and social. Because God's gift of life is sacred, we have a
duty to protect and foster it at all stages of development, from conception to
natural death, and in all circumstances. Because we acknowledge that human life
is also social, society must protect and preserve its sanctity.
Precisely because life is sacred, the taking of even one human life is a
momentous event. Traditional Catholic teaching has allowed the taking of human
life in particular situations by way of exception, as, for example, in
self-defense and capital punishment. In recent decades, however, the
presumptions against taking human life have been strengthened and the exceptions
made ever more restrictive.
Fundamental to these shifts in emphasis is a more acute perception of the
many ways in which life is threatened today. Obviously such questions as war,
aggression and capital punishment are not new; they have been with us for
centuries. Life has always been threatened, but today there is a new context
which we must take into consideration. And this new context shapes the content
of our ethic of life.
The principal factor responsible for this new context is modern technology.
Technology induces a sharper awareness of the fragility of human life. Speaking
in Ravenna last Sunday, Pope John Paul II acknowledged that technical progress
makes it possible to transform the desert, to overcome drought and hunger, to
lighten the burden of work, to resolve problems of underdevelopment, and to
render a more just distribution of resources among people of the world. But he
also warned that the same technology has brought us to see "the land
uninhabitable, the sea unserviceable, the air dangerous and the sky something to
The discovery of nuclear energy, for example, is one of the most important
scientific developments of this century. Despite its benefits to the human
family, however, we have become painfully aware of its potential to destroy life
on a scale previously unimaginable. Likewise, while modern medical technology
opens new opportunities for care, it also poses new threats to life, both
immediate and potential. The extraordinary technological development of this
century has brought with it a qualitatively new range of moral problems.
My basic thesis is this: Technology must not be allowed to hold human beings
as hostages. The essential questions we face are these: In an age when we can do
almost anything, how do we decide what we should do? In a time when we can do
almost anything technologically, how do we decide morally what we should not do?
Asking these questions along the whole spectrum of life from conception to
natural death creates the need for a consistent ethic, for the spectrum cuts
across such issues as genetics, abortion, capital punishment, modem warfare, and
the care of the terminally ill.
Admittedly these are all distinct, enormously complex
problems, and they deserve individual treatment. No single answer and no simple
response will solve them all. But they are linked. Moreover, we face new
challenges in each of these areas. This combination of challenges is what cries
out for a consistent ethic of life.
We desperately need an attitude or climate in society which will sustain a
comprehensive, consistent defense and promotion of life. When human life is
considered "cheap" or easily expendable in one area, eventually nothing is held
as sacred and all lives are in jeopardy. The purpose of proposing the need for a
consistent ethic of life is to argue that success on any one of the
life-threatening issues is directly related to the attitude society has
generally toward life. Attitude is the place to root an ethic of life, because,
ultimately, it is society's attitude—whether of respect or non-respect—that
determines its policies and practices.
At the same time, I hasten to add that ethics concerns itself with principles
which are supposed to guide the actions of individuals and institutions. That is
why I have demonstrated, in a number of recent addresses, that there is also an
inner relationship—a linkage—among the several issues at the more specific level
of moral principle. It is not my intention to repeat these arguments this
Nevertheless, I would like to examine briefly the relationship between "right
to life" and "quality of life" issues. If one contends, as we do, that the right
of every unborn child should be protected by civil law and supported by civil
consensus, then our moral, political and economic responsibilities do not stop
at the moment of birth! We must defend the right to life of the weakest among
us: we must also be supportive of the quality of life of the powerless among us:
the old and the young, the hungry and the homeless, working mothers and single
parents, the sick, the disabled and the dying. The viability and credibility of
the "consistent ethic" principle depend primarily upon the consistency of its
Such a quality-of-life posture translates into specific political and
economic positions—for example, on tax policy, generation of employment, welfare
policy, nutrition and feeding programs, and health care. Consistency means we
cannot have it both ways: we cannot urge a compassionate society and vigorous
public and private policy to protect the rights of the unborn and then argue
that compassion and significant public and private programs on behalf of the
needy undermine the moral fiber of society or that they are beyond the proper
scope of governmental responsibility or that of the private sector.
Neither can we do the opposite!
As I acknowledged earlier, the inner relationship among the various life
issues is far more intricate than I can sketch here this evening. I fully
acknowledge this. My intention is merely to bring that basic linkage into focus
so I can apply it to some of the issues facing health care systems today.
II. Ordinary vs. Extraordinary Medical Procedures
As I noted earlier, the consistent ethic of life poses a challenge to two
kinds of problems. The first are "classical" medical ethics questions which
today include revolutionary techniques ranging from genetics to the prolonging
of life. How do we define the problems, and what does it mean to address them
from a Catholic perspective?
One of the most critical moral questions today is the appropriate use of
ordinary and extraordinary medical procedures, especially in the care of the
terminally ill. I would like to explore this issue with you in some detail.
Two fundamental principles guide the discussion. The first is the principle
which underlies the consistent ethic: Life itself is of such importance that it
is never to be attacked directly. That is why the Second Vatican Council taught:
All offenses against life itself, such as murder, genocide,
abortion, euthanasia, or willful suicide . . all these and the like are
criminal; they poison civilization. (Pastoral Constitution on the Church
in the Modern World, 31)
Consequently, even in those situations where a person has definitively
entered the final stages of the process of dying or is in an irreversible coma,
it is not permitted to act directly to end life. In other words, euthanasia—that
is, the intentional causing of death whether by act or omission—is always
The second guiding principle is this: Life on this earth is not an end in
itself; its purpose is to prepare us for a life of eternal union with God.
Consistent with this principle, Pope Pius XII, in 1957, gave magisterial
approval to the traditional moral teaching of the distinction between ordinary
and extraordinary forms of medical treatment. In effect, this means that a
Catholic is not bound to initiate, and is free to suspend, any medical treatment
that is extraordinary in nature.
But how does one distinguish between ordinary and extraordinary medical
treatments? Before answering that question, I would like to point out that the
Catholic heritage does not use these terms in the same way in which they might
be used in the medical profession. That which is judged ethically as
extraordinary for a given patient can, and often will, be viewed as ordinary
from a medical perspective because it is ordinarily beneficial when administered
to most patients. That being said, it is, nevertheless, possible to define, as
Pope Pius XII did, what would ethically be considered as extraordinary medical
action: namely, all "medicines, treatments, and operations which cannot be
obtained or used without excessive expense, pain, or other inconvenience or
which, if used, would not offer a reasonable hope of benefit."
This distinction was applied by the Congregation for the Doctrine of the
Faith to the care of the terminally ill in its 1980 Declaration on Euthanasia,
When inevitable death is imminent in spite of the means used, it
is permitted in conscience to take the decision to refuse forms of
treatment that would only secure a precarious and burdensome
prolongation of life, so long as the normal care due the sick person in
similar cases is not interrupted.
In other words, while the Catholic tradition forcefully rejects euthanasia,
it would also argue that there is no obligation, in regard to care of the
terminally ill, to initiate or continue extraordinary medical treatments which
would be ineffective in prolonging life or which, despite their effectiveness in
this regard, would impose excessive burdens on the patient.
Recently the American Medical Association's Council on Ethical and Judicial
Affairs adopted a policy statement on withholding or withdrawing life-prolonging
medical treatment. Earlier this year the National Conference of Commissioners on
Uniform State Laws adopted a "Uniform Rights of the Terminally Ill Act" for
proposed enactment by state legislatures. While containing some helpful
insights, this latter document raises serious moral questions which could result
in ethically unsound legislative efforts that would further undermine the right
to life and the respect for life in American society.
In addition, there has been a good deal of media attention given to certain
cases involving seriously ill patients. In light of all this, there is need for
serious reflection on the question of our ethical responsibilities with regard
to the care of the dying.
Again, the consistent ethic of life will prove useful in such reflection.
Here I will limit myself to two observations. First, an attitude of disregard
for the sanctity and dignity of human life is present in our society both in
relation to the end of life and its beginning There are some who are more
concerned about whether patients are dying fast enough than whether they are
being treated with the respect and care demanded by our Judaeo-Christian
To counteract this mentality and those who advocate so-called "mercy
killing," we must develop societal attitudes, policies, and practices that
guarantee the right of the elderly and the chronically and terminally ill to the
spiritual and human care they need. The process of dying is profoundly human and
should not be allowed to be dominated by what, at times, can be purely
utilitarian considerations or cost-benefit analyses.
Second, with regard to the manner in which we care for a terminally ill
person, we must make our own the Christian belief that in death "life is
changed, not ended." The integration of such a perspective into the practice of
a medical profession whose avowed purpose is the preservation of life will not
be easy. It also is difficult for a dying person's family and loved ones to
accept the fact that someone they love is caught up in a process that is
fundamentally good—the movement into eternal life.
In order that these and other concerns may be addressed in a reasoned,
Christian manner, the dialogue must continue in forums like this. The consistent
ethic, by insisting on the applicability of the principle of the dignity and
sanctity of life to the full spectrum of life issues and by taking into
consideration the impact of technology, provides additional insight to the new
challenge which "classical" medical ethics questions face today. It enables us
to define the problems in a broader, more credible context.
III. Adequate Health Care for the Poor?
The second challenge which the consistent ethic poses concerns "contemporary"
social justice issues related to health care systems. The primary question is:
How does the gospel's preferential option or love for the poor shape health care
Some regard the problem as basically financial: How do we effectively
allocate limited resources? A serious difficulty today is the fact that many
persons are left without basic health care while large sums of money are
invested in the treatment of a few by means of exceptional, expensive measures.
While technology has provided the industry with many diagnostic and therapeutic
tools, their inaccessibility, cost and sophistication often prevent their wide
distribution and use.
Government regulations and restrictions, cut-backs in health programs, and
the maldistribution of personnel to provide adequate services are but a few of
the factors which contribute to the reality that—unless we change attitudes,
policies, and programs—many persons probably will not receive the kind of basic
care that nurtures life.
A significant factor impacting health in the U.S. today is the lack of
medical insurance. The American Hospital Association estimates that nearly 33
million persons have no medical insurance. They include the 60% of low-income
persons who are ineligible for Medicaid; nearly half of the "working poor"; the
unemployed, seasonally employed, or self-employed; and middle-income individuals
denied coverage because of chronic illnesses. They include disproportionate
numbers of young adults, minorities, women, and children.
According to the most recent federal data, only one-third of the officially
poor are eligible for the "safety net" of Medicaid. The Children's Defense Fund
estimates that two-thirds of poor or near-poor children are never insured or
insured for only part of the year. It is shocking, but not surprising in light
of what I have just said, that the U.S. infant mortality rate is the same as
that of Guatemala! Forty thousand infants die each year in the U.S. and others
are kept alive by surgery and technology—only to die in their second year of
life. The principal causes are well known: poverty and lack of adequate medical
care. Moreover, many argue that the situation worsens as hospitals become more
competitive and prospective pricing holds down the reimbursement rate.
I assume that we all share a deep concern in regard to adequate health care
for the poor, but we also recognize that providing this is much easier said than
done. Between 1980 and 1982 the number of poor and near-poor people without
health insurance increased by 21%. During the same period, free hospital care
increased by less than 4%.
A related concern is sometimes referred to as "dumping." An article in a
recent issue of the New England Journal of Medicine reported the results of a
study of 467 patients transferred to Cook County Hospital in Chicago in a 42-day
period in late 1983. The conclusions were disturbing for a number of reasons.
First, the primary reason for a majority of the transfers was economic rather
than medical. Second, at least one-fourth of these patients were judged to be in
an unstable condition at the time of transfer.
In addition, only 6% of the patients had given written informed consent for
transfer. Thirteen percent of the patients transferred were not informed
beforehand about the transfer. When the reason for the transfer was given, there
was, at times, a serious discrepancy between the reason given to the patient and
that given to the resident physician at Cook County Hospital during the
transfer-request phone call.
The problems facing Chicago hospitals are by no means unique. They can be
found across the nation. Another article in the same issue of the journal
described the Texas attempt to eliminate "dumping" of patients without valid
medical reason. However, the same article summarized the ongoing dilemma which
continues to face all segments of our society: "Who will pay for the medical
care of the poor?"
Although each hospital must examine its own policies and practices in regard
to uncompensated care of the poor, some recent studies suggest that such care of
itself may not be an effective substitute for public insurance. Arizona, as you
may know, is the only state without Medicaid. Recent studies reveal that the
proportion of poor Arizona residents refused care for financial reasons was
about double that in states with Medicaid programs. On the other hand, poor
elderly Arizona residents—covered by Medicare—were found to have access to
health care comparable to that of other states.
These facts are disturbing to anyone who espouses the sacredness and value of
human life. The fundamental human right is to life—from the moment of conception
until natural death. It is the source of all other rights,
including the right to health care. The consistent ethic of life poses a series
of questions and challenges to Catholic health care facilities. Let me enumerate
just a few.
- Should a Catholic hospital transfer an indigent patient to another
institution unless superior care is available there?
- Should a Catholic nursing home transfer a patient to a state institution
when his or her insurance runs out?
- Should a Catholic hospital give staff privileges to a physician who won't
accept Medicaid or uninsured patients?
If Catholic hospitals and other institutions take the consistent ethic
seriously, then a number of responses follow. All Catholic hospitals will have
outpatient programs to serve the needs of the poor. Catholic hospitals and other
Church institutions will document the need for comprehensive prenatal programs
and lead legislative efforts to get them enacted by state and national
government. Catholic medical schools will teach students that medical ethics
includes care for the poor—not merely an occasional charity case, but a
commitment to see that adequate care is available. If they take the consistent
ethic seriously, Catholic institutions will lead efforts for adequate Medicaid
coverage and reimbursement policies. They will lobby for preventive health
programs for the poor.
My point in raising these issues is not to suggest simplistic answers to
complex and difficult questions. I am a realist, and I know the difficulties
faced by our Catholic institutions. Nonetheless, the consistent ethic does raise
these questions which present serious challenges to health care in this
nation—and specifically to Catholic health care systems.
To face these challenges successfully, Catholic health care institutions,
together with the dioceses in which they are located, will have to cooperate
with each other in new and creative ways—ways which might have been considered
impossible or undesirable before. No longer can we all be "lone rangers." I know
what you have done (and are doing) here in the Brooklyn diocese to maximize the
effectiveness and outreach of your hospitals and other health care institutions.
I commend you for this. In the very near future the Archdiocese of Chicago and
its Catholic hospitals hope to announce the establishment of a new network which
will provide a structure for joint action aimed at the hospitals' market
competitive position, promoting governance continuity, and ensuring maximum
In short, today's agenda for Catholic health care facilities is new. The
context in which we face this agenda is also new because, unlike the past, the
Catholic health care system today confronts issues of survival and of purpose.
How shall we survive? For what purpose? The consistent ethic helps us answer
these questions. It is primarily a theological concept, derived from biblical
and ecclesial tradition about the sacredness of human life, about our
responsibilities to protect, defend, nurture and enhance this gift of God. It
provides us with a framework within which we can make a moral analysis of the
various cultural and technological factors impacting human life. Its
comprehensiveness and consistency in application will give us both guidance and
credibility and win support for our efforts. The challenge to witness to the
dignity and sacredness of human life is before us. With God's help and our own
determination, I am confident that we will be equal to it.
of the Magisterium on Abortion