Issue Five

Across the world the application of new technology at the beginning of life is giving rise to profound ethical questions. How individuals and nations respond to these questions depends primarily upon how they view the moral status of the human embryo.

Stem cells, cloning, frozen embryos and related technologies have moved out of the laboratory into the political arena, with competing and often opposing demands being made for a legislative response to these technologies. In New Zealand the Government is currently drafting such legislation, a difficult task for any government to undertake given the divisions in society about the moral status of the embryo.

The debate in the community centres on whether human life should be accorded unconditional or conditional respect. Belief in the sanctity of life from the moment of fertilization gives rise to unconditional respect, according the embryo the same rights that children and adults have. The right to life is foremost among these rights.

Conditional respect arises from the view that the early embryo is simply a ball of cells, which cannot yet be accorded the status of a person. In this view human rights are contingent upon when the embryo becomes a person, before which time it is considered not to have the same right to protection as children or adults. Because the ball of cells is recognized as being human in nature, some respect is accorded the embryo, with the level of that respect increasing as the embryo develops. However this perspective does not accord the human embryo an absolute right to life.

Debate about the moral status of the embryo has arisen from technological developments, which have sought to address different forms of human suffering. The desire to have children is deep-seated, emotionally and biologically. The anguish and suffering of couples who have difficulties in having children is very real, and medicine has sought to provide alleviation of that suffering for some couples through in vitro fertilization. However the use of IVF has resulted in thousands of spare embryos being frozen and stored around the world, bringing a new form of anguish and conflict as couples, scientists and governments ponder how to deal with the situation. In some countries moves have been made to allow adoption of frozen embryos, but the number of embryos already in existence far outstrips the number of potential adoptive parents. Allowing frozen embryos to perish after a defined period of time, with the consent of their parents, has been seen by legislators as the only practical option, a step taken reluctantly and with discomfort given the different perspectives in the community about the moral status of the embryo.

In the last few years the development of stem cell research has provided hope that there may be a treatment even cure for intractable conditions such Alzheimer's and Parkinson's diseases. These conditions, and others, which may be treatable by stem cell therapy, cause deep suffering to those affected by them. Embryos are one source of the stem cells needed for this research, which has introduced a new context to the debate about the moral status of the embryo.

Embryo Development
An embryo is formed from the union of an egg and sperm. The egg and sperm are referred to by scientists as gametes, a term which identifies them as each having half the number of chromosomes (23) found in other body cells (46). The process of fertilization begins when the sperm enters the egg, and results in a cell, which contains 46 chromosomes. This cell is called the zygote, and has a genetic complement that is different to that of either the father or the mother.

By the second day the process of cell division has begun. The zygote is now called an embryo, and rapidly becomes a cluster of cells. By days 5 and 6 the cluster has become a hollow ball of cells called a blastula. A particular group of cells in the blastula develops into the foetus, while the other cells become the placenta, umbilical cord and other supporting structures for the embryo-foetus.

Until around day 12 the possibility of twinning exists, with the embryo able to split and grow into two separate individuals. This is, for many, a significant biological factor in determining the moral status of the embryo

Ensoulment and Personhood
Central to the debate about ethical issues associated with human embryos is the question of whether or at what point in its development the embryo should be accorded person status. Personhood is a philosophical concept, and there are many schools of thought as to where it fits in the biological development of a new human being.

In the Catholic tradition the language employed has in the past made use of the concept of 'ensoulment' to describe what definitively sets humans apart from other life. There have been many theories about when ensoulment occurs in the development of the embryo or foetus. While terminology may differ, the question being asked is essentially the same as the question about personhood.

Past Catholic theories about ensoulment, now untenable, drew on the best scientific knowledge of the day. The current position of some scientists, moralists, philosophers and others, who argue for legitimate experimentation on embryos within a certain and limited period of time can be seen, in part, as more nuanced attempts to answer the same questions about ensoulment and personhood. Just as past theories about ensoulment were influenced by the science of the time, more contemporary secular approaches centred on personhood may also be seen to be the product of developments in scientific knowledge.

Theories of Personhood
Among philosophers the arguments about when personhood begins are complex. According to Patrick O' Mahony in his book, A Question of Life, the debate falls into five schools of thought: the Genetic School, the Developmental School, the Relational School, the Social Consequences School, and, the Potentiality School.

The Genetic School
In this school of thought O'Mahony places all who argue that the human person comes into existence at fertilization. Development is a process of becoming the one she or he already is. He quotes a proponent of this school, Teresa Iglesias, who says that human beings are one entity and not a composite of two. They are not human organisms first and persons later when the advent of the soul or consciousness takes place. If we can attain self-consciousness at some stage we must already be the kind of beings that can attain it Whatever capacities we have now, have developed from the beginning. These abilities, like self-awareness and choice, are only explicable if there was always the presence of the inherent capacity for those abilities from fertilization. [1]

While there is a vast amount of medical literature to support this view there are two main objections to this perspective, namely, the high percentage of fertilized ova that do not implant and the phenomenon of twinning. During the first week of its development an embryo can divide into two and each then continues to develop separately. It is then argued that it is not possible to attribute personhood to the embryo until the possibility of twinning has passed.

The Developmental School
The proponents of the Developmental School require further development of the embryo before it can legitimately be called an individual human being. Accordingly, some place the beginning of the human individual after the point where twinning can no longer occur. Others require a later stage of development such as the formation of the cerebral cortex because human life manifests its nature through consciousness. According to this School, the presence of the brain coinciding with the onset of the human person parallels the phenomenon of brain death being a criterion for the death of the person. [2]

The Relational School
This School is unwilling to accept merely physical criteria and argues for what is called more personalistic criteria. In other words this School holds that the beginning of human life and personhood cannot be based on biological evidence alone, and is contingent upon the ability to develop relationships with others.

The Social Consequences School
The proponents of this School base their theory about the beginning of human life on psychological or moral factors. For this School life is sacred because of the consequences to society of destroying it. However at the same time those who argue from this perspective tend to see the sacredness of life and the reasons for protecting it as increasing with the development of the embryo-foetus, rather than being absolute from conception. That people feel differently towards zygotes and children is taken as sufficient indication that zygotes are not to be considered human beings.

The Potentiality School
This School is closely linked to the development of biotechnology. Proponents of this School contend that their case does not rest on the view that the embryo is a person from the moment of fertilization. Yet, they argue, there is no doubt that the life of the human embryo begins at fertilization. Their case is based on the embryo having the potential to become a human person.

Implications of the Schools of Thought
Most proponents of embryonic experimentation rely on scientific knowledge to establish that 'person status' cannot possibly be present in the earliest stages of the development of the fetus. It is on this basis that they would allow experimentation on what is simply a blastocyst, a ball of cells, rather than human life. From this perspective human rights are not being violated because the person does not yet exist. Their argument allows experimentation up to the point in time where it is considered that personhood clearly must exist. There is general acceptance that experimentation should not occur after 14 days, because at this point, (a) there is certainty that the embryo will develop into one individual as opposed to two individuals, and (b) cell differentiation has begun to occur. It is clear which cells will form the embryo and which will form the placenta and other supporting structures, thus making the embryo an identifiable entity.

To a greater or lesser degree this thinking does not take into account the continuity of human existence, with a consequent fragmentation of the earliest stages of human existence. This stance includes the idea that freedom, knowledge, decision-making and the ability to relate, etc, are able to be separated from the capacities in which they are rooted. The resulting fragmentation is not consistent with the genetic continuity which begins with the formation of the zygote, a cell with a genetic complement which is different to that from its mother and father, and different from that of any other individual. It would also seem to ignore the fact that our abilities to make choices, think, act and relate are the outcome of the continuous presence of capacities present at the beginning of the embryo's existence when fertilization occurs.

Others argue for allowing research on the spare embryos resulting from treatments for infertility. Their argument is a purely pragmatic one: spare embryos already exist, and cannot be stored indefinitely. The real choice is between destroying the embryos by allowing them to perish, or using their cells for useful research which will ultimately be of benefit to other human beings. Framed in such a pragmatic way, the argument for the use of frozen embryos appeals to those who are uncomfortable with the creation of embryos for research, or for activities such as the development of stem cell lines from embryos. The logic appealed to places some value to a life which appears to have none as an unwanted frozen embryo.

In these approaches moral evaluation of the use of frozen embryos for research involves the weighing up of two possible outcomes. In the first of these the embryo is allowed to perish, considered to be a life of no value because it is unwanted. In the second outcome the embryo is destroyed during research, and in this act gives its life for the sake of others, thus making its short existence meaningful and of value. This second outcome appeals as the moral choice because it confers a reason for existence on the embryo, and casts its death as an altruistic and salvific act. This moral choice is utilitarian in its premise, because the value of a human life is presented as depending upon its usefulness to others.

In arguing that embryos should not be created for research, but that it is morally acceptable to use frozen embryos for this purpose, a second-class status is conferred upon frozen embryos as far as protection is concerned. Embryos created by cloning also have this second-class status, despite the fact that all embryos have the same biology. From a Catholic perspective these arguments ignore the intrinsic value each human life has by its very nature.

Catholic Teaching
In recent years the moral status of the embryo has been made abundantly clear in official Church documents. The 1987 document Donum Vitae [The Gift of Life] stated that the respect due to all persons is to be accorded to the human embryo from the first moments of fertilization:

The human being must be respected - as a person - from the very first instant of his or her existence ... From the time that the ovum is fertilized, a new life is begun which is neither that of the father nor of the mother; it is rather the life of a new human being with his or her own growth. [3]

Contrary to what many people think however, the current Catholic position does not accord 'person status' as such to the embryo in its very earliest stages of development.

Regarding this question, although the Magisterium has not expressed itself in a binding way by a philosophical affirmation, it has still taught constantly that from the first moment of its existence, as the product of human generation, the embryo must be guaranteed the unconditional respect which is morally due to a human being in his or her spiritual and bodily totality. [4]

This view is echoed in the writings and teachings of Pope John Paul II. When writing on abortion in Evangelium Vitae he says:

Some people try to justify abortion by claiming that the result of conception, at least up to a certain number of days, cannot yet be considered a human life. But in fact, from the time that the ovum is fertilized, a life is begun which is neither that of the father nor the mother; it is rather the life of a new human being with his or her own growth. It would never be made human if it were not human already. This has always been clear, and modern genetic science offers clear confirmation. It has demonstrated that from the first instant there is established the programme of what this living being will be: a person, this individual person with his or her characteristic aspects already well determined.

what is at stake is so important that, from the standpoint of moral obligation, the mere probability that a human person is involved would suffice to justify an absolutely clear prohibition of any intervention aimed at killing a human embryo. Precisely for this reason, over and above all scientific debates and those philosophical affirmations to which the Magisterium has not expressly committed itself, the Church has always taught and continues to teach that the result of human procreation, from the first moment of its existence, must be guaranteed that unconditional respect which is morally due to the human being in his or her totality and unity as body and spirit: the human being is to be respected and treated as a person from the moment of conception. [5]

Over time philosophical ideas about personhood and the embryo have changed with scientific advances. The teaching of the Church, as re-stated by Pope John Paul II, does not depend upon apportioning personhood to the embryo at a particular point in the continuum of development. This frees it from dependence on scientific knowledge for its authenticity. Because the human being is to be respected and treated as a person from the moment of conception all human rights, which attach to living children and adults, are accorded to the embryo and to the foetus, prime among those rights being the right to life. The origin of the embryo does not affect this status, and so embryos resulting from cloning or IVF have the same rights as an embryo conceived through sexual intercourse.

The teaching of the Church illuminates with great poignancy on the situation of the thousands of frozen embryos which exist in clinics around the world, and who some consider are a morally acceptable source of stem cells for research. If they are to be treated as persons then experimentation on them is an immoral choice, which is not consistent with the unconditional respect morally due to the human being in his or her totality and unity as body and spirit. Rather than giving value to their existence, experimentation adds indignity to their death.

Amid the sea of shifting philosophies on the moral status of the embryo, Catholic teaching offers sound principles for the ethical and moral analysis of issues arising from the use of new technology at the beginning of life. In their application these principles help to provide protection for the most vulnerable members of humanity. The provision of such protection is a key criterion for society to use in analysing the morality of its decisions and actions.
________________

Anne Dickinson, John Kleinsman, Michael McCabe
©
2001

^1] Patrick O'Mahony A Question of Life: Its Beginning and Transmission London: Sheed and Ward, 1990: 9-10.

[2] O'Mahony 1990:18.

[3] Congregation for the Doctrine of the Faith, Instruction on Respect for Human Life in its Origin and on the Dignity of Procreation [Donum Vitae]Vatican translation. Boston: Saint Paul Books and Media, 1987:12-14.

^[4] The Problems of Threats to Human Life. Vatican City: Vatican Polyglot Press, 1991: 11-12.

[5] Pope John Paul II, The Gospel of Life [Evangelium Vitae] Vatican City: Vatican Polyglot Press, 1995: 60-61.

The doctrine of conscience lies at the very heart of Catholic moral teaching. The Catechism of the Catholic Church stresses that we have a right to act in conscience and in freedom so as to make moral decisions, and that no-one should be forced to act contrary to his or her conscience. [i]

James DiGiacomo, reflecting on post-Vatican changes in the field of moral theology, comments on the fact that the words follow your conscience were hardly heard in Catholic education classes thirty years ago. [ii] The introduction of these three little words into our everyday moral repertoire started, in DiGiacomo's words, when indoctrination or brainwashing became undesirable in Catholic and other educational circles. We all recognise, even if some lament it, that there has been within the Church, as well as in society as a whole, a move away from a strictly rules based approach to moral decision making. What has replaced this morality by rules has been an insistence that people can formulate for themselves a sense of right and wrong that is based on their own interiorised values and felt needs.

Few would deny that the responsible exercise of conscience is preferable to mindless obedience towards authority. Indeed, in the face of extreme brutalities carried out in the course of war, we as a society have time and again roundly rejected as a valid defense, the excuse that a person was simply following orders. The well publicised Nuremberg and My Lai massacre trials are testament to this. At the same time, I believe that these events, and others, have shaped people to understand conscience in a particular and rather impoverished way. In Dick Westley's words, many tend to think of conscience in terms of the lonely and solitary individual standing nobly and doggedly alone against the forces of compliance no matter what the cost. [iii]

Such an understanding also happens to be in keeping with our current Western predisposition toward individualism and its corresponding (and disproportionate) focus on individual rights. 'Conscience' then becomes code for 'opposition to compliance and authority'; 'community' code for 'what restricts individual freedom'; and 'authority' code for 'the crushing of non-compliance and individual conscientiousness.' [iv] Viewed like this authority and conscience appear falsely in opposition to each other, and the demands of conscience would appear to become somewhat arbitrary. Moral norms are reduced to a person's subjective imperatives, and to have acted with good conscience can mean little more than that a person has acted with sincerity, free from any form of external coercion. To talk, in the same breath about the 'primacy' of conscience suggests, furthermore, that one's personal moral judgement cannot be challenged. The fact that a man or woman makes a choice serves to defend its moral rightness.

Without advocating a coercive or strictly rule based approach to moral decision making, because such approaches fundamentally undermine the dignity of the person, the Catholic-Christian tradition rejects as too narrow the understanding of freedom upon which the above understanding of conscience rests. More particularly, a Catholic-Christian approach to and understanding of conscience works out of an understanding of human flourishing which recognises that while individual fulfillment includes the exercising of personal autonomy, it involves much more than a person simply being free to decide for oneself a particular course of action.

A Catholic vision of the human person is grounded in the idea that we are first and foremost not alone in the universe. Indeed the word 'conscience' contains within itself a view of the human person as being fundamentally defined through and in relationships with others. The meaning of the Latin root word we translate as 'conscience' is literally shared knowledge or knowledge with others. Thus Westley writes: It is in virtue of that dimension of conscience that no matter how individual it may be, it is at the very same time always at bottom a call and a summons to all of humankind. [v] Understood like this, the exercising of conscience is a sign of a shared existence, a solidarity with all of humankind. If this is accepted as the jump-off point for understanding human fulfillment, then it becomes apparent that the demands of a Christian conscience are anything but individualistic and arbitrary. Conscience and community are anything but implacably opposed to each other.

Freedom, from such a perspective, involves choosing those actions that are in keeping with our shared human dignity. This in turn presupposes some fundamental agreement regarding what it is that brings about true human flourishing, and the recognition and identification of shared human values. The key question is whether the values that motivate my/our approach to a particular issue reflect those shared values. A strictly Christian approach will reflect the specific values of the Christian Tradition, namely those personified by Jesus himself. The Catholic Tradition upholds a certain understanding of what does and does not bring about human flourishing based on its own reflection on, and understanding of, God as revealed in the Judaeo-Christian story.

In the words of the Irish Bishops, being aware of how an issue appears to my friends, how other people in my community, past and present, have understood it, helps me to make the best, most informed decision. This is essentially what we are referring to when we talk about the value of our Catholic Tradition. This Tradition holds up before us the wisdom and experiences of past generations of Christians, including those who walked and talked with Jesus himself. As such, properly understood and interpreted, it constitutes an authority that acts as both an anchoring point and as a casting off point in our quest to navigate the tides and currents of moral issues and dilemmas that confront us today. Seen like this, authority and conscience are also anything but implacably opposed to each other.

True conscience, then, is knowing with our whole selves and also knowing in relationship to others and with others. [vi] This very Catholic understanding of conscience rescues us from moral relativism. At the same time it continues to uphold the importance of the dignity of the individual, a dignity that is submerged in any authoritarian or narrowly focussed rules based approach to decision making. It rests on the basic truth that no person is an island, that all decisions affect others in some way, and that good morality is up building of community. Above all we are rescued from the false immunity offered by sincerity. Sincerity offers no guarantees about how we arrive at a particular point of decision making. Neither does it offer us protection from our own biases and prejudices. Again, in the words of the Irish Bishops, sometimes the convictions we like to think are reasonable and balanced are nothing more than the product of our biases and prejudices.

From this it naturally follows that a Catholic-Christian understanding of conscience recognises that the formation of conscience is intimately related to the process of forming community. True Christian conscience will be fostered best in a community that shows and practices the unconditional love that we know characterises the God who has called us and revealed self to us. Conscience brings us face to face with the radical grace-filled invitation we receive to enter into a loving relationship with God through loving our neighbour. [vii] This in itself invites a richer and broader understanding towards the traditional Catholic practice of examining our conscience. It supposes that we must identify and 'examine' the communities of influence we move in and out of and critically examine the implicit and explicit values that sustain these communities.

In the words of John Glaser, the invitation to follow one's conscience involves the recognition of an absolute call to love and thereby to co-create a genuine future. The question of what our future might look like is thus an important question when we come to consider the ethics of particular practices in bioethics. This calls for the creative and sustained use of moral imagination along with the disciplined use of moral reason. Of all our faculties, it is the imagination which teaches us new possibilities of existence. [viii] Moral imagination is surely called for more than ever as we try to 'hold up to the light' issues and dilemmas in bioethics that we know have implications for future generations. The task of following one's conscience thus involves the fostering of moral imagination.

To conclude: That people use the same language - follow your conscience - may belie the fact that they understand conscience in quite different ways. A key question involves discovering what people mean by the phrase follow your conscience. I have suggested that it means different things to different people. To some it may mean doing the right thing whatever the cost. To others, it may mean: Don't listen to anyone: you're on your own. And to some others, it may simply mean: do as you please. I have argued that in a Catholic-Christian approach to conscience, autonomy, freedom, community and authority go hand in hand. In line with this I have offered the view that a responsible exercising of conscience goes beyond sincerity and asks questions about a person's communities of influence and also involves the practice of moral imagination.

[i] See Catechism of the Catholic Church, # 1782.
[ii] DiGiacomo, James. (1993). Morality and Youth: Fostering Christian Identity. Kansas City: Sheed & Ward.
[iii] Westley, D. (1988). A Theology of Presence: The Search for Meaning in the American Catholic Experience. Mystic, CT: Twenty-third Publications.
[iv] Ibid.
[v] Ibid.
[vi] Dunn, E. (1998). What is Theology: Foundational and Moral. Mystic, CT: Twenty-third Publications.
[vii] Ibid.
[viii] Davies, O. (2000, 4 Nov). Feeling Another's Pain. The Tablet.

John Kleinsman teaches Theology at the Catholic Education Centre in Wellington and is also a part time researcher for The Nathaniel Centre

©
2001

The following article is a paraphrased version of a Pastoral Letter on the topic of Conscience issued by the Irish Catholic Bishops’ Conference in spring 1998.  The full letter is available on the internet:
http://www.limerick-diocese.org/archive/year/1998/con-title.htm  

When we approach an important decision we go to great lengths to ensure that we make the right choice. Everyone knows the experience of looking back regretfully on decisions taken after the most serious reflection and saying, ‘If only I had realised…'   

To this we might say, ‘So long as you’re sincere, that’s what counts’. From one point of view that is perfectly true. To be sincere means being honestly convinced that we made every effort to ensure we are doing the right thing. Indeed, the phrase ‘You must follow your conscience’ means we should do what we honestly believe to be right. However, this is likely to be little consolation to someone harmed by our wrong decision. Nor does sincerity protect from the damage my mistake may do to me. Being sincere is not the same as being correct. That is why we must not stop at asking ‘Am I being honest?’ Searching for the truth involves trying to answer the question, ‘Am I making the right decision?’ 

We have no right to judge another person. Only God can be the final judge of whether a person is sincere or insincere. Yet, we do not inhabit separate universes and all decisions affect others in some way. Therefore, it is legitimate to wonder whether a particular decision is for the better or for the worse. It is not a matter of condemning people but of clarifying the issues involved. 

We must do what we sincerely believe to be right, but how we arrive at that point may be questionable. Coming to the decision we want to reach can be easier than we like to admit. Sometimes the convictions which we like to think are reasonable and balanced are nothing more than the product of our prejudices. 

We talk about 'the voice of conscience'. That can be misleading.   Conscience is not merely somebody whispering in my ear – as if all we have to do is sit there passively and wait for our conscience to speak. Nor is it just a feeling or an instinct. It is a considered and informed judgement of what is the best thing to do in a particular situation. Thus, in the Catholic tradition we see conscience as "a judgement of reason" (CCC 1778).  

How do we make such judgements? The judgement of conscience is not just about whether the action causes more happiness than pain – sometimes a large number of people can be happy at the mistreatment of an individual or a minority. Neither is this judgement just about what the action achieves. We need to consider what the action itself means, what it says. In every action I say something about the kind of person I wish to be and the kind of values I choose to live by. In every action I say something about how I regard people – as people whose dignity is equal to my own, or as beings I may use or manipulate. The first question a conscience judgement seeks to answer is whether this action expresses the truth about my own and others' dignity. 

In every choice we make, we respond positively to God to the extent that a decision is in accordance with our deepest God-given human dignity. It is in this sense that we may helpfully refer to conscience as a ‘voice’, the voice of God inviting us into the complete truth, inviting us to experience 'life in abundance' (John 10:10). 

We will only hear ‘the still, small voice of God’ (I Kings 19:12) if we are sufficiently present to ourselves. At the same time, I am not being very wise if, when I come to make a decision, I think I have nothing to learn from anyone else. When I face a difficult moral decision, I need not act as if I was the first person who ever had such a problem. I need to look honestly at all the things that can help me come to a right decision. This is what is meant by ‘informing my conscience’. 

When it comes to the Church, there is a tendency to see its moral vision and ideals as regulations that restrict our freedom. Yet, the Catholic-Christian tradition we have inherited is an ally of our personal freedom because of its capacity to challenge us to respond to our situation with courage and creativity  - as our ancestors so often did. Down through the centuries Christians wanting to love God and their neighbour have faced many different situations. 'Christian morality' is really the answer of those Christians and their communities to the questions they faced. To ignore this heritage is to act in a restricted way. When we do so we disregard a wealth of insight. The tradition exists to enhance our freedom by helping us to isolate the truth about what it is to flourish as a person.

It is the role of the Church, through its leaders, to clearly formulate the wisdom contained in our tradition so that people can see its implications for particular decisions they face.This is not just a matter of reflecting the consensus of Church members. It is a question of being faithful to a message which is God's message, and to a Church which extends not only across the continents but across the centuries. The authority of the Church is not dictatorship; it appeals to the consciences of people to accept that what it says is true because of Jesus' promise that the Holy Spirit is with the Church in its teaching task. Direct answers are not always immediately available since the questions we face today are often not the same as those which existed when the Scriptures were written, or those faced by previous generations of Christians. 

That concerned human beings, clearly motivated by compassion, can come to opposite conclusions about a particular moral issue, might push us towards the idea that there is no moral truth, that one person's opinion is as true as anyone else's. But something in us wants to believe that a moral argument is not like a discussion about whether custard has a pleasant taste. Such a discussion is meaningless - some people like custard, others do not, and that is the end of the matter. Physician assisted suicide, for example, cannot be right for some people and not right for others. Thus, in our Catholic tradition, we speak of certain obligations as being 'absolute', as being the same for everyone. While the word 'absolutist' may sound unattractive, in some circumstances it can be another word for 'hero'.  

Heroes are those who would go to any lengths - even death - rather than deny the truth of Christ's Gospel. It is this truth we are referring to when we talk about acting in harmony with the plan of God and co-operating with the Holy Spirit to renew the face of the earth. The Holy Spirit is present in each of us as 'a gentle guest and friend who inspires, guides, corrects and strengthens' us (CCC 1697). That is why, for the Christian, coming to a conscience judgement is not just an effort of reasoning, it is also a prayer. 

In summary
The judgement of conscience applies to a concrete situation the rational conviction that one must love and do good and avoid evil. Our conscience decisions will be either in accord with the truth about our God-given dignity or not. For this reason we say that conscience, the place of decision, is a place of encounter with and response to God. We have a rich community tradition upon which we can call to make informed conscience decisions. 
___________________ 

1/11/2001                                                                                                                                    

“Radiation zap test too risky, says Heart Foundation” was a recent headline in the local evening newspaper.   The first two paragraphs of the article described how the National Heart Foundation did not support the technique for checking patients’ hearts because “the technique is expensive, has not been adequately studied and carries the risk of giving a radiation dose equivalent to up to 400 chest x-rays”.    In response, the test’s provider claimed the radiation figures were scare mongering and that there was good evidence for the value of the scan. [1] 

As Chair of a Regional Ethics Committee, I was interested because this sounded like an innovative procedure that should have come before the Ethics Committee for appraisal and approval. Ethics Committees are charged primarily with protecting research participants from harm and as innovative treatment is new or unconventional, it is, no less than health research is, human experimentation.   Any application for ethical approval “must justify the use of the new procedure, provide reports from the literature if available, compare risks and benefits, demonstrate the experience and qualifications of the clinician and the training required for nurses and other staff, provide copies of information to be given to patients and discuss how informed consent is to be obtained.” [2] 

I am always concerned when medical “experts” disagree so publicly.   While no one disputes that there should be healthy debate in medicine, the community-at-large becomes concerned and confused when those they look to for guidance on technical or very specialised medical matters appear to be at loggerheads.   There is no better example of this in New Zealand than the “great cot death debate”, a debate which has left parents and parents-to-be anxious about how best to protect their babies and has resulted in the reduction of money for cot death research in New Zealand.

Any new screening programme raises ethical issues that must be addressed and satisfied. What are these issues and why is there a difference between a patient who seeks help from a doctor for conventional diagnosis and treatment and those other patients whom the doctor seeks to identify as requiring his or her assistance?   Thomas McKeown wrote: 

“The position is … different in screening, when a doctor or public medical authority takes the initiative in investigating the possibility of illness or disability in persons who have not complained of signs or symptoms.   There is then a presumptive undertaking, not merely that abnormality will be identified if it is present, but that those affected will derive benefit from subsequent treatment or care….   No one should be expected to submit to the inconvenience of investigation or the anxieties of case finding without the prospect of medical benefit” [3] 

He identifies obligations in screening which are to ensure:

a)      that a screening programme is effective, and if it is
b)      that it makes better use of limited resources than the available 
         alternatives
c)       that it reaches the entire at-risk population, and
d)      how to manage the cases when they have been identified

Shortly after reading the article, a representative of the local cardiology community asked me to attend their meeting with the test’s provider. This meeting was informative and evidence was produced to confirm that the test, Electron Beam Computed Tomography [EBCT], has been the subject of research throughout the 1990’s. It also satisfactorily addressed some of the ethical issues, dispelling the notion that the test was an “innovative procedure” but it left others yet to be answered.   It is useful to use the framework of McKeown’s obligations to work through these issues. 

Effectiveness of Test
Research has shown a direct correlation between the amount of calcium in the coronary arteries and the likelihood of a future heart attack. EBCT takes a series of cross-sectional images of the heart, allowing the detection of even small amounts of calcium in the coronary arteries. The amount and density of the calcium allow the calculation of the calcium score. The score will show how an individual fits into various age and risk profiles and whether there is any likelihood of obstructive coronary artery disease in the future. For people at risk, their doctor will recommend an appropriate strategy to maintain cardiac health and may also recommend further testing. [4] 

The American Heart Association is satisfied that “as EBCT has been shown to be sufficiently accurate for predicting the presence of angiographic stenoses (narrowings) somewhere in the coronary arteries and for predicting the likelihood of clinical end points in symptomatic patients, it can be used as part of a cardiological examination done under the supervision of a physician knowledgeable about the significance of scan results and the management of coronary heart disease.” [5] 

However, the Association remains quite cautious about EBCT. Unless the calcific area is greater than 2 mm, the reproducibility of coronary calcium detection with cardiac scanning appears to be insufficient for serial assessment of coronary calcium levels in individual patients. Presently the data are insufficient to recommend coronary artery calcium screening in lieu of stress testing for most patients with chest pain, except in those with atypical chest pain, for whom a negative study may be useful by itself or in addition to exercise testing. The role of EBCT as a screening tool in asymptomatic patients with conventional risk factors is not yet clearly defined.   There is no role at present for application of the test to screen populations of young (less than 40 years old), healthy individuals with no risk factors. The importance of calcification in such individuals will have to await event data that are currently being obtained. [6]

A further limitation of calcium scoring is that although calcium deposition occurs relatively early in the atherosclerotic process, plaque material is not initially calcified. Therefore very early atherosclerosis may be undetected by this technique. This is important since early non-calcified plaque could potentially become unstable (plaque rupture) and cause symptoms (unstable angina or heart attack); if it is not accompanied by calcified plaque, a patient's calcium score could still be "zero." Consequently, any patient with typical chest pain should receive an appropriate evaluation, and calcium scoring at this time does not play a role in the evaluation of chest pain. [7]

In summary, research indicates that the test is effective at detecting the presence of atherosclerotic plaque. The greater the amount of calcification, the greater the likelihood of obstructive disease and high calcium score may be consistent with a moderate to high risk of a cardiovascular event within the next 2 to 5 years. Its use should be limited to areas of proven effectiveness and wider use should only be as part of well designed, scientific study. 

Better use of Limited Resources
Heart and blood vessel diseases cause more than 41% of all deaths in New Zealand each year. At present rates, about one in three New Zealand men will die from a heart attack and one in five women. [8]   For a number of apparently fit and healthy New Zealanders, the first indication that they have Coronary Artery Disease (CAD) is when they have a heart attack. EBCT is sensitive to the detection of early CAD, and extent of plaque burden.   The detection of any degree of coronary calcium indicates that CAD is present. The calcium score provides a quantitative estimate of plaque burden and in general, the higher the score, the larger the plaque burden and the higher the risk of subsequent cardiac events.   It is therefore a valuable “early warning system” for a potential heart attack. 

Heart disease can be slowed, stabilised, and in some cases, reversed when a heart scan is done and detects early signs of calcium in the coronary arteries. EBCT therefore has the potential to reduce both the morbidity and mortality that arise from previously undetected CAD, the extent of which was previously unknown.   But the clear limitations expressed by the American Heart Association should be heeded and EBCT should not be used where research has not proven its efficacy.   EBCT is not adequate for the serial assessment of plaque levels, it should not replace stress testing in people with chest pain, it does not replace angiography as the most reliable technology to accurately assess luminal narrowing in the coronary circulation and that there is no evidence to support screening in people less than 40 with no risk factors. [9]   To use it for these purposes would not be supported by the current evidence and would be termed a poor use of limited resources. 

Reaching an Entire at-risk Population
Research indicates that EBCT is appropriate for both men and women, age 40 to 70, who have any of the following risk factors: family history of heart disease, high blood pressure, smoking, diabetes, overweight, sedentary lifestyle, high cholesterol or high stress level.   The documentation of the presence of CAD would be expected to change or influence any therapy a doctor recommends and people with borderline lipid levels, or mild hypertension may benefit as their doctor could decide whether more aggressive secondary prevention therapies are appropriate. 

Clearly there is a significant sector in the New Zealand population who could benefit from undergoing EBCT.   However, the scan is only available through a private radiology service, at a cost of $560 per scan.   This cost is not currently covered through health insurance.   There is “direct-to-the-public” radio advertising, meaning the public at large is quickly becoming aware of what is conveyed in a 30 second sound bite as an important and potentially life saving test.   The advertisement does mention that people would need to be referred by their doctor for the test but its intention is to market a product. 

For obvious reasons of cost and limited access, the test cannot reach an entire at-risk population . In New Zealand, Māori and Pacific Island peoples are disproportionately represented in the at-risk group but as they are also over-represented in the low socio-economic grouping, they are the least likely people to undergo the test.   There is an issue of equity, or rather, a lack of equity, when many of the people most likely to benefit from the test are unable to access it. 

How to manage cases when they have been identified
EBCT is advertised as a test for which a doctor’s referral is necessary and people undergoing it must fit the risk profile.   Test results are mailed out to both the individual and their General Practitioner.   It is essential that full information is given before the test so that the individual is aware of the nature of the test including an explanation of the calcium score, the likely benefits and risks, costs and alternative tests including the possibility of no testing. 

Having undergone the test, the issue then becomes one of interpretation and management. As the test results go to the General Practitioner, it is up to him/her to discuss the results with the individual and to decide the best course of action. There will need to be continuing medical education provided for General Practitioners so that they are knowledgeable about both the test and its results in order to implement or recommend an effective treatment programme or make the appropriate referrals.   Reducing the risk factors is a sensible course of action even though it is not easy to change a person’s lifestyle.   This often requires considerable support from both family and community groups, meaning more resources would need to be provided for primary, community-based health and support groups. 

The presence of any detectable coronary calcium implies the presence of coronary artery disease but this does not mean a heart attack is imminent or that the person must be referred to secondary cardiology services.   Indiscriminate referral would soon result in an overburdening of already stretched cardiology services and would mean delays in people being seen.   This might not matter for those who are at little risk but could have tragic consequences for high-risk people. 

Detectable coronary calcium may affect patient management by providing impetus for more aggressive hypertension control, lipid lowering, and low-dose aspirin therapy.   Investigators have also noted that individuals, when informed of their score, or shown actual images, have displayed much more willingness to undertake healthy lifestyle changes. Since patients with very high scores (over 400) have a high likelihood of harbouring a significant narrowing, they should probably undergo stress testing. Patients with intermediate scores may require further testing based upon other factors such as age and other risk factors. [10]

All these management options, including General Practitioner and patient education, drugs, support for lifestyle changes, secondary care referral and further diagnostic testing, have resource implications that the EBCT provider has no professional responsibility, apart from informed consent obligations, to either consider or to ensure these are in place.   This raises the ethical issue of a private provider introducing and profiting from what is in essence a private screening programme with significant resource implications for the public sector but does not and is not required to satisfy the obligations identified by McKeown or the WHO Criteria for appraising the viability, effectiveness and appropriateness of a screening programme. [11]

Conclusion
There is little doubt that Coronary Artery Calcification Scanning or EBCT is able to detect Coronary Artery Disease and provided the right treatment and/or lifestyle changes occur, morbidity and mortality can be reduced.   Few would see this as anything but “a good thing” and worth pursuing. However, it is not as simple as providing “up-to-the-minute” technology that might save lives.   Technology is not to be used indiscriminately and it would be a waste of limited resources to use it where research has not shown it to be efficacious.   Almost certainly, cost and inaccessibility would deny the test to large numbers of people most at risk and this would be inequitable.   Finally, having identified a condition in an otherwise well person, the health service providers have a responsibility to provide education, treatment and support to ensure there is medical benefit.

____________________

Sharron Cole is Chair of the Wellington Ethics Committee and National Chair of the Ethics Committees in New Zealand.

©
2001

[1] Evening Post, 17 August 2001
[2] Skinner, Anna & Gillett, Grant   “A Review of Innovative treatment”   in   Otago Bioethics Report, Vol 7 No 1, March 1998, p. 14
[3] McKeown, Thomas ‘Validation of Screening Procedures’ in Screening and Medical Care, OUP 1968
[4] Robert J. Optican   “Coronary Artery Calcification Scanning; Its Time Has Arrived http://www.msit.com/news3.htm
[5] A Statement for Health Professionals From the American Heart Association   “Coronary Artery Calcification: Pathophysiology, Epidemiology, Imaging Methods, and Clinical Implications”

http://www.americanheart.org/Scientific/statements/1996/0903.html

[6] ibid

[7] Optican, op cit

[8] National Heart Foundation http://www.nhf.org.nz/index.html

[9] Optican, op cit

[10] Optican, op cit

[11] World Health Organisation    Report on Criteria for Appraising the Viability, Effectiveness and Appropriateness of a Screening Programme 1996

In June 2001, Cardinal Thomas Williams officially launched a new Catholic entity, Aotearoa New Zealand Catholic Healthcare Limited. The formation of the company brought together 16 Catholic congregations and entities that have a common interest in health care from a Catholic perspective. For a number of the founders it was the culmination of a long journey.

In our world of constant change, it is perhaps, the Health sector that is most affected by the many and turbulent currents that exist. In Aotearoa New Zealand the drivers of change in health include the myriad of different political agendas, the escalating needs in health and care, the high expectations of people, the increasing complexity of health issues and in many instances, the extraordinary cost of health care.

The Catholic presence in health care has been constant and considerable. Congregations, Dioceses and other church organisations have all been heavily involved in an enormously wide range of health and care related activities. The Catholic health family has also been subject to the very same currents described above. For example, in the last three months, even the basic charitable foundation that underlies the Catholic health involvement has been under threat as the government ponders the possibility of rewriting history via the medium of its Tax and Charities discussion paper.

There also have been considerable changes in the providers of Catholic health care. Numbers in those religious orders that provide health care have diminished but the importance of their work has not and a range of new governance structures have sprung up to give a voice for their futures. 

In the 1980s a number of people, mainly women religious, saw the changes that were occurring. Looking overseas they saw the importance of the role of ‘umbrella’ groups such as the Catholic Health Association of the United States and Catholic Healthcare, Australia. 

In particular, they were conscious that in trying to retain the individual missions and callings of the many congregations involved in health care, it was essential to have an over arching entity to provide strength in numbers, spirit and in purpose. While what was happening overseas provided a guide, it was important, they believed, to have a New Zealand approach. 

Early attempts to get such an organisation formed were not totally successful but the flame flickered rather than extinguished.   For the new millennium, the support was there, and the inaugural shareholders include all the Dioceses and those religious orders that are significant health care providers. 

Those shareholders were conscious of the need to ensure that there was a selection of a board of directors based on competence and not just mere representation .An excellent range of skills and abilities have been brought together. The foundation board consists of:

Sister Catherine Hannan who is the chairperson. Catherine is a former congregational leader of the Sisters of Compassion and is also the chair of Caritas.

Cardinal Thomas Williams who, in addition to being a shareholder as the Archbishop of Wellington, is also an important liaison with the other members of the New Zealand Catholic Bishops’ Conference.

Sister Rita Vessey who is currently the coordinator of the Te Ngakau Wairoa Spirituality Centre and is a former administrator of Mercy Hospital and Health Services, Auckland.

Kim von Lanthen, the current Chief Analyst for the Treasury and a former manager for Pricewaterhouse. Kim serves on the boards of a number of Wellington based Catholic entities.

Monty Arnott, the general manager of Sisters of Compassion Limited who has a background in governance, risk management and the health and welfare sectors.

Catherine Roughan, Chief Executive of   St John of God Health and Disability Services, Christchurch. A health professional, Catherine is a former principal nurse and nursing tutor.

Roy Cowley who is a consultant to and a former national chairman of the national board of Deloitte Touche Tohmatsu. Roy serves on the boards of a number of Little Company of Mary entities.

Anne Corry, the Director for Mission of the Mercy Hospital, Auckland and a former senior teacher and youth ministry member in both Australia and New Zealand.

As a priority, the board addressed the issue of an executive officer and appointed the writer on a one year, two days per week basis. A former partner in a legal practice the writer was, for a decade, the general manager, corporate of Mitsubishi Motors NZ. He was also the inaugural chair of the HFA section .51 Committees and chairperson of the National Society on Alcoholism and Drug Dependence. 

An equal priority of the board has been to focus on the vision, mission and values of the company. Good governance is all about good stewardship and consultation with shareholders. Accordingly, the board having undertaken the initial consideration and deliberation is now currently commencing the consultation stage. The vision, mission and beyond are therefore works in progress but there are clear value principles that represent the future for Catholic Healthcare. 

These include :
Fostering the healing mission of Jesus in the Catholic tradition and in the spirit of prophetic Congregational founders. 

Working collaboratively with, mutually supporting and providing a forum for Catholic health carers. 

Identifying and enabling the health care needs of, in particular, the vulnerable and marginalised to be met in changing times. 

Striving for, supporting, promoting and enabling health care that values the intrinsic sacredness of human life.

The consequent action plans are also at the consultative stage but in the next twelve months it is highly likely that Catholic Healthcare will be active as:
An advocate
A coordinator
A facilitator

and a focal point for communication, information and any resource sharing that may be requested by the shareholders. 

The broad outline is in place; the actual detail is being formulated.

The company has set up an office in the Mercy Centre, Wellington. Not only is this appropriately close to the Catholic Centre, Parliament, and the key Ministries, it also means we share a floor, the kitchen and the coffee plunger with The Nathaniel Centre. Catholic Healthcare will as stated, work collaboratively and the relationship with The Nathaniel Centre is very important. We share in common the values of the Catholic perspective and we both recognise that our future paths run in the same direction. 

The Catholic tradition in health and care has been impressive and strong. Aotearoa New Zealand Catholic Healthcare Limited is determined that this tradition continues. We are as an entity, a corporation (albeit a charitable one) and our methods will be business like but we are empowered by values principles and traditions that go back two thousand years.  

__________________________ 

Rob Greenfield is Executive Officer of Aotearoa New Zealand Catholic Healthcare Limited

©
2001

How does one begin to think coherently about the many assorted issues that threaten and diminish the gift of life? How can we enhance our reflection and examination of the complexities in issues affecting the gift of life? 

Together with several prominent American theologians, the late Joseph Cardinal Bernardin, [1928-1996] Archbishop of Chicago, developed a framework, or moral theory, which he called, “The Consistent Ethic of Life”, often referred to as the “seamless garment”.   In order to both understand the many challenges or threats to life such as abortion, euthanasia, war, violence and racial discrimination, and in order to respond to them in a manner that is consistent and comprehensive, we are encouraged to cultivate an attitude of heart that views the gift of life as being on a continuum, or forming a seamless garment, “from the womb to the tomb.” 

The central argument of the consistent ethic is that we will expand our moral and ethical understanding of various ‘life-issues’ by carefully linking them in a framework which allows consideration of an individual issue on its own merits, in a way that highlights the connections among distinct issues. 

Two fundamental questions represent the starting point for Cardinal Bernardin’s teaching: “In an age when we can do almost anything, how do we decide what we ought to do? …In a time when we can do anything technologically, how do we decide morally what we should never do?”   Given that life is a sacred gift, he argued that a consistent and comprehensive framework, or ethic, was required if we are to fulfil the personal, social and moral responsibility we have to protect and enhance life at every stage of its development.

The theology of the “consistent ethic” is based on the principle that human life is both sacred and social. Human life is sacred because it originates in God and has an innate dignity. Consequently it is to be protected and nurtured at every stage of its development from conception to natural death. The view that life is sacred is enhanced when viewed from within a faith dimension, but such a view can be held independently of a faith dimension. Given that life is also social, society has a duty to foster and protect life. As it applies to Catholic moral theology, the word “ethic” relates to the actions we ought or ought not do, as well as to the type of person, or community, we ought or ought not become. 

The need for a consistent ethic is further highlighted by the impact of technology on human life. Innovation in technology and its myriad uses provides a new context for ethical issues and reshapes the content for a consistent ethic. Technology can be used for benefit or for harm. Even beneficial technology can be used for an evil purpose, as the terrorist events of September 11, 2001, sadly revealed. The sad irony of the events in New York and Washington is that when sophisticated technology is used for an evil end, such an action underscores the fragility of life. As with nuclear weapons, technology used for the purposes of terrorism threatens the gift of life, in ways that were previously unknown. The tragedy in the United States of America not only threatened and destroyed life, but also diminished the ongoing quality of life for many, through fear, job loss, and bereavement. 

Many writers reflecting on the life-threatening events of September 11, 2001 have spoken of life-diminishing events that have become an ingrained feature of modern life.   The terrorist events surely represent a watershed and challenge us to discover and rediscover ethical and moral linkages between the many ways life is threatened and/or diminished. While the raw emotions and grief we feel from these events can make the issues appear even more completely unrelated and more like a patchwork , they, in turn, further highlight the need for a seamless garment and consistent ethic of life. 

As we mature we also grow in our appreciation of the fact that moral and ethical decisions are intertwined, not only for ourselves, but also for others. To discover links between the personal and communal, the private and the social, the events of daily life and the history changing events inevitably will mean that we begin to see life as a seamless garment that has no “ethics-free zones.” 

Central in this heightened awareness is an acceptance of the role that conscience has in our moral and ethical growth. Listening to our conscience, and informing it adequately through education and dialogue, enables us to grow in our ability to discover connections and to view the gift of life as a seamless garment. Obviously, there are limits to the number of issues and various ways in which an individual can be involved even though every person and each society can cultivate the ethic of life in a manner that is consistent and comprehensive.

Such an attitude of heart calls us to go beyond the letter of the moral law, or blind acceptance of a particular moral principle, to the spirit beneath it. For example, the commandment “thou shall not kill” clearly means that human life is not ours to destroy or injure. To discover connections or linkages provides a concrete and considerable challenge in living the moral life. It implies that the commandment “thou shall not kill” will also lead us to see that any form of violence or physical abuse or manipulation can also crush and diminish the gift of life in another. The consistent ethic of life is broad and inclusive. It links the humanity of the unborn with the humanity of the homeless. It links the humanity of the isolated elderly in our communities with the needs of those who lack access to adequate health care. We cannot pronounce on issues of technology and global issues while ignoring the other personal and social justice dimensions of morality. 

A consistent ethic of life helps us to locate a particular issue within a broader moral framework while at the same time helping us appreciate the distinctiveness of a particular issue. It also leads us to realise that it is not possible to work for the sanctity of life in one area and erode it in another. To do that is to provide an inconsistent ethic of life. The consistent ethic of life challenges us to establish in our personal, social and political lives a consistent approach that bears fruit in integrity, peace and justice for all. 

Rev Michael McCabe, PhD
Director
The Nathaniel Centre

©
2001