Catholic Medical Center Jamaica, New York
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 related, issues.
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 issues.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 fear."
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 evening.
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 application.
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 morally unjustifiable.
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, which states:
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 tradition.
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 today?
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 mission effectiveness.
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.