Issue Seventeen

During the next 35 years, the traditional view of the sanctity of human life will collapse under pressure from scientific, technological, and demographic developments. By 2040, it may be that only a rump of hard core, know-nothing religious fundamentalists will defend the view that every human life, from conception to death, is sacrosanct.                        Peter Singer, 2005

In the September/October 2005 edition of the magazine, Foreign Policy Professor Peter Singer from Princeton University wrote an Op-Ed piece entitled The Sanctity of Life: Here Today, Gone Tomorrow. In it he argues that, because of significant scientific and technological developments, the belief that life is sacred from conception to death has become, in 2005, untenable. To support his argument Singer cites two examples one at the beginning of life, the other at the end of life.

Earlier this year scientists from South Korea successfully replaced the nucleus of an unfertilized human egg with the nucleus of a human cell. Such a development appears to confirm that any and every human cell contains the genetic information required to create a new and independent human being. The possibility of cloning from the nucleus of an ordinary cell, Singer argues, undermines the idea that embryos are precious because they have the potential to become human beings. For Singer while the life of a human organism begins at conception, the life of a person that is, at a minimum, a being with some level of self-awareness does not begin so early. Similarly, he argues that personhood can end long before an individual dies.

When patients have suffered such irreversible brain trauma from which they will not recover, then, Singer argues, a decision to remove a feeding tube will be less controversial, because it will be a decision to end the life of a human body, but not of a person. For Singer a patient in this condition has already ceased to be a person and only his or her body remains.

While Singer is right that the development of sophisticated technology will increase our ability to make sound judgments about the limits of curative treatment, the leap in judgment that patients who have lost even a minimum of or considerable self-awareness, are no longer persons is disturbing to say the least. While we argue that the unborn, infants and the cognitively impaired have an innate dignity and a profound moral connection to the community, it is clear from the above argument that not everyone agrees.

The implications of Singer's argument are disturbing, not least because such views are not uncommon in secular bioethics.

For example, in his book Dhe Foundations of Bioethics, H. Tristram Engelhardt outlinea the philosophical basis for such an understanding of personhood in general secular morality and, by extension, in so-called secular bioethics. He lists four fundamental elements of personhood: the ability to be self-conscious; rational; have a minimal moral sense and be free. To the degree that a human being is conscious, able to make autonomous choices, and perform actions which benefit society, his or her life has value and the status of personhood. When these qualities are lacking, so is their personhood. Engelhardt states:

not all humans are persons. Not all humans are self-conscious, rational, and able to conceive of the possibility of blaming and praising. Fetuses, infants, dhe profoundly mentally retarded, and the hopelessly comatose provide examples of human nonpersons. They are members of the human species but do not in and of themselves have standing in the secular moral community. Such entities cannot blame or praise or be worthy of blame or praise; they cannot make promises, contracts, or agree to an understanding of beneficence. They are not prime participants in the secular moral endeavor. Only persons have that status. (Engelhardt, 1996, pp.138-139)

Engelhardt argues that such definitions highlight and reflect the tension between general secular morality and traditional Judeo-Christian morality and the bioethics that it, in turn, supports. Inevitably different philosophical starding points lead to a painful gulf between general secular and content-full morality. (1996, p.140)

The logical outcome of the current trends in secular bioethics regarding personhood is a society divided into persons and non-persons. Non-persons would include those who are cognitively disabled in some way, through genetics, accident, or disease. The requirement to exhibit certain cognitive capacities means that some bioethicists do not see newborns as being persons.

The human rights of those declared to be non-persons would be severely curtailed. Some bioethicists have already speculated as to whether they could be used as non-voluntary sources of organs.

From a Catholic perspective the intense philosophical debates about personhood occurring in secular bioethics give cause for considerable concern. Human dignity is the source of rights in Catholic thinking, not a slippery concept of personhood which can be defined and redefined so that some people are designated as non-persons. It is hard to escape the conclusion that in some cases this is being done for utilitarian purposes.

There is reason to be very afraid if this philosophy should make further inroads into public policy in New Zealand, as it is already doing in other parts of the world.
________________________

Rev Michael McCabe, PhD
Director
The Nathaniel Centre

References:

H. Tristram Engelhardt. (1996). The foundations of bioethics. (2 nd ed.). New York: Oxford University Press.

Singer, P. (September/October 2005). The sanctity of life: here today, gone tomorrow. Foreign Policy.

Smith, W.J. (2000, April 3). Is Bioethics Ethical? The Weekly Standard.

©
2005

On an Intrepid Journey programme on television recently a group of Turkish carpet makers gave a mesmerizing demonstration of their craft. With incredible speed they pulled each tuft into the carpet, changing colour without hesitating as they created an intricate pattern. 

The carpet makers provided a visual analogy with life. We make many small decisions every day, often without a lot of thought. These decisions are like tufts in the carpet, collectively creating a pattern in our lives. We would be hugely burdened if we were to pay too much attention to them, so we create routines to simplify our daily decision-making processes. Routine saves us from expending unnecessary energy on making minor decisions. 

“Establish a routine for baby” used to be the rule handed to every new parent and there was wisdom in doing that – within reason – for babies and young children. As we age, the routines we create for ourselves can become an invisible prison. They certainly save energy in decision-making, increase our sense of security and give life a sense of predictability. But at what cost? The dictates of a self-constructed routine can take the colour out of life and restrict both our opportunities and potential for personal growth. If routines come to rule our lives, then any event which threatens them will create stress. 

Some decisions, however, mark a change in the colour or a new turn in the pattern. They may even be definitive in creating the overall pattern either incrementally or as a result of a sudden change. Invariably they involve stepping outside the routine of our daily lives. Sometimes a decision which appears to be relatively minor suddenly brings us to halt when we realize it has moral implications we had previously not considered. John Kleinsman’s article on Moral Cooperation in this Nathaniel Report highlights the complexity of what seems to be simple decision-making if we are to take into account the principle of moral cooperation. As John points out, a teenager’s request to borrow a CD from a friend is actually an entry point into the complexity of moral decision-making. 

Dr Anna Holmes writes about wisdom as “looking both backward and forward”. Taking the time to retrace our way back through the decisions of the day or the week is not always easily done, but it can be very revealing. The interplay between routine and conscious decision-making may not be leading us in the direction we would really like to go. For example, does routine rule out some actions which would have been truly in accord with the Gospel? Does it sometimes over-rule the promptings of the Holy Spirit? 

The forward-looking aspect of wisdom comes to the fore in Dr Elizabeth Hepburn’s article about the use of advance directives in Australia. It takes some courage and determination to reflect upon how we would want medical issues around the end of our lives handled. This is major decision-making, but we may never do it if we are constrained by the routines we have set up to handle the minor decisions of daily life. 

Just as a myriad of small decisions we make can take us towards or away from becoming the kind of person we know we could be, a similiar effect can occur at a community or societal level. The legal freedom to make individual decisions in certain areas may result in a societal movement in a direction not foreseen or not necessarily desirable. Taking stock of where the collective effects of individual decisions are taking us, and then redefining and re-stating where we want to go is wise at the community level as well as at the personal level. 

It is also a wise strategy at the global level. 

On 19 October 2005 the United Nations Educational Scientific and Cultural Organization (UNESCO) adopted a new Universal Declaration on Bioethics and Human Rights. The last decade has seen an acceleration in biotechnological and medical advances, and the Declaration is the outcome of some global stocktaking of the directions in which those advances have been taking us. Many aspects of biotechnology now transcend national borders, with the importing and exporting of embryos, stem cell lines, and organs, and research projects being carried out simultaneously in multiple sites around the world. 

“While it is still up to states to create legal texts and instruments appropriate to their cultures and tradition, the general framework proposed by the Declaration can help ‘globalize’ ethics in the face of the increasingly globalized sciences,” UNESCO said of the Declaration when it was adopted by the 33^rd Session of its General Conference. [1] The Declaration can be found in the Social and Human Sciences section of   UNESCO’s website. [2] 

The Declaration’s first principle is the protection of human dignity and human rights. It is reassuring to see in a new global document an emphasis on human dignity as the fundamental attribute of human beings from which human rights are derived. There has been a strong trend in bioethics in recent years to claim “personhood” as the determinant of rights. This has been accompanied by attempts to define personhood in ways which categorize not only unborn children, but also babies and people with cognitive impairment as “non-persons”, and thus without rights. In his article Personhood and Human Dignity, Father Michael McCabe has set out some of this thinking and its potential effects. In a second article, Spirituality, Suffering and Dementia, he outlines the importance of recognising and responding to the human dignity of those with dementia-related illness, rather than allowing utilitarian concepts of personhood to determine the community’s response. 

There has been some criticism of the new Declaration, including its perceived weakness in statements relating to future generations, the environment and the distribution of the benefits of biotechnology. Questions have been raised about whether it is actually a weaker statement than existing tools such as the Declaration of Helsinki on medical research. [3] If that is the case then there is the potential for the Declaration to lower standards rather than raising them. 

Despite weaknesses born out of compromises among the states involved, the Declaration is a product of reflection on the myriads of decisions which have been, and are being, made in medical research and biotechnology around the world. It represents a global consensus about future decision-making, and has painted the road markings for the route ahead. 

Knowing how difficult it can be at a personal level to reflect upon the many individual decisions we make, to identify patterns and then to discern the directions we wish to take, we should regard a global exercise which has done exactly this with some awe. 

[1] UN News Centre (20 October 2005). Press release UN adopts Universal Declaration on Bioethics and Human Rights, www.un.org/news.

[2] UNESCO (19 October 2005). Universal declaration on Bioethics and Human Rights. http://portal.unesco.org/shs/en/ev.php-URL_ID=1396&URL_DO=DO_TOPIC&URL_SECTION=201.html

[3] Dickson, David (21 October 2005). Sparks Fly over UNESCO Bioethics Pact,   SciDev.Net, http://www.scidev.net/content/news/eng/sparks-fly-over-unesco-bioethics-pact.cfm

 _________________

Anne Dickinson is Executive Officer of the New Zealand Catholic Bishops Conference

©
2005

Introduction
Some forty years ago the Second Vatican Council concluded its deliberations with the very beautiful document, “Gaudium et Spes” - “The Church in the Modern World”. It contains many rich themes, not least, the nature and dignity of the human person and the communal or social nature of that human person. By his or her very nature the human person is not only to be considered “whole and entire, with body and soul, heart and conscience, mind and will” (Gaudium et Spes, n.3), he or she must also be considered as a being-in-community. 

This vision of humanity, which is essentially, and necessarily, holistic, forms the basis and starting point for ethics and morality. For the patient suffering from a dementia-related illness, and for his or her loved ones and caregivers, a holistic vision of the human person is vital in order to meet the unique challenges of caring for such patients. 

After defining spirituality and exploring its link with moral theology and ethics, and after briefly reflecting on the mystery of suffering, this article will outline some of the implications in the spiritual care of such patients.

Understanding Spirituality
The spiritual dimension of the individual helps to makes the person unique. For the terminally or chronically ill this dimension assumes even greater importance – so much so that the issues at the end of life are primarily spiritual or relational. That said, defining spirituality is a significant challenge even for those who acknowledge the unique union of body and spirit in the person. While there is common scientific language for the diagnosis, treatment and curing of disease in the biomedical model of healthcare, a broad and inclusive definition of the spiritual dimension of the person is elusive and fraught. Indeed, the very suggestion of a spiritual dimension in some quarters is risky and can collide with barriers erected by different philosophical positions, cultural background, religious traditions, or political correctness. 

Spirituality can be defined as the life-principle that pervades a person’s entire being and which integrates and transcends his or her biological and psychological nature. While spirituality may be expressed through religious ritual and beliefs, it is different from religion. Spirituality is also intimately linked with an individual’s culture, which further illustrates why the concept of spirituality does not always fit easily into the western biomedical focus on health and illness. For example, in Māori culture, the concept of te taha wairua - the spiritual component of health - understands individual and family health as being linked with the health of the land and with those who have gone before. 

Every person has an innate spiritual dimension and this quality is distinct from other cognitive and physical abilities. In its broadest sense, spirituality defines the human being, as moral theologian, Dennis Billy (2004), observes:

Human beings have the capacity to define themselves in terms of an ultimate end…To truly understand people, one needs only to look at their ultimate goal in life and what they do to achieve it. This combination of goals, attitudes, and practices is nothing other than their ‘spirituality’. (p.81) 

Although the spiritual dimension is the deepest and most pervasive dimension of human existence, it is also the most difficult to express. It is “usually very difficult for people to get in touch with, understand, and then articulate what these deepest yearnings are”. (Billy, 2004, pp.81-82) 

A recent Newsweek feature article on “Spirituality in America”, suggested several ways in which the spiritual dimension of life is expressed in practice. Lutheran theologian Martin Marty describes three types of “sometimes parallel but often divergent routes” in the American spiritual journey. He says that “most people pursue their search in traditional sanctuaries, though often in untraditional ways”. This group is characterised by increasing openness to different forms of “ecumenical” worship, new expressions of traditional liturgies, and significant growth in Pentecostal religions. A second group combines and expresses spirituality through social activism. A third group is described by Marty as men and women who consider themselves “spiritual but not religious”. The latter group

… shun the disorganised fronts of what they call ‘organised religion’, and go their own way, sometimes finding new company…The adventurers consider themselves pilgrims on solid ground, joining all the others on the paths of the never-ending newly prospering spiritual journey … (Marty, 2005, p.65) 

While spirituality feeds and nurtures the individual in a variety of ways, Catholic moral theology emphasises that it does so precisely in, and through, community. Indeed the moral life is born out of spirituality, leading moral theologian Richard Gula to describe morality and spirituality as “inseparable siblings”. For Gula, “morality without spirituality is rootless” and “spirituality without morality is disembodied” (2004, p.162). Thus spirituality is intimately linked with Christian morality and ethics. Equally, in Christian morality, spirituality provides the rationale for human dignity and recognition of human dignity is intimately linked with the well being of the human community. 

Understanding Suffering
For the sick, and for their families, spiritual concerns and spiritual pain are a primary cause of suffering. While there is no direct correlation between a patient’s physical condition and his or her experience of pain and suffering, spiritual concerns and spiritual pain often centre on the question of meaning. 

In his germinal work, The Nature of Suffering and the Goals of Medicine, New York clinician Eric Cassell describes the “topology” of a person – various aspects of which act as a filter, or a lens, for the question of meaning in suffering and pain. This topology helps build a richer understanding of the myriad dimensions of the person, and also reveals how the dignity of the human being can be under threat spiritually when an individual is suffering from terminal, chronic, or dementia-related illness.

Suffering is fundamentally and profoundly personal. It can occur in relation to any of the multifaceted aspects of the person. These particular aspects all impact differently on the spiritual dimension of healthcare, especially at the end of life. While enriching our understanding of personhood and illustrating the potential for injury and suffering that exist within the patient, Cassell rejects any understanding of suffering that is not holistic. Simply put, patients cannot be reduced to any one of their parts: 

Reductionist scientific methods, so successful in other areas of human biology, are not as useful for the comprehension of whole persons… Consequently, any suggestion of mechanical simplicity should disappear from my definition of suffering. All these aspects of personhood – the lived past, the family’s lived past, culture and society, roles, the instrumental dimension, associations and relationships, the body, the unconscious mind, the political being, the secret life, the perceived future, and the transcendent-being dimension – are susceptible to damage and loss. (Cassell, 1991, p.105) 

Spiritual Care of the Patient Suffering from a Dementia-Related Illness Addressing the spiritual dimension of the patient suffering from a dementia-related illness is a significant challenge, not least because the patient narrative is the result of a complex and essentially holistic interplay between body, mind and spirit. The impact of illness will necessarily be mysterious and multi-dimensional for the patient and for his or her family. However, even when particular predicates of personhood are clearly lacking, as in the patient suffering from profound dementia, human dignity remains in its fullness – and a unique human individual remains. This individual is unique precisely because of the holistic interplay between mind, body and spirit, that had taken place since the moment of conception and which continues to do so during his or her illness, albeit in a deeply mysterious way. 

While Alzheimer’s disease is not the only cause of dementia, it is by far the most common form of dementia-related illness. All the aspects of personhood described earlier are damaged to a greater or lesser degree in the patient with Alzheimer’s. The ability to relate or learn new skills, the ability to remember short-term and long-term, and the ability to make decisions are gradually lost as dementia progresses. As muscular condition and freedom of movement decrease, lifetime habits of personal care may also be neglected and ultimately forgotten. The patient and his or her family find themselves on a journey once poignantly described by Nancy Reagan as, “the long goodbye”. 

For the patient, the loss of identity associated with Alzheimer’s disease reveals itself with a gradual disconnection from previously cherished roles. This is often associated with increasing agitation and disorientation, even in well-known environments. Language and thinking can become muddled and the present moment can be confused with past realities. Just as the customary patterns of daily life are fractured by the presence of dementia-related illness, so can the familiar reassurance of regular religious ritual and faith practices be lost as the patient’s cognitive abilities disintegrate. Ultimately, the patient’s loss of connection with roles and environment extends to lack of identification of family, to the point where both parties become strangers to each other. 

These examples illustrate some of the causes of deep spiritual suffering for the patients and families affected by dementia-related illness. James Keenan eloquently outlines four defining experiences for the patient who suffers. They apply equally to the family: 

… first, they find that they are without something necessary for their incorporation with the rest of humanity; second, their personal feeling, experience, or sense of loss heightens their perceived isolation from others; third, they search for a way to renegotiate the future of their lives so that they can recoup whatever humanity that was lost in the first place; and fourth, they look to their many relationships to see who will support them on their search. (James Keenan, 2004, p.69) 

Not only does s pirituality provide an integrative function for the individual narrative, enabling a person to make sense of life’s losses and successes, failures and achievements, it also has an integrative function for the family and wider community. In recognising the bond of interdependence between the patient and his or her family, spiritual care allows for the possibility of healing and reintegration for patient, family and caregiver. 

Spiritual care is an implicit – and explicit – recognition of the human dignity of the patient with dementia. Through such care the community “carries” the sense of the transcendent for the patient who struggles at the edges of life. Equally, such care carries with it a sense of meaning and belief in the transcendent for the patient’s family who may have lost sight of such dimensions through exhaustion, or grief, or both. 

Conclusion
Ultimately spirituality is a work of love and intimately linked with ethics and morality. While spirituality can be shaped and reshaped by reason and rational argument, it is kept alive and nurtured by love in action. 

As James Keenan (2004, pp.75-85) reminds us, suffering compounds for both patient and family when the sufferer’s voice is lost. Suffering is that much greater for the family dealing with dementia when those attributes we associate with identity - memory, cognitive functions, rationality - are lost. 

This apparent loss of identity in those with dementia-related illness can lead to their being treated as “things or objects”, rather than as unique and respected members of the human community, bearers of the human dignity of which spirituality is an integral part. The provision of spiritual care is in itself a visible acknowledgement of the human dignity of the one who suffers, and an important reaffirmation of the identity of the loved one for the family. 

When the community gives the sufferer voice and identity, and does so with a generous spirit through its provision of spiritual care, it “carries” the sense of the transcendent for the sufferer and his or her family.   In its actions the community compensates for what is being lost to illness.
______________________ 

Rev Michael McCabe, PhD
Director
The Nathaniel Centre 

References
Billy, D. (2004). Dialoguing with human experience: a challenge to Catholic moral theology. In J. Keating (Ed.), Moral Theology - New Directions and Fundamental Issues. New York: Paulist Press.

Irish Bishops’ Committee for Bioethics. (2002). End of life care:   ethical and pastoral issues. Dublin: Veritas Publications.

Cassell, E. (1991). The nature of suffering and the goals of medicine. New York: Oxford University Press.

Gold, L., Hehir, B., & McDonagh, E. (2005). Ethical globalisation. Maynooth: Trocaire.

Gula, R. (2004). Morality and spirituality. In J. Keating (Ed.), Moral theology - new directions and fundamental issues. New York: Paulist Press.

Keenan, J. (2004). Moral wisdom - lessons and texts from the Catholic tradition. Maryland: Rowman & Littlefield Publishers.

Marty, M. (2005, August 29 - September 5). "The long and winding road". Newsweek, 65.

McCabe, M. (1996). Clinical response to spiritual issues. In E. Bruera & R. Portenoy (Eds.), Topics in palliative care. New York: Oxford University Press.

©
2005

In Australia there has been a move in public hospitals to encourage the formulation of advanced care directives through a programme known as ‘Respecting Patient Choices’. This programme has prepared a patient information sheet and also instituted a process by which the matters canvassed could be discussed with trained personnel.   In its inception it has much to recommend it. 

In the midst of this activity there were the disturbing cases of Terri Schiavo in the United States and of Maria Korp in Melbourne.   In both cases the decision to remove a feeding tube (PEG tube) had to be made in the absence of any clear statement of the patient’s own preferences.   These had the effect of stimulating public interest in the matter. 

At the same time a large Catholic hospital had submitted their own version of Respecting Patient Choices to their local bishop for approval.   He decided to submit the document to the Australian Catholic Bishops’ Conference (ACBC), Doctrine and Morals Committee for advice.   This committee decided that since the issue was also current in other states, they would prepare a document for national use.   This document was to be published jointly by ACBC and Catholic Health Australia (CHA). 

The members of the ACBC Doctrine and Morals Committee considered that Respecting Patient Choices did not go far enough, noting that while it canvassed choices, it lacked mention of the fact that choices might be good or bad.   They wanted a document that would give reasons for evaluating decisions.   This document would also refer to the Code of Ethical Standards published by Catholic Health Australia (CHA) and approved for use in Catholic hospitals throughout Australia. 

The document, titled Planning My Future Medical Care, consists of four sections:

  Introduction and Guiding Principles
  Planning for one’s future health care
  A model for an Advanced Care Plan Statement
  Implementing an Advanced Care Statement and Professional Integrity

Introduction and Guiding Principles
The introduction deals with the reasons why advanced care planning has come to occupy the minds of many health care administrators and practitioners.   Planning for one’s future healthcare needs is an important aspect of the responsible stewardship of the gift of human life. The document points out that while choice is the right of the patient, there is a moral dimension to our choosing. 

The principles which govern our choices are the subject of specific Church teaching and as the vehicle for health and aged care our hospitals and aged care facilities are both guided by these principles and offer insight into choices for both carers and those who receive our care. 

The Catholic tradition has always emphasised that life is a gift, not a possession and that we should consider very carefully how we respond to this endowment.   We have respect for life and a responsibility to take prudent care of the gift, seeking assistance when sick and generally looking after our own well being.   This prudence suggests that we   may want to make our preferences for treatment known in case we are ever incapacitated to the extent that we are unable to communicate. 

There are limits to human life and we must distinguish for ourselves and for those charged with our care to say where these limits lie.   While there is a presumption in favour of preserving life there is also a point at which we accept that this is the end of this stage of our journey.   In medical terms when a treatment is futile or disproportionately burdensome it is unethical to persist; in ethical terms the treatment is deemed ‘extraordinary’ and there is no obligation to continue pursuing cure.   The obligation to continue care is always present.   However, we do not subscribe to a ‘life-at-any-cost’ ethic. 

Clearly, there are times when the distinction between ‘killing’ and ‘allowing-to-die’ are equivalent but this is not always the case.   As Gillon [1] pointed out, although all acts of killing a patient are wrong, so are some acts of letting a patient die.   The Papal definition of ‘extraordinary’ and ‘ordinary’ is an attempt to guide us through this maze.

Pope Pius XII made the following contribution:

…ordinary means – according to circumstances of persons, places, times and cultures – that is to say, means that do not involve any grave burden for oneself or another [2] . 

Generally, this is interpreted to mean that no one is obliged to submit to a treatment which would be disproportionately burdensome – physically, psychologically, financially, even if the treatment was life saving.   It implies that the person best fitted to make such a judgment is the patient.   It is consistent with our claim that life is eternal and that the best is yet to come.

Planning for one’s future health care
In this section the document presents a number of differing scenarios in which it might be helpful for the person concerned to have made a clear statement of preferences for the kind of care they want. This can be done in a number of ways, orally or in writing. Many people simply trust their families and healthcare professionals to do what is best for them and this is entirely legitimate. However it is done, communication between a person, their family, friends and healthcare professionals is invaluable since good care depends upon trusting collaboration. It is best that the communication occurs by means of many conversations over the years. 

The document notes three different ways in which a person’s wishes might be recorded: medical record, nomination of a specific person with “medical power of attorney”, or statement of future care wishes. It canvasses the issues which need to be addressed including the need for patients to reflect on the kind and extent of the burdens they would or would not want to experience or have others experience. The document notes that euthanasia is both illegal and immoral. 

A model for an Advanced Care Plan Statement
A two page model is then offered as a guide to the preparation of an advanced care plan. The model assists each person to state positively their wishes for future care and includes space to make a personal statement regarding what would be considered ordinary and non-burdensome treatment in regard to the person’s circumstances. 

It is recommended that copies of such a statement be given to one’s doctor with a request that it be made part of medical records, to one’s agent or representative, to one’s family and to one’s health or aged care facility. In other words, that the matter of the document be made public so that no one who is likely to be concerned about end-of-life decisions is in doubt as to a person’s wishes. 

Implementing an Advanced Care Statement and Professional Integrity The final section is primarily addressed to health and aged care practitioners.   It suggests that the implementation of a directive will be made clearer if the following questions are considered:

• Do the present circumstances correspond to the circumstances envisaged at the time when the person recorded their wishes?
• Do the treatment and care options available correspond to those about which the patient made their statement?
• Do the effects of implementing the patient’s wishes correspond to the effects that the patient understood would be their consequence?
• Are there new or changed factors in the present circumstances which the patient may not have taken into account but would have wanted to be considered in the present circumstances? 

The document addresses legal and ethical constraints on the course of action and also speaks of the principle of beneficence which seeks to promote actions in ‘the best interest’ of the person in our care. Finally, the document refers the reader to the Code of Ethical Standards, published by CHA in 2001. 

Conclusion
The draft document is currently being circulated for comment. The final document will be presented to the ACBC and the Board of CHA for approval.   The hope is that as well as providing useful information, the document will stimulate conversations about future medical care, and provide clarity for health care professionals involved in end-of-life care. 
________________________ 

Dr Elizabeth Hepburn (IBVM) is a Loreto sister, currently working in Canberra as Director of Ministry & Ethics for Catholic Health Australia. She is the former Director of the Queensland Bioethics Centre and author of the book "Of Life and Death: An Australian Guide to Catholic Bioethics".

 _____________________

[1] Gillon, R. (1988) Euthanasia, Journal of Medical Ethics, 14, 115.

[2] Jura et Bona and reiterated by John Paul II in Evangelium Vitae, n.65.

©
2005

There is in her a spirit that is intelligent, holy, unique, manifold, subtle, mobile, clear, unpolluted, distinct, invulnerable, loving the good, keen, irresistible, beneficent, humane, steadfast sure, free from anxiety, all-powerful, overseeing all, and penetrating through all spirits that are intelligent, pure and altogether subtle.                                                                Wisdom of Solomon 22-23

We live in a knowledge economy and access to information is power. Those who do not have access to information are disempowered. We live in a world that values scientific knowledge but pays scant attention to wisdom. Indeed it tends to discount any knowledge that cannot be measured and tested by scientific method. Knowledge gained through experience is also often ignored. This trend has been escalating in the past century as scientific understanding of the world has increased. It is almost as if the more we unravel about our physical being and world the less we really understand our real selves and relationships.

Wisdom balances the power of intellectual information against an understanding of the real world, with its imperfections and finiteness, yet infused by the presence of the Spirit.  Wisdom calls us to accept our vulnerability and our relationship with all creation and, for those who believe our relationship with God. In a wise world life becomes a gift to be cherished as indeed is the rest of creation. Wisdom sees and celebrates the Godliness in a child or a grain of sand. Wisdom gazes at the beauty of this world; it does not stare at it to see what use it can be. Such a gaze of love enfolds that which it contemplates.
 
Knowledge - especially scientific knowledge – often divides the world into smaller and smaller fragments in an effort to unravel the mystery of life, of creation. It can fail to recognise that creation, and particularly human beings, are more than the sum of their parts. Those who are dying become
aware of this as they struggle with the physical changes that terminal illnesses may bring. They often complain, “I’m not myself any more.” As they reflect on this they realise that physically humans change from the time they are born until death. However, physical being does not encompass the whole self. Human essence is more than a physical body or mind ­– people exist in a web of relationships with others and the world and they leave impressions on all of these.
 
There are major differences between knowledge and wisdom. While knowledge is continually developing and focuses on the parts, wisdom is about integration of the whole created world. Knowledge shapes our understanding of the world while wisdom brings meaning to life and creation.
 
Intellectual knowledge continually asks questions about creation and is uncomfortable with contradictions until solutions are found. Wisdom has no problem with paradox and mystery as part of creation. Knowledge is seen as a possession that confers power on its possessor and has financial value. Wisdom is a gift to the community available to any who are prepared to contemplate. It also confers power but it is spiritual power of inestimable value.
 
Knowledge generally has a forward focus and often requires a narrow specialist view. Such a view tends to ignore anything it cannot explain.Wisdom reflects on a wider view and looks both backwards and forwards. Wisdom, because it reflects on the whole of creation is timeless whereas knowledge is very much about the present moment. Knowledge is cultivated in debate, competition and intellectual striving. Wisdom emerges from times of quiet contemplation, in letting go of control and accepting the fragile reality of what it means to be human. While over valuing knowledge tempts people to pride and denial of the spiritual, wisdom enables integration of all levels of being and fosters humility, gratitude and openness to all creation.
 
Advances in scientific knowledge are responsible for both advances in health and agriculture as well as threats to the environment and damage to the fabric of society. We talk proudly of the knowledge economy and living in the age of communication, but we also live in an age when the gaps between rich and poor are growing, the whole world environment is changing as a result of human activity and the sacredness of human beings is being sacrificed to the quest for knowledge. Some scientists even claim their work on understanding the human genome will finally make God extinct. 

It is unfortunate that the religions of the world have tended to opt out of debate and reflection with the scientific world particularly when knowledge is expanding at a very rapid rate. The Vatican’s chief astronomer said recently:

So why does there seem to be a persistent retreat in the church from attempts to establish a dialogue with the community of scientists? ...There appears to exist a nagging fear in the Church that a universe, which science has established as evolving … escapes God’s dominion. [i] 

There is a particular need for wisdom in our present world. Wisdom listens and reflects before speaking and is not fixed on ideas or concepts that are tethered in a previous world-view. Both scientists and theologians tend to get stuck in particular world views. 

One of the weaknesses of scientific research is that, because it is based on hypotheses that must be proven, those who stand to gain power or money have a vested interest in pushing forward hypotheses yet to be proven.

The quality of medical and scientific research can be both extremely variable and misleading. A recent article which suggested that only 1% of articles in scientific journals are scientifically sound made the following six points about Health Care Research:
 
1. The smaller the studies conducted in a scientific field, the less likely the
    research findings are to be true.
2.  The smaller the effect sizes in a scientific field, the less likely the
     research findings are to be true.
3.  The greater the number and the fewer the selection of tested
     relationships in a scientific field, the less likely the research findings are
     to be true.
4.  The greater the flexibility in designs, definitions, outcomes, and
     analytical modes in a scientific field, the less likely the research findings
     are to be true.
5.  The greater the financial and other interests and prejudices in a 
     scientific field, the less likely the research findings are to be true.
6.  The hotter the scientific field (the more scientific teams involved), the 
     less likely the research findings are to be true. [ii] 
 
Research on cloning embryos for stem cells fits this category. The studies are extremely small, diverse and do not reach statistical significance. The pressure to be first to make vast sums of money, and gain kudos from the treatment of as yet untreatable diseases is enormous. But is it wise? Will it really benefit humankind? Where will it lead us? If embryos may be used in this way, what is to stop children or adults being likewise used? Human embryos by their very nature are connected to the rest of humanity. To ignore this in the interests of the advancement of science is unwise, and contradicts the biology of human development. Wisdom derived from reflection on history reminds us of what happens when we categorise some persons as less than human.

At the New Zealand Bioethics Conference in 2004, speaker Michael Burgess made the following comments:
 
“There are persistent moral quandaries and moral remainders”
 
“There are pressures for premature closure”
 
“Good ethical dialogue is inclusive, identifies sources of power, and the ethical platforms, and asks the question: what kind of a society do we want?”

The scope of bioethics is very wide. It recognises there is more to life than facts or objective truth. It also understands that knowledge, respect and understanding arise out of a relationship. In 2004 the Chairman of the Bioethics Council, asked a very important question:  “How do we encourage moral strangers to cooperate?” He also suggested “Ethical dialogue is a process of awakening communion” (Sir Paul Reeves NZ Bioethics Conference 2004).
 
Dialogue needs to be pursued in a way that understands and respects the scientific position while maintaining a search for truth and wisdom. Wisdom involves a focus on our relationships with other humans and all creation. There is need to develop an understanding of belonging to a unified creation, not apart from it, or in control of it. 

Acting ethically and wisely in such a complex and evolving world involves a continuous process of debate and truth seeking. Some religious concepts that developed in a world thought to be static and fixed cannot hold in a world where knowledge and truth is still unfolding The conflict between seekers of the truth and those who believe they possess the truth is unbridgeable. Religious fundamentalism is as destructive of dialogue as scientific fundamentalism.

In a dynamic evolving universe, wonderful new insights will continue to emerge. No one can claim all knowledge in such a universe, nor can arbitrary limits be placed on human endeavour. Living without certainty can be terrifying, but on the other hand is that not what faith is really about? Definitive statements will not bring about co-operation between “moral strangers”. It is only in face-to-face dialogue and conversation that we will all be converted by the revelation of our common humanity, and will grow in wisdom and truth.
__________________ 
 
Anna Holmes is a General Practioner who also works in a Hopsice. She has a life long interest in the relationship on wholeness and health fostered by her roles as wife, mother and grandmother.

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[i] God’s Chance Creation George Coyne Tablet 6/8/2005

[ii] On Caution, Bandolier 139 Independent evidence-based thinking about health care
http://www.jr2.ox.ac.uk/bandolier/index.html

©
2005

Having carefully saved his pocket money, my thirteen year old son recently purchased a new music CD. One of his friends immediately wanted to borrow the CD so that he could copy the songs - at no cost - onto his MP3 player, something that is a clear breach of copyright. “Heaps of people do it Dad, but I don’t think it is right. What do you think?” I had to agree with him. “Could you tell him that he can borrow it to listen to, but that you don’t want him to copy it,” I ventured to suggest. “Yeah right, Dad. We both know that he will copy it anyway.” 

My son has been raised to understand that people are responsible for their actions. It would have been easy enough - and even quite logical - for him to have reasoned that he would not be responsible for his friend’s actions and to give into the pressure to lend him the CD. After all, who wants to say “no” to their mates? So why was he uncomfortable about doing it? He sensed that in some way he would still share in the responsibility for what would happen. After all, his involvement (“cooperation”) was essential if his friend was to break copyright. That he strongly disagreed with what his friend was (in all likelihood) going to do was not sufficient to let his conscience “off the hook”. 

Is my son being unnecessarily scrupulous or is he onto something important? 

In a revised edition of Fagotheys classic 1950’s text, Right and Reason, we read that “Only the person who knowingly and willingly does an act can be responsible for it. In this sense no one can be responsible for the acts of another person” (Austin Fagothey, 1981, p.47). 

At first glance this statement seems to be both straight forward and uncontroversial. After all, the idea that we are each responsible for our own actions is a basic moral premise that is universally accepted. At the Nuremburg trials, for example, the arguments of those who pleaded that they were simply “following orders” were roundly rejected. Fagothey might seem to be implying that a person has no responsibility for the actions of others, only their own. However, it needs to be noted that further on he qualifies his statement, arguing that we are responsible for our own acts insofar as knowingly and willingly they affect other persons as an incentive to either good or evil. This indicates that there is also a sense in which we can be responsible for the acts of another person. 

Stated positively, we have the ability to influence others and their decisions for the good through our words and deeds. There is a definite “relational” dimension to what we say or do - or don’t say or do. Stated negatively, our words and deeds have a corresponding ability to undermine the good actions of others and/or contribute to their bad actions. The Catholic moral tradition recognises the negative influence exerted on people by an individual’s attitudes and behaviours (Catechism of the Catholic Church, n.2284), as well as by communal situations and social structures that are the product of the sinful actions of others (Catechism of the Catholic Church, n.408).

We need reminding that taking full responsibility for our personal actions must include an honest assessment of the way in which those actions will impact on others and our world. In particular, we need to consider seriously the extent to which our words and deeds may (intentionally or otherwise) assist or encourage others in carrying out bad actions. We are responsible for “cooperating” in the bad actions of others to the extent that our words or deeds assist, lead, entice, allure, encourage or otherwise influence them to do something wrong, or when we fail to say or do something that   might have reasonably prevented them from some wrongdoing. 

In practice, it is impossible to avoid all deeds or actions that have negative consequences. If that were the case, then “we could do so little that we might as well stop living … life would be intolerably difficult if we had to avoid all actions in which others might find an occasion to do evil” (Fagothey, 1981, p.47). This quote highlights what most of us know already – that it is common for us to find ourselves in situations where doing something “good” simultaneously involves us in causing some sort of harm or “evil”. We are often called to make compromises that involve varying degrees of collaboration or cooperation in moral wrongdoing. 

In the Catholic moral tradition there are a number of principles available to us for resolving the dilemmas that arise when we are faced with the prospect of causing or allowing harm. Key among these principles is that of “moral cooperation”. Moral cooperation happens when a person assists another person in doing something harmful. Cooperation may occur “by joining that person in the actual performance of the act or by supplying him or her with the means for performing it” (Fagothey, 1981, p.48). 

Formal Cooperation
When we knowingly and willingly share in the immoral intention or purpose of a person’s bad action, this is known as formal cooperation.   Anyone who directs, encourages, approves, commands, or actively defends another's immoral act formally cooperates in that immoral act (Gregg, 2001) and shares completely in the responsibility for what takes place, “no matter how small one’s share in the actual physical execution” (Ashley and O’Rourke, 1989, p.188.) Assisting someone to carry out a robbery, or to plan a robbery that others will then execute, are two classic examples given of formal cooperation. 

Formal cooperation would also occur in cases where a shareholder invests in a company that uses cheap overseas slave labour or child labour in order to cut costs. Grisez (1997) explains: 

One normally has no reason to invest directly in a particular company’s stock unless one expects and intends one’s money to be used to make a profit, and one normally cannot intend that without intending that the company … do efficiently all they are aware of its doing to make its profits. If some of the company’s profit-enhancing policies and actions are immoral, the investor normally intends the immorality and so shares moral responsibility for it. (Difficult Moral Questions, p. 505.) 

While some occasions of formal cooperation are obviously more serious than others, formal cooperation is always wrong. 

Material Cooperation
In all other cases, where there is no sharing in the intention of the person performing the bad act, any form of cooperation is properly described as material. Material cooperation occurs when we - knowingly or unknowingly – perform an otherwise good or morally neutral action that assists or encourages others to do something bad.   Where there is a connection between our own action/s (or lack of action) and the wrongful act, then we bear a degree of responsibility for that act. Because material cooperation, by definition, presumes a lack of approval of the wrongdoing and involves an act that is not of itself morally bad, it involves a lesser type of cooperation than formal cooperation. Unlike formal cooperation, it is not always wrong. The bank employee who is forced to open the vault for armed robbers undoubtedly contributes to the success of the robbery, but clearly is to be judged differently from a dishonest bank employee who offers the same assistance because he is in cahoots with the robbers.

In judging whether material cooperation may be morally acceptable we need to first distinguish between “immediate” (direct) and “mediate” (indirect) cooperation. Cooperation is judged to be immediate when it occurs as part of the actual execution of the immoral act. An example of this would be someone not in favour of abortion operating a suction pump to remove the baby from the mother's womb. It is hard to argue in this case that there are two separately identifiable actions. Immediate material cooperation is equivalent to implicit formal cooperation and therefore can never be morally justified. 

Mediate material cooperation, on the other hand, concerns all actions which help to fulfil the conditions necessary for an immoral act to take place. These conditions may involve supplying either the instruments or products required (Pontifical Academy for Life, 2005), or in some other way providing the means, without which the action could not take place. Once we are satisfied that the material cooperation may be classified as “mediate”, then the moral concern relates to the bad circumstances that are caused by what we do. In   Fagothey’s words: “Since the act I do is not wrong in itself, since I do not use the other’s evil deed as a means to any end of my own, and since I have no wrong intention … the only remaining difficulty is that of the proportion” (p.48). 

Estimating the proportion between the good achieved and harm done involves assessing the amount of harm resulting from cooperation, the amount of harm resulting from not cooperating, and thirdly the “closeness” of the collaboration to the harmful act. Commenting on these criteria Fagothey notes that the first two criteria by and large involve common sense. “My duty … does not oblige me to suffer an injury greater than or equal to that which I am trying to ward off ... but it does oblige me to suffer a small loss to prevent a great loss from happening to another” (p.48).   Similarly, Ashley and O’Rourke write that “the good achieved by the cooperation must outweigh the contribution of the cooperator to the evil and the degree of evil” (1989, p.188). Meanwhile, assessing the “closeness” of the collaboration involves a determination of whether one’s actions are “proximate” or “remote”. 

Proximate and Remote Material Cooperation
Material cooperation is described as proximate if the help is closely connected with the bad action. Saunders (2002) notes that a good question to ask is, “Would this action be done without my help?” Moral cooperation is described as remote when it is not so closely connected to the immoral action. The closer the connection the greater the proportionate reason required to make the material cooperation allowable. Working as a theatre nurse and preparing an operating theatre that sometimes carried out abortions while personally opposing abortion is an example of proximate material cooperation. Working as a theatre cleaner in the same hospital is an example of remote material cooperation. 

Material cooperation can be of a passive nature. The shareholder who is personally against abortion but whose failure to vote at shareholder meetings contributes to a decision by the directors of the company to donate money for destructive research on human embryos is an example of passive proximate material cooperation. 

When no one else can assist in an act that involves material cooperation then there is a greater obligation not to be involved because the person is in a position to actually prevent the harmful act from happening. 

Moral Scandal
Whether mediate material cooperation (either proximate or remote) is morally justifiable, depends also on the avoidance of “scandal”. Because we tend to use the word today in a different way Fagothey suggests that it is best translated as giving occasion for evil. Scandal “is any word or deed tending to lead, entice, or allure another person into wrong-doing” (p.47).

The scandal or negative influence we have on others may be either intended by us, in which case it is referred to as “given”, or not intended but nevertheless experienced by another person as scandal, in which case it is referred to as “taken”. Fagothey puts it clearly: 

Occasion of evil is taken but not given when someone with peculiar subjective dispositions is led to evil by another person’s innocent words or deeds. It may be due to the takers malice, and then is wholly the taker’s responsibility. Or it may be due to the taker’s weakness … Love … requires us to avoid words and actions, otherwise harmless, that might be a source of moral danger to the innocent or weak (p.48).

We have a duty to take into account the fact that moral scandal might be taken by others even when there is no intention to give it. This requires an assessment of the degree to which cooperation in immoral acts, even when justifiable from a personal perspective, might undermine acceptance of the Church’s teaching (eg on the sanctity of human life) or make ourselves or others less sensitive to the wrongs involved. Our cooperation might tempt others because they perceive, even if incorrectly, that the wrong is not so very evil in our eyes. Put positively, we have an obligation to uphold the moral objection promoted by law or teaching and not give others the impression that we have forfeited or compromised any objection to a harmful activity. 

Conclusion
While my teenage son had never before encountered the term “moral cooperation”, the nature of his questioning clearly showed that he understood the implications of this traditional moral principle. While lack of intention or a different intention often exonerates us from being blamed for a particular action, the principle of moral cooperation reminds us to take into account the bigger picture. Being vehemently opposed to what others do may not always be enough. Sometimes more is demanded of us because of the responsibility we still bear for what occurs. The principle of moral cooperation can help us decide when our cooperation in doing harm is acceptable and when it is not, whether or not compromise is allowable or whether we are called to make a stand. 

References
Ashley, B., & O'Rourke, K. (1989). Healthcare ethics: a theological analysis. St. Louis: The Catholic Health Association of the United States.

Fagothey, A. (1981). Fagothey's right and reason: ethics in theory and practice. (7th ed. revised Milton A. Gonsalves). St. Louis: The C.V. Mosby Company.

Gregg, S. (2001, October). How to be a moral investor. Crisis. Retrieved October 28, 2005: www.crisismagazine.com/october2001/feature3.htm

Grisez, G. (1997). Difficult moral questions: way of the Lord Jesus (Vol. 3). Quincy, IL: Franciscan Press.

Saunders, W. (2002, September 5). Cooperation with evil. Catholic Herald. Retrieved October 21, 2005: http://www.catholicherald.com/saunders/02ws/ws020905.htm

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

©
2005