CHICAGO
STUDIES
EDITORIAL STAFF
Editor George J. Dyer
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John F. Dedek
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Production Manager
Executive Assistant
Edmund J. Siedlecki
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Editorial Advisors Joseph A. Bracken, S.J. Gerard T. Broccolo Agnes Cunningham, sscm
James P. Doyle John F. Fahey John R. Gorman Vincent C. Horrigan, S.J. Willard F. Jabusch George J. Kane Edward H. Konerman, S.J.
Thomas B. McDonough Mary Peter McGinty, C.S.J. George K. Malone Stephen J. Mangan Charles R. Meyer Joseph J. O'Brien Robert A. Reicher Richard F. Schroeder Edward J. Stokes, S.J. Thomas F. Sullivan
CHICAGO STUDIES is edited by the faculty of St. Mary of the Lake Seminary and the priests¡ of the Archdiocese of Chicago for the continuing education of the clergy. The editors welcome articles and letters likely to be of interest to our readers. All communications regarding articles and editorial policy should be addressed to the editors. Subscriptions should be sent to CHICAGO STUDIES, Box 665, Mundelein, Illinois 60060. Subscription rates: $5.00 a year, $9.00 for two years, $16.00 for four years; Foreign subscribers: add 50c per year. CHICAGO STUDIES is published three times a year with ecclesiastical permission and copyright, 1972, by Civitas Dei Foundation, Box 665, Mundelein, Illinois 60060. Third Class postage paid at St. Meinrad, Ind. Views expressed in the articles are those of the respective authors and not necessarily those of the editors or editorial board. Indexed in The Catholic Periodical Index and New Testament Abstracts. Microfilms of current and backfile volumes of CHICAGO STUDIES are now available from University Microfilms, Inc., 300 N. Zeeb Road, Ann Arbor, Michigan 48106. Manuscripts will not be returned unless accompanied by self addressed stamped envelope.
FALL, 1972
VOLUME 11
NUMBER 3
Articles MORAL RESPONSIBILITY IN CARING FOR THE DYING NEW EPISTEMOLOGY AND THE MORALIST BIOMEDICAL TECHNOLOGIES AND ETHICS CONFLICT: THREAT OR CHALLENGE-THE
I'
"1"
227
John F. Dedek
237
Norbert J. Rigali
245
William E. Ma.y
257
Gerald F. Kreyche
269
William J. Byron, S.J.
279
Warren T. Reich
295
Andre E. Hellegers, M.D.
305
Richard McCormick, S.J.
315
Thomas O'Donnell, S.J.
319
James H. Provost
329 333 335
Vincent J. Hope
VS. THE
INSTITUTION UNCONNECTED SELF INTERESTREFLECTIONS ON ALIENATION AND RELIGION IIIEDICAL ETHICS: THE CONTEMPORARY CONTEXT SOME THOUGHTS ABOUT MEDICAL PROBLEMS FOR CATHOLICS THE NEW DIRECTIVES AND INSTITUTIONAL MEDICO-MORAL RF.SPONSIBILITY INSTITUTIONAL MEDICO-MORAL RESPONSIBILITY: A RESPONSE TO FATHER McCORMICK CHURCH TRIBUNALS AND THE SACRAMENT OF MATRIMONY FUTURE FORMS OF MINISTRY II: A COMMENT AUTHORS INDEX
OUR COVER: Sedes Sapientiae. Beaten metal-five feet high. Louvain University, Belgium. Philippe Denis, sculptor.
John F. Dedek
Moral Responsibility in Caring {or the Dying
How does a physician co1¡rectly decide who will live and who will be allowed to die?
The physician is not only physician and scientist. He is first of all a man, a man who is also a doctor. And so in the practice of medicine he must make more than medical decisions. He has to make the broader human decisions that are called ethical or moral. He must make a great variety of such decisions. But I want to discuss only two of them. One is the question of care for the dying. What measures ought to be used to keep a person alive? For instance, should a physician prescribe insulin for a terminal cancer patient who develops diabetes? Or must a diabetic patient who develops terminal cancer continue his insulin injections? Should a physician always treat and cure pneumonia in an aged and senile patient? When should a physician turn on or tum off a heart-lung machine, begin or not begin, continue or discontinue artificial respiration, oxygen, intravenous drip, and so on? 227
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The other question concerns the selection of patients for care when there are limited medical resources. For instance, if ten patients need hemodyalisis and only five can be accommodated on the kidney machine, which five should be chosen and which five not? On what criteria does one correctly decide who will live and who will be allowed to die? I would like to suggest some ethical principles that can illumine decisions such as these. The pl"inciples of course are not the decisions, nor can they relieve the doctor of the burden of making them. Most men do not like to play God. But man cannot abdicate the responsibility that is his under God's providence. We cannot leave important human decisions about life and death to fate or the natural course of things under the pretense of leaving them in the hands of God. God cannot be counted on to intervene miraculously in human affairs, even the most impmiant ones. The solemn fact is that man must play God. Othenvise that role will not be played. There is of course the absolutist view, more common among physicians than moralists, that a doctor must make every possible effort to keep a person alive. For instance, he must use every means available to stretch out the life of a terminal cancer patient to the very end. According to this view a physician's duty is to cure disease and to do this relentlessly even when the patient cannot be finally cured. He must carry on the fight against. death until the issue is taken out of his hands. Traditional medical ethics commonly has taken a more nuanced position. Medical ethics as it developed in the West introduced the more flexible categories of ordinary and extraordinary means. The majority of ethicists argued and still argue that only ordinary means must be used to preserve life and that extraordinary means are elective not mandatory. Pope Pius XII, who has not gone down in history as a crusading liberal in the area of medical ethics, personally confirmed this moral teaching. THE AMBIGUITY OF THE CATEGORIES
These categories are probably familiar but there is often a difficulty which lies in their ambiguity. There is generally a significant difference in the meaning of the terms ordinary
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and ext1¡aordinary as they are used by physicians and moralists. The physician usually considers ordinary whatever means are standard, orthodox or established medicines or procedures within the limits of availability. He considers extraordinary a medicament or procedure that is fanciful, bizarre, experimental, incompletely established, unorthodox or not recognized. For the moralist, on the other hand, the ordinariness of the means is simply measured by two factors--their convenience and utility. Therefore the moralist defines ordinary means as not only normal food, drink and rest by all medicines, treatments, and operations which offer a reasonable hope of benefit and which can be obtained and used without excessive expense, pain or other inconvenience. He defines as extraordinary means all medicines, treatments and operations wl1ich cannot be obtained without excessive expense, pain or other inconvenience for the patient or others, or which if used would not offer a reasonable hope of benefit to the patient. The last point is important. In determining which means are to be counted as ordinary and which as extraordinary, their usefulness is as decisive as their convenience. Even means that generally are classified as ordinary should be counted as extraordinary if their use will confer no significant benefit on the patient. Suppose the case of a man with tetminal bone cancer, who is conscious, gets only brief relief from pain killing drugs, and will live for several more weeks unless the doctor pulls the plug on the artificial respirator and removes the tubes for intravenous feeding. In the view of the ethicist, these notmal aids are to be judged extraordinary means in the circumstances, since they are not useful means to save life. Their continued use confers no significant benefits on the patient. They do not significantly prolong life. Rather they needlessly and torturously prolong the process of dying. We should not forget in our efforts to save life that dying is one way of being human and to be allowed to die is a precious human right. THE PHYSICIAN AND THE MORALIST
There is a second important difference that often exists between the perspective of the physician and that of the moralist. The physician as a scientist is inclined to see his task as
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treating and curing diseases. The moralist, who is not a scientst, writes for the physician a somewhat different job description. The physician's mission is to cure people and save their lives. His job is patient-centered, not disease-centered. As Paul Ramsey observed, "Doctors do not treat diseases, though they often conquer them. They treat patients, and here finally all fail." This subtle nuance in perspective makes a great practical difference. Take the case of a patient who has two fatal diseases, one whlch can be checked and another which is terminal, for instance a terminal cancer patient who develops diabetes or a diabetic patient who develops an incurable cancer. Is the physician obliged to treat the diabetes, or is the patient obliged to continue on insulin, so that he will die slowly of cancer rather than sooner and more easily in a diabetic coma? Or again, what must be done for a slowly deteriorating senile old man who develops pneumonia? Must he be given antibiotics to cure the disease which has long been known as "the old man's friend"? In these and similar cases the moralist commonly will say that the curable disease need not be treated. His reason is simply that the treatment in these circumstances is not a useful remedy. The treatment will cure one of the diseases. But it will not confer significant benefit on the patient. The subject of medical treatment is the patient who has two diseases. It is not the individual diseases one by one; only a narrowly scientific view would say it is. In deciding whether one is obliged to use insulin for diabetes or antibiotics for pneumonia one cannot merely ask whether the treatment will cure the disease. One must ask whether the treatment will be useful and beneficial for the patient whose dying has already taken irreversible control. One does not realistically prescind from an advanced and terminal cancer in answering that question. THE PATIENT AND THE FAMILY
It is of course first of all the right of the patient himself, not the doctor, to decide whether extraordinary measures should be initiated or discontinued. If the patient is conscious and rational, that is, able to understand and evaluate the situation, it is up to him to decide the issue, and the doctor should
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respect his wishes. If the patient is unconscious or unable to rationally decide, theoretically speaking his nearest kin should make the decision for him. But practically the relatives are often the worst judges of what should be done when someone they love is dying. The immediate family often feels enormous guilt, not because of anything they have done in the past but because of what they imagine they should or might have done to show the love they now so keenly feel. As a result they want everything possible done for him. They want to prolong his living to the last possible moment and beyond any reasonable moral warrant. They cannot bear the added guilt that would come from a decision to discontinue any means that might delay the death of the one they love. In such a situation it can easily become the responsibility of the doctor to take the lead in suggesting what should and what should not be done, what in his judgment would be the best for the dying man. In this way he can help the family come to the right decision and reduce considerably the burden of a decision which otherwise they could not bear. In some instances of course the family -cannot or should not be consulted, and the doctor will have to make the decision himself, according to what he judges is in the best interest of the patient. (I say, "in the best interest of the patient," not of medical science.) There is a growing medical, legal and ethical consensus that one need not, indeed ought not use extraordinary or useless means to save life. Prolonging the process of dying produces no important benefit to the¡ patient, is generally useless and unreasonable, and is often tantamount is forbidden torture. Finally I might note that a few voices are being heard today which say that the distinction between ordinary and extraordinary means as it developed in Western ethical wisdom is nothing but a moral quibble. Once the decision has been made not to engage in all possible efforts to sustain life, the crucial corner has been turned. We should be honest, they say, and admit that sometimes a physician should straightforwardly kill the dying patient by direct euthanasia. I have to admit that there is no perfect clarity here at least -on the theoretical level, and so we should remain open to a ¡further revision of our ethical policy. But at the present time
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I do not think that we should abandon a moral distinction between active and passive euthanasia in terminal cases. This careful discrimination reflects a common sense perception that there is a significant moral difference between killing and allowing to die. The distinction is theoretically defensible, and the point between passively withholding excessively burdensome or useless means and actively administering lethal agents is a practical and reasonable place to draw a line. It is not easy to calculate the societal effects of abandoning this distinction in practice. And crossing that line would set human beings on a road whose direction iB dangerous and end obscure. I do not think that the human race has the wisdom to successfully cross that line at the present moment in its history. WHO SHOULD BE TREATED?
The second problem I want to discuss briefly is the equitable distribution of sparse medical resources. This problem will always be with us in one form or another. One instance is causing increasing concern today. If there are more people in need of hemodyalisiB than can be accommodated on the kidney machine, who should receive the treatments and who should be allowed to die? What criteria should be use in making such a decision? There is of course a more fundamental question here which I shall not try to answer. It is the question of determining our societal priorities. As Leibniz said, "All things are possible but not all things are compossible." We may be able to do anything but we are not able to do everything. And so one question that arises is: Should the medical profession be in the business of hemodyalisis at all? Could the enonnous amount of money and pmfessional talent spent on hemodyalisis each year better be used in research calculated to prevent kidney diseases? I do not know the answer to this question or to the more general question of the priorities in allocating the large but limited resources of our society. I only bring it up because it is the basic issue and should not be decided by indecision but by rational social planning. In any event, let us get to the practical question that must be faced at the present time:
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when all cannot be saved, who should be chosen to live and who should be allowed to die? The first criteria that usually are applied are strictly medical ones. Given the physical and psychological condition of the patient, will dialysis confer significant benefit on him? If dialysis will not be useful on medical grounds, then of course it is quite reasonable to withhold it. One must be careful here. It is difficult for a layman to judge, but it sometimes appears that the medical criteria are not always strictly medical. It is possible for them to hide judgments about social worth. One has to wonder, for instance, whether the automatic exclusion of everyone over 45 or the exclusion of a man because of "uncooperativeness" may implicitly be a judgment about his social worth. If it is, then this should be judged expressly, and doctors are not the only ones qualified to make this sort of evaluation. In the beginning, when dialysis was in its infancy, the medical criteria aimed at selecting good research subjects. Now they are generally expanded to include anyone who will be an acceptable patient. In fact some doctors today claim that you can dialyse anybody. In any event, with the broadening of the strictly medical criteria there are many more acceptable patients than can be accommodated on the machines. The result is that in an estimated 42 dialysis centers patients are selected for treatment on the basis of their social utility. Frequently a lay committee is set up to make this evaluation and selection anonomously. SOCIAL UTILITY
r
Selection on the criterion of social worth or utility is not without precedent. In 1943 there was a shortage of penicillin among the United States Armed Forces in North Africa. It was needed to treat the victims of venera! disease and the victims of battle wounds. The decision of the Theatre Medical Commander was to give the penicillin to those wounded in brothels rather than to those wounded in battle. The reason justifying this decision was that those wounded in brothels could be more quickly restored to fighting capacity. Ability to make war was the most urgent need and best served the com-
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mon good. Triage in disaster medicine follows the same principle. Those most in need of help are quietly set aside, and attention is given first to those who can quickly be restored to functioning, since everyone's efforts are needed in the common purpose of survival. In these cases the necessary goals are easily focused, and social worth and usefulness can be realistically measured. But life is rarely like that. In our pluralistic society we do not have one or several focused goals or a clear consensus on what sort of life or person is worth more to society than another. In investigating what actually happens when committees select patients for medical treatment on the basis of social worth, David Sanders and Jesse Dukeminier, Jr. found "a disturbing picture on the bourgeoisie sparing the bourgeoisie," and remarked that "the Pacific Northwest is no place for Henry David Thoreau with bad kidneys." One wonders how much chance an artist or composer would have before most committees compared with a mother of five children. As one man remarked, "A candidate who plans to come before this committee would seem well-advised to father a great many children, then to throw away all his money." The point I am trying to make is that when a society's goals are not simple and focused, attempts to choose who should live and who should not on criteria of social worth or usefulness will seldom be successful, especially since cultural values are not the same as genuine human values and the nearly total estimate of the value of a man's life which has to be made will necessarily be filtered through the biases of those enlisted to make the choice. RANDOM SELECTION
Another option, which is in use in many dialysis centers, is random selection, either by lot or more usually on a first-come first-served basis. There is legal precedent for random selection on those to be saved when all cannot be saved. It is the rule in United States maritime law. In the United States versus Holmes it was ruled that in the desperate situation of an overloaded lifeboat the decision on who should be saved and who abandoned must be made by lot. It was argued that a
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lottery is the only way which avoids arbitrariness and shows equal respect for equal rights to life. My first reaction to the plan of selecting patients for dialysis by lot was that it was a cop out, an abdication of the human responsibility to make a hard rational decision. At worst, I thought, it was a superstitious pretense of leaving the decision in the hands of God; at best it was decision by refusal to decide at a time when the best possible human decision is called for. If either of these is the mentality behind random selection. then of course it is unconscionable. But that does not have to be the mentality. There is, I think, a deeper and wiser principle here. Random selection of those to be saved when all cannot be saved cuts to the heart of it. It says that a human person is of transcendental value, that the value of a human life transcends one's usefulness or social worth. On this deeper level all lives should be respected equally, and each one given an equal chance. Random selection by lot or on a first-come fir¡stserved basis is the only fair and equitable way. Therefore as a general policy I think that first strictly medical criteria should be applied: is the patient an apt subject for treatment. No judgment should be attempted about his social worth either implicitly in the medical opinion or openly by a lay committee. After some have been screened out on medical grounds, selection should be made randomly, on a first-come first-served basis or by lot. I do not say that this rule is absolute; few things are. But as a general policy I think it is the most honest and fair. It is founded in the belief that the true value of a man's life cannot be calculated in utilitarian terms, that at its deepest level every human life has a meaning which transcends its usefulness and social worth, and that as a matter of fact even a man's social worth can seldom be rightly measured in a pluralistic society with unfocused values and goals. Finally, I do not want to pretend to too much wisdom here. This question has not yet been thoroughly discussed in the literature and no clear consensus has emerged. Nonetheless the solution I have given is gaining increasing support anrl so I propose it for your thoughtful consideration.
N(}rbert J. Rigali
New Epistemology and the Moralist The individualistic epistemology that underpinned ethics is no longe1¡ intact. Both must be essentially social.
"Much more than the new theologies coming out these days, what the Church really needs is a new epistemology." Thus Robert 0. Johann assessed the ecclesiastical situation in 1968 at the time of the Humanae Vitae controversy. "New theology" had by then become a household word in the Church, and theology departments in American Catholic colleges, impelled by the Second Vatican Council, were moving more rapidly t<>ward renewal than were their sister departments of philosophy. European-born, transcendental Thomistic philosophy, to¡ be sure, was making some impact upon Catholic academe in this country, mainly through the influx of Karl Rahner's theology and through the rather belated recognition of Bernard Lonergan's monumental work on Insight. But, although the principle of pluralism had already acquired respectability in theology, one could search the Catholic press in vain to find a view of 237
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philosophical renewal that would progress beyond Joseph Donceel's proposals to substitute the newly acceptable transcendental Thomism for more traditional versions. At the time, Lonergan's brilliant epistemological masterwork was a decade old, and Leslie Dewart's widely-read The Future of Belief, which had appeared in the year following the Council, was in its sixth printing. Nevertheless, Johann apparently still thought it necessary to call for a new epistemology in the Church. And, in a sense, Johann was only expanding a summons issued two years previously by John Giles 1\filhaven which called the attention of professional moral theologians to the lack of an adequate epistemology underlying their ethical reasoning. Neither Lonergan nor Dewart was filling the epistemological gap in the postconciliar Church, but each for very different reasons. Despite the unquestionable genius of Lonergan's work, it is, in the final analysis, modernized Thomism, a Thomistic epistemology brought up to date. As such, it is subject to the inherent limitations and the horizon of its model, which perceives the human knower fundamentally as an individual subject of psychological acts rather than as a person among persons. With this methodology, however, the radically social nature of human knowledge never receives its due, and knowledge appears as a basically individualistic phenomenon. THE THOMISTIC VIEW
The Thomistic worldview, as Johann points out in the New Catholic Encyclopedia, perceives reality as a collection of individual substances only accidentally related to one another instead of as beings essentially constituted by their interrelations. Charles E. Curran has essentially the same criticism in mind when he notes that "many thinkers today view man not as a substantial entity existing in himself with his own nature as the guiding principle of his life embedded within him, but rather as a person existing as a being with others in a network of relationships." The contemporary view of reality and, in particular, of man as relational renders Thomistic epistemology and all its derivatives incomplete and one-dimensional today. The new epistemology will have to be constructed upon a
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principle articulated by Richard A. McCormick; "If man is a person only in relation to others. he is also to some extent a knower only in relation to other knowers."" And it will have to understand McCormick's proposition in the radical sense that a man is essentially a human knower only in relation to other human knowers. Or, in the somewhat more concrete words of the great Jewish philosopher, Martin Buber; "Man has always had his experiences as I ... but it is as We, ever again as We, that he has constructed and developed a world out of his experiences.'' Even within the individualistic frame of reference of Thornism it is true that in some sense a man is a knower only in relation to other knowers. Etienne Gilson, for example, goes so far as to maintain that there is no difference between saying that man is a rational animal and saying that he is a social animal. What the renowned interpreter of Aquinas means, however, is that a man "needs social life in order fully to develop his rationality" since "he cannot actualize the whole potency of his possible intellect without being helped by other men." Gilson's position is really an answer to his own rhetorical question; "If every man had to reinvent by himself the totality of human learning, how far would he go?" On this view, then, the human knower is an individual rational animal, having his own individual intellect, who needs help from others in order to perfect his intellectual capacity and to actualize it to the fullest possible extent. The individual knower is accidentally dependent upon other knowers since without their help he could not progress very far in the totality of human learning. In a word, the knower is an individual rational animal doing his thing, but he could not do his thing very well unless others also did theirs and thus afforded him with help. The Thomistic accidental relations among human knowers are inadequate in view of a new epistemology. If a man is a person only in relation to other persons, and if human knowledge is an essential aspect of personhood, then the new epistemology must recognize from its start the radically interpersonal character of human consciousness. In this respect the Dewart book made a valuable contribution by insisting that human knowledge is a socio-historical process which emerges
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"when the individually circumscribed psychic life of animals is elevated to the level of a common psychic life among many selves." Human consciousness, therefore, is not "an essentially and originally private event afterwards communicated ... to other human beings." Rather, the privacy of consciousness is "relative to its essentially public and originally social and historical nature." The difference in the ways in which the social character of human knowledge is conceived by Gilson on one side and by Buber and Dewart on the other is the distance between the accidental and the essential. For the former, a man cannot go very far alone in the direction of the totality of human knowledge, while for the other two philosophers a human world and human knowledge come into being only through communal, interpers0na1 consciousness. If Johann was calling for a new epistemology at the very moment when Dewart's work was rolling off the press for the sixth time, the reason may be that-despite the book's many insights, its originally wide appeal, and the lively discussion that it immediately stimulated-The Future of Belief was a book without a future. Embellished with traditional scholarly apparatus and published as a work of a professional intellectual, the work as a whole can hardly stand the test of time and be taken completely seriously by other scholars. Indeed, its second chanter, devoted to the attempt to establish the author's incredible theory that Christianity and Marxism are really both the same kind of atheism, must rank as one of the most carelessly argued and tendentious pieces of theological and epistemological analysis to appear as a professional study in the postconciliar Church. THE CATHOLIC CONCERN
That in recent years Catholic moralists have been as much -or more-concerned about a new epistemology as epistemologists themselves is understandable. For all moral discourse presupposes some kind of epistemology. To say that this or that is good implies some specific way of knowing what is good, whether or not the speaker reflexively knows what way he is implying. And when one's understanding of the good and
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morality changes, a corresponding change has occurred in the implied epistemology that is operative but not necessarily grasped by reflexive consciousness. As the events surrounding the publication of Humanae Vitae illustrated, just such a change in the understanding of morality has recently occurred within the Church and, in particular, among many of its theologians and moralists. But this change has created a special problem for the moral theologian. The professional competence of the moralist should include a reflexive, scientific understanding of the epistemological presuppositions which he is employing in his own science. As long as Scholastic philosophy held undisputed sway in the Church, the moralist knew where he stood with regard to epistemology and never had to concern himself about it. Generally, the epistemolob'Y underlying his science was the perennial, Scholastic version that he had learned in the seminary or college, and that was that. But with a changed understanding of morality, many moralists realize that their earlier epistemology is no longer intact. They find themselves now with a collection of insights, including things old and new. But a collection of insights is not a science, a body of knowledge that is viable, complete, and reflexively integrated. In brief, many a contemporary moralist is in the unenviable position of lacking a scientific grasp of the epistemological foundations of his own field. And he finds no help in sight. If a man is what he is, namely, a person, only in relation to other persons, he can know what he is only by knowing himself in relation to other persons. And if he can know what he is only by knowing himself in relation to other persons, a man can know what he should do only by knowing himself in relation to other persons. For the root of a man's knowledge of what he should do is, of course, his knowledge of what he is. The basis of all morality and ethics, then, is an interpersonal, social foundation. And this is the reason why Cunan and other present-day theologians have rejected the individualistic concept of man as an entity existing in himself with his own individual nature as the guiding principle of his life embedded within him. A person does not read what he is to do in a human essence enclosed within himself; he reads it in his being-
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in-community. Being-in-community is the locus where morality is read because it is the locus of what is authentically human, and the moral order is the human order. Morality and ethics are fundamentally communal. To say that ethics is essentially social is not to imply that it is not concerned with what one man should do--whether as one man like all others (essential ethics) or as the unique person who he is (existential ethics). Rather, only as a study of the moral order, which is an interpersonal, social order, can ethics speak about what an individual man should do. SOCIAL ETHIC AND THE INDIVIDUAL
Although morality and ethics are essentially social, traditional Catholic ethics not only was deficient in social consciousness but even assumed the form of an ethics of the individual man. For the locus of humanity was considered to be an essence of rational animality embedded in the individual instead of the sphere of relations among men. As the locus of humanity was within the individual, so was that of the moral order. In the "Philosopher's Notebook" that he used to write for America, Johann rejected the common individualistic conception that "a man has rights prior to his contact with his fellows" and that "he comes into the world, as it were, already endowed with them by his Creator." Johann then set forth an interpersonal understanding of rights: "It is only because I am in your presence-you who are a person ... called by your native share in reason to respond to beings in terms of what they are and do--that the reality of my personal life first takes on the character of a claim or right." Here Johann made a first, great step toward transferring the locus of the moral order from an enclosure within the individual man to the open realm of the interpersonal. However, not only rights, but duties also originate only through a man's being with others. And this is what the moral or human order is: the order of mutual rights and duties of men living together in the world. It is not enclosed within an individual man in the form of an orientation of himself to his own individual, final end, and it cannot be read there.
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The process of man's understanding himself in relation to others has been a gradual historical development, and it is only recently that a universal consciousness or the awareness that all men are members of one world-wide community seems to have begun to emerge. As long as man understands himself in a tribal fashion-whether the "tribe" is an aboriginal band, a chosen people, the polis of ancient Greece, a nationalistic state, or white society in twentieth-century America-fully human morality and ethics must remain undeveloped. Perhaps one can detect an emergent universal consciousness in the Church, for example, in the recent progress of its teaching office from the promulgation of "just war" ethics to Pope Paul's appearance before the United Nations General Assembly to make his impassioned appeal to the world: "jamais plus Ia guerre !" In its form of an ethics of the individual man, traditional Catholic thought made a distinction between natural and supernatural morality. Within every man there is a human nature orienting him to a natural morality, but within the baptized individual there is also the supernature of sanctifying grace, with the supernatural virtues of faith, hope and charity, which directs this individual to a supernatural end and a supernatural morality that both elevates and transcends natural morality. On this view, there is a natural, human morality exclusive of charity, since the latter is a divinely infused virtue that does not pertain essentially to human nature. It is charity and not the natural virtue of justice, Leo XIII could accordingly distinguish, that obliges a rich man to share his goods with the poor. The Leonine position implies that it is not his very humanity but only a superimposed, superhuman principle within him that requires a man to be effectively concerned about his less fortunate and needy fellowmen-a view which any ethics that recognizes its own essentially social nature can hardly maintain. Contemporary Catholic theology has left this dichotomy between natural and supernatural morality behind, largely through the influence of Karl Rahner's well-known ideas about "anonymous Christianity." It is this dichotomy that is being negated, for example, when Curran denies that there is "a dis-
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tinctively Christian ethic" and when McCormick asserts that there is "only Christian morality, not a natural and a Christian morality." If at first glance the two eminent moralists appear to be in fundamental disagreement, each is actually expressing from a different viewpoint the oneness of authentic human morality and rejecting the notion of a truly human, natural morality that is exclusive of what has been traditionally understood as the supernatural virtue of charity. To this extent the two views coincide. The dichotomy between a natural and a supernatural morality was largely the result of the individualistic conception of morality behind it, namely, the idea that the moral order derives from natural and supernatural principles embedded with the individual man. Like Johann's relocating human rights from their enclosure within the individual to the interpersonal arena, the rejection of the dichotomy between natural and supernatural morality can be seen as one of many examples of the contemporary attempt to purge Catholic ethical thought of the individualistic bias that permeated it in the past. But at present the purification is a rather random process, and necessarily so. For it cannot be accomplished systematically and definitively, it would seem, until the Church is presented with a new, scientifically developed epistemology, which will firmly and lastingly estabilsh, among other things, that all moral and ethical knowledge is interpersonal knowledge. Only when the new epistemology appears will the Catholic moralist be in a position to cease calling for it and to return gladly to minding his own business.
William E. May
Biomedical Technologies and Ethics The biowgical revolution is underway. What are its technologies, its motives? In his perceptive essay, "The New Biology: What Price Relieving Man's Estate?", Dr. Leon R. Kass of the National Academy of Sciences emphasizes that the central issue in deciding the further development and utilization of biomedical technologies is the meaning of man. Toward the close of his article he makes the following comment: "Our ethical dilemma is caused by the victory of modern natural science with its nonteleological view of man. We ought therefore to reexamine with great care the modern notions of nature and of man, which undermine those earlier notions that provide a basis for ethics. If we consult our common experience, we are likely to discover some grounds for believing that the questions about man and human good are far from closed. Our common experience suggests many difficulties for the modern 'scientific view of man.' For example, this view fails to account for the concern for justice and freedom that appears to be characteristic of all human societies. It also fails to account for or to explain the fact that men have speech and not merely voice, that men can choose and act and not merely move or react. It fails to explain why men engage in moral discourse.'' Although there is always the danger-and. it seems to be 245
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one of the major professional hazards for Catholic theologians and moralists--of making apodictic and aprioristic judgments about the implications of scientific discoveries and of being compelled later on to acknowledge that conclusions had been reached too hastily, it is also apparent that evaluations of the development and application of new biomedical technologies depend in large measure on the view that one has of man. Mortimer Adler has lucidly shown us what immense differences it makes whether one regards man as different from other animals only in degree or radically different in kind. Obviously Kass agrees with Adler that man does differ in kind from other animals. It is not to our purpose here to explore this question in depth; but it is imperative to recognize that this question is at the heart of discussions on bioethics. My presupposition is that man does differ, and differs radically, in kind from other animals and that this difference is rooted in his capacity for conceptual thought, propositional speech, and selfdetermination. It is a difference, moreover, implicitly recognized by the majority of contemporary scientists and is affirmed in a very striking way in a comment made by Willard Gaylin, M.D., professor of psychiatry and law at Columbia University, in his recent article in the biological revolution in the New York Tirnes Magazine when he wrote: "The human being is the only species capable of systematically altering its 'normal' biological system by use of its equally 'normal' intellectual capacity." ¡ THE CHARACTERISTICS OF MAN
Since Kass calls attention to some "earlier notions" that provide a basis for ethics, it might be of value to look at some of these. F01tunately, James V. Schall, a Jesuit political scientist, has summarized some of these notions in his recent book, Hurnan Dignity and Hurnan Nurnbers. In the course of this work Schall formulates nine propositions that in his view represent "the characteristics thought historically to compose the human being as a distinct being in nature." Although each of the propositions Schall lists can be questioned, they do provide a decent summary of what we can call the tradition of western civilization insofar as this civilization has been influenced by the Jud~Christian heritage. Moreover, the substance of
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the propositions is reflected in such documents as the Declaration of Independence, the Constitution of the United States, the Charter of the United Nations, and the Declaration on H uman Rights of the UN General Assembly. They thus reflect the "common experience" to which Kass refers. The propositions are as follows: 1. Man is in some basic sense different from animals. 2. Each individual is unique and irrepeatable. 3. Man is two sexed, male and female, existing in approximately the same proportions. 4. Human offspring are begotten by a union of a human male and a human female, according to a natural process wherein gestation takes place in the female womb, birth occurring about nine months after conception. 5. The human family, centered on human parents with a right and a capacity to produce their own children, is the locus in which the child is nurtured and raised to maturity. 6. Virtue and vice are the results of free will choices and knowledge. 7. Man can attain full human perfection in his earthly aspect only in a political community. 8. Man is mortal, subject to sickness and eventual death. 9. Man's basic form and dignity to be man are not created by man. My purpose here is not to argue for the truth of any of these propositions. None is self-evident, but each can be suppo!1oed by good evidence. It is also tme that all of these propositions can be questioned and in fact are being questioned today. My point here is simply that the affirmation or denial of these propositions is critically significant in charting the direction that a discussion of biomedical technologies will take. By this I do not mean to imply that acceptance of any of these propositions necessa,rily forecloses a consideration of the possible uses of these technologies. I do intend, however, to imply that acceptance of these propositions can se1¡ve as a criterion for judging and evaluating issues in bioethics. We shall return to this point later. Before considering some of the technologies currently available or soon to be available in the estimate of scientists, it is worth examining a popular myth. One popular myth is that if man can do something he will do it and in fact ought to do it, simply because it is there to be done. Here some reflections of Gay lin seem pertinent. He writes: "The types of questions that normally arise about any new and dramatic technological¡
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procedure fall into the categories of: can man, will man, and ought man. There is a tendency, particularly in anti-technology treatises, to lump the first two together and to consider the third and independent question. This kind of reasoning usually assm¡es us that what science can do, it will do. The facts are more complicated, as usual, than the polemics. There is much that man can do which he does not d<r-because he is aware that he ought not. We do not, for example, perform many behavioral experiments on babies, even though some research would unquestionably contribute to knowledge and the common good. Societal morality has traditionally disapproved of the use of human beings as research animals. Their humanness protects them from certain kinds of destructive t¡esearch. But even this rule is being violated in some instances. In at least one recent situation, for example, human fetuses that were about to be aborted were used as part of an experiment to determine the potentially harmful effects of ultrasound." My point here is simply that it does not necessarily follow that a man will do something if he can do it. Man can, for instance, bring life to an end on this planet through nuclear holocaust and biological warfare. But because man can do this, must we conclude that he will? Unless we are fatalists and determinists, we must at least admit the possibility that men will choose not to do some of the things made possible by scientific discoveries. Admitting this possibility is itself an affirmation that man does differ in kind, and not merely in degree from other beings, and obviously this belief is the motive force behind opposition to using human beings as experimental animals. Although Gaylin sees some erosion in this belief in recent experiments with fetuses, it is possible that the experimenters involved proceeded on the supposition that fetuses are not human. This supposition ought to be seriously questioned, and indeed is subject to very weighty objections, and it has, moreover, implications for evaluating some of the aspects involved in contemporary biomedical reseat¡ch. On this see, among many sources, Daniel Callahan, .Abortion: Law, Choice, and Momlity, New York, Macmillan, 1970; and Germain G. Grisez, Abortion: The Myt/u;, the Realities, and the Arguments, New York, Corpus, 1970.
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But what is the biological revolution that is proceeding at present, what are some of the technologies involved, and what are the motives behind the research? To take motives first, we might note, with Gaylin, that the new technologies are all motivated by the most humanitarian ends. Their purpose is to relieve suffering, to conquer illness, to restore normal capacities. Many of them are undertaken with the desire to halt the deterioration in the human ¡genetic pool, a deterioration brought about, paradoxically, by the advance in medical science that has enabled segments of the population severely impaired genetically to live until they are old enough to reproduce themselves. The potential seriousness of this gradual degeneration of the human genetic pool has ben stressed by a number of writers, in particular the late Nobel biologist Herman Muller of Indiana University. According to MUller "it is probable that some 20 per cent, if not more, of a human population has received a genetic impairment that arose by mutation in the immediately preceding generation, in addition to the far larger number of impairments inherited from earlier generations. If this is true, then, to avoid genetic deterioration, about 20 per cent of the population who are more heavily laden with genetic defects than the average must in each generation fail to live to maturity or, if they do live, must fail to reproduce. Otherwise the load of genetic defects carried by that population would inevitably rise." Since man is an intelligent being capable of altering his environment and even his heredity, and since man has a responsibility not only to himself and to those men who are his contemporaries but also to future generations of men, it seems quite legitimate for him to take some kind of action to stop the degeneration of human heredity. Moreover, we all recognize the human tragedies occasioned by the birth of seriously deformed children and the heartache experienced by men and women who would like to bring children into the world, provide them with life and love and a home, yet are, for various reasons, incapable of having children. There are, consequently, many exceptionally valid reasons for seeking to alleviate these and other human needs and for determining whether the tech-
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nologies provided by contemporary biomedical science will provide the means for achieving worthwhile goods. It ought also to be obvious that if one adopts a purely consequentialist ethics, that is, an ethics that judges the moral worth of actions exclusively in terms of the good effects that these actions are capable of bringing about, one may well be disposed to give carte blanche to any biomedical technology that promises to eliminate many sources of human tragedy and to better the genetic potential of the entire human race. Before describing some of the technologies currently available or being developed in the area of genetic control, it seems advisable to note that proposals based on these technologies provide some of the alternatives capable of achieving some of the desired goals-e.g., a halt to the deterioration of the human genetic pool; they do not, however, of necessity exhaust the possibilities open to man in his efforts to find a solution to some very real problems. This point is important because one characteristic of man as an intelligent and moral being is his ability to pose alternatives and to judge among them on the basis of many factors, moral as well as pragmatic, economic, and technological. GENETIC MANIPULATION
At any rate, in contemporary discussions of biomedical technologies we can note, with Kass, that there are two principal modes of genetic manipulation: therapeutic or negative, and eugenic or positive. The purpose of the first is to obtain normal copies of the "right" gene through biological and chemical means and to introduce these copies into defective individuals. The goal of the second is to insure the amelioration of the human genetic pool by seeing to it that genetically well endowed individuals are allowed to propagate--and to propagate in significant numbers-and that genetically ill endowed individuals are not allowed to generate new human beings. First we shall examine positive or eugenic manipulation. Two particular methods feature prominently in current discussions of positive eugenics. These are artificial insemination and cloning. The process of artificial insemination is already well known and in fact is widely practiced. According
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to statistical studies, approximately 1 out of every 200 children born in the United States today was conceived through artificial insemination. But there are some new wrinkles to this procedure in current proposals. These would call for the establishment of sperm banks (and, in the near future, of ovum banks, when it will be possible to preserve human ovae in the same way that we can now preserve human sperm) and the amelioration of the human genetic pool by uniting the sperm of genetically superior males (for instance, Einstein) with genetically superior females (for instance, Golda Meir). (For present purposes we shall not consider the application of artificial insemination to the problem of the childless couple.) This method of halting the deterioration of the human gene pool was advocated strenuously by Herman MUller in his program of positive eugenics. He argued for the program with two broad aims. The first, and it is significant to note this, was the improvement of man's character, whereas the second was the elevation of man's native intelligence. MUller maintained that these twin goals could be best achieved by using the sperm of superior men to impregnate women of superior quality. When MUller advocated this program, the feasibility of ovum banks was not too likely, but now this must be taken into consideration. Today, moreover, there is the possibility of developing a fertilized human ovum (fertilized in vit.-o) in an artificial placenta. Conceivably a significant percentage of the future generation of mankind conkl be "manufactured" by fertilizing select ova with select sperm and developing the fetuses thus engendered in an environment completely separated from the female womb. This seems rather straightforward, but several questions can be raised concerning the procedure. First of all, MUller's proposal, and others like it, rests on the supposition that heredity significantly determines a person's moral character. Although some embers of the scientific community, among them Julian Huxley, share MUller's optimism in this respect, many others, including both biologists, cultural anthropologists, and sociologists, seriously doubt that the moral character of a human being is so significantly shaped by his heredity. As Hudson Hoagland has noted, "We know too little about the human genotype to feel confidence in our ability to do anything to
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modify it in favor of desirable traits." Most scientists would grant that an individual's character or personality is as much dependent on environment as it is on heredity. Studies have shown that a significant change in the environment of children leads to a marked increase in their intellectual capacity and social awareness. To this scientific evidence we can add the observation that most people, reflecting on the "common experience" of which Kass speaks, think that something in addition to heredity and environment is involved in the development of character and personality. And this is the person himself, a being with the capacity for making, at least to some extent, his own choices and for taking responsibility for his own actions. CLONING
Cloning, much discussed in recent years, offers the possibility of propagating the human species in an asexual mannerthat is, of generating new human beings without sexual intercourse and development in a human uterus. There are, in fact, two types of cloning theoretically possible. The first would simply require scraping any cell from a human body, placing it in a test tube, mixing it with appropriate enzymes, reducing it to the embryonic stage, and then activating it so that it "thought" it was a fertilized egg and thus stimulating it to develop into a complete human being. Because of economic and technological problems, however, this method of cloning does not appear likely for application for the human species. Consequently some scientists contemplate an alternative mode of cloning, one that has worked successfully with amphibians, as the experiments of Professor John Gurdon at Oxford have demonstrated. In this mode the nucleus of a fertilized egg is destroyed by radiation without damaging the body of the egg. The nucleus from an ordinary body cell of the individual who is to be the sole genetic "parent" is then implanted into the egg to take the place of the original nucleus. The egg, with its new nucleus, can now be developed into a human being whose entire genetic package derives from the individual who has donated the nucleus. Theoretically the egg could be either implanted in the uterus of a surrogate mother or developed completely extra uterum in an artificial placenta. Not only would this procedure enable individuals of either sex who are
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of outstanding genetic potential to reproduce themselves in the fonn of exact replicas, "identical twins," as it were, of themselves; it would, if perfected, be capable of mass production, so that soon we could have limitless basketball teams composed of Kareen Abdul-J abbars, baseball teams made up of Hank Aarons, think-tanks loaded with Herman Kahns or Daniel Ellsberg;;. Truly this is a fantastic possibility and perhaps cloning, precisely because it offers such fascinating and imaginative possibilities, best serves to illustrate the capabilities put in man's hands by the development of new biomedical technologies. THE DESIRED RESULTS?
But even here, and speaking only pragmatically, we must stop to ask whether the cloned individuals will really be the products desired? Will a clone of Einstein, for instance, be another Einstein, the clone of Neil Armstrong a superb astronaut? Just as identical twins do not necessarily turn out to be exactly the same kinds of persons, with the same interests and character and personalities, so too with the identical twins made possible by cloning. In addition to the pragmatic and utilitarian objections that can be levelled against sperm banks and cloning, other questions ought to be considered. The technology itself, for instance, requires scrutiny. Take cloning. Here we must keep in mind that the procedure, as currently envisioned, requires us to begin with a fertilized human egg. This means that we must begin with a living organism that is itself genetically distinct from either parent, that has in itself the potential to develop into a five-month-old fetus, a neonate, a six-year-old child, an adolescent, an adult. This means, in short, that we are making our experiments upon a living organism that is, in the view of very many peopl~and their view can find substantial suppm"t both scientific and philosophial-a human being. Even if it were possible eventually, through cloning, to "produce" beings with the genetic potential of an Einstein, a Mother Theresa of Calcutta, a Gandhi, and even if the environments in which these "products" would live could be structured so that their full potential could be developed, would it really be worth it?
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The manufacture of human beings through cloning or artificial insemination (particularly in the more exotic forms currently envisioned) certainly entails the denial of some of the propositions of "common experience" formulated by Schall. I suggest that these procedures, inasmuch as they necessarily entail a complete reversal of our way of viewing human sexuality, marriage, and the human family, are quite likely to entail as well the destruction of the "human." Here the comments offered by Kass seem particularly apt. "The price to be paid for the 'optimum baby,' " he writes, "is the transfer of procreation from the home to the laboratory and its coincident transformation into manufacture. Increasing control over the product is purchased by the increasing depersonalization of the process. The complete depersonalization of procreation (made possible eventually with the development of the artificial placenta) shall be, in itself, seriously dehumanizing no matter how optimum the product. It should not be forgotten that human procreation not only issues new human beings, but is itself a human activity." In short, it can be urged quite reasonably that the ultimate price to be paid in developing and applying some of the biomedical technologies advocated so enthusiastically is the voluntary self-degradation and dehumanization of the human beings involved and of the societies of which they are members. For these reasons I cannot see how the methods advocated for positive eugenic manipulation can be morally appropriate. These procedures, far from alleviating or enhancing the human condition, seem to involve its depersonalization and dehumanization. HUMAN EXPERIMENTATION
The development and utilization of new technologies in therapeutic or negative genetics, however, pose a different question. Here it does seem possible that deleterious genes in an embryo can be deleted through laser beams and the normal or right gene introduced through a virus. This, at any rate, is a potential development that some scientists believe could be accomplished within the relatively near future. But even this kind of technology has its problems. Remember that the organisms
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upon which experimentations must take place in the very development of therapeutic procedures are fertilized human ova, i.e., living human organisms. Moreover, in all likelihood, serious tragedies will inevitably result, because the laser beam may destroy beneficial genes as well as deleterious ones, and some of the damage may not be detectable until years later. What is to be done with the enormously defective and malformed beings that result? Have we a right to expose living fetuses to the very real dangers experimentation of this kind entails? We cannot, in the name of scientific advancement, simply push these questions under the rug and pretend that they do not exist. They must be confronted, and confronted honestly, before experimentation proceeds. I do not intend to foreclose experimentation, and I am not maintaining that we cannot morally take some serious risks, but I am affirming that these risks must be taken into account and seriously examined. The better procedure, in my view, would be to delay experimentation until later in the life of the human being. The precise genetic malady can be identified more exactly and the possibility of developing specific viruses carrying quite precise types of information in the form of DNA exists. Correction of genetic defects might possibly be more feasibly undertaken in this way than by experimentation with possible horrible 1¡esults during the embryonic stage. On this matter, however, there is need for further direction and advice from the scientific community, and the moralist ought not to paint himself into a corner by closing off viable alternatives. GENETIC COUNSELLING
Another very valuable technique in ameliorating the human genetic pool and in avoiding some tragic human situations lies in the area of genetic counselling. It is now possible for people thinking of getting married to learn, with a good degree of probability, whether or not they will have children with serious genetic defects, such as Tay-Sachs disease, phenylketonuria, amaurotic idiocy, mongoloidism, microcephaly, etc. Through counselling prospective parents could be encouraged to forego their right to propagate-or at least made cognizant of the probabilities of "defective" children-and advised to extend
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their procreative love in other directions. Naturally this is not the perfect solution. After all, most couples who would present themselves for genetic counselling would already be deeply involved interpersonally and emotionally, and there is always the danger that this procedure could become inhuman and make the process of "falling in love" a search for the "properly endowed" genetic mate. But these problems, I believe, could be confronted in a very human way. Genetic counselling could be, in faet in my view, ought to be, made mandatory in the future for couples contemplating marriage. And the educational process could be initiated at an even earlier age. This process of counselling would provide an alternative for achieving some of the goals rightly considered as worthwhile by advocates of both positive and negative genetic manipulation, and this process need not carry as its consequence the dehumanization and depersonalization of the transmission of life from one generation to another. Genetic counselling, combined with the human and sophisticated development of techniques of negative or therapeutic genetic manipulation, provides a viable alternative to the achievement of the human goods held before us. These procedures could be carried out in a manner that keeps intact the vision of man articulated in the propositions formulated by Schall, the image of man generated by the "common experience" of which Kass speaks. The criterion suggested by Schall's propositions and Kass's language would seem to rule out the more exotic technologies advocated by some proponents of the new genetics-and their proposals can also be criticized on more pragmatic and even economic groundsbut it would not be subverted by eugenic counselling, even if . this were made mandatory, or by the possible development of new techniques in negative or therapeutic genetics.
Gerald F. Kreyche
Conflict: Threat or Challenge-,...,....,_ "/" vs. The lnslilulion 1 ne The ]Yrincipal conflict of our times is that of the individual vers1<.s the institution.
By calling and by temperament, the philosopher is, in the words of Jaspers, a "specialist in the general." From the days of Socrates, he has also been a critic, public conscience, mediator and reconciler. He works in the realm of ideas, but with persons. Dialogue has often proved his most effective medium of communication. This article attempts to mirror this description and this medium. Conflict, if not an existential definition of change itself, certainly is produced by change. Today change is concretized in new ideas, new values, new interpretations and new relationships. In ideM: when we break out of a bias in which our thinking was locked. Instances are the new math, the responsibilities of industry toward environment, the purpose and worth of college, a phenomenological view of man. In values: when we move out of an enclosed subculture to the riches of pluralism in the world at large. Instances are what is appropriate 257
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and stylish in dress, stocks and bonds replacing land as the most basic private property, differing concepts of various eastem religious experiences, the worth of zero population growth. In interpretations: when we see old things in new perspectives. Instances are the meaning of myth in secular and sacred cultures, the nature of "due process" and "separate but equal" clauses in civil law, the meaning and limits of civil, ecclesiastical and parental authority. In relationships: when we established different types of bonds in previously constituted groups and among various persons. Instances are the commune, the citizen's role in government and industry, the work of the policeman in the community, and most of all, the changing relationship between the I and the Institution. Change and its "rapidization" in our time has served as a kind of shock treatment for us. Change has produced in all of mankind, a general condition of heightened consciousness. This spirit of consciousness is our Zeitgeist and takes two specific forms : consciousness of the self and consciousness of the institution. These in tum force a consideration and constant reappraisal of the interrelationships between self and institution. These relations are fundamentally dynamic and swing back and forth like a pendulum. Both extremes of the dialectical pendulum produce conflicts. Examples are the conflicts of the traditional vs. the novel; the old vs. the young; the conservative vs. the progressive. In our time, the principal conflict takes the form of the individual vs. the institution. Let us attempt to explore the nature of the individual and that of the institution. We will do so by seeing each's view of the other. The presentation will be by means of a dialogue. If, at times, it presents a caricature instead of a photograph, it is because often this is the way individual and institution view each other. The protagonists of the dialogue can be known simply as "Mister Institution" and "Mister Person." As we near them, we hear "Mister Person" presenting his views on the nature of the institution.
Mr. Person: "Almost every 'bind' we find ourselves in today, can be blamed directly on the institution. By institution, I don't mean simply the state, church, or big business. I apply that term to whatever is generally designated as 'the establish-
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ment.' I see it as applying even to the family. Our need is to de-institutionalize all of society. I go along with Ralph Nadar who thinks that the human race 'blew it' by focussing all of its powers into institutions. Of their very nature, power groups of institutions become self serVing-trade unions, 'colleges, the military. Take for example, one form of institution, the corporate state, so well described by Reich in his G.-eening of America. It is a non-person and a non-entity (such as the¡ masses themselves) ; yet it is all powerful and all controlling, and completely self serving. Instead of seeing me as a person, it sees itself as the model which I must imitate, if I would curry its favor. Within it, I feel reduced to Sartre's 'useless passion.'
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"The existential question is well put by the conscientious objector and draft evader, 'Why should I die for the establishment, when it shows no concern for me?' Oh, I concede that at one time it had a 'common good' which in some ways was identified with the good of the person. But today this has changed from the common good to that of the vested interest. The sad thing is that those in power don't even recognize this radical shift. In many respects, the present institution or establishment still has as its model the Greek notion of species. This carries with it the mistaken view that the individual is for the sake of the species rather than the reverse--like the Queen Bee in her hive, or the salmon fighting her way up stream to lay eggs and die. The contemporary institutional view and the ancient Greek view always has the individual bend before the immutable archetype which brooks no change in its pre-conceived eternal and abstract essence. Christ himself fought this mentality in Biblical times when he pointed out that the Sabbath is made for man. In the animal kingdom the species may reign supreme; but not in the human order. I personally resent the institution's view of man which is essentially Hobbesian in outlook. Like Hobbes, it sees the state of nature as a war of fang and claw. When conflict between individual and institution arises, the institution follows its own most basic drive, the law of self preservation. "Accordingly, in such times of conflict, the individual is always regarded as expendable. It matters little whether the
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institution characterizes the expendable individual as hero or goat. The end result is the same. And history is a living lesson in this. Gandhi, Martin Luther King.... The current debate on amnesty for co's and draft evaders is another case in point. The institution can show no forgiveness, because that would reveal a seam in the. monolith."
Mr. Institution: "Whew! If you ask me, what the person needs today is a good laxative, to get all this out of his system. The person's problem is one of over-consciousness resulting in a universal state of hypochrandia-better known as 'don't touch me-itis.' The case with consciousness is like that of medicine. If a little is good, is more necessarily better? I believe it was Dostoievsky who warned, 'I swear gentlemen, too much consciousness is a disease--a thoroughgoing disease.' And it was Kierkegaard who wrote, 'The most injurious thing to digestion is constant reflection on digestion.' Everyone wants rights today; no one, responsibilities. Archie Bunker of TV's All in the Family is essentially correct. All this stress on personalism at the expense of the institution is but a social form of philosophical nominalism. Changing individuals think only they exist; there are no lasting values nor universal goods. "If this contention is true, how can you answer Lippman's
questions, 'Why do old men plant trees under whose shade they will never sit?; Why do young men sacrifice their lives for the liberty of others?' I just can't accept your vicious attack on institutionalism. You're only repeating Feuerbach (with some minor changes) declaring, 'To enrich the person, the institution must become poor; that the person may be all, the institution must be nothing.' I see this as essentially a false dichotomy and an equally false spirituality of the variety, 'the less me, the more thee.' Your attack on institutionalism is becoming so effective that it has forced a loss of confidence of society in itself. Government is afraid of its protestors, the church of its members, the professor of his students, parents of their children, management of its workers. (James Roche, former Chairman of G.M., has my sympathies when he said, 'You wonder if Mr. Nader had come along about sixty or seventy years ago, where the automobile business, or where the United States, nilght be today.') While the mood of the individual is that of
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confrontation, the mood of the institution is more and more that of avoidance. Why even recently at Northern Illinois University, the national anthem was banned for fear it would precipitate a riot. "We have today a dictatorship of the individual who is in a deep state of despair without ever quite realizing it. His real problem is not a lack of freedom, but what Toffler in Futu1·e Shock terms the crisis of 'overchoice.' Bewildered by options, unable to choose, he moves direction less to a non-goal· oriented and ephemeral future. The individual doesn't hesitate to condemn the establishment while accepting its subsidies with a snarl. He wants to be fully civilized; yet he doesn't understand the root meaning of the word civil. The fact is that in rejecting authority and touting the supremacy of the individual, he fails to make some necessary distinctions. For example, there is political authority which is over people, educational authority which is expertise over a subject, etc. In condemning institutionalism and authority in such blanket fashion, you have also confused the order of opinion with lmowledge.
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"Don't you see what is happening? As we continue to dignify the individual at the expense of the institution, we become the victims· of our own deception. This manifests itself in something as prosaic as the amateur taking over the role of the professional. Frank Sinatra did the Life pictures of the AliFrazer fight, Dean Martin appears with Arnold Palmer on the TV golf circuit, Joe Namath is signed to a screen contract, the ethnic group leader without credentials wants to teach college history. This kind of confusion and involvement by all in a pool of ignorance doesn't help anyone. \Vhy is it that when anything important comes along, you want the professionallike in figuring out your income tax rebate, having an appendectomy, etc. But in what doesn't really matter to you personally, anyone without qualifications will do. I hate to admit it, but maybe Agnew was right whe11 he asked, 'What do the poor know about poverty?' What does the student know about designing his own curriculum? The citizen about spending funds for urban renewal?"
Mr. Person: "Hold on! What I dislike most is the institution's view of man. It's drawn completely from the spirit of
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technology. I believe Marcel had his 'finger on the pulse' when he defined teelmology as 'reason trying to manipulate the entire earth and all living things within it.' Because you can manipulate nations, man and nature, you think that you thereby understand them. Far from it, for you're mistaken in thinking that science is the paradigm for all knowledge. Science says that water is H,O, when existential man knows it to be a cool refreshing drink, a place to swim in, etc. Science has worked with systems and models for so long that it thinks it makes reality conform to its own narrow image of it. This is like B. F. Skinner's Frazier in Walden II; he says that he must deny freedom since he can't fit it into his system. You claim that man is too free, has too many options. Well, knowledge has run in advance of itself for so long, that it seems only fair that we allow freedom the same privilege. "But getting back to technology. Its spirit has produced 'the modular man' whose functions and indeed, bodily parts, are increasingly interchangeable. I tell you, man is not a unit module, he is not the sum of his parts; neither is he a computer. Space Odessey 2001 and Zorba the G1¡eek illustrated that well enough. Sure, science and technology have put us where we are today, and with that there is something good and something bad. The good, of course, is more food, better clothing, jobs, leisure time. All this I grant, but the bad is that technology continues to produce the non-human human and the non-natural nature (Guardini's phrase, I believe). In short, man continues to be alienated. Marx's description of this holds and if you'll permit me a quote: 'Alienation is apparent not only in the fact that my means of life belongs to someone else, that my desires are the unattainable possession of someone else, but that everything is something different from itself, that my actual activity is something else, and finally (and this is also the case for the capitalist) that an inhuman power rules over everyhing.' " '
Mr. Institution: "Well, you're certainly up on your quotes. But don't be too hard on technology. True, it's a bit heady with its own success, but it'll mature. If I recall correctly, philosophy went through that stage with great regularityDescartes, Leibnitz, the Vienna Circle, etc. Your objection to
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technology strikes me as little more than a new form of old romanticism. We're riding its crest today you know. It has all the strengths and weaknesses of its 18th and 19th century counterparts. It combines the movement of storm and stress with unbelievable naivate. It wants to produce an unwork¡ able egalitarianism. In appealing to Marx and Rousseau (in a back to nature movement), you romantics fail to appreciate that we can't ever go back to anything. I believe your friend Kierkegaard called the shot on that-repetition in life is impossible. You can't repeat last Saturday's party, nor relive your good or bad times again. When they're gone, they're gone! "I believe you're infected with nostalgia, a trait you usually accuse us older people of having. Look at the clothes of the young-or should I say costumes? The 'flapper look' of the twenties is in with the girls, as is the peasant look; with the boys, its the Zapata drooping moustache, and the full beard of the Civil War days replete with 'lambchop sideburns.' You ought to remember that romanticism (with its overemphasis on wish) is but a short step removed from despair (with its underemphasis on hope). I'm strictly for realism, that's why I'm in favor of the institution as the most effective way of making progress for mankind. I think Mortimer Adler pointerl out that from the moral standpoint, individual man hasn't progressed much, but from the same standpoint, collective man -the institution has shown a history of becoming increasingly moral."
I
''
M1¡. Person: "Morality! Yon should talk about morality. Do you realize that in the past 50 years, 100 million people have been killed by people. And who's responsible? The little guy? He doesn't want war. He doesn't want power. But power! That's what you feed on, and that's why you back technology as the way to social salvation. For you there are no tragedies, only errors. Power! Power! Power! That's all the institution ever wanted. You're still the Hobbesian. In Western history you thought you got it from God, then the state, the self; and now it's the machine that produces your power. You pick on our costumes. These are but symbols and in part are meant to 'put you on.' They are a form of protest against yourself, the establishment. On still another point, you're the
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dreamer, not I, when you think you can use teehnology, to deteehnologize and ...."
Mr. Institution: "Oh! . Oh! I'm afraid that he's going to throw in pollution .... " Mr. Person: "Yes, I am! We've got to de-industrialize industry and get away from polluting nature the world over.... " Mr. Institution: "Oh boy! You're asking for it. Two quick points. The first is to throw back at you the charge of ignoring reality. In present society, symbolism has become so dominant as to assume the place of the reality it was meant to signify. Institutions went through this error some time ago; the Church isn't rid of it yet! Symbolic values may be therapeutic for the protestor, but hardly helpful to the cause. They remind me of a college course in creative writing. It started out all right, but soon degenerated into therepeutic writing. The strange thing was that neither the instructor nor the student reeognized the change. "The seeond point is your romantic call to de-industrialize. We couldn't even if we wanted to. Oh sure! Perhaps this country could, but then ten others would stand up in our place. I can just hear the under-developed nation (on the verge of becoming industrialized) : it's saying, 'You got yours-all the benefits of industry-now you want to keep me from getting mine. You're like a fat lady married to a thin husband. You go on a diet and expect the husband to sit around with you eating nothing but cottage cheese.' You present day individualists, you're absolutely inconsistent. What you formerly praise in white cultures, namely, sticking together among Jews, Wasps, etc., you now condemn in black culture as you move away from colleetivism toward individualism and they move toward the group. In a sense, the person is like advertising. His essential aim today is to create dissatisfaction.''
Mr. Person: "No! No! You don't understand. As a person, I must create my own values, if I am to regard them as truly mine. Necessarily, these come into conflict with ready made values, whether those of state, church or family. The institutionalist essentially has a speetator view of life, man and reality. He doesn't warit the individual to participate and
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muddy up his waters. And since the institution doesn't provide meaningful entrees for the individual, the individual looks outside the system for meaning. So once again we're back to alienation."
'
Mr. Institution: "Well, there's a measure of truth in what you say, but you're pushing a bit too hard. Your effort is contrived. Don't you see that the institution can't function unless it sometimes abstracts from the role of person 7 If we keep person foremost, how can we hire chicken pluckers, garbage collectors, and sewer rodders. How could we get mothers to change babies' diapers? You're got to appreciate the practical side of things. To cry 'Down with institutions!' 'De-school the society!' All of these are themselves institutional slogans. Let's face it. We're social and cannot live the human and civil life any other way. We can modify the present structures. We can replace some with others, but we can't live without structures. And institutional structures don't just happen, they are planned, worked at, and kept running through a good deal of personal sacrifice. I allow that it takes a certain amount of maturity to recognize that, however. You forget that the institution itself is made up of individuals-{)[ persons. So if you blame institutions, you wind up blaming yourself, the person.'' Mr. Person: "Wait a minute! The institution does something to the inrlividual almost in a way that a mob does something to its members. (Remember The Oxbow Incident? ) And that is the danger of institutionalism: It shapes anrl prostitutes the person making him into a character found in 1984. It forces him to become a non-person, like the boss who fires a family man from a job, because a company decides to go on an economy binge. I can't overstress this, for it's almost diabolical the way the institution perverts the individual who is its member. It's like a college going on an IBM system. Supposedly, it was put in to help reduce professors' and administrators' paperwork. Instead, it has increased the very thing it was meant to decrease. We've just got to get back to simplicity again.''
Mr. Institution: '"Look, I'm as wistful as you in wanting to go back-but we can't! What we've got to worry about (both
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you as person and I as iru;titution) is that we keep in balance the perspective of dialectic and dialogic as necessary and vital to our mutual and integrated well being. To regard each other as a threat instead of as a challenge, will push us to one of two extremes. The first is that one will seek to eradicate the other, thereby having it's own view reign supreme; the second is that the one will 'cop out' and let the other prevail, just as absolutely. Either way, reductionism or monism prevails, not pluralism. Either way, to see a threat instead of a challenge is to provoke conflict and war in which all morality goes on leave. We should be able to do without the sappers, the snipers, the bombers and crowd shooters. They're as much your enemy as mine. Perhaps we can at least change our present attitudes. Let's look at the future as possibility for progress instead of as perdition. Let's see change as the possible concretion of human hope. Let's look at the constructive side of dialectic and show a willingness to enter its arena of give and take. Let's temper mmanticism with realism, and realism in turn with your youthful idealism. We must make a fresh beginning. And in doing so, let's remember with Ortega y Gasset that every beginner is a skeptic, but that every skeptic is only a beginner."
¡ Mr. Person: "That sounds suspiciously like rhetoric to me. And I've been fooled with it before. But I guess I'm not beyond using some rhetoric myself ... but only on occasion. The truth is that I no longer trust you as I am sure you don't trust me. And we both have our good reasons ... " At this point, we can walk away, assured that further listening would be non-productive. I wonder if we could summarize the views of the Institution and the Person. They both express two rather different attitudes and life styles. These shape their respective visions of present and future and their grasp of man and his relation to other men and to the world itself. On the one hand, the institution seems to show good will toward progress for man, but its actions don't empirically match its intentions. On the other hand, the person who has finally won a certain recognition, is not about to relinquish it to anyone. (Women's Lib is a good example. Why should a woman
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who marries surrender her name?) The institution tends to see persons and problems under the aspect of quantity (for quantified data are most amenable to practical handling-like social security numbers, college credit hours and work productivity). The person feels this constitutes his depersonalization and wants to be seen under the aspects of quality, hence emphasis on the quality of life. What the institution puts under the label of functions, like a man's work and other activities, the person puts under the label of values. These are certainly two ways of seeing things. I'm not sure what the resolution is, or even if there is a resolution. In fact, I wonder if the two characters in the dialogue were talking to each other or at each other. Where do you stand on the issues? What do you think? Do you need to choose sides? If so, whose side are you on? The person's or institution's? Why? To answer that, you will have to think and reflect. You will have to put your ideas in historical and cultural contexts; you will have to evaluate them and discuss them in the crucible of the experience of yourself and others. You will have to measure this worth against the demands of the present and the future. Oh ! Incidentally, if you do all this, you'll be philosophizing.
Willmm J. Byron, S.J.
Unconnected Self Interest -Reflections on Alienation and Religion. Alienation permeates our culture, persuading man that he is alone. lost, unconnected, incomplete. Religion speaks to this central feature of human existence. If religion says anything at all to modern man, it tells him
he is not alone. Religion ties man back to (religare) Something or Someone who transcends the limitations of space and time, who speaks to him, who gives ultimate meaning to his life, who is accessible through prayer, ritual and the happenings of life. By contrast, if alienation has anything to say to man, it tells him he is alone--estranged, lost; unconnected, incomplete. Now believing, as I do, that reconciliation is the work of religion, I would want to suggest in this essay that religion should not merely coexist with but counteract the alienation which permeates our culture. I shall use the term alienation to cover four situations: alienation from God (theological alienation) ; alienation from self (psychological alienation) ; alienation from the group or community (sociological alienation) ; alienation from work (technological alienation). In the category of alienation from
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work, I would include the alienation of man from nature. To each of these conditions of man, I shall propose a response from religion. And I take tâ&#x20AC;˘eligion itself to be an organized response to revelation involving both belief and practice. In offering my understanding of the concept of alienation, I would want first to agree with philosopher Walter Kaufman's view that "alienation is neither a disease nor a blessing but, for better or worse, a central feature of human existence." ("The Inevitability of Alienation," An Introductory Essay to Richard Schacht, Alienation, New York, Doubleday, 1970, p. xv.) Our individual and collective failure to adapt creatively to this central feature of human existence is, however, in my opinion, an evil, a disease that I would characterize an "unconnected self interest." As will become clear later in this article, I am indebted to Bernard Murchland's insistence throughout The Age of Alienation (New York, Random House, 1971) that the imagination is man's connective as well as his creative faculty. In a prenote to his book, Murchland quotes Kierkegaard's remark that "All burrowing into existence consists in establishing connections." If man's private pursuit of self-interest works against him by closing off connections, it is my view that this unconnected self interest is in fact a disease threatening his existence. Religion speaks to this disease by reminding man that he must lose his life in order to find it (Mt. 16:26). In the unconnected state, self interest can become destructive of the individual or collective self (the community). Our failure to connect ourselves to God, to self, to group, to work and nature is, I would want to argue, a failure of the creative connective imagination and, at bottom, a failure of man to respond to gmce. I thought of this multiple failure while reading Josephine Hendin's review of Sallie Bingham's The Way It Is Now, a "finely written collection of stories about those nm¡row, unhappy women who connect with nothing but themselves. They ... are curiously alike--all irritable and unfulfilled ... hopelessly constricted, hopelessly narrow, hopelessly unable to escape the dead center of themselves" (The New York Times Book Review, April 2, 1972, p. 6.) The point Miss Hendin. may have missed is that such women are probably quite alienated from themselves as well. My concept of alienation is, therefore, broad enough to in-
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elude a sense of estrangement from God, from self, from fellow man, from work or nature. One or all of these referents may be the appropriate "whom" or "what" from which an individual or group is alienated. ALIENATION; THEOLOGICAL AND PSYCHOLOGICAL
Alienation from God is sin. The response from religion to this problem of theological alienation is put simply and clearly by St. Paul: "It is all God's work. It was God who reconciled us to himself through Christ.... For our sake God made the sinless one into sin, so that in him we might become the goodness of God" (2 Cor. 5:18, 21). This, of course, is the work of grace. It is gratuitous. In St. Augustine's happy phrase, "We were fooled by the wisdom of the serpent, but saved by the foolishness of God." Religion, therefore, speaks to sinful man and tells him his God is divinely foolish, loving and generous. Religion pleads with man to believe that he is reconciled. But man mny not believe. He may refuse to believe at all, and thus choose to remain alienated from God. Or, he may find himself saying with the man in Mark's gospel, "Lord, I believe; help thou my unbelief" (Mk. 9 :25). The varieties of unbelief are too numerous to catalogue here. But the point to note would be that even for the believer who accepts reconciliation with the Father through Christ, there will be elements of estrangements as he finds himself wondering, from time to time, not whether God exists or has power to save, but whether God is here with him in a caring capacity at this hour, in this place. Doubt does not disqualify him from the community of believers; it does however leave him in a partially unconnected, partially alienated state. Religious belief and practice assist man in managing the problem of his alienated part, his unbelief. Alienation from self is a complicated psychological phenomenon. The Christian religion has been speaking to the issue for centuries as it ponders the meaning of St. Paul's expression of our double-mindedness: "I cannot understand my own behavior. I fail to carry out the things I want to do, and I find myself doing the very things I hate" (Rom. 7 :15). Among the alienated today there is, to an alarming degree, evidence of self-hatred. This is something beyond self doubt,
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self distrust and a conviction of personal inadequacy. Moreover, it is something not limited to youth and the drug culture. We too facilely speak of "alienated youth" and assert that "they" are alienated from "us." We fail to note that there are in both groups-the "they" and the "us" --eountless self-alienated people, people who are separated from themselves by self doubt, self distrust and self hatred. It was chilling for me to listen recently to a young man refer to himself as "a walking graveyard." It is even more frightening to realize that many men two or three times his age say the same thing almost daily, but they say it to themselves. What is the response of religion? It is my opinion that one of the most difficult tasks for the Church and churchmen is to convince people that God loves them and that they are indeed loveable. "For our sake God made the sinless one into sin, so that in him we might become the goodness of God" (2 Cor. 5:21). Religion should assist man in celebrating the fact of his redemption. It should assure the individual that he can assimilate within himself the Paschal mystery, the doctrine of death and resurrection. It should assure him that he is or can become "the goodness of God." If 1 may use religion in a sense broad enough to include faith and theology, I would say that religion must respond to self-alienated man with a theology of human worth, a theology of failure, and a moral theology imaginative enough to bind the Christian to use his connective imagination to come to terms with his own doublemindedness. Thus integrated, the Christian is ready for the next stages of responsible growth and social obligation-connection of himself to others and connection of one group to another. SOCIOLOGICAL ALIENATION
Alienation from the group or community invites a creative response from religion today. Kenneth Keniston sees in alienation from society "an explicit rejection, "freely' chosen by the individual, of what he perceives as the dominant norms or values of his society" (The Uncommitted, New York, Harcourt, Brace and World, 1965, p. 455). Thus a person or group can be in society but not of it. In one sense, the Christian tradition has always encouraged this. The monk rejects many of society's dominant values. James, "the brother of the Lord" and
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leader of the Judaeo-Christian community in Jerusalem, wrote around the year 50 to Jewish Christians in the Graeco-Roman world in rather stern language: "You are as unfaithful as adulterous wives; don't you realize that making the world your friend is making God your enemy? Anyone who chooses the world for his friend turns himself into God's enemy" (Jas. 4 :4). As used here, and also in Paul and John, "world" means opposition to God. Assuming, therefore, non-opposition to God in the dominant norms and values of the society, those who reject those norms and values alienate themselves from that society. Call them the "actively alienated." (Someone could accept the dominant values but reject the dominant behavior norms of a society. I would call such a person deviant rather than alienated.) Assuming, on the other hand, an admixture of opposition-toGod elements in the dominant norms and values of the society (I am thinking at the moment of racism and materialism), those who are rejected by the society in function of these opposition-to-God values, are also alienated, although not by choice. Call them the "passively alienated." Among the actively alienated in out¡ society, the young hold centerstage. One of the lessons of the 1960's is that the cui-¡ tural gap between generations can be as great as the cultural gap between nations. In America, therefore, the religious response to the alienated young might well be a missionary response. But a contemporary missionary response is called for. This means going when and where you are invited, and listening once you get there. Just as the missioner must be a transcultural intermediary avoiding triumphalism, imperialism and unenlightened nationalism, the religious agent of transgenerational reconciliation must avoid the mindless excesses of missioners of another era. He must also understand that conversion really means today. I think the meeting ground for transgenerational reconciliation is in the area of commitment. Keniston calls his study of "Alienated Youth in American Society," The Uncommitted. The actively alienated young reject social norms and values which they regard as false, or thin, or constrictive of human potential. They quest for something worth committing their lives to, but they all too often give up the quest without finding
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a cause and settle for someone to cling to. Whether in a counter-culture, a sub-culture, or a commune, the actively alienated youth removes himself from the negotiating table where a transgenerational shared search for commitment (a quest for a cause worth giving you life to) might have been possible. The President's Commission on Campus Unrest (the Scranton Commission), speaking of American youth culture in the 1960's, reported that: "The tools of the workaday institutional world-hierarchy, discipline, rules, self-interest, self-defense, power-it [the youth culture] considered mad and tyrannical. It proclaimed instead the liberation of the individual to feel, to experience, to express whatever his unique humanity prompted. And its perceptions of the world grew ever more distant from the perceptions of the existing culture: what most called 'justice' or peace' or accompishment,' the new culture envisioned as 'enslavement' or 'hysteria' or 'meaninglessness.' As this diversion of values and of vision proceeded, the new youth culture became increasingly oppositional" (Report of the P1¡esUlent's Commission on Ca,mpus Unrest, Washington, Government Printing Office, 1970, p. 62). 1
1
THE WORK OF RECONCILIATION
The work of reconciliation is the work of religion. Man was reconciled to God in a poor and broken Christ. Perhaps a renewed commitment to poverty, simplicity and self-sacrifice is the meeting ground for men and man, group and group, in our fragmented Christian society. Religious institutions (and those who tend and attend them) must be authentically Christian-free, flexible, poor and powerless. Young Christians, who accept the Christian faith while rejecting the institutionalized Christian religion, must confront themselves with radical gospel principles and ask themselves whether their present alienation is leading to narcissism or to the Christian ideal of life through death to self. Perhaps a mission, in the name of religion, to the passively alienated (the subordinated blacks, the rejected aged, the excluded pOOr and powerless, the unconnected loners) is the way to fill the gaps that divide institutional religion from the llCtively alienated young in America today . The prospect, how-
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ever, is not promising. And when one's view is broadened to include the passively alienated in an international perspective, the prospect is less promising still. It must not be forgotten that religion in the cultic sense, through its liturgical actions and celebrations, has a definite response to alienation. At the altar of sacrifice, Christians celebrate together the fact of their reconciliation with God, the fact that alienation from God through sin is healed in Christ's redeeming sacrifice. Today, however, it should be noted that at the same altar, viewed more as a table of communion than an altar of sacrifice, man's estrangement from his fellow man can be reduced as he comes together with others, summoned out of his isolation into a community of love, a worshipping, celebrating community of believers united in the Eucharist. OUR SIN OF OMISSION
Our Catholic-Christian failure to build community in this context is our great sin of omission in this age of alienation. Our "religious" concern for rubrics and regularity has been more evident than our Christian concern to minister to the alienated. True religion, the Epistle of James tells us, is "coming to the help of widows and orphans when they need it" ( J as. 1 :27). For us, the "widows and orphans" are the alienated. Our sin of omission has been capitulation to the evil of "unconnected self interest" through individual and collective failure to act imaginatively in the dealienation of society. In this regard, we have displayed neither creative leadership nor creative followership in the Church. "The imagination is man's connective as well as his creative faculty. This is to say that man must create his meanings; the kind of link between self and world we are talking about is not something given; nor is it something discovered; it is literally something made." (Bernard Murchland, The Age of Alienation, New York, Random House, 1971, p. 188). We have been seeking a better world as if it were 'out there' waiting to be discovered, instead of realizing-as we must-that it is quite literally something 'in here' waiting to be made. The American environment presents formidable cultural impediments to the kind of religious response that would foster the
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creative, cormective formation of community. Summing up my reflections thus far on man's alienation from God, from himself and from his fellow man, I would want to note that human experience verifies an inward and an outward impulse in all of us. In both directions we can find God; religion supports the quest in either direction. There is the inwardness of reflective solitude and the outwardness of community. The man who avoids either impulse is at best a parttime human being. In either direction the impulse can be impeded, e.ven thwarted, by alienation from self or from the group. Moreover, in either direction God can be touched, so to speak, but not possessed. Hence the incompleteness of even the most unalienated of men. Religion, however, supports him in his incompleteness. And faith, of course, supports him too. "Only faith can guarantee the blessings that we hope for, or prove the existence of the realities that at present remain unseen," writes the author of the Letter to the Hebrews to his discouraged Jewish-Christian audience (Heb. 11 :1). At this point in the progress of my argument, a mid-course correction may be necessary. I would not want to give the impression that Christianity should fit into the mainstream of contemporary culture. Quite the contrary. Christianity is in fact a counter-culture. Whether or not it can transform (convert?) the dominant culture to the point where gospel values predominate is another question. Some theologians would say that the Church will always be a "remmant," a small community set apart. My personal view is that the "community of believers," however large or small, may well be contemporary man's best hope for an answer to the problem of sociological as well as theological alienation. TECHNOLOGICAL ALIENATION
Let me tum now to technological alienation, or the alienation of man from work and nature. The economic roots of the concept of alienation are traceable to Marx and relate primarily to the economic order and the world of work where in the Marxian analysis, men involuntarily surrenders his right to the product of his labor. With the accelerated advance of technology in the 20th century, man have been separated not only from the products of their labor but from their jobs as well
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through what has become known as technological unemployment. Moreover, work is organized in impersonal ways. Men at work have less and less contact with nature and with each other. The young postpone their entry into the labor force by taking technical education for work in a technological world. The very complexity of this world prompts some of the young to "drop out" of the Pt¡eparation process, or having completed their education, to reject the occupation for which they have been trained. Faced with the stepped-up competition and complexity of life, the alienated young display a hostility to the instrumentalization of man and to industrial society's emphasis on effort, disciplined work, and economic rewards and punishments. The causes of the campus unrest which surprised America several years ago may, in the view of the Scranton Commission, lie deep in the economic structures which have been developing in Western industrial society for more than a century. "It is at least remarkable," the Commission reported, "that so many of the themes of the new international youth culture appear to revolve in one way or another about the human costs of technology and urban life, and how often they seem to echo a yearning to return to ¡an ancient and simpler day" (Scranton Repm1;, 1970, p. 87). The contemporary "back-to-nature" impulse on the part of the alienated young poses a threat to institutional religion. This is unfortunate and unfair because the impulse is misdirected. It substitutes a reverence for nature for a reverence through nature, putting us on the road toward what Willis Elliott of New York Theological Seminary has called "poetic naturalism," a label which, he predicts, will be descriptive of the dominant American "religion" in the year 2000. Institutional religion must raise up another Jeremiah who can say to the poetic naturalists: "What a brood you are! Listen, this is the word of Yahweh: Have I been a desert for Israel or a land of deepest gloom? Then why do my people say, "We will go our way, we will no longer come to you'? Does a girl forget her ornaments, a bride her sash? And yet my people have forgotten me, for days beyond number." (Jer. 2 :31-32) The contemporary counter-cultural return to nature and the simple life is an adaptation to the separation of contemporary
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man from work and nature. It displays, I think, a disturbing potential for fostering an alienation from God for future "days beyond number." Those who are alienated in a Marxian sense are not free because they are captives of an alienating economic system. Religion in its contemporary concern for "widows and orphans" must challenge the alienating elements in the world of work. Just as Christ became man so that he could be where the alienation was in order to heal it, now the Christian seems called to the secular world to work to heal the technological alienation that is there. Once there, what does he do that is different from anyone else? Nothing that immediately meets the eye. However, his motivation for being there should be different. It should be Christological and therefore reconciliatory, grounded in the New Commandment and thus apostolic. Moreover, the results of his having been there may eventually become visible if through his creative and connective faculty, the imagination, he has discovered meaning in work; if he has under the impulse of Christian love designed a more human organization of the world of work; and if the witness of his Christian commitment has drawn a response from the connective imaginations of other workers enabling them together to weave the fabric of community. But here again, incompleteness, unconnectedness and some estrangement will admittedly remain despite the best efforts of the most creative intellects. After nudging him on in his vocation to make a better world, religion will remind the inhabitant of the world of work that he has no lasting city here (Heb. 13 :15), but will sustain him through prayer, belief and ritual as he lives with the difference between the present reality and the New Jerusalem.
Willmm J. Byron, S.J.
Unconnected Self Interest -Reflections on Alienation and Religion. Alienation permeates our culture, persuading man that he is alone. lost, unconnected, incomplete. Religion speaks to this central feature of human existence. If religion says anything at all to modern man, it tells him
he is not alone. Religion ties man back to (religare) Something or Someone who transcends the limitations of space and time, who speaks to him, who gives ultimate meaning to his life, who is accessible through prayer, ritual and the happenings of life. By contrast, if alienation has anything to say to man, it tells him he is alone--estranged, lost; unconnected, incomplete. Now believing, as I do, that reconciliation is the work of religion, I would want to suggest in this essay that religion should not merely coexist with but counteract the alienation which permeates our culture. I shall use the term alienation to cover four situations: alienation from God (theological alienation) ; alienation from self (psychological alienation) ; alienation from the group or community (sociological alienation) ; alienation from work (technological alienation). In the category of alienation from
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work, I would include the alienation of man from nature. To each of these conditions of man, I shall propose a response from religion. And I take tâ&#x20AC;˘eligion itself to be an organized response to revelation involving both belief and practice. In offering my understanding of the concept of alienation, I would want first to agree with philosopher Walter Kaufman's view that "alienation is neither a disease nor a blessing but, for better or worse, a central feature of human existence." ("The Inevitability of Alienation," An Introductory Essay to Richard Schacht, Alienation, New York, Doubleday, 1970, p. xv.) Our individual and collective failure to adapt creatively to this central feature of human existence is, however, in my opinion, an evil, a disease that I would characterize an "unconnected self interest." As will become clear later in this article, I am indebted to Bernard Murchland's insistence throughout The Age of Alienation (New York, Random House, 1971) that the imagination is man's connective as well as his creative faculty. In a prenote to his book, Murchland quotes Kierkegaard's remark that "All burrowing into existence consists in establishing connections." If man's private pursuit of self-interest works against him by closing off connections, it is my view that this unconnected self interest is in fact a disease threatening his existence. Religion speaks to this disease by reminding man that he must lose his life in order to find it (Mt. 16:26). In the unconnected state, self interest can become destructive of the individual or collective self (the community). Our failure to connect ourselves to God, to self, to group, to work and nature is, I would want to argue, a failure of the creative connective imagination and, at bottom, a failure of man to respond to gmce. I thought of this multiple failure while reading Josephine Hendin's review of Sallie Bingham's The Way It Is Now, a "finely written collection of stories about those nm¡row, unhappy women who connect with nothing but themselves. They ... are curiously alike--all irritable and unfulfilled ... hopelessly constricted, hopelessly narrow, hopelessly unable to escape the dead center of themselves" (The New York Times Book Review, April 2, 1972, p. 6.) The point Miss Hendin. may have missed is that such women are probably quite alienated from themselves as well. My concept of alienation is, therefore, broad enough to in-
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elude a sense of estrangement from God, from self, from fellow man, from work or nature. One or all of these referents may be the appropriate "whom" or "what" from which an individual or group is alienated. ALIENATION; THEOLOGICAL AND PSYCHOLOGICAL
Alienation from God is sin. The response from religion to this problem of theological alienation is put simply and clearly by St. Paul: "It is all God's work. It was God who reconciled us to himself through Christ.... For our sake God made the sinless one into sin, so that in him we might become the goodness of God" (2 Cor. 5:18, 21). This, of course, is the work of grace. It is gratuitous. In St. Augustine's happy phrase, "We were fooled by the wisdom of the serpent, but saved by the foolishness of God." Religion, therefore, speaks to sinful man and tells him his God is divinely foolish, loving and generous. Religion pleads with man to believe that he is reconciled. But man mny not believe. He may refuse to believe at all, and thus choose to remain alienated from God. Or, he may find himself saying with the man in Mark's gospel, "Lord, I believe; help thou my unbelief" (Mk. 9 :25). The varieties of unbelief are too numerous to catalogue here. But the point to note would be that even for the believer who accepts reconciliation with the Father through Christ, there will be elements of estrangements as he finds himself wondering, from time to time, not whether God exists or has power to save, but whether God is here with him in a caring capacity at this hour, in this place. Doubt does not disqualify him from the community of believers; it does however leave him in a partially unconnected, partially alienated state. Religious belief and practice assist man in managing the problem of his alienated part, his unbelief. Alienation from self is a complicated psychological phenomenon. The Christian religion has been speaking to the issue for centuries as it ponders the meaning of St. Paul's expression of our double-mindedness: "I cannot understand my own behavior. I fail to carry out the things I want to do, and I find myself doing the very things I hate" (Rom. 7 :15). Among the alienated today there is, to an alarming degree, evidence of self-hatred. This is something beyond self doubt,
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self distrust and a conviction of personal inadequacy. Moreover, it is something not limited to youth and the drug culture. We too facilely speak of "alienated youth" and assert that "they" are alienated from "us." We fail to note that there are in both groups-the "they" and the "us" --eountless self-alienated people, people who are separated from themselves by self doubt, self distrust and self hatred. It was chilling for me to listen recently to a young man refer to himself as "a walking graveyard." It is even more frightening to realize that many men two or three times his age say the same thing almost daily, but they say it to themselves. What is the response of religion? It is my opinion that one of the most difficult tasks for the Church and churchmen is to convince people that God loves them and that they are indeed loveable. "For our sake God made the sinless one into sin, so that in him we might become the goodness of God" (2 Cor. 5:21). Religion should assist man in celebrating the fact of his redemption. It should assure the individual that he can assimilate within himself the Paschal mystery, the doctrine of death and resurrection. It should assure him that he is or can become "the goodness of God." If 1 may use religion in a sense broad enough to include faith and theology, I would say that religion must respond to self-alienated man with a theology of human worth, a theology of failure, and a moral theology imaginative enough to bind the Christian to use his connective imagination to come to terms with his own doublemindedness. Thus integrated, the Christian is ready for the next stages of responsible growth and social obligation-connection of himself to others and connection of one group to another. SOCIOLOGICAL ALIENATION
Alienation from the group or community invites a creative response from religion today. Kenneth Keniston sees in alienation from society "an explicit rejection, "freely' chosen by the individual, of what he perceives as the dominant norms or values of his society" (The Uncommitted, New York, Harcourt, Brace and World, 1965, p. 455). Thus a person or group can be in society but not of it. In one sense, the Christian tradition has always encouraged this. The monk rejects many of society's dominant values. James, "the brother of the Lord" and
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leader of the Judaeo-Christian community in Jerusalem, wrote around the year 50 to Jewish Christians in the Graeco-Roman world in rather stern language: "You are as unfaithful as adulterous wives; don't you realize that making the world your friend is making God your enemy? Anyone who chooses the world for his friend turns himself into God's enemy" (Jas. 4 :4). As used here, and also in Paul and John, "world" means opposition to God. Assuming, therefore, non-opposition to God in the dominant norms and values of the society, those who reject those norms and values alienate themselves from that society. Call them the "actively alienated." (Someone could accept the dominant values but reject the dominant behavior norms of a society. I would call such a person deviant rather than alienated.) Assuming, on the other hand, an admixture of opposition-toGod elements in the dominant norms and values of the society (I am thinking at the moment of racism and materialism), those who are rejected by the society in function of these opposition-to-God values, are also alienated, although not by choice. Call them the "passively alienated." Among the actively alienated in out¡ society, the young hold centerstage. One of the lessons of the 1960's is that the cui-¡ tural gap between generations can be as great as the cultural gap between nations. In America, therefore, the religious response to the alienated young might well be a missionary response. But a contemporary missionary response is called for. This means going when and where you are invited, and listening once you get there. Just as the missioner must be a transcultural intermediary avoiding triumphalism, imperialism and unenlightened nationalism, the religious agent of transgenerational reconciliation must avoid the mindless excesses of missioners of another era. He must also understand that conversion really means today. I think the meeting ground for transgenerational reconciliation is in the area of commitment. Keniston calls his study of "Alienated Youth in American Society," The Uncommitted. The actively alienated young reject social norms and values which they regard as false, or thin, or constrictive of human potential. They quest for something worth committing their lives to, but they all too often give up the quest without finding
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a cause and settle for someone to cling to. Whether in a counter-culture, a sub-culture, or a commune, the actively alienated youth removes himself from the negotiating table where a transgenerational shared search for commitment (a quest for a cause worth giving you life to) might have been possible. The President's Commission on Campus Unrest (the Scranton Commission), speaking of American youth culture in the 1960's, reported that: "The tools of the workaday institutional world-hierarchy, discipline, rules, self-interest, self-defense, power-it [the youth culture] considered mad and tyrannical. It proclaimed instead the liberation of the individual to feel, to experience, to express whatever his unique humanity prompted. And its perceptions of the world grew ever more distant from the perceptions of the existing culture: what most called 'justice' or peace' or accompishment,' the new culture envisioned as 'enslavement' or 'hysteria' or 'meaninglessness.' As this diversion of values and of vision proceeded, the new youth culture became increasingly oppositional" (Report of the P1¡esUlent's Commission on Ca,mpus Unrest, Washington, Government Printing Office, 1970, p. 62). 1
1
THE WORK OF RECONCILIATION
The work of reconciliation is the work of religion. Man was reconciled to God in a poor and broken Christ. Perhaps a renewed commitment to poverty, simplicity and self-sacrifice is the meeting ground for men and man, group and group, in our fragmented Christian society. Religious institutions (and those who tend and attend them) must be authentically Christian-free, flexible, poor and powerless. Young Christians, who accept the Christian faith while rejecting the institutionalized Christian religion, must confront themselves with radical gospel principles and ask themselves whether their present alienation is leading to narcissism or to the Christian ideal of life through death to self. Perhaps a mission, in the name of religion, to the passively alienated (the subordinated blacks, the rejected aged, the excluded pOOr and powerless, the unconnected loners) is the way to fill the gaps that divide institutional religion from the llCtively alienated young in America today . The prospect, how-
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ever, is not promising. And when one's view is broadened to include the passively alienated in an international perspective, the prospect is less promising still. It must not be forgotten that religion in the cultic sense, through its liturgical actions and celebrations, has a definite response to alienation. At the altar of sacrifice, Christians celebrate together the fact of their reconciliation with God, the fact that alienation from God through sin is healed in Christ's redeeming sacrifice. Today, however, it should be noted that at the same altar, viewed more as a table of communion than an altar of sacrifice, man's estrangement from his fellow man can be reduced as he comes together with others, summoned out of his isolation into a community of love, a worshipping, celebrating community of believers united in the Eucharist. OUR SIN OF OMISSION
Our Catholic-Christian failure to build community in this context is our great sin of omission in this age of alienation. Our "religious" concern for rubrics and regularity has been more evident than our Christian concern to minister to the alienated. True religion, the Epistle of James tells us, is "coming to the help of widows and orphans when they need it" ( J as. 1 :27). For us, the "widows and orphans" are the alienated. Our sin of omission has been capitulation to the evil of "unconnected self interest" through individual and collective failure to act imaginatively in the dealienation of society. In this regard, we have displayed neither creative leadership nor creative followership in the Church. "The imagination is man's connective as well as his creative faculty. This is to say that man must create his meanings; the kind of link between self and world we are talking about is not something given; nor is it something discovered; it is literally something made." (Bernard Murchland, The Age of Alienation, New York, Random House, 1971, p. 188). We have been seeking a better world as if it were 'out there' waiting to be discovered, instead of realizing-as we must-that it is quite literally something 'in here' waiting to be made. The American environment presents formidable cultural impediments to the kind of religious response that would foster the
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creative, cormective formation of community. Summing up my reflections thus far on man's alienation from God, from himself and from his fellow man, I would want to note that human experience verifies an inward and an outward impulse in all of us. In both directions we can find God; religion supports the quest in either direction. There is the inwardness of reflective solitude and the outwardness of community. The man who avoids either impulse is at best a parttime human being. In either direction the impulse can be impeded, e.ven thwarted, by alienation from self or from the group. Moreover, in either direction God can be touched, so to speak, but not possessed. Hence the incompleteness of even the most unalienated of men. Religion, however, supports him in his incompleteness. And faith, of course, supports him too. "Only faith can guarantee the blessings that we hope for, or prove the existence of the realities that at present remain unseen," writes the author of the Letter to the Hebrews to his discouraged Jewish-Christian audience (Heb. 11 :1). At this point in the progress of my argument, a mid-course correction may be necessary. I would not want to give the impression that Christianity should fit into the mainstream of contemporary culture. Quite the contrary. Christianity is in fact a counter-culture. Whether or not it can transform (convert?) the dominant culture to the point where gospel values predominate is another question. Some theologians would say that the Church will always be a "remmant," a small community set apart. My personal view is that the "community of believers," however large or small, may well be contemporary man's best hope for an answer to the problem of sociological as well as theological alienation. TECHNOLOGICAL ALIENATION
Let me tum now to technological alienation, or the alienation of man from work and nature. The economic roots of the concept of alienation are traceable to Marx and relate primarily to the economic order and the world of work where in the Marxian analysis, men involuntarily surrenders his right to the product of his labor. With the accelerated advance of technology in the 20th century, man have been separated not only from the products of their labor but from their jobs as well
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through what has become known as technological unemployment. Moreover, work is organized in impersonal ways. Men at work have less and less contact with nature and with each other. The young postpone their entry into the labor force by taking technical education for work in a technological world. The very complexity of this world prompts some of the young to "drop out" of the Pt¡eparation process, or having completed their education, to reject the occupation for which they have been trained. Faced with the stepped-up competition and complexity of life, the alienated young display a hostility to the instrumentalization of man and to industrial society's emphasis on effort, disciplined work, and economic rewards and punishments. The causes of the campus unrest which surprised America several years ago may, in the view of the Scranton Commission, lie deep in the economic structures which have been developing in Western industrial society for more than a century. "It is at least remarkable," the Commission reported, "that so many of the themes of the new international youth culture appear to revolve in one way or another about the human costs of technology and urban life, and how often they seem to echo a yearning to return to ¡an ancient and simpler day" (Scranton Repm1;, 1970, p. 87). The contemporary "back-to-nature" impulse on the part of the alienated young poses a threat to institutional religion. This is unfortunate and unfair because the impulse is misdirected. It substitutes a reverence for nature for a reverence through nature, putting us on the road toward what Willis Elliott of New York Theological Seminary has called "poetic naturalism," a label which, he predicts, will be descriptive of the dominant American "religion" in the year 2000. Institutional religion must raise up another Jeremiah who can say to the poetic naturalists: "What a brood you are! Listen, this is the word of Yahweh: Have I been a desert for Israel or a land of deepest gloom? Then why do my people say, "We will go our way, we will no longer come to you'? Does a girl forget her ornaments, a bride her sash? And yet my people have forgotten me, for days beyond number." (Jer. 2 :31-32) The contemporary counter-cultural return to nature and the simple life is an adaptation to the separation of contemporary
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man from work and nature. It displays, I think, a disturbing potential for fostering an alienation from God for future "days beyond number." Those who are alienated in a Marxian sense are not free because they are captives of an alienating economic system. Religion in its contemporary concern for "widows and orphans" must challenge the alienating elements in the world of work. Just as Christ became man so that he could be where the alienation was in order to heal it, now the Christian seems called to the secular world to work to heal the technological alienation that is there. Once there, what does he do that is different from anyone else? Nothing that immediately meets the eye. However, his motivation for being there should be different. It should be Christological and therefore reconciliatory, grounded in the New Commandment and thus apostolic. Moreover, the results of his having been there may eventually become visible if through his creative and connective faculty, the imagination, he has discovered meaning in work; if he has under the impulse of Christian love designed a more human organization of the world of work; and if the witness of his Christian commitment has drawn a response from the connective imaginations of other workers enabling them together to weave the fabric of community. But here again, incompleteness, unconnectedness and some estrangement will admittedly remain despite the best efforts of the most creative intellects. After nudging him on in his vocation to make a better world, religion will remind the inhabitant of the world of work that he has no lasting city here (Heb. 13 :15), but will sustain him through prayer, belief and ritual as he lives with the difference between the present reality and the New Jerusalem.
Warren T. Reich
Medical Ethics: The Contemporary Context The ve1-y stuff oI which medical ethics is made is constantly developing, ¡raising new questions, altering the terms oI old questions.
Medical ethics is drawing more attention today than possibly any other area in moral theology. Although the life sciences have been causing dilemmas and posing choices which frequently seem inscrutable, most of the practical, day-to-day questions of medical ethics change very little. Yet our analysis of these medico-moral problems and our response to them are subject to some degree of development, for the context and some of the presuppositions of these questions are variable. This article will attempt to give a contemporary view of medical ethics, its context and its presuppositions, in four parts. The first part will describe the tasks of medical ethics, particularly as they affect one who is engaged in the pastoral ministry. Some observations on natural law and Scripture in the second part will serve to introduce certain elements of renewal in medical ethics. The third part will set forth some of the 279
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problems involved in medical ethics as taught by the magisterium. Part four will deal more specifically with some principles of medical ethics and some cases which point up the current differences of opinion on medical ethics as pursued in a Catholic context. l. PASTORAL REQUIREMENTS OF MEDICAL ETHICS
Partially because those engaged in the ministry are called upon to fill a great variety of roles besides that of moral counselor, it has become a widely accepted dictum that they cannot supply pre-determined answers to a whole host of questions in the field of medical ethics. Their limitations in medical ethics, however, are not dictated solely by the demands of their vocation to pastoral service. The very stuff of which medical ethics is made is constantly developing. Very little remains static in the life sciences, for medical progress is constantly raising new questions and altering the terms of the old questions. Furthermore, medical ethics itself continues to develop its own methodologies according to the questions that are being asked. In this situation a contemporary presentation of medical ethics may be as adequate as its authors are capable of producing, but it will always leave something to be desired. The medical professions and health care institutions issue codes of ethics which are usually statements of some principles and of what is minimally required for purposes of declaring, preserving and sometimes enforcing certain standards of behavior which uphold the goals and objectives of these professions and institutions. But these codes leave many important questions untouched; and although they focus on good and acceptable behavior within the professions, they offer very little guidance in many of the more difficult areas of good ethical decisionmaking. In the Catholic Church in this country, those who hold the position of official teachers of religious and ethical doctrine have, in recent years, turned their attention to medical ethics and have issued (in 1971) a set of Ethical and Religious Directives for Catholic Health Facilities. These directives have become official policy for most Catholic health facilities, and they
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propose some important standards for good medical ethics. They contain some specific prohibitions which probably ought to be fmther revised; and, in fact, ecclesiastical leaders have encouraged steps leading to further revision. The Directives have been criticized for not striking a good balance between the presentation of institutional policy on the one hand and on the other hand the need to admit certain ambiguities which necessarily arise in the context of plumlism and of a legitimate freedom of conscience. Yet even the most adequate set of directives arrived at by common agreemnt will fail in filling all the needs of the moment. What needs to be kept in mind is that there will usually be a considerable time lag between a medical advancement and a mature evaluation of its ethical implications. An example can be found in the Catholic Church's teaching on organic transplantation from one living person to another. In the 1950's, initial reactions from the pope and from the theologians who most closely followed him in their writings were quite skeptical, leading at first to a common opinion opposed to this action ; yet today there is scarcely anyone who would deny the licitness and even the heroic virtue involved in such a procedure. What should be noted is that most of the initial progress in transplants was accomplished before this favorable theological consensus existed within the Church. Nonetheless, neither the ethical spokesmen for the Church nor those within the medical profession can completely avoid the "emban-assment" of this time lag, for one is not always prepared philosophically and theologically to react both swiftly and maturely to new biomedical advances. This state of affairs creates certain pastoral demands pertaining to personal study, methods of decision-making, and the development of a personal ethic. First, it is more apparent than ever before that it is essential to be well informed on newer developments in the principles and methods of medical ethics, as well as in the varieties of opinions offered on a particular problem area such as the definition of death, informing the dying, human experimentation, genetic counselling, and the like. Every clergyman or chaplain must know the experience of not having the full answer at hand and having to rely vet-y much on his own study,
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reflection and insight to assist others in their attempts to make responsible decisions. Second, because the medical situation is changing rapidly and the ethical responses are in many cases tentative, the art of ethical decision-making becomes important. It is essential that we become sensitive to the contingencies and variables involved in the ethics of medicine. To arrive at a reasonable solution for many questions, good ethics focuses very much on weighing the beneficial against the imperfect. For example, when not all the desirable goals can be achieved in a marriage without some conflict of values, what measures ought to be taken to control the powers of reproduction? The questions of contraception, seterilization, fertility testing and treatment of infe>i:ility are very complex, involving many deeply felt human values and aspirations. Only one who is sensitive to these values in their human context and to the requirements of personal responsibility will be prepared to facilitate wise decisions by those faced with difficult problems of ethical decisionmaking. Third, the present situation calls for the development of a refined personal ethic on the part of those dealing with the ethics of life and death. Even firm and unambiguous codes of ethics or ethical directives can neither guarantee nor take the place of "the ethical physician," "the ethical nurse," "the ethical hospital administrator," "the ethical patient," and so on. The goal of medical ethics is not simply the development of a policy which can be admired, but rather the enhancement of real, effective goodness on the personal and social level. Ultimately, it will depend on the individual decision-maker and his own ethical values as to whether this will actually be achieved, especially in a period when the the01¡etical ethics on many topics develops slowly and offers differing opinions. The chaplain and the clergyman, through their pastoral service and their own personal religious and moral resources, can be powerful agents in assisting the development of a personal ethic on the part of the professionals and patients involved.
II. NATURAL LAW AND SCRIPTURE There is a great deal of controversy today over many issues in medical ethics. Most of the normative principles which
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come to us in traditional Catholic medical ethics have been conclusions drawn from a natural law theory, or from "the law of reason." This method has been an attempt to know the will of God through his work in human nature, so that a corresponding conformity to the "law of nature" might assure conformity to the will of God. Prime examples of this have been in the area of sexual ethics, where respect for the "purposes of nature" has led to the absolute prohibition of certain acts which frustrate the natural (in the sense of physical) purpose of the act, such as contraception and sterilization. The natural law tradition has provided a solid basis and firm norms in a long-standing tradition of medical ethics. But in the past 15 years or so, serious questions have been raised about many of the presuppositions and conclusions of the dominant natural law methodology. For the most part, theologians and other ethicists have not concluded that the natural law approach should be rejected, but that it be reformed so as to incorporate other truths about human nature and man's relationship to God. A re-thinking of natural law ethics has been stimulated especially by newer insights gained from scriptural studies. An examination of the relationship between natural law ethics and biblical ethics should be of assistance in understanding the elements of Christian ethical decision-making in the area of medical ethics. Some leading theologians in the 1950's and Vatican II in the 1960's called for a renewal of moral theology based on the Scriptures. The attempts to base morality on the word of God are well known, and have resulted in a renewal of religious education. While Scripture has immeasurably expanded our ethical vision of man, its use has also pointed out that the answers we have relied upon in natural law teachings are not always so adequate and incontrovertible as we may have thought. For example, while the natural law teachings have been based predominantly on the notion of man as created, the New Testament places a great deal of emphasis on man as redeemed. The law of grace enjoys a certain primacy in man's pursuit of the ethical. God's call to man and man's personal response in grace are more than beautiful truths: they can and do create their own imperative which cannot be adequately ex-¡
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pressed in any ethical nmm elaborated by Church or society. A set of nonns is needed to remind us of our sinfulness and weaknesses and to assist in the educational process of fotming a social moral force against sin in the world. For instance, unless a social group (whether a church or a secular group in society) subscribed to a n01m in defence of innocent human life, there may not be the social solidarity and moral pressure needed to withstand the selfish anti-life forces in the world. Yet it would be mistaken to believe that the Bible systematically proposes concrete notms all of which are valid for all times and which can answer the medical dilemmas of today and tomorrow. The New Testament does not present a systematic normative ethic as a fundamental guide to Christian living, but a religious message of salvation-and that message is that the kingdom of God is at hand and that the merciful God offers love and salvation in his son Jesus Christ. Christ was not one whose t.a.~k was to perfect the moral laws as such; but rather, he invited all men to subject themselves, their lives, their actions and their ethical norms to the one law of love which was his first and greatest command. Nonetheless, the ethics of Jesus did find expression-especially in the apostolic preaching-in concrete ethical demands, such as the need to avoid gross indecency, gluttony, and improper use of potions. The nonns were, in varying degrees, historically and culturally conditioned. The New Testament writings did not create a new system of ethics nor did they set out to change social conditions and social institutions, such as male dominance, oppression of the laboring class, the meaning of marriage, etc. Instead, the preaching of the early Church attempted to subject to the radical demand of love the historically conditioned cultural and religious norms which were known at that time. In this way, it was possible for the New Testament preachers to take a stand on which concrete demands should be made of Christians in their historical milieu by their life of faith and love. All directives and admonitions were considered an application of the more basic and unchanging law of love to the life of those times.
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Consequently, some scriptural norms "withstand the test of time" and some do not. A universal and lasting norm. is the moral demand that the relationship of spouses should perfect itself in love, and that the consequence of true love is an unconditioned bond of fidelity. In this respect, what was judged good behavior for the first Christians also has an abiding importance for our age, according to the radical demands of love. A more culturally conditioned norm which has not withstood the radical demands of love is St. Paul's directive that the wife be subservient to the husband. If the natural law medical ethics of today is to be Christian,
it must be subject to the same methodology. It must enter into the unceasing process of subjecting various medical procedures, health care measures, and research efforts, together with our present-day medico-moral standards, to the radical demands of love. New Testament models for Christian behavior may shed some light on the contemporary question, but on the other hand they may leave most of the search for ethical norms to the Church of today which is living in the midst of various societal value systems. The individual in his own moral life and the Church in a more corporate way will be able to take a moral position on the issues of life and death even if some of the norms have to be formulated in a somewhat tentative fashion. An example of the impact of this "biblical methodology" on modern medical ethics can be seen in the Catholic Church's judgment on organ transplantation, particularly after kidney transplantation became feasible in 1954. After the procedure was frowned upon by Pius XII in the 1950's-apparently because its justification through the principle of totality (the only relevant principle Pius seemed to be aware of at that time) might open the door to the manipulation of people and their parts for national and social purposes-many theologians justified transplantation inter vivo8 by subjecting the concept to the demands of love. They concluded that it was a licit and even praiseworthy action because it was an expression of those bonds of love between donor and 1¡ecepient which incline the donor to do for others what he would want done for himself. Many contemporary problems in medical ethics find little explicit clarification in Scripture. Organ transplantation was
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unknown in those times and behavior modification could not be manipulated as today. Scripture teaches the sacredness of human life but gives little help for the practical decisions about the use of "extraordinary means" for preserving life. However, the ethic for the newer problems is not completely lacking today: it is to be found among the works of contemporary philosophy and theology, in the scientific literature, and in the pastoral reflection on the impact of certain kinds of behavior on Christian life today. A scripturally inspired medical ethics would turn to contemporary wisdom of any sort, subject it to the radical demands of love in the light of similar scrutinies in the Church's past, and then courageously propose a type of behavior which will serve as an ethical orientation for our times. This methodology is not just one to be pursued by the theologian in a theoretical way, but also by pastoral persons in concrete cases. Without in any way belittling the process by which we arrive at legitimate moral norms, it can be said that a courageous scrutiny of difficult problems in medical ethics under the clarifying light of the demands of love can also give us a concrete (or "situational") awareness of values, violations of values, and an indication of preferred courses of action. This would be particularly true in such areas as the right to informed consent, the primacy of the good of the patient over the preferences of the physician, and the dignity of the retarded. Complex philosophical reflection is not an essential requirement in the determination of all good principles in medical ethics. Ill. MEDICAL ETHICS AND THE MAGISTERIUM
The Church does not rely solely on Scripture and contemporary ethics for its understanding of the ethics of medicine and of the life sciences. The Catholic Church also relies in a special way, though not exclusively, on its officially designated teachers and their magisterium, or teaching office. The largest bulk of papal teaching on medical ethics was issued by Pius XII, who spoke on such widely scattered topics as organ transplants, prolongation of life, lobotomy, artificial insemination, abortion, natural childbirth, and the shortening of life through use of drugs.
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It should be noted, however, that there is a legitimate development of ethical doctrine within the Church. For example, teachings¡ on the morality of war have varied greatly, papal teachings on usury has been abandoned, and 19th century papal utterances on religious liberty could hardly be reconciled with the statements of Vatican II on the same topic. The ethical teaching of the Church's magisterium is historically and culturally conditioned, though in some instances the truth of its teachings obviously withstands cultural revolutions and historical developments. Certainly it would be a mistake to accept a doctrinal assertion as unalterably true simply because it appears to be traditional and has been taught by the hierarchy. Catholic teachings in medical ethics are particularly subject to change because of the limitations of the competence of the Church in giving a definitive ethical word on matters scientific. Thus, changes have occurred in "Catholic thought" as theologians have become better informed medically. But the devel. opment of Church teaching is also served by new theological insight, for hierarchical teaching is always dependent on theology for a religious and modern interpretation of the modern world and its problems. A "traditional" magisterial teaching may not be a definitive teaching and usually is not binding in an absolute way. The papal teaching opposed to direct sterilization, for example, has a relatively short history; it has been less forcefully taught in the past as compared with papal condemnations of contraception; and it is more highly qualified nowadays even by the more conservative moral theologians, so as to permit sterilization in more instances (after childbirth, in danger of rape, in cases of psychiatric disorder, etc.) . The obvious development in the Church's understanding of the ethics of many medico-moral procedures helps in understanding why the formal binding power of normative ecclesiastical statements is something less than infallible. They should be taken seriously due to the seriousness of the question and because of the importance of these teaching functions within the Church. But it should also be acknowledged that these norms always carry with them a characteristic of tentativeness--a
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certain provisional quality which means that they are neither absolutely certain nor are they arbitrary and unimportant. They are assertions by a Church teaching authority which knows it ought not be silent in the face of an important issue, and yet knows it cannot give the final word. It is a 1¡eligiously motivated assertion of a moral insight "according to the best lights" of the magisterial authority. The teachings of the official magisterium on questions of medical ethics will never achieve their purpose unless they are set in dialogue with other persons and groups within the Church and within society, such as medical and hospital personnel, patients, potential patients, etc. To claim for these teachings the full force of law or the compelling finality of a revelational-doctrinal assertion is to block their reinterpretation, stultify their moral application, an<\ conceal their real ethical value. It is important to regard the Church as an open "system" in whicl! many diverse factors work together both for the clarification of our faith-consciousness and for the development of principles and norms for our moral life. In the past it was often said that debated questions in the field of medical ethics were settled and no alternative options we1¡e realistically available if a statement of a pope, particularly the decrees and allocutions of Pius XII, were found to take an explicit stand in the issue. Since the issuance of Hurnanae Vitae, however, the hierarchical statements of many national episcopal conferences and studies conducted by Catholic theologians have made it clearer than ever before that a position of dissent from non-infallible papal teachings is legitimate under the following conditions: (1) that the one who dissents have competence or experience in the topic under consideration (but this should not be inteqn¡eted to mean that dissent is only possible for the elite) ; (2) that he have good reasons arrived at after serious study and reflection; (3) that he continue his investigation and not consider his opinion in any sense definitive; ( 4) that he retain his respect for the teaching authority of the Church and give full religious respect to the "authoritative" teaching of the hierarchy; ( 5) that no undue harm be done to the life, well-being or rights of a third party; and (6) that he take whatever steps are needed to
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avoid scandal-which is not the same as avoiding anything that causes surprise or amazement on the part of others, but rather means that precautions be taken to prevent this exception from causing more harm than good, so as not to significantly hinder the moral welfare of others. ¡The clarification of the right to dissent in recent years helps to establish a new atmosphere for the pursuit of medical ethics, for we now acknowledge more honestly that the analyses and conclusions of yesterday are not necessarily true in every instance and for all times. But the counselor, advisor, or teacher should be aware that in many ways the explicitation of the right to dissent in good conscience only opens the door to a host of new questions. Irresponsible dissent can roll back the force of human values which required centuries to develop, such as a respect for the sacredness of human reproduction. Dissent-with-ease can encourage professional and institutional abuses, such as sterilization of "undesirables." Those who know of the right and responsibility to judge the applicability of a directive in medical ethics may easily overlook one or the other criterion for legitimate dissent; thus the need to avoid undue harm to the life, well-being or rights of a third party might be neglected in an abortion case. We have come to the end of the Vatican II period of the discovery of dissent-a heady era which opened many eyes and started a vast renovation of much of our moral theology. Now there is need for an honest scrutiny of the social and ecclesial effects of dissent, as well as for a more thorough education concerning the limits of dissent, so as to avoid or at least minimize abuses. But abuses in making exceptions to the norm do not rel)love the right and the responsibility enjoyed by patient and physician to make conscientious judgments in a context of freedom, just as abuses in the enforcement of norms do not remove the need for official ethical policies for ecclesiastical institutions. The need to strike a balance betwee these two claims is certainly the major problem in the medical ethics of health care institutions today. Much more consultation, dialogue, study and reflection are required to advance knowledge and promote wisdom in this area.
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IV.
TOWARDS THE TOTAL GOOD OF THE PERSON
The "natural law" upon which Catholic medical ethics has relied is not so much a body of principles and norms about human nature as it is simply a moral methodology for understanding man and his moral life. The natural law methodology has been subjected to some uncritical uses. For example, to assume without further ado that what corresponds to the physical and biological "laws of nature" is also required by the moral laws of nature results from a narrow view of human nature which is too exclusively preoccupied with the physical. This view of human nature is erroneous because it fails to give sufficient importance to the moral law as a law of reason. It is only through the use of reason that man can discover which goals in life are the preferred ones, which values are to be given precedence, and which actions are going to be judged contrary to the good of man. Man's reason makes it apparent that man is more than physical parts, physical faculties and physical acts: human nature is the entire person-physical, psychological, spiritual and social. In fact, this is the major trend in natural law thinking today: the trend away from the isolated act analysis toward judging morality in terms of the total person and the total good of the person. It can be quite misleading to categorize acts as right or wrong in the abstract simply in terms of how they are physically describable. We are speaking of the negative moral absolutes ("thou shalt not ... "), which are principles according to which a specific external action, defined in physical, nonmoral terms, may never be used as a means, no matter what the circumstances or end in view. The implication is that there are certain acts which, if used as a means even to a good end, are always immoral. The problem is whether it is really true that a specific external action, defined in physical, non-moral terms can nev.er be used as a means no matter what the circumstances and the end in view.
An example would be the act of killing, or more precisely the direct killing of an innocent person. The act of shooting ¡ a person cannot be called morally wmng unless some moral
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circumstance is added. If done as an unjustifiable act of aggression it is an illicit act of violence; whereas if done in self-defense it would be licit and even virtuous. The ethical quality of the act should not be judged simply on the basis of its physical description, but also as informed by a certain motive. Theologians are more inclined now than in the past to give weight to the motive or intention as an important and sometimes determining element of morality. The move a\vay from the isolated act--isolated both in terms of physical description and intentionality-is also seen in the trend to judge actions in terms of their effects or consequences. A mere consequentialism should be avoided, if by this we mean that one does not know whether an individual act is good or bad until it is completed and one measures the good that has been accomplished or the harm that has been done. But there is also a traditional and more valid consequentialism, which groups together acts of a certain kind and, in light of the ethical and specifically Christian values involved in the total moral context, judges their ethical quality from consequences. For instance, the most predominant explanation given for the traditional disapproval of non-marital sexual intercourse has been that of St. Thomas Aquinas which was based on consequences. The non-marital sexual union is transitory, and because it lacks a permanent bond, of its very nature it would deprive the children who might be born of such a union of the proper conditions for their up-bringing. Thus, the ha1mful effects of "fornication" on the "education" of possible offspring is the determining moral reason. A conSâ&#x201A;Źquentialism must necessarily be employed in judging the morality of some of the newer, relatively uncharted options that are or soon will be before us. For instance, we do not yet know how in vitro human fertilization or asexual human reproduction will affect the values of family life, nor do we know the full significance of the love of natural parents for the child. According to some, there already exist good reasons for excluding these procedures; but it would seem that a moral judgment on them would be more solidly based and more reasonable if more were known of their effects. At the very least, this example shows that the natural law cannot be considered a
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predetermined set of moral principles known a priori. A law of reason, especially if it is to establish reasonably a priori norms, must rely more on the a posteriori experience of human behavior. A more common case can be given as an example of the need for rethinking our ethics in view of the total moral situation, including the consequences. The Ethical and Religious Directives for Catholic Health Facilities (1971) states in par. 16: "In extrauterine pregnancy the dangerously affected part of the mother (e.g. cervix, ovary, or fallopian tube) may be removed, even though fetal death is foreseen, provided that: (a) the affected part is presumed already to be so damaged and dangerously affected as to warrant its removal, and that (b) the operation is not just a separation of the embryo or fetus from its site within the part (which would be a direct abortion from a uterine appendage), and that (c) the operation cannot be postponed without notably increasing the danger to the mother." Thus, the organ or part where the pregnancy is located may be removed even when this involves the death of the fetus, but the fetus itself may not be removed in such a way as to leave the reproductive organs undamaged. When one considers that the Catholic ethical system has forcefully sustained the obligation of openness to new life, it is rather paradoxical (though admittedly not inconsistent) that of two cases involving the death of the fetus the sterilizing procedure is approved, whereas the one which retains the possibility of future children is rejected. Theologians today would particularly criticize the exaggerated distinction between "direct" and "indirect" involved in the Directives' solution. It should be noted how the above cited paragraph focuses moral intentionality on the correction (removal) of the "dangerously affected part" and makes the more consequential danger (to the mother) seem rather secondary. ¡ ¡The trend in contemporary medical ethics is clearly toward seeing the. total good of the person as the overriding ethical criterion. Thus, the principle of totality, in contemporary moral literature, is not so exclusively defined in terms of seeking the good of the physical totality of mar1, but directs our
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moral concern toward the wtal good of the total man-physical, psychological, spiritual and social. If this more wtal view of man were an acknowledged part
of official Catholic ethical Directives, the total fertility of the woman cited above might have been accorded a higher priority. So too, cases in which a woman cannot sustain future pregnancies should be judged in terms of the woman's total effective fertility (which has ceased, since viable life is not possible) and in terms of her total welfare (which should indicate that a responsible recourse to sterilization might well¡ be extended beyond the present limits imposed by the current official interpretation of the meanings of direct and indirect sterilization). CONCLUSION
Moral theologians are not always in agreement on matters in medical ethics that seemed quite settled less than a generation ago. As this article has tried to indicate, the reasons for today's pluralism of thought within the Catholic Church are found at the very roots of ethics-how it is affected by Scripture, how it is qualified by the magisterium, and how it is given new directions by contemporary views of the meaning of man. While a review of this kind may not solve many specific problems, a deeper understanding of these developments of thought in medical ethics should be a good preparation for facilitating and assisting responsible ethical decision-making in today's world of medicine and health care.
Andre E. Hellegers, M.D.
Some Thoughts about Medical Problems {or Catholics A distingltished obstetriciwn. asks whether the new Hospital Code fails to speak to the problems of contemporary medicine. If there is not enough communication between theologians and physicians, the fault is more that of the medical profession than of the theologians. It is always easier for a doctor to get to talk in a seminary than it is for a theologian to get to talk in a medical school. As an obstetrician, I feel that the new Catholic Hospital Directives fail to recognize the changing nature of medical practice. I personally think that they are excellent Directives in a medical context in which a patient directly chooses her own physician in part for his skill, in part for his bedside manner, and possibly in part for his value system. In this same context the obstetrician would then choose a hospital directly. He would choose it for its value system, its facilities, and for all the other reasons. This hospital often would be provided for by a denominational community. In the context of a vertical choice system, things would be fairly simple and Directives fairly easy to follow. 295
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The new problem that faces us is that this choice has become much more complicated. For instance, we have developed group practices-two or three doctors working together-so that, for instance, you may never know the doctor you are going to get on the night you deliver. It depends on the doctor who is on call that night, or that weekend. So now you are no longer in a one-to-one relationship. We have developed group clinics where you do not even go to a given doctor, but you buy a horizontal concept of group service; here, by virtue of your insurance, you are referred to some doctor, not necessarily of your choice. The choice is no longer totally yours. We have developed horizontal affiliations between institutions; affiliations in which house staffs in one institution rotate to another. They are then subject, in the course of their training, to the rules and regulations of Administrators, Boards of Trustees, and of others who may have diametrically opposing views on what is or is not ethical. The physician is no longer being taught as an apprentice by one doctor whom he appt¡eciated. He goes into a hospital he thought he appreciated, and finds that he is rotated to a number of other hospitals, some of which he may not appreciate at all. We have an additional problem in the establishment of government health care centers which, in a sense prevent a poor man's ever being able to hire and fire his own physician. And if one is a poor person, stuck into a system like that, the free choice of a physician is really not there. We are in the process of establishing pre-paid insurance plans. We ought to start thinking right now what will happen when a patient through a pre-paid insurance mechanism contracts with a particular physician or a particular hospital for all services. The technical question then becomes whether we shall sublet some of the contracts, some of the services to other hospitals or doctors because we cannot or will not render them. Or shall we render them? And if so, which? As we know, the federal government is developing a direct legal interest in hospitals through help in funding construction, establishment of intensive care units, etc. In my opinion the
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question we now face is whether we should get out of health care voluntarily or whether we will be forced out of it before we change some things voluntarily. All that I have said spells out one thing. We are witnessing the death of private practice, the one doctor-one patient relationship. With it will come the death of the new Catholic directives. Let me turn to a few specific problem cases. It has already been asked what to do when there is no plurality of choice for patients. This is a problem which is upon us, as in the State of Alaska, for instance, in which an isolated hospital in an isolated area, county-owned, staffed by an order of sisters, is suddenly faced with a state which introduces an abortion on demand law. How do they now act? This is what some of the problems are going to be about. The physician's problem is a well known one, which many have gone through. For instance, when you happen to be the only obstetrician on an Air Force base, what is your moral freedom of choice as to how you practice? I know of several cases in Britain in which obstetricians had to get out of senior consultant jobs in obstetrics and gynecology. They were expected, according to government rules, to countersign for various procedures done obstetrically, of which they disapproved. They either had to sign or leave the service. I suggest this is the kind of thing which will be increasingly upon us. TOWARD A NEW SOLUTION
If these are some of the problems we must start to face as physicians, and if pressures will be put on Catholic hospitals, then one might start asking "How do we solve some of these?" I would like to say, first of all, that I can see a considerable difference between what practices might be in the obstetrically acute, emergency, case, and in what we call the elective case. Let me give you an example of that. A woman came to Georgetown having had ten children and three miscarriages. Her particular problem was that for the last three pregnancies she had intrauterine fetal growth retardation. The fetus did not grow well in the uterus. She was exremely obese. There were problems in determining precisely how far pregnant she was. Her physician in town suggsted she come to Georgetown because we
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had the facilities for diagnosing how far pregnant she was. We _had also received from the federal government a pediatric intensive-care newborn nursery with the latest equipment. It was considered logical that we would be the establishment to which to go. When she first registered in our hospital she requested to have a tubal ligation after this eleventh child. It was immediately said emphatically that at Georgetown we do not do sterilizations and she would have to go elsewhere. After a lot of talking back and forth, the following decision was taken: she would deliver vaginally at Georgetown and, having delivered, and used our obstetrical and pediatric facility, she would then go to some other hospital and get her tubal ligation six weeks post-partum. On that basis we said "fine." We don't need to sterilize her; yet we can offer her the facilities. She agreed. We hadn't foreseen what would develop. This was a lady with chronic hypertensive vascular disease who suddenly developed superimposed Preeclampsia. It turned out to be uncontrollable. The problem now became that the fetal heart became irregular, and the situation was that, at that point, we felt we had to do a cesarean section. We took a cesarean section operation permit to her and she said, "Oh no you don't, unless you tie my tubes at the same time." The situation now became quite different. We were now no longer in an elective situation between her and us. Different, patticularly, because she said, and she was medically right: "Why should I undergo two abdominal operations within six weeks just simply because of your religious feelings?" Well, we discussed it and we transfetTed her to another hospital where she had a cesarean section and a tubal ligation. I do know that on the way to the other hospital that fetus might have died. I suggest to you that, at that point, a malpractice suit might have been brought against every obstetrician involved in the case, and against the hospital. I think that case would have been adjudicated as malpractice, a practice not compatible with those in the community. It would have been pointed out that there was no medical contraindication to sterilization here, and that, as a matter of fact, it was malpractice: a) to subject her to two operations in six weeks and/or b) to cause a fetal death. I would suggest, further, that I would have gone to court and
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said that this was malpractice. Now is this malpractice justified on religious grounds? So, as we begin to develop our thinking on the subject, it would be unfortunate if we could not distinguish what is the acute situation in which free choice does not exist on the two sides, and the elective kind of situation where there really is no reason why we should do a procedure rather than someone else. We ought to ask the ethlcists whether, in fact, legal implications of this order do have moral import or not. THE NEED FOR CLARITY
I would hope that whatever rationale would be developed for doing certain procedures would at least be based on principles that are understandable to all physicians and all men. I hope that we do not come up with some kind of solution that says it will be all right to sterilize providing she has pain in her left ear or right toe. I do not think what is called for at this point is a determination of what are the obstetrical conditions under which, yea or nay, .contraceptives may be given, or sterilization performed.' I think that is much better left up to us professionals. But I do think it important that we develop a logical statement by which it can be explained to people in general why it is that we might be forced to do some of these things, and what the governing theological principles are that would make us behave that way. I suggest quite simply that if the explanation for practices in Catholic hospitals cannot be reasonably and logically explained to physicians, then there is danger of giving very serious scandal. If theologians cannot explain it to doctors, don't expect us to explain it to the patients. If we are forced into a situation of providing services (which we do not presently wish to provide) by virtue either of government funding or other legal mechanisms, then one may ¡rightfully ask where approximately might lie solutions to these things. I am aware that there has been a long tradition in the Catholic church about the theology of cooperation. Let me suggest simply that if one looks at a series of textbooks on morals and medicine, I detect a reading of the ethics of cooperation as always being vertically structured. That is to say, there is up
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there a primary decision maker and the primat-y moral decision lies with him. The anesthesiologist sits up at the other end from "where the action is." It's not so grievously sinful for him to give the anesthetic while somebody else ties the tubes. We then become increasingly paternalistic as we go down the line. The resident just works here. The intern is just standing by. The nurse is in no place of importance. What I am saying here is that as I read the theology of cooperation, it is a rather vertically structured system in terms of people having decreasing responsibility for what goes on. That is quite proper in a medical context where the choosing of physicians is a vertical choice, as I described it at the begining. I think it becomes high time that in theology, at the level of private cooperation between group practices of doctors, and of hospitals, in this country, we should strive to develop a horizontal theology of cooperation. The kind of thing which will discuss my problem is one of the three obstetricians on an Air Force base. If Mrs. Jones has contracted with my colleagues to have a tubal ligation, then what should I do in an emergency when I am on call? Am I then the primary decision maker, or am I at this point in a situation of non-primary responsibility? Let me suggest that this kind of analysis could also be made horizontally between institutions. And I would like to offer a case example. One year or so ago, a judge in Washington, D.C. ordered the District of Columbia General Hospital to perform some abortions. It was a Court Order. D.C. General Hospital fought it and lost. Now D.C. General Hospital has an obstetrical service which is shared by two universities-Georgetown and Howard. The simple fact was that neither of the two services running the D.C. General Hospital wanted to do abortions on demand, while the court, in essence, ordered the hospital to do them. We simply worked out a scheme of setting aside one operating room and one recovery room. The city hired a couple of people to come in and do abortions every morning. They hired their own nurses and anesthesiologist. We took no part in the activity and we went right on with our work. It might have been argued that in the "good old days" we might have walked out of the city hospital and left it, because of these dire practices.
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We were faced with that question and we said: "Not on your life. Why on earth should the poor women of Washington who want to have their kids pay the penalty, and be deprived of our help, for the fact that some other women don't want them. We are going to stick right in there. We won't do any abortions, and let some independent service do it." I want to bring out that in this horizontal arrangement between doctors there may be problems about what degrees of cooperation exist. There may also be such problems that exist horizontally in cooperation between institutions. Then comes the obvious question of scandal. I do not know how to handle that problem. There is one way I know that one does not handle it, and that is to refuse to talk about the subject; to keep on being silent about it and yet to know the problem exists. It is much better to make people fully informed on the complexity of all these problems; then they won't be scandalized so easily. I think the worst thing is to not dare to tell the doctors what the problem is if you are a theologian ; and to not dare to tell a theologian if you are a doctor. That way games get played till one gets caught by an outsider like the Federal Government. I think that, in a difficult situation like this, the first thing to do is to try to get things out of your own hospital and sublet and subcontract them to some other place. I wonder whether we will have to do that with subcontracting in pre-paid health insurance plans. Without a doubt this will involve contraception and sterilization. Let me summarize this aspect: I think the Directives are good and well as they stand for the medicine that was. I think they will rapidly go out of date, if they are not already out of date, for the medicine that is beginning and will be. I suggest that unless in some form we manage to work out the problems, then indeed either we leave the hospitals or we will be forced out. I fault the Directives in that they pretend there is no problem when doctors and administrators know there is. A BROADER VISION NEEDED
Now I would hate to see us forced out of medicine on these grounds, because I would just simply hate for the Catholic Church to have to say that the only way we can bear witness to
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Christ in medicine is below the umbilicus. And yet that is the way in which it heavily comes through. About 15 out of 43 Directives deal with obstetrics and gynecology. I am really looking forward to the next set of Directives that will say something meaningful about the care of the poor, or about average fees or the teaching duties senior doctors have toward interns. Maybe also about doctors' teaching duties toward nurses, in which a little bit of time is spent with the nurse to explain instead of just leaving orders. Something might be said about rights of employees before the unions force it on us. It might be nice if we did it before we were forced to. Something might be said about the segregation of patients. Something might be said about a white woman who comes into an obstetrical service and has a semi-private room to be shared with another patient who is a Negro. There is another room next door in which there is only one Negro, but two beds. The obstetrician comes into the chief and says: "Would you mind getting the Negro patient out of there and sticking her in with the other Negro patient, because my lady happens to be a very wealthy suburbanite and is terribly upset about having to share a room with a Negro patient." We might say something in the Directives about other forms of segregation. We might say something about what to do with a physician who lets his interns on the obstetrical service do pelvic examinations on his white patients except when the intern happens to be a Negro. Perhaps there ought to be a directive someplace which says something about these kinds of things. I would hope to hear the argument which says that if you do not obey papal encyclicals or bishop's directives in areas of social justice (Qwulragesimo Anno, etc.) that is vet-y bad because it will automatically lead to masturbation, euthanasia, and things like that. Right away we say if you masturbate, it leads to contraception, which leads to abortion, which leads to infanticide, which leads to euthanasia. I never hear much about the automatic dire consequences of not going along with encyclicals other than Humanae Vitae, especially social justice ones. I am appalled, as an obstetrician, that in 1972 we should
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lump masturbation, contraception, and abortion together, when the latter is killing, and the former are not. I would have thought that ldlling was slightly more important than masturbation. I would also add something about a complex problem, something for which I have been rebuked by cardinals, bishops, and others. If you really believe in Hurna1111e Vitae, as a document, it clearly states in there somewhere or other that as doctors we should make the rhythm system work. I can tell you that making it work depends on our financial resources. Where are the funds to make it work? They are sitting in the federal kitty. Where are they sitting in the federal kitty? In the budget of the National Institute of Child Health and Human Development. Where is it sitting as a line item in its budget? It sits within the Center for Population Research. And the line item in there is entitled "Contraceptive Development." Now what does contraceptive development mean? It is the section of the NIH activity which goes into the whole of endocrinology, the whole of the menstrual cycle, sperm survival, ovum survival. Whether you are interested in bringing sperm together with ovum, as in curing sterility; whether you are interested in destroying the sperm, as in some male contraception, whether you are interested in destroying the ovum, as in some female contraception; or whether you are interested in making the one avoid the other, as in rhythm-the fundamental biological knowledge needed is the same. It is expensive research. It is protein chemistry, enzymology. It demands large scale funds. I get a little tired every year of going to the appropriations committee and testifying in favor of these funds as I think I should if we are going to get this problem solved. Then I get letters fmm bishops and .others saying, "How dare you go out and testify for contraceptive development?" Then I have to write five pages back that gently explains the facts of sperm and ova, and that, if perfect rhythm is to be developed, these are the funds which must be appropriated. I would suggest to you that a great many problems of this below the navel morality would disappear if we did our work in getting the funds, raising the money, doing the research. If we don't do that, then certainly on some other problem fif-
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teen years from now we will be right back holding another emergency meeting on Catholic Hospital Directives-on other issues. I realize I have not restricted my comment to Directives foâ&#x20AC;˘Âˇ Catholic Hospital Facilities only. I have talked of problems of Catholic doctors, Catholic patients and of hospitals. I have done so on purpose, for the problems although not identical, are intertwined and can not be totally separated. The Directives are but one facet of a much more general and serious problem. It is a problem of non-communication between the suppliers and consumers of only one product-medical carewhich should go into the development of the whole person. Regardless of how much consultation is alleged to have occurred between bishops, theologians, administrators and doctors, the fact of the matter is that there is none. There are bodies pasing motions and others writing paragraphs. What we need is prolonged, daily contact and joint study. It seems to me that only then can we produce catholic directives (note the small c) instead of slicing a person up into a soul and a body, and, at that, one body below and one above the umbilicus. We will need structures of communication which are functionally much more real and permanent if we are not soon to be without hospitals as we fear being without schools. In Europe the church is still wondering how it lost the working classes. I hope in the U.S. we will not wonder in 50 years how we lost the health professionals.
Richard McCormick, S.J.
The New Directives and Institutional Medico-Moral Responsibility The new ethical code for Catholic hospitaL,: a critique. I would like to describe the Catholic hospital of the past and the Catholic hospital as it exists now. I speak from the viewpoint of moral theology as one moral theologian sees it. First with regard to the past. The Catholic Church, since its beginning in N 01th America, has been concerned with the welfare of the sick and the extent of this is evidenced by the vast network of hospitals that stretch across the country-some 775 Catholic hospitals. This has been made possible by the generous efforts of staff and religious. Now what was the purpose served by these health facilities? Primarily it was a desire to witness to the continuing concern of the Church and Christ for the ill as well as to insure that medico-moral standards demanded by his gospel would be put into the practice of medicine. Now the function of a code is to facilitate that overall mission: to aid the achievement of these goals by providing a normative statement of what we believe the gospel of Christ demands in this particular area of human concern. To a large extent the existence of Catholic hospitals in this country is due to the fact that the Church was the only social group either willing and/or capable of discharging the function of caring for the sick. And by the Church I mean the larger group than just the Catholic Church-the Churches. The function was then seen as an act of charity and mercy and not an 305
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act of justice concerned with the rights of the patient. We were reaching out with Christ's kindness to the sick. In such circumstances Catholic facilities were Catholic in several senses. They were built very often with Catholic monies. They were operated by the contributed services of Catholic religious. They were staffed very heavily by Catholic doctors. They catered to a heavily, though not exclusively, Catholic clientele. They followed Catholic moral policies. You may recall that as recently as 15 or 20 years ago, moral theologians in the Catholic community debated the moral legitimacy of inviting a non-Catholic minister to the bedside of a dying non-Catholic patient in a Catholic health facility and often found extreme difficulty in justifying such a practice. Institutional responsibility was read according to a parental model. Other institutions such as universities were similarly operated. Circumstances made it possible to enforce Catholic policies in a Catholic health facility in a way which was compatible with good medical practice. And the circumstances were, briefly, these: First, a widespread sense of certitude in the Catholic community where medical and moral norms are concerned and a greater unanimity of judgment and feeling. This unanimity was supportd by juridical factors in the Church which did not encourage a fully free exchange of moral opinions and judgment. The second factor was the existence of laws in our society which buttressed many of the positions we had taken in our Catholic health care facilities. Thirdly, there often was an institutional and personal insensitivity to the idea of freedom of conscience enjoyed by those not sharing our moral convictions. Fourthly, there was a seller's market where staffing was concerned. Doctors were often in competition to be accepted in our facilities. Fifthly, there was a rich abundance of generous religious women staffing the offices and floors of our health facilities, therefore making them financially viable and autonomous. Finally, there was a ready cultural acceptance of authority and especially institutional authority and the imposed, so to speak, decision. A NEW IDENTITY
In 1972 the self-identity of the Catholic hospital has changed rather drastically because of the circumstances in which it
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finds itself. The change can be summarized in the following way. There are now many more community facilities then there were before. In these new circumstances, where our Catholic health facilities have opened up much more and became community facilities, they must face much more seriously than they were asked or bound to in the past the pluralism of the communities which they serve. I am not going to suggest that they should not have moral policies. But it does mean that we live in circumstances where the enforcement of moral policies is much more difficult and sometimes not even desirable. Circumstances are such that the parental model of responsibility in our institutions no longer obtains. The hospital is no longer a parental medico-moral decision maker. But what are some of the circumstances in which the Catholic hospital presently finds itself? I see them as the following. First, the financial. The practical necessity of the Catholic hospital yesterday is the practical impossibility of maintaining it privately today. The physical, medical and financial demands made by scientific advances are beyond the ability of any particular social group to bear. The support and maintenance of our Catholic hospitals has gradually shifted first to the community and then increasingly to the federal government. As the community assumes more responsibility for building, operating and maintaining our Catholic facilities it is naturally going to seek a stronger voice in their administration. Secondly, there is a decrease in the certitude surrounding some traditional medico-moral principles and even dissent in large segments of the Catholic community, to say nothing of the non-Catholic community. Thirdly, there is a sharp recognition of the fact that other traditions and conclusions can be a source of genuine enlightenment to the Catholic community, a fact that we were reluctant to admit in the past. Our Index of Forbidden Books would indicate this. Fourthly, there is an increasing recognition on our part as a community of the freedom of conscience enjoyed by those who do not share our moral convictions. There is a new readiness to take seriously the implications of honoring freedom of conscience in other people. There is a line to be drawn here, obviously. But it would be a shame for us as a Catholic community to honor freedom of conscience in others, but not allow
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them to exercise it in any way in our Catholic facilities. The next factor is the buyer's market in medical services. We are in competition for competent medical staffs and this is just the opposite of what prevailed before. Finally, there is a growing opposition in our culture to the imposed decision reached on a non-sharing basis. These factors put the Catholic hospital in a changed situation. One of the corollaries is that we can no longer impose our moral directives as we once could, nor is this desirable. The total good of the patient, as indicated by the Directives, is our basic norm, but this cannot be etched out of purely Catholic perspectives. A SHIFT IN RESPONSIBILITY
The circumstances in which we now find ourselves indicate, as far as moral guidelines or policies are concerned, that the responsibility has shifted to some extent from institutional and administrative overseers to the staff, the personnel, the doctor and the patient. Not in every respect. There are lines to be drawn where the public good is so obviously at stake that an institutional position must be taken. What I am suggesting is that Catholic hospitals are now in the throes of a transitionphase of their existence. They are in an institutional identity shift. This has already happened in our universities. Catholic presence in institutions has to be conceived in a different way. It is different in concept, aim and style than it was twenty years ago. And this will be true of Catholic hospitals. The Canadian Archbishop, James M. Hayes, addressing the Catholic Hospital Association in 1968, made some remarks that touch on some of the statements made by Cardinal Dearden. I would like to quote briefly from Archbishop Hayes' statement, because it indicates a direction, not a certitude or desirability: "It seems to me inevitable that as developments continue there will be no place for specifically Catholic hospitals in the institutional sense as we now know them. However, this does not mean that the purposes for which Catholic hospitals were established have ceased to exist. These purposes will have to be fulfilled. But this fulfillment will rest on the shoulders of the Catholic practicing medicine and not on the¡ shoulders of a Catholic administration. There is no reason why . Catholics
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should not have a role in caring for the sick. In fact, the role is essential. But it is the character of that role which is in question. Public authority will continue to assume more and more administrative and policy making responsibility. The bearing of Christian witness in the promotion of Christian ethical standards will be the responsibility of the staff and the practitioner. Moral judgment and responsibility will be taken out of the hands of a specifically Catholic administration and will reside in the individual Christian conscience. This poses fundamental problems regarding the orientation and the tone of any future revised code of medical ethics. It must clearly and forthrightly speak to the conscience of Catholic doctors and nurses. We must allow them the maximum possible scope for action in their professional work. It must show an unmistakable confidence in theit¡ willingness and ability to assume moral responsibility for their action." Now this is the type of problem, these the kinds of factors and perspectives that the three theological drafters of the new Hospital Code attempted to face as they went about revising the Code. This point can be made rather clearly if I read you from the dossier a couple of letters presenting typical problems that our institutions are facing. They arc serious and you are all familiar with them : A TYPICAL PROBLEM
"To give you a brief resume of our local situation, our hospital is one of four general hospitals in X city with a 175,000 population plus a surrounding five or six counties. We are the only Catholic hospital. This city's Catholic population is rated at two percent with a state average of less than one percent. "Last yea1¡ our admissions totalled 17,543 and only 488 patients registered as Catholics. The utilization of our obstetrical department has been a particular concern to us with its steady decrease in patients. We have confe1Ted with major groups of obstetricians who use our facilities and all state that the inability to do tubal ligations here is a major contributing factor to the decline in the utilization of this department. These men have a policy that the first patient to go into labor on a given day or night has her choice of hospital. The remaining patients must then go to that hospital. In the case where the
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patient is scheduled to have a tubal ligation done following delivery, the patient automatically goes to another hospital and we suffer the loss of that patient and a large number of patients who really would prefer our hospital. "We have considered closing the department because of declining usage. But several factors thus far keep us from doing so. One is that the state licensure procedure and requirements demand that a general hospital provide obstetrical care. This has already been tested in court and the hospital involved had to reopen its department. "Other factors are that professional and nursing students use this department as a necessary part of their educational programs and our program ranks highest in the state. The physicians are pleading with us not to close the unit because as they themselves admit, ours is the best department in the city and they all send their problem cases such as diabetes, toxemias, etc. to us. We advised them that we need routine obstetrical cases to balance out those costly cases because our present losses in the labor, delivery and nursery areas are great and cannot long be endured." THE HOSPITAL CODE OF ETHICS
Now that type of letter can be reproduced in many areas of the country. It is this type of problem that we tried to face in writing a Catholic Hospital Code. In trying to face such problems we concluded that it would be unrealistic to think that we should write into a composite Hospital Code something that would change papal teaching as found in Humanae Vitae and the documents of the recent magisterium. For one thing, that would be unacceptable to the bishops. Nor, more importantly, would it be necessary. Therefore, we felt we should write a Preamble that would state the circumstances in . which we exist, a way of interpreting in the light of circumstances of individual location, and so on. We were suggesting and spelling out the fact that far more often in the present than in the past will a Catholic health facility find itself in the position where it would be in a position of tolerating practices which its own Directives judged as morally inappropriate. The circumstances which led us to that conclusion are these: First, a shift in the notion of institu-
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tiona] responsibility due to the circumstances I mentioned. Secondly, the legitimacy of and respect for sincere and responsibility dissent within the Christian community. Thirdly, the moral pluralism of the communities being served. And fourthly, the utterly essential distinction between policy and enforcement of policy. The final version of the Code as we now have it, and especially the Preamble, is that, I presume, of the doctrinal commission of the Catholic bishops. It was an almost total reversal of the Preamble which we had submitted to the bishops. At this point my remarks will be a critique of the Preamble. The Preamble, as it now stands, does not face the problems of many of our hospitals. It is unrealistic in view of the situation in which Catholic hospitals find themselves. And it will not bear careful theological scrutiny. TWO OBJECTIONS TO THE CODE
I wish to spell out two objections. My first objection is as follows: The Code states: "The Catholic-sponsored health facility and its board of trustees, acting through its chief executive officer, further, carry an overriding responsibility in conscience to prohibit those procedures which are morally and spiritually harmful. The basic norms delineating this moral responsibility are listed in these Ethical and Religiou" Directives for Catholic Health Facilities." The categorical statement "overriding responsihility in conscience to prohibit" is simply not clear. The hospital in our circumstances is not a parent or a guardian. It is a facility. It is different from a home for delinquent girls or an orphanage. The primary, though not sole responsibility in a Catholic health facility rests on the people most directly involved-the staff of the hospital. The administrators, therefore, in my moral judgment, play a subsidiary role in terms of medico-moral decision making. If a patient and a doctor find themselves in a situation where they are doing something judged immoral by the Code, the administration certainly has obligations. But that these obligations are overriding and are always obligations to prohibit-this I question. What decision the hospital will make in these difficult circumstances has to be made in terms of the traditional teaching of
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toleration or cooperation with what we judge to be improper. Where more overall harm will come from the enforcement of policy, cooperation is justified. On the basis of the overriding hospital responsibility, the Code concludes as follows: "Any attempt to use a Catholic health facility for procedures contrary to these norms would indeed compromise the board and administration in the responsibility to seek and protect the total good of its patients, under the guidance of the Church." I think this statement is simply false. Even traditional principles of cooperation or toleration will not support it. I am not arguing that Catholic hospitals should abandon moral policies. Nor am I arguing that all must tolerate certain deviations from the Code. I'm simply insisting that to say that any toleration is out, as the Code does, is simply false. On the other hand, when you begin to tolerate things which you consider, according to your own moral code to be morally inapporpriate, where do you draw the line? If you will allow selective sterilization, why not abortions? There is a real and a delicate problem here and it would be wrong to minimize it. Conceivably, opposition against the Code on abortion could mount to such a degree and become so destructive that the Catholic health facility would be untrue to its basic mission if it did cooperate. At that point it should close its doors as a Catholic health facility. Thus, if either factually or legally we cannot operate a Catholic hospital without the widespread availability of abortions, we should get out of the business in that pat-ticular area. However, the more general problem of toleration has not been adequately faced in the Preamble. DISSENT IN THE CATHOLIC COMMUNITY
My second objection is that the Preamble does not take seriously or deal adequately with the phenomenon of dissent within the Catholic community. Sincere and, I believe, responsible dissent from Humanae Vitae is widespread in the Catholic community. The Code says at one point in the Preamble: "Any facility identified as Catholic assumes with this identification the responsibility to reflect in its policies and practices the moral teachings of the Church under the guidance of the local
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bishop." Several things are questionable here. What does it mean to "reflect in practice"? Does it mean that any departure is a source of scandal to the Catholic community? No. But it aU too easily reads that way. We know that toleration need not mean approval. Secondly, consider the statement "the moral teaching of the Church." This is, I submit, increasingly ambiguous as a phrase. If dissent is taken seriously within our community, it cannot be ¡viewed as paternal eye-shutting to the errors of an immature child, something just to be tolerated. It must be listened to. Reflective and prayerful dissent is the beginning of new evidence. If large segments of the Catholic community find certain aspects of a particular moral teaching unacceptable, this must be taken as a source of new evidence. Otherwise, we have ruled personal reflection out of order in the teaching-leaming process of the Church and compromised our own growth in understanding. We have to come to grips with this and it does become delicate. To continue to refer without qualification to the moral teachings of the Church is to give the word "Church" a rather one-sided, unrealistic meaning and to view the teaching-learning process in our community in exclusively juridical terms. Dissent is not simply a legally tolerable thing. It is something which we should with appropriate humility welcome as a new source of understanding. The Code does not face up to the magnitude of this problem as we are experiencing it in the Catholic community. The present Preamble is the product of a juridical mind. THE CONTEMPORARY QUESTION
Beneath the Preamble as it now stands is a theology of Church, an ecclesiology which is no longer in step with the self-awareness of contemporary man. We have here a notion of magisterium which is the product of a .Church conceived along narrowly juridical lines. This is the heart of the matter. If we close our eyes to that, we will continue to hobble along with one segment appealing to authoritative statements and another segment in the Church appealing to arguments and analysis. We will never get together and our institutions will be caught in the middle.
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The ultimate responsibility for teaching in the Church and in the community belongs to the bishop as the Code correctly points out in the Preamble. But the contemporary question we face is not who has the right to teach, but rather the means and processes to be employed if this teaching is to be effective and persuasive in our community. In our day, competence has been cut-up and spread around. It is no longer located in one person. Therefore, the right to teach in the Church implies, above all, the duty to learn. In the juridical notion of the Church, the right to teach is often translated as the right to decUle, even about legitimately debated questions. In conclusion, what I have said here is by no means a challenge to the notion of a teaching authority. I am convinced that the teaching authority of the Church at the international and local level is an utter necessity and enormous value without which we would all suffer. And not least, the theologian would be exposed to and victimized by the imperiousness of public opinion. I only insist that the teaching authority in the Church and the processes by which it proceeds has to be rehabilitated to conform its manner of operation to what contemporary man thinks about the teaching-learning process. In this rehabilitation process all of us have a part to play. The magisterium in our time cannot be conceived as a one-waystreet-type of communication. It is an ongoing teaching-learning process of giving, receiving, exchanging, advancing. The part of reflection in this process is great. The part of obedience while real is much smaller than we once considered it. Obedience is concerned above all with subject-superior relationships. Human reflection is concerned with the teachinglearning process. We, as a community, are striving to learn how our charity, the charity of Christ, should be expressed in an effective way in our time. The heart of the problem is the notion of a teaching Church and how we understand and respond to. it. If we are to continue to enjoy the privilege of the magisterium or teaching church we have to begin to incur the responsibility of taking part in that process ourselves by our own courageous reflections and exchange. Medico-moral norms and hospital directives are not exempt from this reflection.
Thomas O'Donnell, S.J.
Institutional Medico-Moral Responsibility: A Response to Father McCormick The 1·esponsibility for faith and morals rests primarily with the hospital's Board of Trustees not the hospital staff.
Today we read a great deal of the new theology and new morality which is coming off the press •·ather rapidly. I would refer to this new school of thought as "ecclesial termites." As we read one book after another of this school, we see that in the first chapter they gently begin to nibble away at the teaching authority of the Church and by the end of the last chapter, it seems to me, the last line should read, "I can't believe I ate the whole thing." I agree with Father McCormick that we are not in a crisis of obedience. I wish we were. We are not in a crisis of authority. I wish we were. We are not in a crisis of this sort. My main thesis is that the Church today, not in regard to the 315
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Directives, but in regard to Humanae Vitae, is in a crisis of Faith. As I read the new theology, most of the books are very much alike. And the fundamental thesis seems to be that in our day and age a little bit of abortion, and a little bit of euthanasia, and quite a bit of contraception are probably all right. And I do not read that in the documents of Vatican II. Although, surprisingly enough, many of these textbooks begin by an appeal to Vatican II, particularly by an appeal to the Constitution on Religious Liberty, I am not sure that is what the Constitution means. From there, they proceed to deny a great deal of what was taught in Vatican II. It is a crisis of Faith. The Catholic Church in her authentic, though not infallible teaching, such as Vatican II, calls for eliciting the assent of Faith to the teaching that contraception, contraceptive sterilization and abortion are moral evils. The word "moral evil" is an old word which always meant, but is being better understood today to mean, that these things are somehow disruptive of the integrity of the human person. It is a crisis of Faith. Although the Church (not as a bureaucracy, but as the ongoing salvific and redemptive ministry of the Lord Jesus Christ) teaches that contraception and contraceptive sterilization are disruptive or harmful to the integrity of the human person, there are a large number of priests, nuns, Catholic doctors and laity, who do not believe this.
This disbelief is reflected sometimes even among some of the newer theologians who dig in their heels in seeking to find means of legitimately providing contraception and contraceptive sterilization to the non-Catholic patients in a Catholic community health facility in a pluralistic society under the rubric that these things are medically acceptable, that they are not contrary to the conscience of the patient. Therefore, they conclude we have no right to refuse them. But suddenly, when abortion is mentioned, a sharp line is drawn. I wonder why. Many Catholic physicians who have a reluctance to impose, as they say, on the non-Catholic patient the Church's moral ethic,
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have no reluctance whatsoever to impose upon their non-Catholic patients their own personal moral ethic. I do not think we are imposing our moral ethic. Freedom . of conscience goes both ways-freedom of conscience of the patient and the freedom of the collective conscience of the Catholic hospital. There has been some extrapolation of the legitimate doctrine of dissent to mean that where a sincere Catholic does not agree with a doctrine of the Church as taught by the bishops of the world in union with the Pope, reasonable dissent means one is therefore free to follow in these cases one's own conscience. That is by no means what "reasonable dissent" means. It also needs to be pointed out that apparent disagreement
of some national conferences of bishops is only an apparent disagreement. If we read the documents of the national conferences of bishops, although we find different approaches in some cases to the pastoral problem of the perplexed conscience, we do not find any conference of bishops denying the fundamental teaching of Humanae Vitae. Nor do we find any conference of bishops saying that contraception, sterilization and abortion are all right and the Pope is all wrong. So we have here a unique encyclical which has the subscription of the bishops of the world. The problem is a problem of cooperation -material cooperation in a pluralistic society. What Father McCormick did not mention was the teaching impact of the Catholic hospital among the other multiple dimensions and faces it presents to the public. It is not a teaching role, because it is not a university and not a part of the CCD program of the Church. But it has an impact. Because it is a fact that the Catholic hospital teaches Catholic truth. The danger of material cooperation in the matter of contraception, sterilization and abot-tion would be, in the United States today, a terribly weakening blow to the already weakened Faith of the Church and again, I almost weep to say, weakened by the clergy with regard to the Church's teaching on contraception yesterday and abortion tomorrow. Finally, the responsibility for moral rectitude has been put, by Fr. McCormick, more on the staff than on the board of
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trustees. In the Code of Ethics, we are talking about the responsibility for the protection of Faith and morals and the responsibility of handling on uncompromised the salvific word of the Lord Jesus as he is continued in His Church. And that responsibility rests with the bishops of the diocese according to the documents of Vatican II. And the medium a bishop uses to implement the day to day discharge of the responsibility is, according to the Directives, the board of trustees of the institution.
James H. Provost
Church Tribunals and the Sacrament of Matrimony Helena's Chancellor describes the attempts being made to resolve the thorny problems surrounding some marriage cases.
Complicated forms and questionnaires, delays, and a seeming insensitivity to the feelings of people have given Church Tribunals not only a bad name, but a certain degree of discredit among the parish clergy. Tribunal personnel are aware of this, and over the past several years have attempted to change some of the procedures, simplify some of the forms, and speed up the attention given to individual cases. This has not been without some controversy, strange as it may seem. Only recently the Bishop of Baton Rouge described to his people a procedure which has been developed in various parts of the country to resolve what might otherwise be not only an "impossible" canonical situation, but from a pastoral point of view, also an intolerable one. While his action was not intended to be sensational, it caused sufficient stir to warrant a warning through the Apostolic Delegation to all Tribunals. 319
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So, the following reflections do not attempt to represent everything that is going on. Nor are they intended to be "sensational," though obviously controversy can arise from even the most serene presentation. Instead, I will share some of the perspectives we are attempting to develop in a Tribunal of a small (in population) diocese of the Northwest. UNDERLYING PHILOSOPHY
Our basic outlook is that the Church is concerned with people -not formalities. A parish priest's primary concern is to bring the reconciling presence of Christ to his people. The Tribunal's role is to assist him in achieving this reconciliation. It should not force a parish priest to uphold a legal fiction which in his heart and with true pastoral prudence, he knows is destroying the reconciliation of Christ in the lives of people. Here in the United States, a church Tribunal is concerned primarily with readmitting people to the sacramental life of the Church. Our civil laws take care of protecting the rights of individuals-spouse, children or other. Protecting the Sacrament of Matrimony itself is not achieved by a rigid, hard-line approach to a marriage which has already disappeared. Rather, the sacrament is promoted more by helping people to live and express their sacramental life through marriage than through some inquisitional courtroom atmosphere. The attempt to implement this basically pastoral outlook has not always been successful in the history of American Tribunals. We are caught in a cross-fire whose origins we often do not realize. The laws a church Tribunal must follow are made in the context of Europe and the European experience of law. Yet these same laws are to be applied by American Tribunals in the context of the United States, and the Anglo-American experience of law. While the relationship between these two systems of law is complex, it can be roughly described as follows. European or "civil law," drawing its sources from the codification of Roman law done by Greek-minded jurists of the Byzantine Court, sees law as the ultimate expression of the ideal ordering of society. It is a maximum, an ideal, something to be striven for-though something not expected to be fully lived up to at every moment. This legal system is built on ex-
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ceptions, privileges and dispensation from the law. The underlying attitude in Anglo-American law is that the law provides a common denominator. No one is excused from the rule of law. So law is to be kept to the minimum necessary and is something which everyone must follow. American Catholics in general, and canonists in particular, are caught in the bind of attempting to live according to a law which is meant as an ideal, but according to an attitude of mind which sees law as a necessary minimum. This taking the law ultra-seriously has been reinforced by a desire of the young American Church to be just as "Catholic" as any other part of the world and a moral training colored by the rigorist positions of the last century. FLEXIBILITY: A CATHOLIC PRINCIPLE
The history of the Church, however, indicates that greater flexibility in applying the law has been the rule when dealing with less settled areas of Christianity. The practical decisionmaking authority of the great missionary Sees of Middle Europe in the early middle ages, or the special faculties enjoyed by early Jesuit Missionaries in Africa and India, evidence a much more adaptable approach by Rome, especially on marriage questions. The present Code of Canon Law incorporates this principle. Canon 1125 extends the special faculties enjoyed by the Jesuit Missionaries to any other region in the Church which seems to have similar circumstances. It does this specifically with regard to man-iage. But since the canon does not list the specific application, the general attitude as well as the provisions of these Faculties would seem to be incorporated into the law itself. In more recent times, Pius XII admonished Church judges that the supreme goal of Church law is "salus animarum." To implement this purpose, American Tribunals have attempted to reintroduce legitimate flexibility in the application of Church law. FIRST STEP : PROCEDURES
The first major breakthrough came on a procedural level. The Bishops of the United States adopted changes in Tribunal pro-
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cedures recommended by their canon lawyers. After some negotiating in Rome, most of these were approved for a threeyear experiment. Indications now are that these procedural changes have not only speeded up the paperwork, they also have stimulated other adaptations more in line with present pastoral needs, On the local level in our diocese, additional procedural steps have followed these approved for the country. First, all priests assigned to a parish, without distinction as to their title (Pastor, Co-Pastor, Associate-Pastor, etc.) share the same faculties. All are empowered to dispense from all Banns for a valid reason, to resolve lack of canonical form nullity cases, and to introduce any other cases which come to their attention to the Tribunal. The approach is one of "no holds ban¡ed," since a couple have the right to be heard no matter how shaky the grounds may appear at first hearing. Second, a simplified procedure for introducing cases was developed in workshops conducted by the Tribunal for each area of the diocese. This reinforced the person-centered thrust of the Tribunal's role and initiated a much broader understanding of the priest's role in caring for people in "bad marriages." It also clarified the hopes parish priests can have from their Tribunal. Finally, taking advantage of procedural shortcuts permitted under the experimental American Norms, the Tribunal has broadened the understanding of the grounds for annulment and speeded up the processing of cases at the same time. SECOND STEP:
SUBSTANTIAL DEVELOPMENTS
The most promising breakthrough in recent years has been a deeper understanding of marriage. Just comparing the Code of Canon Law and the Second Vatican Council's approach gives a good picture of this. The Code sees maHiage as primarily a contract for "acts which per se are apt for the generation of children." Its concern is focused on the moment the consent is exchanged, thereby initiating the contract and on the primary purpose for the contract, which it sees in terms of the procreation of children. The Second Vatican Council-promulgated as a law, and
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therefore a genuine source of law for man·iage cases--has broadened the Code's perspective. In the Pastoral Constitution on the Chnrch in the Modern WoTld. matrimony is referred to as a "community of love," and "intimate partnership of life and love." It is "rooted in the conjugal covenant of irrevocable consent" so that "a man and a woman, who by the man-iage covenant of conjugal love 'are no longer two, but one flesh' rende•· mutual help and service to each other through an intimate union of their persons and of their actions." As this perspective on what constitutes marriage was developing, so too was a keener awareness of the psychological factm·s involved in marriage itself. The greater use of psychological grounds by American Tribunals is where all this begins to affect the parish level. Some Tribunals call the invalidating elem~nt a "Jack of due discretion." Others speak of "an inability to fulfill the obligations of marriage," or "psychological in~ptitude." Our Tribunal has approached it from the perspective of impotence. Physical impotence invalidates marriage not just because canon law says so. The deeper reason is that a person who is physically impotent is incapable of fulfilling an essential dimension of the man:iage covenant--what the Code referred to as the object of the consent which made the contract, or "acts per se apt for the generation of children." Someone who cannot fulfill the basic purpose of a contract cannot even enter into the contract itself. But a person may be capable of carnal copulation (physically c:msummating the man-iage), yet not be capable of establishing a true community of life and love with this person at this time and stage of development. This inability can stem from psychological factors, traditionally recognized in the Church under the rubric of "amentia" or insanity. But a person does not have to be a "nut" to be incapable of establishing a true marital relationship. It could be just that this person has not grown up sufficiently; even a deeply-rooted behavioral factor could hinder his ability to assume marital obligations effectively. The obvious question is, how do you know this? Most of the time it surfaces only after the facts; some object that this is a type of situation in which someone is pulling the wool over the eyes of the Tribunal.
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First, one must presume when people approach a Church Tribunal in the United States that they do so in good faith. There is nothing to hinder their being married by the civil courts once they have obtained a civil dissolution. Rather, they are actually seeking readmission to the sacraments. For someone to use an evil approach or evil means to obtain a spiritual good is not only reprehensible, but normally not conceivable. And even if their concen1 is more a social than a sacramental one, the solution does not lie in overly-rigorous attitudes by Tribunal officials, but more vigilant and faith-centered pastoral practice. Next, some Tribunals use psychological testing of the principal parties to determine whether the grounds actually exist in such cases. However, testing facilities of this type are not readily available in our part of the country. Even if they were, the cost of such testing would be an undue imposition of most petitioners. Some Tribunals submit the parties, or a copy of the testimony, to a psychiatrist for his evaluation. A simplified method is to send the psychiatrist a "hypothetical question" which summarizes the question at issue. The evaluation of such experts is normally required under Church law. Yet what do you do when there is practically no psychiatrist available in an area as large as Italy or Western Germany, and where the few who do exist here are either so overworked or so questionable professionally as to make them practically unavailable to the Tribunal? Since the decision in a marriage case is up to the Tribunal anyway, and not the psychiatrist, we have had recourse to a solid principle from the Common Law. Indeed, this is common to Thomistic and Aristotelian ethics. The honest estimation of the average person, knowledgeable in the situation and not unduly biased for one or the other party, is certainly equivalent to the expensive technical report of a peritus who knows the situation only through these same witnesses anyway. By adopting this approach, we have cut time and costs, and yet still achieve a reasonable certitude concerning psychological or behavioral factors influencing a person's ability to assume marital obligations. Finally, the basis for resolving marriage cases has always been "moral certitude." American canonists have tended to be
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more rigorous than our European counterparts in determining what "moral certitude" means. Many decisions of American Tribunals in the past, if they were affirmative and granted an annulment, were of such a casebook type that there was hardly any need for a human judge to be involved; a computer could have come to a decision in many instances, faster than it took the Tribunal! "Moral certitude" is a rather delicate act on the part of the judge. He must weigh all the evidence having the force of law, eyjdence which is truly credible. He must build as clear a picture as possible of what the situation actually was, and to do this he must take careful use of various presumptions. But in the end, he must come to a reasonable human solution to the case, not a machine-like one. OTHER CASES: PRIVILEGE OF THE FAITH
When the first Helena Case was submitted from this diocese in 1922, it contained a request to Rome that the faculty to grant this type of solution be given to the local Bishop. While the first section of the petition in the case--asking for the dissolution of the natural bond between a baptized and a nonbaptized persons--was answered; the second part of the petition has never been directly answered. This is but one example of the clouding and somewhat hesitant manner in which this way of reconciling people with Christ has developed in this century. Apparently there are differing points of view in Rome itself, for the practice of who may receive such a dissolution of marriage, how it is done, and under what circumstances has varied even in the past five years rather dramatically. ¡ But a little understood canon in the present Code of Canon Law has given rise to a procedure followed in some dioceses to bring the reconciling concern of the Church to bear more directly on some cases. The canon is 1127, and it states that "in doubtful matters, the Privilege of the Faith enjoys the favor of the law." What it means is the basis for the procedure some are following. In addition to investigating the non-baptism of at least one of the parties, an equally thorough investigation is made into
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the reality of the marriage to be dissolved. If there are reasonable grounds to introduce a marriage case for annulment, as well as proof of non-baptism and conversion of one of the other party in the case, the Tribunal is faced with a situation in which there is a doubtful matter (the marriage itself), as well as the conditions necessary for the Privilege of the Faith. The obvious interpretation of canon 1127 is that in such a circumstance, the law itself grants the Privilege of the Faith. The intervention of the Tribunal is necessary to apply the law to the case; but it does not grant the Privilege itself. That was done when the Code of Canon Law itself was promulgated by the Holy Father. Obviously, this is not a common practice. A private request to the Holy Office some time ago asked about the use of this interpretation. The only reply was an indication by the Holy Office that its present practice should be observed-either treat the case in a formal annulment trial, or submit it to the Holy See as a Privilege of the Faith. Nevertheless, this is a private, administrative reply, and still does not resolve the question of the authentic interpretation of the application of canon 1127 to such cases. THE SO-CALLED "GOOD FAITH" CASES
Yet another tool developed by local jurisprudence in several parts of the country has been the "good faith" case. The situation is basically this. A case is presented which has a suspicion of nullity. An investigation follows, but for various reasons is unable to surface adequate evidence to come to an annulment, although it does not disprove the suspicion of nullity either. Faced with this "insoluble" or "impossible" case, additional information on the Catholic practice of the couple--insofar as they are able to participate in the life of the Church is concerned-is sought, as well as some indication of the attitude of the community. The entire matter is then submitted to the Promoter of Justice. His office is little used, and probably less understood, in the Church today. Yet only he and the couple themselves have the right under law to attack the validity of a marriagec After he has examined the case, if he is unable to attack the first marriage (because adequate proof is
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unavailable), and if he refuses to attack the present marriage (because if the Church were to force this couple to separate, grave scandal would result in the community), he returns the matter to the Tribunal. The Tribnnal considers his l"P.port, as well as the pastoral evaluation of the couple, and if it is warranted by the reasons given and no danger of serious scandal is evident, the Tribunal has been granting a decree "Non Inquietandi." The means that the couple are not to be disturbed but are to be considered in good faith in attempting to live a holy life as Christians even though barred from receiving the Sacrament of Matrimony. They are then readmitted to the sacraments of penance and eucharist, although the marriage itself is not "validated." This provides a canonical procedure to handle situations which in many paris of the country priests are doing on their own, in the Confessional or elsewhere, and often to considerable confusion in the community. It provirles a serious investigation, a careful study of the matter, and full consideration of the effects on the indissolubility of marriage and the dignity of the sacraments. The letter from the Apostolic Delegate indicates the matter is under study in Rome. The American Bishops have a special study underway themselves, and several dioceses are looking into the question of what to do for marital breakdown as such. The Canon Law Society of America is even studying alternatives to the whole tribunal system in an effort to bring the reconciling presence of Christ to bear more realistically on these difficult situations. THE ULTIMATE CONCERN:
MARRIAGE ITSELF
Much of the foregoing can appear to be playing games. It would be, except that it takes place in the context of a renewed concern for marriage itself. Marriage enrichment, ministry to married couples, and a renewed concentration on the family as the "ecclesiola" or fundamental cell of the Church, are all contemporaJ¡y phenomena. Tribunal procedures, the grounds for considering annulments, and the whole question of the sacramental life of the
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Church point more toward the need for reinforced pastoral activity in preparing young people for marriage and supporting married couples. Rigorism in the law court or laxity in the Tribunal are really unimportant. In life, what counts is how realistically we as a Church are concerned for the life of married people. To mouth the words and not produce the effort to aid them in creating truly mature, psychologically compatible and sacramentally alive marriages is perhaps the greatest danger any of us face today.
Vincent J. Hope
Future Forms of Ministry II: A Comment The author comments on our summer issue
The Church has a grave duty to get involved in the social, political and economic affairs of men.
For a good many years, most Christians have been engaged in a serious debate over the question whether the Church should dirty its hands by getting involved in social, political and economic problems. After all, weren't we taught that the Church exists to help us get to heaven and not a better life in this world? There are a Jot of sincere, serious people on opposite sides of this debate. Both claim to be following the true meaning of Christ's gospel. One side claims that the Church ought to be concerned exclusively with the salvation of men's souls. The other side claims with equal firmness that social structures have such a powerful influence on men's religious efforts that the Church must do all it can to make these structures a help and not a hindrance to the genuine Christian life. 329
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For Catholics, the beginning of an answer was given by Pope Leo XIII in 1891 in his encyclical on labor, Rerum Novarum. That answer was frequently amplified in the ensuing years by other Popes, and was most fully set down in the Council's Constitution on the Church in the Modern World, in Pope John's Pacem in TeTris and Pope Paul's Progressio Po1mlomm. Perhaps the definitive answet¡ is this sentence in Chapter II, Section 43 of Gaudiwn et Spes: "The Christian who neglects his temporal duties neglects his duties toward his neighbor and even God, and jeopardizes his eternal salvation." This is the implicit warning that unifies these eight essays in the Summer Issue of Chicago Studies. It would hardly seem necessary these days to convince priests of the validity of this principle. Rather, what many if not most of us need is specific evidence of injustice and intelligent guidance as to how to get actively involved in secular tasks and how to convince others of the sacred character of temporal activities. This is exactly what the authors of these essays have done very successfully, beginning with "Social Sin and Conversion" by Peter J. Henriot, and ending with "Ministry for Justice and Peace" by Eugene J. Boyle. In between there is "The Challenge of the Second Development Decade" by James R. Jennings; "Ocean Space and World Justice" by John J. Myers; "Arms Limitation" by Patrick P. McDermott; "Theology of Liberation" by Patrick Kerans, and "International Affairs and Ethics" by J. Bryan Hehir. Each of these articles is a thoughtful and trenchant analysis of some grave, urgent problem that faces humanity today. The way these problems are treated was inspired by these words of the 1971 Synod of Bishops: " ... we have questioned ourselves about the mission of the People of God to further justice in the world." On this basis alone these essays are worth attentive reading and study. Without deprecating in the slightest way the work of the other contributors, I consider that for the average parish priest the article entitled: "Justice and Peace: A Radical Analysis" by Eugene Toland, Thomas Fenton and Lawrence McCulloch as the most valuable because it is the most practical. The authors point out how difficult it is to get at the real causes
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of social injustice compared to the ease with which we can preach about the effects of injustice. The reason is that the seminary curriculum has never allotted much time for the study of economics. So, a priest can without much preparation deliver an eloquent sermon about the social evils that people must endure without noting the source of those evils and how to correct them. They have chosen an apt subtitle, "A Radical Analysis," for their essay, because nothing less will be vigorous enough to cleanse our minds of the myths we hold about the basic injustice of the American economic system. The P.R. boys of Madison Avenue and elsewhere and the popular mass media have done a good job of persuading us that we live in an economic democracy in which kindly capitalists desire to provide us with the best products at the lowest price possible. So successful have they been that Americans only reluctantly after a long wait accepted Ralph Nader as an honest crusader for truth in the market place. No doubt the thousands of defective autos recalled by Detroit did help some. In order to understand clearly the "why" of economic injustice in the U.S., one must take a hard, searching look at the plutocratic monopolies that really dominate this nation. We are too predisposed to submit our minds subconsciously to the endless waves of advertising that flow over us every hour of each waking day. But, if we battle against the tide, we still may be shocked to read that Robert Townsend, former president of Avis-RentA-Car, as the authors tell us, once wrote: "Frustration with unemployment, inequity, taxes and prices, to be sure, but, under it all, a rage at the giant impregnable, impenetrable, anonymous, unaccountable, irresponsible bastions of power." If that sounds exaggerated, every day the newspapers and TV newscasts innocently give proof for the charge. It is because of such blunt, radical writing that I consider this the most valuable in a most extraordinary collection of essays on Justice and Peace. Yes, the Church surely does have a grave duty to dirty its hands by getting involved in the social, political and economic affairs of men.
AUTHORS IN THIS ISSUE William J. Byron, S.J., is associate professor of Social Ethics at Woodstock College, N.Y. City. His article is based on a paper delivered at Fordham University's Eighth Biennial Institute in Pastoral Theology. John F. Dedek is a professor of moral theology at St. Mary of the Lake Seminary, Mundelein, Illinois and associate editor of Chicago Studies. Andre E. Hellegers, M.D., is professor of Obstetrics and Gynecology and Physiology-Biophysics at the Georgetown University Medical School, and the Director of the Kennedy Institute for the Study of Human Reproduction and Rioethics. Richard McCormick, S.J., is a professor of moral theology, Bellarmine School of Theology, Chicago and a past president of the Catholic Theological Society of America. William E. May is a member of the Department of Religion and Religious Education, Catholic University of America. Thomas O'Donnell, S.J., is currently stationed in Clinton, North Carolina. He is closely associated with the Committee of Health Affairs of the U.S. Catholic Conference in regard to the new Ethical and Religious directives for Catholic Health facilities. James H. Provost is Chancellor and Presiding Judge of the Diocese of Helena, Montana. He is also a CFM Chaplain and member of a Marriage Encounter Team. Warren T. Reich is senior research scholar at the Kennedy Center for Bioethics at Georgetown University and Editor-in-chief of the Encyclopedia of Medical Ethics. He was formerly Associate Professor of Moral theology at Catholic University. Norbert J. Rigali, a research associate in Social Studies and Moral Theology at the Cambridge Center for Social Studies, Cambridge, Mass., is now at the University of San Diego, San Diego, California. 333
INDEX TO VOLUME 11 (1972) n. I (Spring), 1-112
n. 2 (Summer), 113-224 n. 3 (Fall), 225-336
Boyle, Eugene J., Minisi1y for Justice and Peace Imperative for PriestjUSA ·--------------------------------·-··------- 209 Byron, William J., Unconnected Self Intm·estReftections on Alienation and Religion -------··-··-------·-·-- 269 Buckley, Michael J., S.J., The Priesthood as a Religious Event .... ____ ------------ ________________________ . _____________ ____ 101 Dedek, John F., Remaking Man---·------------------------------·--------- 15 Moral Responsibility in Caring for the Dying ____________ 227 Fenton, Thomas, Justice and Peace: A Radical Analysis ____ 131 Harrington, Daniel J., S.J., Baptism in the Holy Spirit: A R evie?v Article ____________________________ . _________ ______ __ ___ ________ ___ 31 Hehir, J. Bryan, International Ajjain and Ethics···----------- 197 Hellegers, Andre E., M.D., So1ne Thoughts about Medical Problems for Catholics ---------------·-·------------------··--·----------- 295 Henriot, Peter J., S.J., Social Sin and Conversion: A Theology of the Chu1·ch's Social Involvement ·-·----------- 115 Jennings, James R., The Challenge of the Second Development Decade ---------------------------- __________ .. __ ... _________ 145 Kerans, Patrick, S.J., Theology of Libemtion ---··-·------------- 183 Kreyche, Gerald F., Conflict: Threat or ChallengeThe "I" vs. the Institution----------------------------·---------····--- 257 Lussier, Ernest, S.S.S., Mariology Post-Vatican II ____________
73
McCormick, Richard, S.J., The New Directives and Institutional Medico-Moral Responsibility ------··--·-------·· 305 335
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McCulloch, Lawrence, Justice and Peace: A
Radical Analysis __________________ --------------------- ____ ------------------ 131 McDermott, Patrick P., Arms Limitation---------------------------- 173 May, William E., Biomedical Technologies and Ethics ______ 245 Meyer, Charles R., The Other World------------------------------------
3
Myers, John J., Ocean Space and World Justice __________________ 159 O'Callaghan, John, S.J., Christian Conscience and Laws
of the Church _________________________ --------------------- ______ -------------O'Connell, Timothy E., The Sea1·ch fo•· Ch1·istian
Moral Norms __ __ __ _____________ _________ ________ __________ __ __ __ ________ ______
59 89
O'Donnell, Thomas, S.J., Institutional Medico-Moml
Responsibility: A Response to Father M cC01-mick ____ 315 Provost, James H., Church Tribunals and the Sacra.ment
of Matrimony __ -----------------------------------------------------------·-·· 319 Reich, Warren T., Medical Ethics: The Contemporary
Context ·--- _______________________________________________________ ~----------------- 279 Rigali, Norbert J., New E]Jistemology and the Moralist ____ 237 Sittler, Joseph, Theological Developments of
Luthemn-Catholic Dialogue --···-------------------------------------
45
Toland, Eugene, Justice and Peace: A Radical Analysis ____ 115