Issue Nineteen

A Submission from The Nathaniel Centre – The New Zealand Catholic Bioethics Centre

General Comments
We are called to show the utmost respect to a person’s body at all times, including after death. This respect is an ongoing expression of the dignity owed to each person on the basis of our shared humanity. To desecrate or in some way to violate someone’s body is simultaneously to desecrate and violate the person. A person’s body is integral to, rather than incidental to, their personal identity. In New Zealand this responsibility is reflected in the longstanding current law which holds that no one can ever “own” the body of another. 

In the Catholic tradition we believe that all human beings are created in the image of God. We speak of human nature as being corporeal and spiritual. Yet, while accepting such a distinction (sometimes expressed in terms of “body” and “soul”) we reject any dualistic understanding of the human person. The body is not merely a vehicle or container for the person. Spirit and matter are not two natures united, but rather their union forms a single nature. We understand all life to be a gift that is entrusted to us from the Creator. The dignity accorded to human life can be understood as a direct response to the belief that life is a gift to be held in trust. 

The donation of one’s organs and tissue after death is a response that is consistent with the respect we are called to show towards our own life. Catholic statements and teaching on organ and tissue transplantation speak of it as a form of “self-giving”, a selfless act of love modelled on, and motivated by, Jesus Christ’s unselfish offering of his own life. For this reason, the donation of human tissue and organs is often referred to as an “enduring gift”. No one should ever presume such a gift. Provoked by love, and freely offered, an act of tissue or organ donation can be seen as an expression of human solidarity that serves the common good. 

Organ Donation and Consent
1.       Nobody should be able to lay a claim to the body of another except on the basis that it has been “gifted”. The gifting of human tissues or organs, either before or after death, is not something that anyone should feel obliged to do, or be pressured into in any way. 

2.       For this reason, the use of all or parts of a person’s body should only ever be done with their explicit consent, or, where such consent has not been recorded, with the consent of next of kin or close family recognised as knowing the mind and intent of the person. We recognise and uphold the intent of the proposed Human Tissue (Organ Donation) Amendment Bill legislation to ensure that all consent is informed and free of duress.  

3.       From a moral standpoint we regard the donation of one’s body as a “heroic action” and a rich gesture of generosity to fellow humans. The Catholic theological analysis of organ donation as an “enduring gift” highlights the respect given to informed individual choice. Those who are ultimately responsible for shaping legislation around tissue and organ donation must seek to preserve and promote such actions for what they truly are - rich gestures of generosity. For this reason we would be opposed to an “opt out” register based on “presumed consent”. The onus is on our society to properly educate and inform persons and obtain their informed consent. We support the proposed Amendment Bill which emphasises the need for persons to “opt in”. 

Consent – Binding or Non-Binding:
4.       In New Zealand, respect for the autonomy of the patient is a fundamental principle that informs the provision of healthcare in New Zealand. This principle is upheld in “The Code of Health and Disability Services Consumers’ Rights”. Right 7 spells out the “Right to Make an Informed Choice and Give Informed Consent”. Right 2 upholds the “Right to Dignity and Independence”. While recognising that the principle of autonomy exists alongside - and may at times be in tension with - other key ethical principles, we hold the view that proper respect for the dignity of a person normally implies that their expressed wishes as to what happens with their body after death would be upheld.  

5.       In reshaping the legislation relating to organ donation after death, we wish to highlight the importance of giving proper consideration to the cultural and religious diversity of New Zealanders. The dominant model of informed consent upon which health-care decisions in New Zealand are made is largely premised upon particular cultural assumptions about personal identity and well being in which the person is defined first and foremost as an ‘individual’. These assumptions are somewhat inconsistent with other cultural understandings in which an individual’s personal identity is more strongly tied to the family or whanau group to which they belong. The differences in assumptions provide for different approaches to personal decision making, which at times can set up a tension. While the strong presumption should always be to act in favour of an individual’s expressed wishes, we would be uncomfortable with a legal framework that ruled out absolutely a family’s rights to veto their loved one’s wishes. A system that seeks to resolve this tension by creating an automatic legislative preference for one set of cultural or religious assumptions over another is arguably unfair. We see that the application of the principle of informed consent within different cultural and religious frameworks provides one of the greatest challenges in shaping the new legislation.  

6.       The existence of an individual’s clearly stated wish to be an organ donor creates a strong moral claim in favour of carrying out those wishes. At the same time, the medical process of obtaining the organs necessarily changes the natural dynamics that surround the death of a loved one. As a result, the actualising of a person’s decision to be a donor makes significant additional demands on a person’s family / next of kin, especially when it is filtered through the lens of anticipatory grief. The needs of family and loved ones also matter. The benefit of not departing from current best practices around organ donation (whereby health professionals will only proceed if there is family or next-of-kin approval) is that there is a guaranteed incentive to work closely with, and be sensitive to the multiple needs of the family of the deceased person.  

7.       One of our concerns is that there may not be the same incentive for health professionals to work alongside the grieving family if future legislation was to insist on an absolute presumption in favour of acting on the dead person’s wishes regardless of her/his family’s approval.  

8.       We wish to see the appointment of independent personnel, specially trained in grief and trauma and with specialised knowledge about the process of organ donation, to manage the process around organ donation. Such people are already working successfully in many hospital environments world-wide. The advantage of such personnel, apart from being specially trained, is that they are not involved in decisions around care and treatment options, and nor are they involved in the actual transplantation process. Thus there exists a clear separation between those assessing the likelihood of death and those involved in any subsequent harvesting of organs. They can address the particular grief needs of the deceased person’s family/next-of-kin without having any perceived agenda. This system would also assuage the identified – and understandable - hesitation of some ICU doctors to approach families for consent.  

9.       The wishes of the deceased are paramount, and an individual’s wishes should be upheld in all but exceptional circumstances. In cases where the family of a would-be donor object on cultural or religious grounds, it would be part of the role of the trained and independent personnel to work with the family. It should be their starting presumption that the issue would be resolved in favour of the individual’s wishes. We believe such a process would in most cases resolve family/next-of-kin concerns while upholding the express wishes of the deceased, bringing about a win-win situation.  

10.   Nevertheless, in the face of continued cultural and/or religious objections we believe that the legislation should provide a degree of ethical and legal space for the wishes of the family to prevail. Respect for cultural and spiritual values is a strong aspect of New Zealand culture and is enshrined in many important pieces of legislation relating to health and welfare. Furthermore, to insist otherwise, that is, to provide for absolutely no circumstances in which the family could over-ride the deceased wishes, could, in the long-term, have a negative effect on the overall willingness of some individuals belonging to certain groups to become donors.  

11.   While much has been made of the fact that the current legislation allows family members to over-ride the expressed wishes of family members, it is our understanding that it has not been established that this is necessarily a significant factor in New Zealand’s low rate of organ donation. In our opinion, making all New Zealander’s more aware of, and educating and informing them about, the issues surrounding organ donation are the key factors in positively influencing the rate of donation in New Zealand.  

12.   The importance of keeping family closely involved in the decision making at all points becomes all the more evident when one considers that a sustained campaign to increase donor rates has the potential – even if unwittingly – to change the dynamic around end of life decision making. With a more focused drive to source organs comes an increased risk of abuse; that is, decisions being made that may not, in the first instance, be in the best interests of the critically ill/dying person. It is never permissible to bring about or hasten the death of a person for the purposes of retrieving organs, even when this is done to prevent the death of other persons. The input of the family remains an integral part of the care of the person and a key to ensuring that good decisions are made, and the risks of abuse minimised.  

13.   Furthermore, the necessary participation of family and loved ones in the decision whether or not to withhold or withdraw treatment or life-sustaining equipment is part of the process of organ donation.   This means that the family are already intimately involved in the process of organ donation. Good legislation will take this reality into account as opposed to presenting the decision about organ donation as a ‘stand alone situation’ that should be managed quite apart from what precedes and follows it.  

Systemic Issues:
14.   Mindful of the relatively low rates of organ donation in New Zealand, we recognise the need for individual New Zealander’s to be encouraged to think more seriously about their own willingness to act as donors. Education programmes integrated into the health curriculum could provide an important means for achieving this. Effective marketing strategies such as have already been undertaken by the Ministry of Health on various issues may also be an effective strategy. The proper resourcing of these campaigns requires a certain amount of political will. A higher level of awareness among New Zealander’s will hopefully mean that more and more people will have discussed their decision to be a donor with family and next-of-kin at the time when they make their informed choice and well before the actual circumstances in which their decision needs to be effected.  

15.   We agree strongly that the current process, whereby individuals record their consent to be an organ donor at the time they renew their driving certificate, is inadequate and ineffective. This is the case not least because the option of becoming a donor is presented in a way, at a time, and in a place where there is insufficient time and information for people to make a properly considered choice. The setting up of the Organ Donation Register as specified in section 4B seems a suitable and robust means for people to have their wishes recorded.  

16.   We also believe that the relatively low rates of organ donation in New Zealand may reflect inadequacies within the current health system such as a shortage of available ICU beds. Issues such as these are of a more systemic nature. Once identified, they are also best dealt with through political means. 

Conclusion
A comparison of New Zealand organ and tissue donation rates with other countries shows that we have one of the lowest donation rates in the world. We support efforts to increase the rates of organ donation in New Zealand. The nature of organ and tissue donation is that it is a “gift” and the processes around organ and tissue donation must respect this absolutely. Respect for a person’s autonomy suggests a strong presumption to act in accordance with an individual’s expressed wishes. The dynamics around end of life decisions, not to mention the needs and grief of family and next-of-kin, require that they remain closely involved in the process and that all attempts be made to ensure their support for a person’s wishes to be a donor. 
___________________
 

Nathaniel Centre Staff
©2006

The anguish and despair following the suicide of someone we love can be overwhelming. Two questions that we ask over and over are WHY and WHAT could we have done to stop them. At a national level, knowing that we continue to have high rates of suicide for some age groups compared with other countries raises the same questions; WHY and, as a nation, WHAT can we do about it.
       The Honourable Jim Anderton, Associate Minister of Health

Approximately 500 New Zealanders die each year by suicide and five times as many as this figure are hospitalised after a suicide attempt. Suicide in New Zealand is a serious problem annually more New Zealanders die this way than on our roads.

Eighty percent of all suicides in New Zealand occur with people aged 25 and over, with the majority of these deaths in the 25-44 year age group. While the young are particularly vulnerable to suicide the impact of suicide is felt across all age groups in New Zealand including the elderly and socially isolated, those who live in the most deprived areas of the country, the unemployed and those suffering from depression. Young Māori men and women have a significantly higher rate of suicide and hospitalisation for suicide attempts than non-Māori. Although more females are hospitalised after attempting suicide more males actually die by suicide.

The emotional devastation caused by suicide is profound for families as well as for the wider community. Suicide also has a major economic effect on the community. It is estimated that the annual cost of suicidal behaviour in New Zealand is nearly 1.4 billion dollars.

In his foreword to The Ministry of Health's recently published The New Zealand Suicide Prevention Strategy 2006-2016, Associate Minister of Health, the Honourable Jim Anderton hoped that the release of this new strategy will mobilise renewed efforts to work together to prevent suicide and suicidal behaviour. He noted that suicide prevention is complex and many would admit there is no quick fix to this social problem in New Zealand which affects so many every year. Nevertheless, with sustained and coordinated action at many levels in society, and with a variety of approaches, it is possible to achieve significant results in suicide prevention.

The Suicide Prevention Strategy builds on an earlier national strategy aimed at lowering youth suicide [The New Zealand Youth Suicide Prevention Strategy 1998.] The rate of suicide has decreased for young males as a result of this earlier strategy and there are more services and community resources in place to help the young and the wider community understand suicidal behaviour and suicide prevention.

In this latest strategy the focus has now expanded to all age groups, acknowledging the fact that suicide has a significant impact in other age groups, most notably in elderly males who have a higher rate of suicide than younger males. The prevention strategy outlines a framework that shows how the various activities across a range of sectors in the community can come together to prevent suicide across all age groups. Underpinning this framework is a fundamental vision of a society where all people feel that they:

• Are valued and nurtured
• Value their own life
• Are supported and strengthened if they experience difficulties
• Do not want to take their lives or harm themselves.

The strategy aims to reduce the rate of suicide and suicidal behaviour and equally to reduce the harms and impacts that are associated with suicide on families/whanau, friends and the wider community.

The seven goals of the New Zealand Suicide Prevention Strategy are to:

1. Promote mental health and wellbeing, and prevent mental health problems
2. Improve the care of people who are experiencing mental disorders associated with suicidal behaviour
3. Improve the care of people who make non-fatal suicide attempts
4. Reduce access to the means of suicide
5. Promote the safe reporting and portrayal of suicidal behaviour by the media
6. Support families/whanau, friends and others affected by a suicide or suicide attempt
7. Expand the evidence about rapes, causes and effective interventions

With some insight the strategy notes that while suicide is a serious health and social issue, and represents a significant loss to our society it is also an indicator of the social wellbeing of the population.

The importance of societal factors in suicide was recognised more than one hundred years ago by Sociologist Emile Durkheim in his 1897 book Suicide: A Study in Sociology. He was the first to discount non-sociological explanations of suicide. He sought to show that, what masked as a highly individual and personal statement, could be explained, in part, in terms of the degree of social integration within a particular society. He argued that suicide was an echo of the moral state of society and was in fact dependent on social causes and not on individual conditions even though the latter were a factor in suicide. For Durkheim, a high rate of suicide in a particular society or particular social group was in direct proportion to the lack of social cohesion in that society or that social group.

Examination of the World Health Organization's Map of Suicide Rates helps to illustrate this point. Countries with the highest rate of suicide include Australia, New Zealand, Russia, China, Eastern and Central Europe. Predominantly Catholic and Islamic countries have some of the lowest rates of suicide. Do these statistics reflect the more secular nature of our New Zealand society or are there other sociological factors beneath such disparity? Might a society that valued the transcendent have a better appreciation of the role of religion and faith in suicide prevention? The Suicide Prevention Strategy would be strengthened if there was wider recognition of the place of faith and spirituality and their role in helping to protect the vulnerable against suicide.

The strategy document does not address the issue of physician-assisted suicide or euthanasia and claims that this subject raises separate ethical, legal and practical issues. While the issues appear to be separate they are very much linked to the wider issue of suicide in society, as Durkheim implied so many years ago. This is particularly so when one considers a topic such as 'the meaning of life' from the perspective of the elderly.

In recent years the increase in numbers of the elderly is reflected in the growth of retirement communities which provide a continuum of care that ranges from independent living to rest-home and finally to hospital care. While retirement homes can offer wonderful care, a greater sense of security and opportunities for community living, they can unwittingly leave the elderly feeling isolated with minimal influence in society. To the extent that this is perceived as being true, or is true in reality, then some elderly may well feel that their lives have lost meaning long before they lose their lives. This perception may well predispose the elderly to greater risk of suicide. Because their physical frailty may limit their ability to commit suicide, voluntary euthanasia and physician-assisted suicide offer a false form of security.

Given the very high rate of suicide in elderly males in New Zealand it is timely to recall the fact that the calls for voluntary euthanasia and physician assisted suicide reflect a high level of suicidal ideation in this group as well as in the chronically and terminally ill.

Conclusion
The Suicide Prevention Strategy depends on adequate mental health services for all ages and therefore highlights the need for a deeper understanding of the mental health requirements of the elderly. Further, because voluntary euthanasia and physician assisted suicide is part of the pattern of suicide in our society, it has to be recognised and addressed for what it is a method of committing suicide.

The strength of the Suicide Prevention Strategy document is in the way it openly addresses a major personal and profound social problem in New Zealand. The prevention strategy rightly states that there are no quick fixes to a problem of such depth. Nevertheless, in recognising the social causes of suicide, even implicitly, and in providing a strategy to help prevent the untimely and devastatingly tragic death of New Zealanders, it helps provide a way forward for all in the society. Durkheim described this path as social cohesion. It can also be described as the path to stronger communities.
_____________________

Rev Michael McCabe, PhD
Director
The Nathaniel Centre

©
2006

On 24 July, 2006 Toi te Taiao The Bioethics Council released a booklet designed to encourage discussion about the use of human embryos for research. The publication of this document reflects the responsibility Toi te Taiao has to consider the cultural, ethical and spiritual issues raised by the use of biotechnology in New Zealand and to get people thinking and talking and to encourage them to get involved.

The booklet anticipates the release of draft guidelines on the use of embryos for research by the Advisory Committee on Assisted Reproductive Technology (ACART) later in the year. All New Zealander's have the opportunity to submit their comments on these draft guidelines.

The desire to carry out research on embryos reflects a hope that stem cells unspecialized cells which have the ability to give rise to particular tissue-specific cells may one day provide the key to a wide range of cures and therapies. Embryos are one way of sourcing stem cells commonly referred to as embryonic stem cells (ESC's). The dilemma is that such stem cells can only be gathered by destroying the embryo.

Other types of stem cells - known as adult stem cells - can be obtained from a variety of other sources such as cord blood and bone marrow. The sourcing of adult stem cells does not require the destruction of embryos. For this reason, research on adult stem cells poses far fewer ethical dilemmas. At the same time, however, adult cells are more limited than ESC's in terms of the range of tissue-specific cells that they are potentially able to develop into.

It is because adult stem cells are more restricted in their ability to differentiate than ESC's that many researchers regard ESC's as holding greater promise. This has led to considerable pressure being put on governments around the world, including New Zealand, to make human embryos available for such research.

There are, broadly speaking, two key sources of embryonic stem cells; embryos specifically created for implantation by fertility clinics and which are now not required for implantation (sometimes called spare embryos) and embryos created expressly for destructive research. Embryos created for destructive research may be produced in one of two ways; through donated sperm and eggs the same process used to create embryos for infertile couples - or by a process of cloning (SCNT) in which the nucleus of an egg is replaced with the nucleus of a body cell (skin cell, hair cell, etc) containing the full complement of chromosomes of a particular person.

While a distinction is made between cloning for research and reproductive cloning (a practice that is illegal in New Zealand and universally banned) the process is essentially the same. The key difference is that in research cloning the embryo is allowed to grow for only seven days after which time it is destroyed so that its stem cells can be removed.

The booklet notes that individual attitudes to embryo research reflect a person's understanding of the moral status of the embryo. Some regard the embryo as merely a collection of cells, deserving of no special respect. Others regard it as meriting some protection but believe that for very good reasons such as the search for therapies embryos may sometimes be used for research. Catholic teaching holds that without exception the living embryo is, from the moment of fertilisation, a human being with an absolute right to life. On that basis all embryos are entitled to the same respect as persons.

Stem cell research holds real promise for the prevention and treatment of serious diseases. However, we have a moral obligation to pursue good outcomes by using only ethical means. It is an old axiom that the end does not justify the means. Sufficient account needs to be taken of the moral harm associated with the destruction of human embryos, including its wider repercussions for the way we look at all human life. Appealing exclusively to the future benefits that may come about as a result of destructive research on human embryos obscures broader ethical issues.

In the case of stem cell research, the use of adult stem cells provide an ethically acceptable alternative and we have a moral obligation to pursue this alternative. There is also other promising research which is seeking ways of obtaining cells with the same properties of embryonic stem cells without the need to create or harm human embryos.

For a fuller discussion of the Catholic understanding of the moral and ethical issues associated with stem cell research refer to The Nathaniel Report:

issue number five: The Moral Status of the Embryo

issue number twelve:Stem Cell Research in New Zealand

Toi te Taiao will be facilitating a web based discussion forum on embryos and researchat: www.bioethics.org.nz/dialogue/forum/index.html

Draft guidelines on embryo research will be available later in the year from the ACART website at: www.newhealth.govt.nz/acart

Submissions may be sent directly to ACART through their website.

Familial relationships
When the Second Vatican Council spoke of “familial relationship” between the laity and the pastors” (LG 37), it was making the point that each learns something from the other when it comes to understanding, interpreting and applying the Church’s teaching. 

The practical implications of this were later spelled out in c.212, which emphasises both the rights of the laity and the respect due to the teaching ministry of pastors. But more than that, good collaboration in practising and presenting the Church’s teaching is rooted in the relationships proper to a community of Jesus’ disciples. Their learning from each is qualitatively affected by friendship between them. 

A little learning
If before the Council it was the insights and the rights of the laity that were often neglected, perhaps today it is the ministry of the pastors that is being disrespected – not by careless Catholics, but by zealous Catholics, who seem to be very sure of themselves. Of whom was the poet speaking when he said: “a little learning is a dangerous thing”?

The harshness and sarcasm to which pastors are sometimes treated does not come from those family relationships the Council describes, and not from the Holy Spirit.

Adequately presenting the Church’s teaching involves much more than just getting information, even from the best of sources. Information on its own is not knowledge. Much less is it wisdom. Someone has rightly asked:   whatever happened to wisdom that it got buried in knowledge; whatever happened to knowledge that it got buried in information? 

Information is only the raw material for knowledge.   It needs to be processed through the methods proper to theology. In this way we see individual teachings in the light of each other and in the light of the whole. This involves years of study. 

At the time the Catechism of the Catholic Church was issued, Cardinal Ratzinger emphasised the importance of “mediating” the Catechism. This is something more than merely drawing conclusions for local application, and it is more than merely repeating the text. It involves a process of internalising, interpreting and re-expressing the text in other ways. He even said the Catechism “is not and cannot be the only possible way, or even the best way, of giving a catechetical re-expression to the Christian message”. It belongs to the ministry of bishops and bishops’ conferences to oversee these processes of “mediation” and ensure faithfulness to the apostolic tradition. 

In a private discussion with two of New Zealand’s bishops during the 1989 Synod, Cardinal Ratzinger confirmed that bishops and bishops’ conferences have a similar role in interpreting and applying Instructions issued by Roman Congregations for the Universal Church.

How did Cardinal Ratzinger get it so wrong, if it is sufficient just to repeat what can be read in the Catechism or in an Instruction? 

What would be left of the charism and vocation of theologians if the ability to read the internet or the Catechism were all that is needed, without the need for years of theological study? 

And what would be left of the teaching ministry of bishops if it were reduced to merely repeating what anyone could pick up from the media? 

These are the kind of questions that must be faced by those who use information (albeit accurate information) in isolation from theological method and independently of the teaching ministry of bishops. 

They might also notice that according to the Council, the factors which give rise to ongoing development and growth in the Church’s understanding of its faith are rooted in the lived experience of the faith (DV n.8) – and therefore in the life of the Church at every local level. 

The need for bishops to speak up
That is why the charism and responsibility for authenticating Catholic teaching belongs to the whole episcopate, including and especially the Bishop of Rome.   Regional bishops would be acting in an un-Catholic way if they were not to assume their share of responsibility for how the Church’s teaching continues to be clarified and expressed. 

If the reaction of some Catholics to a recent explanation of the Church’s teaching on contraception and avoiding the spread of infection proved anything, it proved the need to say what was said. Otherwise, people really will think that clarifications such as those recently offered by at least two Cardinals and a consultor to the Congregation for the Doctrine of the Faith amount to a “change” in the Church’s teaching. It was important to explain why this is not so. 

It is also required of pastors that they hold the torch for those thinking Catholics and others who know instinctively that some of the Church’s teachings have been inflated beyond what the Church actually teaches. 

Wisdom
Beyond knowledge is wisdom. Knowledge is its raw material still being processed through prayer, reflection and life-experience. Of course, it is also a gift. Those who are least likely to feel the need for wisdom are those who are most sure of their own knowledge. Lots of information and easy access to it have become their power-base. (The power-base in society used to be with those who hold wisdom). 

Some of those who rely heavily on information would probably find Cardinal Ratzinger’s remarks on mediating and on the role of bishops’ conferences bewildering – even if they are not so long out of the seminary.

The Catholic laity are entitled to pay more attention to those who have heard more confessions, visited more homes, worked with more addicts, failed more often, and experienced their own vulnerability over a longer period of time. They seem to know something that is not taken from the internet.   (I used to feel scandalised by these priests – I had learned the books very well. I was yet to learn humility.) 

An increasing need
Legislation on social, economic and industrial issues, and ethical questions arising from bio-technology, are just some obvious areas in which pastors and laity need each other for a proper understanding of how the Church’s teachings apply. This will become more so, not less so. How shall we put in place the structures needed to facilitate friendship? 
_________________ 

Bishop Peter J Cullinane is Bishop of Palmerston North Diocese and New Zealand Bishops’ Conference Deputy for The Nathaniel Centre.

©
2006

The challenges and needs of people at the end of life are multifarious. In the first instance the priority is to enhance quality of life by providing relief from pain and other distressing symptoms. This calls for a holistic approach to care that integrates the physical, psychosocial and spiritual dimensions, and that also takes account of the needs of families/whanau and other caregivers who are accompanying and caring for the dying person. 

The desire to provide integrated and holistic palliative care to persons “of all ages with a life-limiting illness, with little or no prospect of cure, and in whom death is the likely outcome”, is ultimately an affirmation of the fact that dying is a normal process, an important part of living. That this is so underlines the importance of all New Zealanders having ready access to comprehensive palliative care throughout the course of a life-threatening illness, whether death is “hours, days, weeks, months or sometimes years away.” 

In 2001 the Ministry of Health released the NZ Palliative Care Strategy with the aim of setting in place “a systematic and informed approach to the provision and funding of palliative care services.” It is readily acknowledged that current inequalities exist within the national approach and that these “include access for Māori, Pacific peoples, isolated communities, children, the very old, those with non-malignant disease, as well as those with special needs: asylum seekers/refugees, people in prison, and those with mental illness.” 

In order to make the Palliative Care Strategy a success, and to help address the inequalities, a Palliative Care Subgroup of the New Zealand Cancer Treatment Working Party has prepared a Discussion Document that focuses on “palliative care definitions”. Why the focus on definitions? “Definitions form the basis upon which a comprehensive, cohesive and effective palliative care service can be built and sustained. They help clarify core service components, elucidate structure, and promote understanding. They are also a key component for national palliative care service specifications.” 

While the document draws on the 2002 World Health Organisation palliative care definitions, it readily acknowledges the importance of defining palliative care in a New Zealand context. To that end it highlights five key factors critical to New Zealanders:

• The fundamental place of the Treaty of Waitangi and the Māori Health Strategy, and the need to acknowledge the holistic Māori philosophy/model Te Whare Tapa Wha and its four dimensions: psychological health, spiritual health, physical health and family health.
• The changing nature of society, disease and illness and expectations within New Zealand.
• The need for Palliative Care support to be dynamic, reflecting changing needs, and to be available throughout the course of a life-threatening illness according to need.
• Delivery of services through an integrated approach that seeks to include the family, and in which there is a place for palliative care specialists as well as generalists such as the general practice team.
• The need for a patient’s primary care team (eg general practice team) to provide continuity of care.

Generalist palliative care is defined as community based care provided as an integral part of routine standard clinical practice. Some generalist providers will have ongoing contact throughout and following illness, while others such as district or ward nurses will have episodic contact depending on need. Providers of generalist palliative care will have defined links with specialist palliative care for support and advice and in order to refer patients with complex needs. Specialist palliative care is provided by Hospice based community services or hospital based palliative care services, both with expert interdisciplinary teams of health professionals who have undertaken specific training.

It is envisaged that specialist palliative care provision will work in a ‘direct’ way – providing direct management and support – and ‘indirectly’ – providing advice, support, education and training of other health professionals and volunteers to support their generalist approach to palliative care provision.

“Depending on the complexity level of palliative care need, smaller (level 1) specialist palliative care services will at times require input from a broader and more developed service (level 2) which may be geographically distant [but] … readily available through defined linkages and processes.”

In founding the hospice movement its pioneers had as one of their primary goals the ongoing education of the medical and nursing profession and the wider community. The discussion document reflects this in its wording. There is considerable emphasis on the role of specialist palliative care providers providing comprehensive education for the local generalist care providers and also coordinating an education programme for specialist palliative care regionally. The specialist providers will also have “organisational quality and audit programmes.”

The document is written in language that is readily accessible and may be obtained by visiting the following link:

http://www.community.net.nz/NR/rdonlyres/267FA6D9-E44C-449F-8ADE-D19717C6108E/32895/pcdefs.doc

The document is for the widest dissemination and feedback on it is sought particularly from those at grass roots level involved in care provision, as well as those involved in managing, planning and leading services. 

Feedback may be sent to Anne MacLennan, Chair of the Palliative Care Subgroup of the NZ Cancer Treatment Working Party (NZCTWP) at the following address: 
                                     c/- Nick Polaschek
                                     Senior Project Manager/Team Leader
                                     DHB Funding and Performance Directorate, MOH
                                     Ministry of Health, 1-3 The Terrace, Wellington 
                                     emailto:Nick_Polaschek@moh.govt.nz

©
2006

“For Christians, Jesus’ offering of himself is the essential point of reference and inspiration of the love underlying the willingness to donate an organ, which is a manifestation of generous solidarity"  
                                               Pope John Paul II, 1992 

John Paul II’s description of organ and tissue donation in terms of the sacrificial love of Jesus Christ highlights the acceptability of organ transplantation within the Catholic Tradition. Yet, when it was first raised as a serious issue in the 1940’s and 1950’s, the morality of organ donation caused vigorous debate among Catholic moral theologians. Ashley and O’Rourke (1989, p.305) note that initially the question was discussed from a largely theoretical point of view because, prior to 1950, transplants were contemplated but not yet possible. The subject was therefore not included in the moral manuals of the time. However, as advances in medical science and surgical procedures made organ transplantation a viable option, ethicists and moralists were forced to give the matter closer scrutiny. 

There are basically two types of organ donation possible – from a dead person to a living person and from a living donor to another living person. This article will trace the development of Catholic thinking about organ and tissue transplantation over the last sixty years.

Organ Transplantation from a Dead Person to a Living Person
The Catholic moral tradition, along with most other religious groups, readily endorsed the worth and ethical acceptability of transplanting organs from a dead person to a living person. Pius XII was an articulate spokesperson for the development of Church thinking on this matter. On May 14, 1956, in an allocution to a group of eye specialists, Pius XII informed his audience: “The public must be educated. It must be explained with intelligence and respect that to consent explicitly or tacitly to serious damage to the integrity of the corpse in the interest of those who are suffering, is no violation of the reverence due to the dead.” He was clear that the practice of organ retrieval from dead persons should not be forbidden. Persons are free to “dispose of their bodies and to destine it to ends that are useful, morally irreproachable and even noble.” In fact, Pius XII concluded, “This decision should not be condemned, but positively justified.” (Tissue Transplantation. (May 14, 1956), in The Human Body: Papal Teachings, pp. 380-83.) In taking this stance Pius XII had in mind the needs of “medical science and the training of future physicians” as well as those with “the desire to aid the sick and the suffering.” 

Nevertheless, Pius XII’s endorsement was not without its concerns. A key concern was that the body not be treated merely as a physical or biological entity. The human body deserves to be regarded differently than the body of an animal because human persons are formed in the image and likeness of God, and “something of this dignity still remains in the corpse.” Another of his concerns was that “ordinarily the deed cannot be presented as a duty or as an obligatory act of charity.” The liberty and spontaneity of the parties involved must be respected. 

Other concerns that surfaced in discussions about the retrieval of organs from dead persons stemmed from factors other than the concept of transplantation per se. They included such things as: the high costs involved; questions about accurately determining the exact point of death of a donor and fears that some donors might not have actually died; and relatively high failure rates. (Ashley and O’Rourke, 1989, p. 305.)  

Organ Transplantation by a Living Donor
Determining the moral acceptability of organ transplants between living persons proved to be a greater challenge for Catholic moral theologians of the 1940’s and 1950’s. The dilemma was initially framed in terms of the question as to whether a person could ‘mutilate’ him or herself for any purpose. 

It has always been a fundamental tenet of Catholic teaching that the human body is under God’s dominion and that we may not, therefore, dispose of it in any way we wish. Proper recognition of God’s dominion calls for persons to exercise a sense of stewardship over their bodies.   Consequently, all forms of mutilation - as well as suicide - were outlawed because they were deemed to be a violation of that dominion. In their attempts to resolve the quandary posed by “surgical mutilation”, theologians such as St Thomas Aquinas (1225-1274) developed the Principle of Totality, a principle that by the middle of the 20^th Century had become “an integral part of the moral methodology which had come to the fore in Catholic medical ethics.” (Kelly, 1998, p. 305-306.) Put simply, the Principle of Totality, as articulated by Pope Pius XII in 1952, holds that the part exists for the whole. Consequently, it follows that the good of the part remains subordinated to the overall good of the whole. Therefore, the whole may be seen as a determining factor for the part, able to “dispose” of it in its own interest. 

In its most common application, the Principle of Totality provided the logic used to justify the “surgical mutilation” of a person’s body - for example the amputation of a gangrenous leg to save that person’s life. However, its consistent application in this type of context also shaped the way in which the principle came to be understood, particularly when applied to other moral dilemmas. In Kelly’s words, “the principle of totality had come to be limited to the physical good of the individual physical body.” (1998, p. 306). 

Interpreting the Principle of Totality in a physicalist and individualist way, most moral theologians were convinced that the surgical mutilation of any part of a person’s body could only be justified for the better functioning of the person suffering the loss. Because persons are not related to each other as part to the whole (they each possess an innate and equal dignity), they drew the conclusion that surgical intervention was only ever permissible when an organ was harmful or useless to a particular person. The outcome seemed clear cut. The Principle of Totality ruled out live organ donation for philanthropic motives. It was on this basis that Pius XII proclaimed to a group of military surgeons in 1953: “The patient … has no right to dispose of his own existence, of the integrity of his organism, of his particular organs and their functional capacity, except in the measure demanded by the good of the whole organism.” Thus Kelly notes: “For a period of time Catholic moral theology was more apt to forbid [living donor] organ transplantation than to permit it.” Indeed, there was almost unanimous agreement from Catholic moral theologians that the practice was morally unacceptable. 

As early as 1944, however, (writing before organ transplantation was even possible) Bert Cunningham CM had posited an opposing point of view. Drawing on accepted Catholic thinking that recognised the validity of a person sacrificing his/her life in order to save the life of their “neighbour”, Cunningham speculated that charity should be able to authorise something “less” than the taking of a human life. He therefore offered the “probable opinion” that living donor transplantation involved no opposition to the “natural or supernatural moral law” and that they were therefore licit.

In arguing his case Cunningham’s central thesis was that living donor transplantation was not a violation of the Principle of Totality. The key problem, as he saw it, was that the Catholic Tradition was interpreting the principle in too narrow a way. Cunningham then proposed that the “body” be redefined to include not only the individual physical body from which the organ is removed, but the entire Mystical Body of Christ. Drawing moral implications from what was essentially a theological doctrine, he concluded that “… men are ordinated to society as parts to a whole, and, as such, are in some way ordinated to one another.” This spiritual ordering would, he thought, allow any person to “mutilate” themselves physically for the overall good of the Mystical Body. 

In analysing Cunningham’s approach, other theologians seeking to develop a Catholic rationale for a more liberal opinion were wary of Cunningham’s thesis that individuals are ordained to society as parts to the whole. In particular, his approach appeared unable to properly uphold the dignity and rights of the individual over their body and life, a failure that left the way open for the needs of individuals to be sacrificed in favour of the common good of the community.   In the end, Shannon notes that it was Cunningham’s “highlighting of the principle of charity rather than arguments about the unity of the human body – mystical or physical – that carried the argument supporting living organ donation.” (2001, p. 289) 

By 1955, there were enough moral theologians of sufficient stature within the Catholic community for Gerald Kelly SJ to conclude that living organ donation may be permitted. Kelly thought the Principle of Charity validated living donations provided that there was only “limited harm” to the donor. More recently, other theologians such as Ashley and O’Rourke have sought to justify the practice by drawing a distinction between “anatomical integrity” and “functional integrity”: if one kidney is missing from a person’s body, there is a lack of anatomical integrity, but if the other healthy kidney is present and working, the body retains its functional integrity because one healthy kidney is more than able to meet the body’s needs. (Ashley and O’Rourke, 1989, p.306) 

Most recently it was Pope John Paul II who articulated Catholic thinking on organ and tissue donation. In 1991 he described the therapeutic use of organ and tissue transplants as one of the many remarkable achievements of modern medicine. “It is surely a reason for satisfaction that many sick people, who recently could only expect death or at best a painful and restricted existence, can now recover more or less fully through the replacement of a diseased organ with a healthy donated one: We should rejoice that medicine, in its service to life, has found in organ transplantation a new way of serving the human family, precisely by safeguarding that fundamental good of the person.” “We are challenged to love our neighbour in new ways; in evangelical terms, to love ‘to the end’ (cf Jn 13:1), yet within certain limits which cannot be exceeded.” (“Many ethical, legal, and social questions must be examined in greater depth” (June 20, 1991) Dolentium Hominum, Vatican Press n. 3 pp. 12.)

For John Paul II, the limit which cannot be exceeded “above all” is that organ donation must remain “a human act of donation. In effect, transplantation presupposes a prior, explicit, free, and conscious decision on the part of the donor or of someone who legitimately represents the donor, generally the closest relatives.” John Paul II exhorts health professionals involved not to lose sight of the donor’s act of self-giving and “the mystery of love involved” in what they are doing. “Nor should the recipients of organ transplants forget they are receiving a unique gift from someone else: the gift of self made by the donor … The progress of the biomedical sciences has made it possible for people to project beyond death their vocation to love.” Subsequently, the donation of tissues and/or organs has come to be described by many as an “enduring gift”. 

On the question of living donations, John Paul II states that “a person can only donate that of which he can deprive him or herself without serious danger or harm to their own life or personal identity, and for a just and proportionate reason.” “Vital” organs should only be donated after death. 

Organ Transplantation and Compensation
In his 1956 teaching Pius XII was ambivalent as to whether one should “refuse on principle all compensation” for organ donation. While he did not doubt that grave abuses could occur when payments are demanded, he concluded that it was commendable for a donor to refuse recompense but “not necessarily a fault to accept it”. John Paul II, meanwhile, advocated a firmer line; the provision of an organ should be “a decision to offer without reward a part of one’s own body.” John Paul II adopted this stance because of his belief that the commercialisation of body parts would amount to a materialist reduction of the human body. 

Such a reductive materialist conception would lead to a merely instrumental use of the body, and therefore of the person. In such a perspective, organ transplantation and the grafting of tissue would no longer correspond to an act of donation but would amount to the dispossession or plundering of a body. (Address to participants in a conference on organ transplants, June 20, 1991)

Within New Zealand there has developed a strong culture of resistance to the notion of commercialising transactions involving human tissue. Unlike other parts of the world, New Zealanders have never received compensation for giving blood, for example. This attitude has been most recently enshrined in legislation such as the Human Assisted Reproductive Technology (HART) Act which prohibits the commercial supply of human embryos and human gametes and also prohibits commercial surrogacy arrangements.  

One of the ways in which the notion of organ and tissue donation as ‘gift’ may continue to be upheld in law and practice in New Zealand is by ensuring that there are robust processes for recording a person’s positive consent to be a donor. 

The absence of specific consent raises the question as to whether anyone else can make a proxy decision in favour of organ donation for a dying person. At first glance, the concept of organ donation as an act of ‘self-giving’ might seem to rule out any notion of substituted or surrogate consent. In line with this, from the time of Pius XII, Catholic teaching has consistently maintained that “public authority” has no direct right to dispose of the existence and integrity of the organs of its innocent subjects. Nevertheless, Catholic teaching continues to affirm the right of the family or next-of-kin to make such a judgement. It does this on the basis that such persons are in a genuine position to know what their loved one would have wanted, and provided that the person concerned had not previously made known their opposition to such. 

Conclusion
Moral theologians of the 1950’s and 1960’s faced new dilemmas as a result of technological and medical advances. The history of Catholic moral teaching on organ transplantation shows how the Catholic position on ethical issues sometimes develops over time. In this case there has been a movement from condemnation to commendation, from describing it as mutilation to describing it as donation, and from a very individualistic approach informed by the principles of Totality and Stewardship to a more social view of the issue informed by the principle of Charity. (Jonsen, 2005) 

The initial responses of many theologians to the possibility of organ and tissue transplantation were both informed by, as well as limited by, existing principles and ways of thinking inherited from the moral tradition. In the light of condemnations of the practice, a few theologians were prepared to challenge the conclusions of the majority, among other things motivated by an “intuitive” sense that it seemed wrong to forbid transplantations. In developing a rationale for a more positive assessment of transplants they refined accepted principles and extended Catholic moral thinking. 

In our own time we are facing many new dilemmas related to new advances in technology and medicine. We would do well to recall the history of the debate over organ and tissue transplantation as we seek to apply established moral principles to issues raised by reproductive technologies and developments in genetics and biotechnology. 

The experience of theologians of the 1950’s and 1960’s should inspire us with boldness to contribute to the debates of our own time based on a confidence in our rich moral tradition. At the same time we should also bear a healthy sense of humility and scepticism, even (and perhaps especially) towards those solutions that seem so “obvious” and clear cut. We are also challenged to listen openly to those who propose alternative solutions. 

In the meantime, the debate over how best to promote a more effective organ donation system in New Zealand continues. The legacy of John Paul II, Pius XII and many competent moral theologians places Catholics and others in an excellent position to contribute to the discussion. While the moral acceptability of organ and tissue transplantation is now a given, risks remain and ongoing ethical vigilance is required. In particular, future developments such as xenografting and transgenesis will surely require us to revisit the basic principles in order to resolve new questions and dilemmas that are bound to arise. 
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John Kleinsman is a Researcher for The Nathaniel Centre

©
2006