Issue Seven

“Trust is most problematic when we are in states of special dependence – in illness, old age, or infancy or when we are in need of healing, justice, spiritual help, or learning. This is the situation in our relationships with the professions that circumstances force us to trust. We are forced to trust professionals if we wish access to their knowledge and skill. We need the help of doctors, lawyers, ministers, rabbis, priests, chaplains, or teachers to surmount or cope with our most pressing needs. We must depend on their fidelity to trust and their desire to protect rather than exploit our vulnerability.”

                              Edmund Pellegrino and David Thomasma [1] 

The concept of community is a central motif in bioethics. It is based upon the belief that the human person is fundamentally a social and cultural being who lives in relationship, and finds meaning in and through those relationships. The term “the common good”, for example, illustrates the belief that the welfare of the individual is inextricably connected with the welfare of others. 

A profession can be viewed as a “community” which exists for the purpose of meeting a human need, and which is based upon a body of knowledge and a particular set of skills. Professions have unique educational and socialisation processes, together with codes of ethical practice, which help to guarantee and shape the integrity of relationships both within the profession and between the professionals and those they serve. Professional codes of ethics help to establish accountability and to preserve the ethical boundaries within which the nurturing and continuation of trust can happen. When professional obligations are neglected or exploited by some members of a professional community, the sense of belonging can be undermined for others in the community. Members of a profession can feel isolated and let down by the unethical actions of fellow professionals. 

Recent experiences in the medical and teaching professions and in the Church could lead to a deep-seated ambivalence about involvement with professionals in various fields, and relationships in general. Because people require the services of the caring professions when they are at their most vulnerable, a betrayal of trust exacerbates this sense of vulnerability, eroding a sense of security for the injured individual, the community and the particular profession itself. This feeling of heightened vulnerability, the consequence of very real hurts and grave injustices, may lead us to become even more cautious and diffident in our relationships with others, and possibly deter us from seeking professional help when it is needed. In these circumstances such diffidence in relationships becomes a form of self-protection. 

When trust is removed or lacking in human relationships the ability to live fully in society and the ability to attain the essentials of a satisfying life are diminished. Possibilities of growth and fulfillment are restricted. Loss of trust inevitably impacts on the transcendent dimension of life for individuals and for communities, namely, in the ability to be creative and in the ability to anticipate the future in a hope-filled manner. Ultimately, the withdrawal of trust removes the very possibility of healthy community life. 

Trust entails risk. As Pellegrino and Thomasma note, to trust and entrust is to become vulnerable and dependent upon the goodwill and motivations of those we trust. In times of conflict and hurt, such as in the betrayal of professional trust, whether individually and/or institutionally, the ability and willingness to risk trusting requires even greater courage. While the withdrawal of trust can be justified as a form of self-protection, personal growth is only fully achieved within community and will always involve taking risks. 

The restoration of trust cannot be achieved without the building and maintenance of clear boundaries. Neither can it be restored without fulfilling the requirements of justice. In the Catholic tradition justice is prior to charity, which means relationships cannot be fully restored while any injustice remains.

It is possible that talking about the betrayal of trust may only further erode an already battered professional confidence, and threaten the fragile relationships between professionals and those they serve. That is a risk for those involved, and it is a real risk. But the damage that will ultimately be done by silence or concealment is a much greater risk. Renewed wisdom and potential healing can only emerge with honesty and with courage. Silence prevents both reconciliation and growth and provides conditions for multiplying the harm. That has been the lesson at the heart of recent events in the Catholic Church. 

In recent months the actions of medical personnel at Green Lane Hospital provide an illustration of how trust can be rebuilt.   Following revelations of organs being retained without consent by hospitals in Great Britain and in Australia, Green Lane Hospital initiated its own self-review of procedures.   Subsequently, they accepted responsibility for the fact that certain actions of hospital staff, the result of both individual decisions and systemic processes, were both unacceptable and unethical.   Most importantly, in the face of uncertainty over the current laws in New Zealand relating to post mortems, they have not sought to hide behind legal ambiguities but have acknowledged the need to do things differently.   Significantly, the ability to move ahead and the potential that now exists for trust to be re-established between the caregivers and patients at Green Lane Hospital is a result of the honesty and courage to name and discuss the issues.   Painful as this process has been, the openness with which the discussions have taken place has allowed both the deep hurts and pain to be expressed and a more ethical practice to emerge. In my view this is a wonderful example of rebuilding trust so that patient care and respect, high quality research, and professional practice are all enhanced. 

Rebuilding trust has profound implications for those who have broken a trust, be they individuals in the professions, or within the institution itself. Even after this has been achieved, and it will inevitably be a very painful process, the rebuilding of trust will also have implications that are personal, communal and institutional. Nevertheless, to rebuild trust is to reinvest in a hope-filled future.  

Rev Michael McCabe, PhD
Director
The Nathaniel Centre

©
2002

[1] Pellegrino, E., Thomasma, D. (1993) The Virtues in Medical Practice. New York: Oxford University Press. p. 65.

Introduction 
The relationship between professionals and those they serve implies of its very nature a certain need, and therefore vulnerability, on the part of those who seek help. It is this vulnerability and sense of dependency that can become deep hurt and insecurity when trust is betrayed by the professional. To whom does one go when those that one trusted have become the threat and the danger?

This is what underlies the moral imperative to restore broken trust. Failure to do so, and failure to acknowledge the need to do so, only compounds the original injustice. The problem is how to do so, especially as some ways of trying to do so can further exacerbate the problem. 

John the Baptist lashed out at the perpetrators of injustice who had broken the trust which was inherent in their office. In doing so John triggered a further and lethal act of injustice. It perplexed him that Jesus seemed more tolerant, even choosing sinners as his closest companions. John sent messengers to Jesus to ask if he really was the one God was going to send for undoing of sin. But 

…..Jesus seems to have understood that the only real and lasting contrition occurs, not when one is confronted with one’s sins, but when one experiences the gust of grace that makes a loving and forgiving God plausible. John warned of the approach of the kingdom and passionately enjoined his listeners to renounce their evil ways. Jesus inhabited that kingdom and made it a palpable reality for others by forgiving sins, restoring faith and hope to those around him, and bringing people he touched fully alive. [1]

Election time debates seem to bring out all the John the Baptists – good people who want to impose right order. Their solutions involve various mixes of punishment, banishment and scapegoating. That primal need to have someone to blame and punish can be frenzied up, and even church leaders can find themselves moving from the extreme of having swept these problems under the carpet to opposite extremes. The problem with simply punishing and banishing offenders is that it may not change anyone’s inner dispositions. In fact, the barricades that these “solutions” erect stand as evidence of non-change because they keep the victims, the offenders and the community away from each other. The restoration of trust requires an entirely different solution.

Moving On 
Pope John Paul II teaches that: 

…..both individuals and peoples who have been the victims of abuses of power and oppression need a sort of healing of memories in order to become free of past evils. This does not mean forgetting past events; it means being able to see them with a new attitude… The truth is that no one can afford to remain a prisoner of the past. [2] 

It is necessary “to get on with life” without being glib about “forgiving and forgetting”. To endlessly go back over what has happened on the one hand, or try to forgive and forget too quickly on the other, are both ways of enabling the original offence to linger on. It is one thing to integrate a permanent and painful memory into a mature recovery. It is another matter to leave it festering either because of moving on too fast or by not wanting to move on at all.

“Moving on” is difficult. Individuals can get stuck at the point where they have been most traumatised by the offence. The sheer horror of it will focus some people’s attention on the need for punishment, or the need to ensure that it cannot happen again. Others will get locked into feeling they will never be able to trust the offender again, or the group of professionals to which the offender belongs. Others will be so aggrieved at having been deceived, cheated and betrayed that the need to make the offender accountable will dominate their thinking. 

When people find themselves unable to “move on” this can limit their expectations, and limit access to what they need most of all – hope. They need to know that their present feelings are “okay”, and that those feelings are appropriate to a particular stage on the journey towards a new chapter of their lives. (It will be too soon for them to accept that forgiveness and restored trust in the professional group, perhaps even in the offender, may be the theme of that new chapter.) This is true for the primary victim/survivor of the original injustice; it is true also for the community to which he/she belongs; and it is true for the offender. 

The journey needs to proceed at each one’s own pace. Each may have blockages, and each may need assistance, including professional assistance, to help them through. And yet, the journey of each is linked to the journey of the others. This important point comes to light when we take a closer look at the journey of each in turn. 

The Primary Victim (Survivor) 
Anger, hurt and mistrust are appropriate responses to the outrage of sexual abuse. These feelings result from trauma , and no moral judgement needs to be, or can be, put upon them. 

But there are other judgements that also need to be made. Health professionals who speak about stress remind us that strong emotions, such as hostility, cause biochemical changes in us, and that in some circumstances these can cause or aggravate disease. They also point out that the inability to forgive is a stress factor in the life of the person who is unable to forgive. So while these feelings are not something the victim needs to feel guilty about, nor are they necessarily harmless, they do need to be seen as belonging to a stage along the journey towards wholeness.
Consequently, even if at this stage the primary victim feels she/he never wants to see the offender again, or have contact with other members of the offender’s professional group, we would hardly want her/him to be under the offender’s power, even in this sense, for the rest of her/his life.

For the same reason, to respect the victim’s pace is not some kind of end in itself. It is part of helping the victim to move forward to where she/he might yet be. Is there not an implied goal even in the victim’s request for help? And isn’t the victim entitled to look to the counsellor as one who carries hope and the possibility of further healing and liberation? So the process is not merely a matter of adapting the victim’s life to his/her present feelings. Counsellors may feel the need to be non-directive, but their clients have a right to know that the process is not directionless. 

The Offender 
We are all familiar with the depths of denial and lack of victim empathy that characterise many offenders. It is not hard to see how the offender’s journey towards wholeness is unfinished so long as he/she has not fully accepted responsibility for their crime, repented of it and committed themselves to reparation. 

Those involved in restorative justice claim that meeting the victims can sometimes help offenders to move towards a deeper realisation of what they have done, acceptance of responsibility for it, and feeling the need to make reparation . The victim’s needs and stage of journey must be given first consideration, which means that such meetings may not always be appropriate. But the experience of restorative justice, or its more ancient antecedents in some indigenous cultures, should not be lightly dismissed, especially as we ourselves are still looking for the processes we need for promoting justice and reconciliation. 

Extreme solutions , such as banishing the offender , tend not even to allow the opportunity for restorative justice. 

The Community (Secondary Victim) 
The community too is on a journey and needs to move beyond hurt, anger and mistrust towards healing and wholeness. Here, too, the goal is not being proposed as a substitute for the steps along the way, and so it will be necessary for the community to allow the truth to be told, justice to be done and seen, and the risk of future offending properly provided against. 

But can the community leave it at that, and hope the offender will stay out of town, “out of sight and out of mind”? A parish, school or other Church institution, certainly cannot lick its wounds forever, or pretend it has none, or try to return to how things were before. The offence is now part of its history. It needs to take on board the requirements of justice, reparation and accountability, and provide against future risk. In this way it avoids denial, and it avoids marginalizing the victim by acting as if these needs were the victim’s alone. The community also needs to assure itself that the offender has met his/her obligations towards the primary victim.

Experience show that primary victims’ two greatest needs are: (1) the need to be taken seriously and (2) the need to know that the offender will not commit the same offences against others. There can be no healing and no restoration of trust if these needs are not squarely met. 

By the same token, “solutions” that make no distinction between offenders who could offend again and offenders about whom it can be certain that they won’t, can create new forms of injustice. The obligation on church leaders to do justice for the benefit of all includes the obligation not to do injustice to any. For church leaders, and the communities they lead, there are big challenges here. 

The community might also find it challenging to face and overcome its own fears. Some of these fears “tap a deep well of fear and anger that goes beyond the facts of (the) crime”. Speaking of paedophiles, Stephen J Rossetti says: 

They challenge us to face an unconscious and primal darkness within humankind. Our inability to face this darkness causes us to stereotype and banish all who embody our estranged dis-passions. In the past, this process spawned Molokai and a host of other human prisons. Today we are banishing the child molester. [3]

Putting such people “out” to where we would have even less control of their movements is hardly doing justice to the wider community.

Mercy 
Sensitivity to the present situation makes us wary of referring to the need for mercy. The Christian community needs at this time to place beyond all doubt its commitment to meeting the needs and right of the victim and the needs and rights of the community. And so we try to avoid language that might be mistaken for leniency, or a let-out or cheap grace. But the misuse of words like forgiveness and mercy is not a reason for avoiding their proper use. Ultimately, our Christian faith is about mercy – about being loved while we were still in our sins, and about opening ourselves to mercy by being merciful. That is why the gospel really is radical. If it is rather silly to use “mercy” in any way to condone evil, it is ultimately worse to use evil as a reason for avoiding mercy.

There is a need for clear thinking. Forgiveness is not a matter of forgiving offensive behaviour; we reject the behaviour, and forgive the person when that person also repudiates the offensive behaviour . Nevertheless such forgiveness calls for great courage on the part of all involved. 

This is where we must also speak of responsibility. As well as having needs and rights, all parties have responsibilities. Their responsibilities arise from the fact that they all belong to a common humanity in which each one’s sense of belonging, and ability to overcome alienation, can depend on what others do to help them belong. Here the gospel of life is quite at odds with the ideology of individualism. The journey back to wholeness for each of us also involves the journey back to wholeness of others. That is because wholeness involves belonging, and ultimately we only belong t ogether. This journey does not “happen”, we take responsibility for it. 

The connection between receiving mercy and showing mercy is intrinsic, not merely arbitrary. Mercy is enabling both for the offender and the offended. We come to a deeper experience of being liberated and being healed through the experience of forgiving and giving hope and life to others. 

It is an interesting paradox that the hard-line approach, despite itself, gives the offender power over everyone else by making everyone else’s healing dependent on what the offender must do first. It is a comforting though challenging paradox that the victim and the community retain the initiative only by going outside their strict rights and becoming instruments of mercy. 

Leaders and their communities will be more able to carry out their responsibilities when, with Kierkergaard, they believe the opposite of sin is not virtue, it is grace. 
________________________

Bishop Peter Cullinane is President of the New Zealand Catholic Bishops’ Conference.

©
2002
 ______________________

[1] Bailie, G. (1995). Violence Unveiled: Humanity at the Crossroads. New York: The Crossroad Publishing Company, pp.208-9.  

[2] Pope John Paul II.   (1997). Offer Forgiveness and Receive Peace. Origins 26:28, pp.453-458.

[3] Rossetti, S. (1995). The Mark of Cain: Reintegrating Paedophiles. America 173:6, pp.9-16.

In June 2002 Anne Dickinson was a participant in the Kennedy Institute of Ethics 28^th annual Intensive Bioethics Course (IBC XVIII) at Georgetown University, Washington DC. Here she writes about the part of the course, which focused on the principles of bioethics. 

IBC XVIII was structured to give participants an early opportunity to consider recent thinking about the “Georgetown mantra” – the principles of respect for autonomy, non-maleficence, beneficence and justice which are generally accepted as the core principles of bioethics. The lecturers in this part of the course were Professors James F Childress and Tom L Beauchamp, co-authors of the well-known bioethics text “Principles of Bioethics”, and Robert M Veatch, Professor of Medical Ethics at the Kennedy Institute of Ethics. 

Respect for Autonomy 
James Childress spoke strongly about what he believes is a “crisis of autonomy and respect for autonomy” in the USA. He expressed concern about current tendencies to over-emphasize and over-extend the principle of respect for autonomy, with too much weight being placed on it, and questioned the use of respect for autonomy as a trump card in relation to the other principles. He also expressed disquiet about tendencies to make informed consent or refusal too individualistic, rationalistic, formalistic and legalistic; tendencies which are undermining the central tenet of the principle of respect for autonomy – respect for the person who is making an autonomous choice. 

Respect for autonomy must take into account the many nuances of the person, including variations in the capacity to know and decide, social-cultural contexts, changes in the pattern of a person’s consent or refusal over time, and the many different forms of consent. In the USA informed consent processes have in some cases become less about respect for the person and more about protecting the institution from potential legal action. 

In Childress’ view the principle of respect for autonomy needs to be rescued from its defenders as well as its critics. He believes this can be done by recognizing anew the complexity of the principle, by restricting its range and scope, reducing the weight placed upon it, and by treating it as one principle among several rather than as the dominant principle.

Non-maleficence and Beneficence 
In dealing with the principles of non-maleficence and beneficence, Tom Beauchamp outlined recent problems of risk in the protection of research subjects, which have resulted in shutdowns of several research facilities. He believes that, in general, Ethics Committees and Institutional Review Boards are overburdened and under-resourced, and while these systems exist to protect subjects from undue risk or harm, they have become inverted to protect institutions from risk. This has favoured the dominance of the principle of respect for autonomy over the other principles when, in Beauchamp’s view, non-maleficence is the principle of priority in research using human subjects. 

Beneficence, on the other hand, should be seen as the core commitment of health systems. The centrality of beneficence for both the healthcare professional and the health system raises questions about the nature and end of medicine. Beauchamp contends that defining the end of medicine as healing excludes many medical services, for example, assisted reproduction technologies and cosmetic surgery. If the end of medicine is not restricted to healing, then what constitutes harm and benefit is a much wider question: Is benefit what the patient regards as benefit? 

At this point Beauchamp’s arguments took a direction that was very provocative for the course participants asking the question: Could physician-assisted death be a benefit? He pointed out that, while it is legitimate to worry about people killing themselves, it is not a moral violation to withhold treatment which a patient has validly refused. In this respect the physician’s cooperation is benevolent. With regard to more active involvement in hastening the death of a terminally ill patient, policies and procedures have evolved rapidly since the Karen Quinlan case in 1976. Do Not Resuscitate (DNR) orders and advance directives have become accepted practice. The State of Oregon in the US now allows a terminally ill patient to ask a physician for drugs for use in bringing about death. In Beauchamp’s view, the legalization of physician-assisted death is a logical next step in the sequence of legal decisions which have evolved since the Karen Quinlan case - if a person with good reason desires death then it is a benefit which medicine should be able to provide. 

Beauchamp also examined organ donation in relation to the application of the principles of respect for autonomy and beneficence. The current system of organ procurement in the USA is constructed on the absolute primacy of respect for autonomy. Organ donation is a benefit, but the need for the consent of the potential donor impedes the procurement of organs. Beauchamp sees beneficence and respect for autonomy as being wrongly structured in relation to organ procurement. Providing it could be done efficiently, he would support a system in which retrieval of organs is routine, and in which dissent to organ donation would be registered rather than assent. The justification for such an organ procurement system would lie in beneficence rather than in respect for autonomy.

Drawing from the two situations he had examined, physician-assisted death and organ procurement, Beauchamp posed two questions in his conclusion: What constitutes harm and benefit? As individual patients see harms and benefits differently, has medical ethics been “too wooden” in its views on harms and benefits? 

Justice 
Robert Veatch entitled his lecture on the principle of justice “ Fairness and Equality in Healthcare”. Because the Hippocratic Oath focuses on the needs of the individual patient, not on public health systems, Veatch contends that the Oath makes all systematic research unethical, and removes the need for a doctor to consider cost containment when treating a patient. In his view, much of what is wrong with healthcare delivery in the USA can be traced to the Hippocratic Oath. With its emphasis on non-maleficence and beneficence, the Hippocratic Oath has a consequentialist approach to morality between doctor and patient. An alternative approach to morality between individuals would be non-consequentialist, based on inherent moral duty rather than on regard for consequences. Such an approach involves respect for persons, shown in respect for autonomy, fidelity, veracity and the avoidance of harm. 

Neither the Hippocratic principles of non-maleficence and beneficence nor the duty-based principle of respect for the person assist in resolving public health issues. Both sets of principles focus on morality between individual doctor and patient, and are silent on the distribution of healthcare benefits. A shift from individual morality to social morality is required if ethics is to assist the hard-pressed planners of institutional and national healthcare systems.

Social utility is a consequentialist approach to social morality, which involves “maximizing the aggregate net good from available resources”. This approach does not take into account which groups in society receive a particular healthcare benefit, focusing instead on achieving the maximum total of benefits possible. 

A non-consequentialist or duty-based principles approach to social morality requires the inclusion of the principle of justice. Justice requires a fair distribution of benefit, expressed as equality of well-being, regardless of whether the total of benefits is maximized. 

The difficulties facing healthcare planners, and the difference between a social utility approach and a justice-based approach, were well illustrated by an example Veatch used involving kidney donation. The six antigens involved in rejection of a donated kidney by the recipient can be determined by tissue-typing. It appears logical to ensure that donated kidneys go to recipients who have the greatest chance of the transplant being successful, based on compatibility established through tissue-typing. However if tissue types alone are used as the criteria for transplant, research has shown that one race, one gender, one age group, and one socio-economic group – young, Caucasian, upper class males - receives a disproportionately high number of transplants. All other groups lose out proportionately. While social utility would favour achieving the greatest number of successful transplants, justice requires policies that ensure fairness in access to kidney transplants, despite the fact that overall there may be fewer successful transplants. 

Finally, Veatch returned to his statement about the Hippocratic Oath and its negative effects on healthcare systems, posing the question: “What should be the role of the clinician in dealing with the principle of justice?” He provided two alternative responses: Either clinicians could abandon their uncompromising Hippocratic loyalty to the individual patient and take on some social ethical duties, that is, consider the good of all patients. Or society could give clinicians a limited exemption from social ethical duties, allowing them to be loyal to and advocate for their individual patient. 

The only acceptable alternative to both patients and clinicians is the limited exemption of clinicians from social ethical duties. However, in a world of finite resources, that alternative requires both patients and clinicians to accept that there must be others in the healthcare system who restrict what clinicians and patients can have, in order to maximize fairness and to meet the requirements of justice.
____________________

Anne Dickinson is Director of Caritas Aotearoa New Zealand

©
2002

“Healthcare ethics is about the medical art of curing where possible, and the human art of caring always.”             Richard C. Sparks

The Catholic moral tradition emphasises that life is a free and totally unsolicited gift from God.   An appreciation of this fact engenders an attitude of profound gratitude and thanksgiving.   When we look at life like this, Christian morality is nothing other than our response to the unconditional and amazing love of God: ‘How ought we who have been so gifted by God to live?’ Like any special gift, we instinctively feel that life is something to be treasured and to be used in a responsible way. This is the starting point for any Catholic approach to bioethics.

The absolute dignity accorded human beings in Catholic teaching reflects the biblical message that each person is created in the image and likeness of God (Genesis 1:26-31). The belief that human life is a reflection of God’s own nature means that personal worth and human dignity are inherent or innate characteristics; that is to say, our worth comes from ‘inside’ the human person rather than from anything ‘external’.   Human dignity is absolutely independent of our value to others, our ability to function, our age, health, gender, race or economic status. The belief that dignity is innate explains why the Catholic moral tradition upholds, absolutely, the teaching that persons may never be used by others as a means to an end, no matter how worthwhile the end may be. 

Acknowledging God as the author and giver of all life calls us to recognise the sacredness of, and our interconnectedness with, all of creation. In other words, human persons are fundamentally relational beings. The person is always person in relation to the totality of reality; self, other people, all created reality and God. Due recognition of this highlights the responsibility we have of living in “right relationship”. Often expressed in the biblical terminology of “stewardship”, our interconnectedness is not, however, to be confused with “absolute dominion”. Instead, the interconnectedness of all life demands recognition of, and respect for, the fact that there are limits to what we as humans should do.   Our responsibility to protect and enhance the integrity of all relationships is the key to identifying what the limits are. 

These limits have been, and continue to be, well traversed (even if not always agreed on) in regard to our responsibilities towards other human beings.   That we are fundamentally social beings means that the human person, adequately considered, is a cultural person. Our ability to function in autonomous ways and to develop as individuals is always dependent upon our identity with a particular cultural group. Such a perspective nurtures a broad vision of the human person as called to live within caring communities. We find our fulfillment as committed individuals bound in kinship, friendship, and fellowship to our families and our neighbours.   Yet the Gospel reminds us that we owe loyalty not only to those whom we readily choose as friends, but also to strangers and even to enemies. In Catholic language the term “common good” is used to describe the fact that our individual welfare and flourishing is inextricably connected with the welfare of others. 

At the very heart of Catholic respect for human life is a special and persistent advocacy for those who depend on others for survival itself.   Indeed, Jesus Christ teaches that the moral heart of any society may be measured by how well it provides for those who are most vulnerable and dependent. The beginning and end of life are areas of special interest and concern in bioethics because people are particularly vulnerable at these stages of their life journey.

The limits of human freedom have perhaps been less well delineated in regard to the relationship between humans and the rest of the created order. As recently as 1999, Pope John Paul II, in an address given to the WTO Conference in Seattle, Washington, has talked about the need to address the ecological crisis: “Faced with the widespread destruction of the environment, people everywhere are coming to understand that we cannot continue to use the goods of the earth as we have in the past … [A] new ecological awareness is beginning to emerge … The ecological crisis is a moral issue.” 

Our own New Zealand Bishops have also written that it is “in keeping with the traditions of the Māori of Aotearoa that we need to respect the sacredness of creation, as partners in life with the earth, the oceans, the lakes, the animal world, the mountains, the fish of the sea and the birds in our forests and gardens.   From such sources, balanced by the infinite hand of God we draw all life and nourishment.” [1] The integrity of all creation needs to inform our bioethical discussions with regard to the lengths to which we humans are prepared to go in order to delay death or to improve the quality of our life. 

Recognition of the need to respect limits itself calls for a certain approach to understanding personal freedom, one that may be at odds with the way in which freedom is sometimes understood. Freedom can never mean the experience of simply exercising choices or options for action. A Catholic-Christian approach upholds an understanding of autonomy (the idea that we are the authors of our own fate) that includes the notion of our inter-dependence with others. We act freely when we act in ways that help us to flourish according to our deepest needs and yearnings, including our need to be in caring community.   “Human nature” is a term sometimes used in Catholic teaching to refer to that which is in keeping with our deepest human yearnings.

A further principle that underpins a Catholic-Christian approach to bioethics is the belief that faith informed by human reason can discern the good.   This means that, in their endeavour to determine what is appropriate human conduct, Catholics are committed to dialogue with all the sciences.   In the words of John Paul II: “Faith and reason are like two wings on which the human spirit rises to the contemplation of truth.” 

From the above broad and general vision of the goodness and sacredness of the created order the following set of key moral and ethical principles inform a Catholic-Christian approach to the interdisciplinary science of bioethics: 

·         The sanctity of life
·         The dignity of human persons
·         The relief of suffering
·         The duty to care for one’s own health
·         The duty to care for those who are sick – in body and in spirit
·         The existence of limits, including the limit to provide treatment
·         The promotion of the ‘Common Good’
·         Respect for culture
·         A preferential option for those who are most vulnerable and 
          deprived
·         Respect for the integrity of all creation
·         Justice – the equitable distribution of risks and benefits
·         A commitment to truth telling
·         A consistent ethic of life
·         Respect for autonomy

While the above principles are identifying of a Catholic-Christian approach, it will be obvious that they are not uniquely Catholic and that they resonate with the values of all other people of good will.   That this is so is not at all surprising since the Gospel values of Jesus Christ, upon which these principles are based, ultimately point us to what is most truly and deeply human and to what will lead the whole of the created order to flourish: “I have come that you might have life and have it in abundance.” (John 10:10) 

(Previous editions of the Nathaniel Report have explained the implications of some of these principles as understood in the Catholic moral tradition.) 

For further reading see: 
Beauchamp, T.L., Childress, J.F. (1994). Principles of Bioethics. Fourth Edition. New York: Oxford University Press.  

Brody, H. (1989). Transparency: Informed Consent in Primary Care. Hastings Centre Report 19:5, pp.5-9.  

De Dios Vial Correa, J., Sgreccia, E. (Eds.) (1998). Human Genome, Human Person and the Society of the Future: Proceedings of Fourth Assembly of the Pontifical Academy for Life. Vatican City: Libreria Editrice Vaticana.  

De Dios Vial Correa, J., Sgreccia, E. (Eds.) (1999.) The Dignity of the Dying Person: Proceedings of Fifth Assembly of the Pontifical Academy for Life. Vatican City: Libreria Editrice Vaticana.  

Gormally, L (Ed.). (1999). Issues for a Catholic Bioethic. London: The Linacre Centre.  

The Hastings Center. (1987). Guidelines on the Termination of Life Sustaining Treatment and the Care of the Dying. Bloomington: Indiana University Press.  

New Zealand Catholic Bishops’ Conference. (1997). A Consistent Ethic of Life – Te Kahu-O-Te-Ora. Wellington: Catholic Communications.  

O’Rourke, Kevin D. & Boyle, Philip. (1993). Medical Ethics: Sources of Catholic Teachings. Washington, D.C.: Georgetown University Press. 

The Pope John Center. (1989). Conserving Human Life. Braintree, Massachusetts: Pope John XXIII Medical-Moral Research and Educational Center.
________________

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

©
2002

[1] New Zealand Catholic Bishops’ Conference. (1997). A Consistent Ethic of Life – Te Kahu-O-Te-Ora. Wellington: Catholic Communications.

Introduction 
Truth telling (veracity) is a key factor in the relationship between patients, their families and health professionals.   The Oxford dictionary defines truth as: a quality or state of being true, genuine, loyal, faithful; in accordance with fact or reality, exact, accurate.  

Yet, for the health professional, there is more to telling the truth than simply being accurate and exact, factual and literal.   Relationships with human beings are far more complex, as is the way we speak the truth.   There are many aspects to communicating the truth to patients and families.   Adopting a blanket “they must know at all costs” approach, or even having policies and protocols that provide a fixed framework for patient health professional dialogue, does not adequately deal with the complexity of truth telling. What is called for is a mix of skill, knowledge, wisdom, intuition and insight.   Further variables to be considered in an understanding of truth telling include the context, rapport, professional relationships and institutional culture.   This article will briefly explore some of the issues around truth telling from a nursing perspective. 

Principles and Truth Telling 
It is not unusual for nurses to have a number of discussions each day around the issues relating to a particular case.   The well known principles of autonomy, beneficence and non-maleficence are used by nurses as guides to assist them in the ‘to tell or not to tell’ debate.   Helpful as they are, however, the reality is that these principles often conflict with each other and require balancing in our efforts to communicate with patients and their families. 

Lichter (1989) believes it is vital to tell the truth to a patient because they have a right to know. He therefore advocates overriding the principles of non-maleficence (whether the “full” truth may in some ways be detrimental to a patient) and beneficence (whether it is to the patients advantage not to know the full truth) in favour of autonomy (the right to choose who we wish to be, to make our own decisions and to be in control of what is being done to us).   Kendall (1995) argues that “an action can be harmful at the same time as being beneficial” and draws an analogy between truth telling and chemotherapy treatment.   While chemotherapy introduces toxins that can cause extreme harm, the outcome of this treatment may well be beneficial for the patient.   Likewise, telling the painful truth can be beneficial by allowing patients and families to facilitate planning and decision-making in regard to their lives and future care. 

The views of Lichter and Kendall are representative of many others and lead us to conclude that the debate about truth telling in the area of healthcare is no longer around ‘to tell’ or ‘not to tell’, but rather about who should tell, when to tell and how to tell.

Nurses and Truth Telling 
A review of the relevant literature reveals that many health professionals will only tell the truth to patients if asked outright.   Recent studies analysing this fact suggest that the culture of the institution in which nurses work has a significant influence on nursing practice when it comes to discussing diagnosis or prognosis with their patients.   (Kendall, 1995, Dunniece et al, 2000, Costello 2000) 

Of particular interest is the research that shows how nurses tend to distance themselves from their patients for fear of reprimand from medical staff for disclosing information asked of them by the patient.   When a nurse is unsure of the response from medical staff she/he may avoid the patient in order not to be asked a question outright, rather than lie. (Kendall, 1995)

In recognition of this unsatisfactory state of affairs, codes of nursing ethics and nursing practice have been changed, providing nurses with the opportunity to challenge the traditional premise that doctors alone are responsible for disclosing information, and enabling nurses to be truthful in their responses to patients’ questions rather than avoiding them. (See Beauchamp and Childress, 1989)   For example, whereas earlier versions of the International Council of Nurses “Code for Nurses” highlight the “nurse’s obligation to carry out the physicians orders, intelligently and loyally” the revised code of 1973 states that   “the nurse’s primary responsibility is to those people who require nursing care.” (New Zealand Nurses Organisation, cited Johnstone p.465)

This shift in emphasis is also evident in the New Zealand code of nursing ethics, revised in 1993, which states the importance of nurses “communicating with the client in an open, honest and truthful manner” (New Zealand Nurses Organization, Code of Ethics 1993).   Further understanding of the impediments that nurses experience in communicating truthfully is essential if changes in their role are to be effected. 

A Framework for Truth Telling 
There are a number of key elements that help to provide a framework that enhances truthful communication.   Firstly, there is the need to develop open and honest communication from the very beginning of the patient-health professional relationship.   Secondly, the health professional needs to use patient preference as a “gauge” by asking them what they wish to know, how much they wish to know, and determining what they already know.   In other words, it is a responsibility of the health professional to get a ‘feel’ for the situation, including the patients’ perception of the situation. 

It is not only the giving of the truth that as health professionals we are responsible for, but also the way in which the truth is delivered and received.   Therefore, as a corollary of truth telling it is vital that the health professional is available to assist the patient and family/whanau in understanding what has been said, as well to support them in situations where there may be distress.    Many commentators note that the way in which bad news is delivered, and the available support at the time, has a bearing on how people cope with their illnesses and prognosis (Bok, 1978, Centeno-Cortes, 1994, McCabe, 2001). 

Nurses in particular have a key role to play in supporting patients and families/whanau when bad news is given, as they are most frequently the health professionals at the forefront of patient care and treatment.   The nurse is the health professional that spends most time at the ‘bed-side’ and this presents a unique opportunity for the establishment of trust. (Bok 1978, Johnstone 1999, Kendall 1995).   The provision of intimate personal care that can lead to the development of close relationships can in turn provide nurses with privileged insights.   Nevertheless, nurses are not always present at outpatient appointments or at the bedside when a patient is given information that might be distressing.   Consequently, when nurses are asked for information by a patient and they are not sure what medical staff have already discussed with the patient, nurses report increased anxiety among themselves. (Bok, 1978)

For communication between nurses and medical staff to improve, and in order for it to become common practice for nurses to be present at times of important disclosure, healthcare institutions need to adopt a strong multidisciplinary approach toward patient care.   A feature of palliative care is the way it champions the concept of multidisciplinary teams.   This concept acknowledges the unique skill and expertise that the different disciplines bring to the team. Team members work together and along side the patient and family/whanau to ensure that the care provided is appropriate and timely.   In circumstances where frank discussion is required or when truthful disclosure is called for, team members can discuss strategies in advance.   Decisions can then be made as to who might be the most appropriate person to communicate the news to the patient.   Because everyone knows what is going to be discussed, the team’s ability to provide the necessary support to the patient and family is enhanced.   In addition, such an approach also allows the team to offer support to each other. 

Conclusion 
Truthful communication is multifaceted and multidisciplinary.   The health professional must be committed to giving the truth and then be prepared to support the patient when the truth has been delivered.   Presenting the truth needs to be done in a sensitive and timely manner. 

It appears that in some settings health professionals find it difficult to tell the truth to patients and families and it is reasonable to suggest that institutional culture has some bearing on this.   Relationships between health professionals and patients can be jeopardised if truthfulness is not part of their every day communication.   Truthfulness is one element that engenders trust without which there can be no real partnership between the health professional and patient.   However, truthfulness involves more than being ‘accurate and exact’.   Truth telling is best understood as a process that calls for skilled communication and respect for the person and their perception of their circumstances, including their desire for information and how much they wish to know. Intuition, wisdom and knowledge are integral to the process. 

Nurses are the health professionals at the forefront of patient care in hospitals and hospices and, because of their position, can provide vital support that facilitates patient choice and understanding in an environment of truthfulness. 

References: 
Lichter, I. (1989). The Right to Bad News.   B.A. Stoll (Ed.), Ethical Dilemmas in Cancer Care. London: Macmillan Press, pp.7-16.  

Beauchamp, T. L., Childress, J. F. (1989). Rules of Fidelity. Principles of Bio-medical Ethics. 3rd Edition. New York: Oxford University Press, pp.341-349.  

Bok, S. (1978). Lies to the Sick and Dying. Lying: Moral Choice in Public and Private Life.   Brighton: Harvester Press, pp.220-241 and 309-311. 

Centeno-Cortes, C., Nunez-Olarte, J. M.   (1994). Questioning Diagnosis Disclosure in Terminal Cancer Patients: A Prospective Study Evaluating Patients’ Responses.   Palliative Medicine 8, pp.39-44.

Costello, J.   (2000). Truth telling and the dying patient: A Conspiracy of Silence? International Journal of Palliative Nursing 6:8, pp.398-405. 

Dunniece, U. Slevin, E. (2000).   Nurses’ Experience of Being Present With a Patient Receiving a Diagnosis of Cancer. Journal of Advanced Nursing 32, pp.611-618.  

Johnstone, M. (1999). Ethics, Bioethics and Nursing Ethics: Some Working Definitions. Bioethics: A Nursing Perspective. Australia: Southwood Press Ltd, pp.57 –64, 465.  

Kendall , M.   (1995). Truth-telling and Collusion: The Ethical Dilemmas of Palliative Nursing. International Journal of Palliative Nursing 1:3, pp.160-164.

McCabe, M. (2001). Striking a Balance in Truth Telling, The Nathaniel Report, Issue 4.

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Debbie Wise is a palliative care specialist Nurse employed by the Mary Potter Hospice, Wellington.

©
2002

The Biblical meaning of the Land 
The Old Testament is a story of the gift of good land and the loss of that land. At the start of the first millennium before Christ, the sacred writer reflected on the history of tribal squabbles, of migration and of conquest out of which the Jewish nation was born. From the first he saw it as a story of disharmony between men and women, between shepherd and farmer. Interwoven in this story was the battle of the people to find good soil and become rooted in it.

At the heart of this growing understanding of land was the notion of covenant. The covenants made with Abraham (Gen. 17.1-21) and Moses (Ex 31.12-17) were far more than personal or even racial. Each of these set out to restore harmony and balance in relationships between God, human beings and the earth, and among humans themselves and with all the other creatures of the land. The cosmic covenant between God and Noah is foundational to all other covenants that followed it. Yahweh promised the entire earth community never to obliterate life from the face of the earth again. This solemn promise was made "…between me and you [Noah] and every living creature that is with you, for all generations." (Gen. 9.12).   This pledge is also made "between me [Yahweh] and the earth." (9.13) 

The first effect of this treaty is that the Jews must use the land in certain ways or they will lose it. They must see themselves more as tenants than owners, "The land shall not be sold in perpetuity; for the land is mine, and you are but aliens who have become my tenants." (Lev. 25.23.) Whether in war or peace, in planting crops or settlements, the new tenants of the land of Canaan must keep before their minds that God has plans for this land.   These plans have a sweep far grander than Jewish national aggrandisement. For Yahweh is not just a tribal deity attached to a certain plot of land, "All the earth is mine, and you shall be to me a kingdom of priests and a holy nation" (Ex 19.5-6.) For the Jews are also the instrument of God's far wider hopes - to bless other nations and to teach them his love, so ultimately bringing all peoples back to his word and worship (Gen. 12.1-3, Is 42.1-4). 

Since this land belongs to God and not the Jews, they have duties as tenants. The first is that of gratitude. "... when you have eaten your fill, you must bless the Lord, your God, for the good country he has given you." (Dt. 8.10) They also have particular obligations to the animals, plants and people already living there. They must be neighbourly, showing kindness to one another, generosity to strangers, and honesty in trading. The Torah, the law, even prescribes the correct way to treat animals e.g. Dt. 22.6-7,

“If, while walking along, you chance upon a bird’s nest with young birds or eggs in it… and the mother bird is sitting on them, you shall not take away the mother bird along with her brood; you must let her go, although you may take her brood away.   It is thus that you shall have prosperity and a long life.”

Though Yahweh would never reverse his promises, it was all too possible for the people to forget theirs. In this case, creation would unravel; animals would die in the reverse order to that in which they had been created, and the harmony between the land and its inhabitants would be shattered (Hos.4.1-3, Joel 1.16-18). 

Aotearoa/New Zealand : also a Treaty/Covenant Land 
At the time of their principal settlement (possibly 12^th-13^th century) Māori found a land covered in dense forests (c. 85%). It abounded in birds, seals and seafood. Apart from a couple of native bats there were no mammals. Instead a staggering variety of birds flourished: swan, pigeon, falcon, rails, snipes, even the largest eagle ever identified (Haast’s giant eagle). The people do not seem to have brought their own pigs or chickens with them, expecting the same lush fertility as in the other Polynesian islands they had settled. Though favourite foods such as breadfruit or taro would not grow here, in some regions yams and kumara survived. At first it must have seemed like paradise. The flightless birds, like the eleven species of moa, had no enemies, apart from the occasional giant eagle. Remains of moa found in burial middens point to somewhere between 100,000 – 500,000 killed and eaten. 

Such hunting and the taste that the Polynesian rat, kiore, and the village dogs developed for both eggs and chicks led to the annihilation of many species: the native swan, giant goshawk, coot, crow, rails, snipe, wren.   Early Māori burned off large tracts of lowland forest, particularly on the East Coast of the South Island, places where moa were numerous and it was possible to grow the sandy gardens the iwi favoured. Huge fires burned continuously both on lowlands and on mountain slopes from 1400-1550. Surrounded by such plenty, the settlers may well have been surprised by how rapidly moa populations became non-sustainable and collapsed. By the end of the 16^th century survival had become much more difficult.

As a result, scattered groups of iwi coalesced to share their labour and resources better and to defend them against other raiding groups. At the same time there seems to have been a deepening awareness of the spiritual links between the people and the fruits of the land. To preserve the vital life force of the land (mauri), rules concerning tapu and rahui were developed and intensified. They put certain sources of food and places out of bounds during some periods, so respecting their need for rest and protection. Such times and places had their own spiritual guardians (kaitiaki) to ensure their inviolability. It is not hard to see similarities between such notions and the Jewish ideas of a covenant with the land.

European impact on the land was immensely greater than that of the Māori. Kauri forests once covering 1.5 million hectares were reduced to 7,000 ie 99.5% destruction. Settlers also clear felled most of the remaining lowland podocarp hardwood forests, leaving just 15%. They destroyed almost without trace the great kahikatea tracts of swampy areas such as Thames Valley and Horowhenua. What little forest remained was soon profoundly altered by introduced species such as deer and possum. Flocks of sheep and cattle spread over the paddocks of clover and grasses sown for their coming. 

Whatever the mixed motives and different understandings of the signatories of the various treaties of Waitangi, what is of great significance is that both people, Māori and pakeha, tried to create a covenant to enshrine the status of land, forest and fisheries. However it is conceived of, the notion of rangitiratanga or dominion is much deeper than just who has the power to make financial deals. It touches upon the deepest spiritual links between Māori and the land in which they were rooted. That is why Crown failures to defend the treaty go beyond legal ties of justice.   Land and much of what lived in and on it were devastated in some areas.   Destruction of habitat and species, pollution of major waterways, land subsidence and flooding, and contamination of traditional coastal seafood areas are still the legacy of this failure.

The Issue of Genetically Modified Food and Organisms 
We can never return to our pristine land, a land clothed with forest from mountain to sea.   But we can learn from the mistakes that our ancestors, both Māori and pakeha, made. We can also learn from the covenant model of relationship between God, the people and the land that we observe in the Jewish scriptures. Humans have always shaped the dominant ecosystems to their own needs and that also is part of nature. Yet both peoples must acknowledge and reflect upon the needless scars they have inflicted upon the earth. We have destroyed forty-one species of birds, some of the most unique forms that had evolved on our planet. At this time there are still about five hundred native plants and animals still considered at risk. The GE debate must be conducted in the light of this history. 

In respect of both genetic modification and engineering the questions most commonly asked are: why is this procedure necessary or beneficial? What dangers are involved? Who benefits? In the light of our reflections so far, a fourth question must be added, will GE increase or diminish the respect we owe to this unique land and its life-forms that is God’s gift to us?

The commonest justifications for GE are development of our world food sources, and research, especially medical. The first of these is important in a world where 18% of the population are still constantly hungry. Sadly though it is becoming increasingly clear that the main problem here is not one of production. Both Kofi Anan and the FAO have recently stated that there is ample food to feed the entire planet. The problem is that because of internal policies such as farm subsidies in the European Union the 800 million who hunger cannot afford to grow or buy their own food. In some parts of Africa in particular endemic social strife and wars intensify this problem for hapless local farmers, making growing and delivery of food almost impossible. Raising productivity eg by testing to see whether an introduced gene can inhibit wet rot in potatoes may be commendable. If our dominant motivation is economic eg catering to well-developed consumer or niche markets then it is necessary to acknowledge that honestly and to face the other questions such as, at what risk? for whose benefit?

GE research is often touted as the great hope for producing a cure for appalling diseases such as cystic fibrosis or Huntingdon’s chorea. Again, who could possibly question such goals. Yet long experience of efforts to find cures for cancers and AIDS have pointed to the need for long trials, turning up multiple drugs and procedures that bring about gradual incremental improvements. It is true that entirely unexpected breakthroughs have arisen from purely theoretical research in the past.   In an era, however, of contested and precisely targeted funding this becomes less and less likely. In such scenarios we have to ask whether in the long run it is pharmaceutical firms that will be the main beneficiaries. 

This leads us to the question, at what risk? The danger of accidental release of transgenic organisms or cross contaminations of crops is minimal but cannot be totally discounted. The same may be said of a totally unpredicted transgenic hybrid, the sort of event that forms the basis of Paul Adam’s frightening novel, Genesis II. In such examples haste to get a product on the market for commercial advantage proves a key factor. 

In our New Zealand situation if the moratorium on the public release of GE is to be lifted, the stipulations of the Royal Commission must be adhered to strictly, that is, case by case consideration with meticulous analysis of risks and benefits. Among the goods to be defended must be the protection of the last remaining pockets of wilderness in New Zealand and our unique species. This is not just an economic and aesthetic preference. This is a treaty value whose defence may help to deepen a bond between Māori and pakeha, one built on the sense of tapu and guardianship, the sense of the holy and protected in the midst of the profane. For pakeha New Zealanders, especially Christians, this is a chance also to rediscover the spirituality of land hidden in the bible. Beyond the battles and injustices that have divided the two peoples may lie a new unity founded upon a common determination to treasure the land that now sustains us all. For such a hope to be deeply rooted, it cannot rely merely upon financial expediency but must rest on a deeper spiritual vision. 
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Dr Neil Vaney is a Marist priest and lecturer at Good Shepherd College,   Auckland

© 
2002