THEOLOGY AND THE FOUR PRINCIPLES OF BIOETHICS: A ROMAN CATHOLIC VIEW
by John Finnis and Anthony Fisher, O.P.
in Raanan Gillon (ed.), "Principles of Health Care Ethics" (Chichester:
John Wiley & Sons, 1993), 31-44.
I
<The true context of the four principles>
'The four principles of bioethics' have their rational basis and
truth only within the wider set of moral principles. Outside that context,
they demarcate a rather legalistic ethic while also, paradoxically,
providing labels for rationalising almost any practice.
Morality's principles (including 'the four') can be recognised by
anyone following reason's guidance, undeflected by distracting emotion,
prejudice or convention. They are matter for moral philosophy. But reason's
full implications, and morality's practical applications, are well
understood only when full account is taken of the human situation. And our
human predicament and opportunities include some realities adequately and
reliably revealed only by the life and teachings of Jesus Christ, through
the Church's scriptures and tradition. All moral principles are thus
matters also for doctrine, faith, and theology. They are guides to a life
which befits human nature, responds to the divine calling, and prepares
people for eternal life in God's family. They educate conscience, shape
virtues, and make possible wise decisions in particular cases.
What is it reasonable to do? What choices 'make sense', are 'good',
'fair', 'right'? Moral philosophy begins its answer with two basic features
of human persons. We are responsible, i.e. can deliberate rationally and
make free choices [1], [2], [3]; and nothing short of a happiness and
flourishing in which we might share can give our choices rationally
sufficient point [4].
<Freedom>. When tempted, e.g. to fabricate or steal some experimental
results, we see through excuses like 'only following orders' or 'my
upbringing' or 'I'm slave to my passions'. In judging oneself or others
culpable, or in thinking 'if only I'd...', one recognizes one's freedom to
choose and to choose rationally. Inherited characteristics, upbringing,
present restrictions and pressures, all can influence but none need
eliminate the demand to choose, to adopt one proposal for action (or
inaction) in preference to others. <Autonomy> (self-rule) is less a
principle than a fact.
Free choosing is self-making and self-telling [5]: choices shape and
express one's life and moral identity ('character'). Choices last: they
continue affecting who one is, at least until one makes some contrary
choice. Some big choices commit one to a certain relationship; but each of
my morally significant choices actualizes and limits me, and orients me
(and everyone to whom my choice tacitly speaks as an 'example') towards
similar future choices. Each such choice thus has implications far deeper
and wider than the external behaviour and states of affairs which were its
direct object and outcome [6]. Morality takes account of all this.
<Integral human fulfilment>. No-one finds real happiness in sheer
pleasurable experience, independent of worthwhile accomplishment. Happiness
(including its joys) is personal completeness or harmonious wholeness,
something achievable only along with and through other people. An
<integral> human fulfilment, answering to all of one's reasonable desires,
would be the happiness and flourishing of all human persons and their
communities [7], [8]. Authentic morality is not social convention, nor a
law supported by threats and prizes, nor a key to egoistic self-fulfilment.
It articulates what is involved in being rationally interested (without
sub-rational restrictions or deflections) in integral human fulfilment [9].
<Morality>. Morality's guidelines for making one's choices fully
reasonable all make more specific the most general and foundational moral
principle: that one should will those and only those possibilities whose
willing is compatible with integral human fulfilment [9].
The various aspects of this fulfilment provide the real <reasons for>
all human actions: these are such basic human goods as life and health,
knowledge, skills, friendship, practical reasonableness, and religion [10].
None of these basic human goods is a mere means to any of the others; all
are equally fundamental and intrinsically good [11], [12]. Fully realised
and actualised in all human lives, they would constitute integral human
fulfilment, total human happiness. What sorts of choices are incompatible
with that?
Various sorts. Choices shaped by egoism or partiality are not open to
<integral> human fulfilment. So one basic moral principle is the Golden
Rule: 'In everything, do to others as you would have them do to you'
(Matthew 7.12). This is central to <justice>. Moral philosophers speak of
'universalizability'. Common speech talks of fairness. In the Old
Testament, it was formulated along with <non-maleficence>: 'And what you
hate, do not do to anyone' (Tobit 4.15). Jesus extended the Old Testament
formulation so as to link it also with <benevolence>: 'You shall love your
neighbor as yourself' (see Matthew 7.12 and 22.40).
Still, there are principles of non-maleficence distinct from the
Golden Rule. Blood feuds, for example, need not be unfair, but are immoral.
For, acting on hostile feelings towards oneself or others cannot be in line
with a will to integral human fulfilment. Respect for the dignity of
persons -- treating them always as ends in themselves and never as mere
means -- involves more than treating them fairly.
Positive feelings, too, can motivate one to do evil -- to destroy,
damage or impede an instantiation of some basic human good. Such choices
are often defended as the greater good, or lesser evil. But, though many
comparisons of values and disvalues are possible, any comparison which
hopes to guide moral judgment by an overall 'weighing' of the goods and
evils at stake in morally significant options is always made by feelings,
not rational commensuration. Such 'calculations' can only be
rationalisations. Choices to 'do evil', in the sense just defined, willy
nilly play favourites among instantiations of basic human goods, just as in
violating the Golden Rule one plays favourites among persons. No such
choice is compatible with a will towards integral human fulfilment. Moral
philosophy thus clarifies and justifies the common sayings: 'The end does
not justify such means', 'Never treat anyone as a mere means', 'Do not do
evil that good may come'.
Moral philosophy articulates other strategic moral principles, and
identifies the virtues or character-traits which facilitate a life in line
with all these guidelines for a conscientious openness to integral human
fulfilment. But here we turn, instead, to note some implications of the
additional data made available to conscience by revelation.
<Christian moral life>. In these wider and deeper perspectives,
integral human fulfilment is no mere 'ideal of reason' for the critique of
a will distorted (rather than supported) by feelings. Instead it is a
reality which, by virtue of God's promise and grace, can begin in this life
and extend into the completed kingdom and family of God [13]. In restating
Christian hope, the Second Vatican Council indicated the intrinsic
relationship between every morally good act, done in God's friendship, and
the life of heaven. Even when defeated by events in this world, good works
and dispositions are 'material' which God has promised to raise up into a
city which will last for ever [14], [15].
Thus the most fundamental moral principle of openness to integral
human fulfilment becomes: 'Love the Lord your God, and your neighbour as
yourself' (cf. Leviticus 19.18; Deuteronomy 6.5; Matthew 19.19, etc.), and
'Seek first the Kingdom' (Matthew 6.33). Morality identifies not arbitrary
laws and rewards, but sets us on the way to the ultimate happiness of
communion with God's Trinitarian self, through living lives worthy of
children of God the Father, of siblings and members of Christ the Son, and
of temples of the Holy Spirit (Mt 12.50; Jn 1.12; 1 Cor 6.19; Eph 2.21;
4.1; Phil 2.15, etc.). Human nature's unity and dignity, and the permanence
of the principles (the moral 'natural law' as clarified and supplemented by
the revealed 'divine law') articulating conditions for its integral
fulfilment, are guaranteed by Christ's sharing that nature with every human
person, past, present and future, and by his having come once-for-all as
teacher and saviour[16].
Moral teachings, like other matters of faith, can be definitively and
thus by divine assistance infallibly taught. This authoritative
distillation of the tradition can be by explicit definitions by a Pope or a
general Council, as in the Council of Trent's teaching against polygamy and
divorce. Or it can be by the concurrence, at some point in time, of the
bishops, agreeing in teaching something as a moral truth to be definitively
held [17], as in the teaching against adultery, abortion and indeed any
direct killing of the innocent. Such teachings, like others authoritatively
proposed by the Church's magisterium, either restate or consistently unfold
implications of Christ's very firm moral teaching e.g. against divorce and
remarriage, and his reassertion of the morality of the Ten Commandments
(see Matthew 19:18-20)[18]. Thus they trace the implications of a free
commitment to a way worthy of our earthly-heavenly calling, and befitting a
human nature shared and redeemed by Jesus.
<The witness of Christ>. Care for the sick, the weak, the suffering
and the sinful was a principal focus of Jesus' life. A healing ministry
taking many communal forms -- monastic pharmacies, hospitals, nursing
homes, hospices and nurses' training run by religious orders, lay faithful
committed to healthcare as their vocation, sacramental and other pastoral
care for the sick, reflection on medical ethics -- fulfils the vocation to
be a servant of humankind and mediator of God's healing power: true
beneficence.
But pain and death will not be eliminated in this life. Suffering must
be faced head-on, against the pervasive temptation to demand an immediate
technological 'fix' for every discomfort, and to marginalize those who
suffer so that the rest can withdraw undisturbed. Faith recalls the
profounder possibilities for good occasioned by illness and pain: for the
sufferer, re-evaluation, conversion, growth in virtue, setting things right
with God and other persons; for onlookers, compassion and selfless
behaviour [19]. The crucified God gives new significance to these
redemptive qualities of suffering; contemplation of the cross and uniting
oneself with Christ's passion make possible greater endurance, assist in
our redemption (see e.g. Romans 8.17-18), and overcome temptations to a
false beneficence and delusive mercy.
The Resurrection, too, has implications for bioethics. It recalls the
eternal destiny of the moral agent who has only one life in which to choose
for or against God; it discourages a therapeutic obstinacy born of secular
despair of an afterlife; it demands that we respect the person's dignity to
the end, and give special pastoral as well as medical care to the dying;
and it requires that we honour even the symbol of that dignity, the corpse:
their mortal remains.
II
<Some false contexts for moral discourse>
Moral principles tend to lose their meaning and their rational warrant
when they are announced (as by Beauchamp and Childress [20]) as if plucked
out of the air, a 'moral code' akin to civil law or club rules to be
strictly applied, compromised or 'balanced'. A bioethics with such oracular
'foundations' overlooks the true basis for a rational (and thus, too, a
Christian) ethics [21], [22], [23] as set out in Part I. Such a bioethic is
legalistic and fails, we think, to meet the contemporary challenges to
morality in healthcare.
These challenges include:
-- using the prevalence of bioethical controversy to 'validate' denials
of moral responsibility or a relativised or privatised morality ('what's
right for me might not be right for you', 'I don't want to impose my moral
beliefs on people', 'I can do whatever I please as long as I don't hurt
anyone else'...). Slavery and genocide, even when 'controversial' or
vigorously defended, were not thereby made right.
-- appeals to conscience as self-validating. To violate one's conscience
by choosing options one believes wrong is indeed immoral, even when one is
actually mistaken in judging them wrong [24], [25]. But it is also immoral
to leave one's conscience uneducated, settling serious moral questions by
mere preferences or private 'intuitions'. For conscience is simply one's
ability to know moral truth, recognize objective moral standards, and bring
them to bear in practical judgments about particular options -- an ability
dependent for its proper use (as is every other intellectual capacity) on
willingness to learn, attention to relevant data, self-discipline, and the
help of a morally decent culture.
-- dreams of a 'value-free', 'objective', 'scientific' bioethic, as
opposed to 'moralizing', 'judgmental', 'religious' or 'interfering'
bioethics. Supposedly 'objective' principles like 'scientific progress
should be allowed to continue unencumbered' are as value-laden as other
ethical approaches. To call one's preferred ethic 'value-free' or one's
principles of deliberation 'scientific' simply prepares one to shirk
justifying them and to pursue uncritically whatever one's feelings or
environment happen to favour.
-- subjection to the 'technological imperative': that whatever we can do,
we inevitably will, and should or must. The illogicality of deeming all
technological advances justified and good is not well disguised by tagging
opponents 'backward' or 'fearful'.
-- consequentialist misconceptions of beneficence and denials of true
non-maleficence. Claims that any means can be justified by a sufficiently
good end are unreasonable, as we show in sections III and IV below. They
also contradict the Western medical-ethical tradition (with its absolutes
such as 'never kill, or exploit, your patients'), the political-legal
tradition of inalienable and inviolable human rights, and the moral
<tradition> of most Christian churches (with their constant teaching
against doing evil for the sake of good -- cf. Romans 3.8 -- and against
every direct killing of the innocent)[26].
Take <in vitro> fertilization as one example (among many!) of all
these conflicting ethical voices. 'Value-free' technological imperativists
might say: this technology is available, its application is 'inevitable',
so go ahead. Relativists: it's for the individual couple or their doctors
or their society to decide. Legalists: the Law of Beneficence requires it
(or: this holy book forbids it). Consequentialists: though not the best way
to have a child, it is the only way for some, and on balance is good (or:
it will lead to Brave New World and on balance is bad).
A better approach [27], [28] recognizes that not all ways of supplying
good desires are truly open to integral human fulfilment; some ethical
principles cannot rationally be compromised. More specifically, human life
must not be intentionally destroyed or damaged, even in its earliest stage.
And the radical equality of parents and child is wrongly contradicted when
the child is brought into being precisely as a product of mastery over
materials. Nor can there be any genuinely rational 'balancing up' of IVF's
bad effects (such as the disjunction of the life-giving and love-giving
dimensions of marital intercourse, the enslavement and destruction of many
embryos, the dangers to the women and children, etc.) with the good ones
(giving a childless couple a child, new scientific knowledge, income and
kudos for the scientist): for these values and disvalues are all so
basically different. There remain also the self-making aspects of such
choices. Acting as master of the destiny of tiny human beings, choosing to
manipulate or kill some for whatever purposes, disintegrating human
sexuality and parenting, all will mould us as certain kind of people and
sway our future attitudes and choices in many, perhaps all, our activities.
The Catholic moral judgment against all laboratory reproduction of human
beings [29] is, then, considered and definite; it is not a 'law' or a 'ban'
but a rational judgment about moral truth, drawing on an understanding of
the human realities which is enriched by revelation.
Still, while it thus draws on a wider and deeper context of principle,
it can also be taken as a conclusion about what, in this matter, truly is
beneficent and just, and what is maleficent and unjust because imposing, in
the name of parental or scientific autonomy, new forms of human domination
and subjection. So, against this background, we offer a few further
observations on 'the four principles'.
III
<Beneficence>
Healthcare's traditional vocation (object and responsibility) has
been: Promote the good health of your patients and cure (or prevent) their
illnesses. Though serving other basic benefits too -- knowledge, skill,
community between patient and professional, practical reasonableness...--
healthcare has as its primary rationale the basic human good of life.
'Life' here includes health, the well-integrated, harmonious functioning of
a living being of an organic, sentient and rational nature.
Healthcare often calls for 'calculation', to find the most efficient
cure, palliation, management... the best proportion of likely therapeutic
benefits to burdens. In relation to each available therapy one considers
various factors; some are objective though partly indeterminable
(prognosis, likely and possible side-effects, costs...); some are
subjective (the patient's fears, ability to cope with pain, own assessment
of benefits and burdens...).
This kind of assessment need involve no 'end justifies the means'
ethic (consequentialism). The best-known consequentialism,
'utilitarianism', exists in many incompatible forms, but all assert
something like: choose what seems most likely to maximize good and minimize
bad effects. Lately, some Catholic bioethicists have proposed various
hybrids of consequentialism with classical Christian morality. 'Situation
ethics', for instance, counsels choosing whatever, in the particular
'situation', seems most humane or loving or in line with 'faith
instinct'[30]. 'Proportionalism' (in its main forms) bids us seek the
option promising to maximize the balance of 'premoral' goods (such as
lives, health, contentment) over premoral evils (such as deaths, sickness,
sadness) [31], [32], [33], [34].
Such approaches have been refuted at length elsewhere [35], [36],
[37], [38], [39]. They all fallaciously assume that because some rational
comparisons of value are possible, therefore it is possible, at least in
principle, to make a determinate rational comparison of the goods and bads
anticipated in options. Extrapolating rashly from what is (at least
logically) possible in a technical, cost-benefit problem with a single
definite goal, they all gratuitously suppose a similar logical possibility
in moral deliberations, which involve an open horizon, many different
benefits and harms, and one's whole stance towards integral human
fulfilment.
True beneficence, then, will not be so narrowly focussed on
'foreseeable consequences' that it overrides questions of means and
intentions (which have implications and consequences that only divine
providence can adequately foresee, master and dispose).
IV
<Non-maleficence>
<Primum non nocere> ('first of all, do no harm') was a classic first
principle of medical (and other) ethics. As the Hippocratic Oath puts it:
'I will use treatment to help the sick to the best of my ability and
judgment, but I will never use it to injure or wrong them'. But what is
harm, what is wrong?
In section I, we sketched the rational basis for such traditional
formulae as: 'The end does not justify the means', 'Never treat anyone as a
mere means', 'Do not do evil that good may come'. It is always wrong to
choose to destroy, damage or impede an instance of a basic human good for
the sake of some ulterior end. That good provides a reason against such a
choice, and because that good cannot rationally be 'outweighed', that
choice will be not merely against <a> reason but against <reason>.)
In healthcare practice, three forms of maleficence are common: (i)
lying, (ii) killing and (iii) mutilation.
(i) In <lying>, one expresses outwardly, and tries to get others to
accept, something at odds with one's inner self. One thus divides one's
inner and outer self, contrary to one's own self-integration and
authenticity, and impedes or attacks the real community that truthful
communication would foster, even when deception seems very desirable. So,
though telling the whole truth (or even telling anything at all) is quite
often destructive or heartless, lying is always wrong.
(ii) <Killing>. Someone who brings about death, intending to do so as
an end or as a means (and whether by action or deliberate omission), is
said to kill 'directly'. (Causing death only as a side-effect, however
predictable, is 'indirect' killing.) The <direct taking of innocent human
life> always violates the principle of maleficence and is always wrong [40]
[41]. (Some but not all indirect killings, too, violate the principles of
justice and non-maleficence.) Whether in abortion, eugenic prenatal testing
and selection, embryo experimentation and non-therapeutic genetic
engineering, infanticide of the handicapped, assisted suicide or
euthanasia, direct killing always demeans both victim and perpetrator,
invites further 'therapeutic' killing, and violates the divine trust given
us in human life.
'Quality of life' decisions to deal with certain persons on the basis
that they are 'better off dead', because their life 'is of no benefit' or
has no (or a negative) value are notoriously arbitrary and elastic. They
also, and inevitably, violate either the principle of non-maleficence, or a
principle of justice (or both). Even the very reduced and deficient life of
the irreversibly comatose is an instance of a basic human good; it is the
very existence of a unique person, who can still be harmed, e.g. by being
subjected to indignities. A decision to discontinue feeding and hydrating
may be either direct killing (as a means to relieve others of burdens
created by the patient's continued existence) or, if motivated solely by
desire to avoid the burdens of <feeding and hydrating>, an abandonment
which could be just only in circumstances of emergency or poverty rarely if
ever found in modern Western society [42], [43].
Of course there may be good <therapeutic> reasons for withholding or
withdrawing some treatments. Their continued use may be futile, i.e. of no
therapeutic value. Or they may impose a burden (such as pain, indignity,
risk, cost etc.) which those concerned feel is out of proportion to the
benefit gained. Here the healthcare worker does not indulge in arbitrary
'quality of life' decision-making, but rather makes a (sometimes difficult)
therapeutic judgment about the helpfulness or not of the proposed medical
treatment in dealing with the patient's illness. On this basis some
treatments will be medically indicated and morally required ('ordinary');
others will be optional ('extraordinary'); and still others will be contra-
indicated (and immoral) [44], [45], [46].
(iii) <Mutilation>. Respect for persons and the good of life includes
respect for their physical, psychological and spiritual integrity. Non-
maleficence forbids mutilation, even when consented to (e.g. to facilitate
begging, preserve choristers' voices, or prevent conception). For example,
sterilization chosen in order to prevent conception is, at best, a bad
means to a good ulterior end, an act of well-motivated but morally confused
maleficence. For in no way does sterility as such truly benefit anyone; it
only facilitates sexual intercourse -- a distinct act in and through which
some benefit is expected -- by excluding conception. Even when well-
motivated, every choice directly to impair a function involves an intention
to damage a basic human good, and is always wrong.
But it can be morally good and even obligatory to remove a part of the body
when this removal, of itself, protects or promotes health, and one does not
intend the detriment to function as a means to any end, but only accepts it
as a side effect. For example, an infected limb or nonvital organ may
rightly be amputated or excised when that is necessary to prevent the
infection from doing great harm to the whole body. Even a healthy part may
be removed if doing so has natural consequences which are necessary for the
health of the whole body and cannot be effected in another, less
detrimental way.
Donating parts of one's remains after death damages no human good, and
can rightly be done to benefit another or others -- provided, of course,
that death is properly established and there is proper respect for grieving
relatives and staff. Donating blood typically involves no harm and very
little risk, is permitted by the principles of non-maleficence and can be
recommended or even required by the principles of beneficence. The live
donation of an organ (e.g. a cornea), when the benefit to another will be
secured only and precisely by detracting from the functioning of the donor
(e.g. the donor's depth vision), is a bad means to a good end, and always
wrong. But the live donation of an organ (e.g. a kidney) can be right, when
it involves only some risk of future detriment to function; for here the
potential loss of function is not part of one's chosen means but only an
accepted side effect.
These distinctions are often explained by Catholic moralists by
reference to a 'principle of totality': mutilation is morally permissible
when necessary for the good of the whole body [47], [48]. But that
principle is no more than the application, in a particular context, of the
quite general considerations which determine when there is and is not a
choosing of evil for the sake of good. Catholic moralists, during the last
200 years or so, often discussed those considerations under the heading of
the 'principle of double effect'. But that principle [49], [50] (which is
misrepresented in many works, e.g. [51]), is reducible, on analysis, to two
propositions: (i) neither as an end nor as a means may one choose to
destroy, damage or impede any instance of a basic human good; (ii) a result
of a choice is not a chosen means merely because it is foreseen as a
probable or certain result but because it is part of the proposal which one
shaped in deliberation and adopted in that choice. The analysis of chosen
actions, to establish what one is and is not really intending, can be
difficult and delicate. It affords much opportunity for rationalisation and
self-deception. But it is eminently a matter for rational reflection and
discussion. It is also a matter on which, for salient conclusions about the
morality of some specific types of choice, one can look to the Church's
authoritative wisdom.
V
<Autonomy>
Ideals of autonomy today contain much that is unacceptable. They often
involve or promote a dream of absolute self-sufficiency, independent of
God, community, reason and reality. Social authority is seen as a necessary
evil for limiting social conflict, but ideally one should be free to do as
one pleases, adopting one's own lifestyle and conception of fulfilment.
'Privacy' and 'my right to my body', in the context of such ideas, veil a
hardening of hearts against human beings for whose very existence one is
responsible. Conscience is considered a private internal voice with
authority to judge without too much regard for reality, truth and wisdom.
The ideal of autonomy woven of these strands, though widely felt to be
self-evident, is but the distorted shadow of a truth clarified by
revelation: every human person has the dignity of one redeemed by Christ,
and none is properly the slave or instrument of another's purposes. So the
greatest of Catholic moralists have made the cornerstone of their ethics
this proposition: mature human persons, having free will, image God
principally by being rational masters of their own acts [52], [53].
Properly understood, then, the principle of autonomy is an
acknowledgement of both the radical equality of all human beings, and the
inalienable responsibility of all who can choose to make their choices open
to integral human fulfilment.
We have mentioned one way in which that radical equality is denied (in
IVF). Here is another: well-intentioned lying. Those who lie to their
patients manipulate them. Very often they overconfidently judge what they
cannot know: that the one they try to deceive cannot deal with reality,
cannot make good use of the freedom that only truth can give, and will not
suspect or even detect the deception, with a consequent loss of trust. By
their impact on freedom and fostering of mistrust, supposedly helpful lies
often do great, although unintentional, harm.
As to each individual's inalienable responsibility: the primary duty
of health care is one's responsibility to look after oneself, physically,
psychologically and spiritually -- to treat one's health as one of the
'talents' entrusted by God to one's stewardship. In seeking and consenting
to the needful help of others, one cannot repudiate one's personal
responsibility or grant them authority to do more than one can responsibly
ask. Interventions by healthcare professionals which do not respect the
proper directions of a patient fail to respect the patient as (like all
human beings) the healthcare worker's radical equal.
We shall not here repeat the still generally sound norms of the
healthcare professions concerning respect for patients, informed consent,
nurturing of trust, confidentiality of records, and so forth. Instead we
express a fear. Unhinged from its true ethical context, the principle of
autonomy (often reduced to the right to 'privacy' or 'to choose') soon may
become the principal formula for rationalising the extermination of many
sick and handicapped persons, young and old. For if non-maleficence is re-
interpreted so as to allow assisted suicide and voluntary euthanasia in the
name of autonomous 'self'-liberation from a burdensome life, it doubtless
will soon be held that those who <cannot> (and in many cases <never> did or
could) give their consent to it should not thereby be deprived of their
equal 'privacy right' to liberation from burdensome life. The 'right' will
be exercised 'on their behalf' by someone who will choose for them the
death which, it will thus be presumed, they would have (or should have)
chosen had they been capable of choice. A false 'principle of autonomy'
could thus be the constitutional and ethical vehicle for the profound
injustice of a 'beneficent' maleficence, ridding the community of many
lives deemed 'not worth living' (<lebensunwertes Lebens>).
VI
<Justice>
There are two senses of 'justice' [54]. As fairness, justice is a
principle distinguishable from beneficence and non-maleficence. As respect
for all the rights of others, justice is a principle which includes
beneficence, non-maleficence and true autonomy. Here, then, we add only a
few points.
Concern for the common good -- 'love of neighbour', or 'solidarity' --
requires fellow-feeling, genuine self-giving, joint effort with others to
promote the flourishing of all, encouragement and support for the efforts
of others. Healthcare certainly requires joint effort and deliberate
coordination, at various levels of institutions, communities and
governments. But true autonomy requires that larger communities should
assist smaller ones, not absorb them -- this is the principle of
'subsidiarity' -- just as smaller ones should help individuals to help
themselves. Governments should assist with resources, coordination and
encouragement, but not take charge of all the functions of smaller groups
where (given suitable freedom and assistance) those smaller groups could
direct and perform these functions [55], [56].
Justice supports neither centralized control of all aspects of
healthcare (a violation of subsidiarity), nor leaving healthcare, a
fundamental right [57], to the whim of 'market forces' (which violates
solidarity). As we have the right to expect the help of others, so we have
the reciprocal duty to help others in need of healthcare, whether through
our taxes, insurance payments, or provision of personal care. A system of
healthcare violates the Golden Rule (I must presume) if I would think that
system unfair were I (or someone I loved) in the weakest position in the
community. The world's material resources are given to all humankind, for
the needs of all, and so while private property is often a requirement of
justice, the needs of others establish duties on the part of those who have
more than they need towards those who have less than they need -- in
healthcare as in other basic human needs [58], [59], [60].
Special care for the (materially and/or spiritually) poor,
underprivileged, powerless and desperate is something the Church considers
itself called upon to give ('the preferential option for the poor') [61].
Among the various just regimes of healthcare distribution which are
possible in a community [62], the Christian will prefer ones which give
special care to the most needy and defenceless.
Mercy calls us to go beyond (without violating) the principles of
justice and non-maleficence in healing every form of evil [63]. Is 'mercy
killing' (euthanasia) the truly compassionate way to treat those in severe
pain or incurable illness or coma? Or to distribute finite health
resources? Compassion means wanting the best for the other, having empathy
with them in their suffering, and seeking positively to assist by acts of
mercy in keeping with their dignity. Far from contributing to 'death with
dignity', support for euthanasia promotes a culture which whispers to the
old and infirm 'Your condition is intolerably undignified. You would be
better off dead. We would be too, if you were dead. You may even have a
duty to acquiesce in being killed.' Thus false views of mercy and justice
can conspire to institute a 'beneficent' maleficence, injustice, and the
ultimate negation of autonomy [64].
REFERENCES
1 Boyle, Joseph M., Germain Grisez and Olaf Tollefsen. Free Choice: A
Self-Referential Analysis. Notre Dame and London: Notre Dame
University Press, 1976
2 Grisez, Germain, and Russell Shaw. Beyond the New Morality: The
Responsibilities of Freedom. 3rd edition. Notre Dame: University of
Notre Dame Press, 1988; 11-22
3 Finnis, John. Fundamentals of Ethics. Oxford: Clarendon Press, 1983;
137
4 Finnis, John. Practical Reasoning, Human Goods and the End of Man.
Proceedings of the American Catholic Philosophical Association 1984;
58:23-36; also in New Blackfriars 1985; 66:438-451
5 McCabe, Herbert, O.P. What is Ethics All About? Washington DC: Corpus
Books, 1969
6 Finnis reference (3); 139-144, 153
7 Finnis, John, Joseph Boyle and Germain Grisez. Nuclear Deterrence,
Morality and Realism. Oxford and New York: Oxford University Press,
1987; 281-284
8 Grisez, Germain and Russell Shaw. Fulfillment in Christ: A Summary of
Christian Moral Principles. Notre Dame and London: University of
Notre Dame Press, 1991; 79-81
9 Grisez, Germain, Joseph Boyle and John Finnis. Practical Principles,
Moral Truth, and Ultimate Ends. American Journal of Jurisprudence
1987; 32:121-131
10 Finnis, John. Natural Law and Natural Rights. Oxford: Clarendon Press,
1980; 59-99
11 Grisez, Boyle and Finnis, reference (9); 106-110
12 Grisez and Shaw, reference (8); 54-56
13 Grisez, Germain. The Way of the Lord Jesus. Vol. I: Christian Moral
Principles. Chicago: Franciscan Herald Press, 1983; 115-140, 459-476
14 Vatican Council II. Gaudium et Spes. (Pastoral Constitution on the
Church in the Modern World, 7.12.65); paras 38-39. In Flannery,
Austin, O.P. (ed.). Vatican Council II: The Conciliar and Post
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15 John Paul II, Pope. Sollicitudo Rei Socialis. Encyclical for the
Twentieth Anniversary of Populorum Progressio (30.12.87). Vatican
City: Libreria Editrice Vaticana; paragraph 47
16 Finnis, John. Moral Absolutes: Tradition, Revision, and Truth.
Washington DC: Catholic University of America Press, 1991; 24-28
17 Ford, John C., S.J., and Germain Grisez. Contraception and the
Infallibility of the Ordinary Magisterium. Theological Studies 1978;
39: 258-312; also in Ford, John C., S.J., Germain Grisez, Joseph
Boyle, John Finnis et al. The Teaching of Humanae Vitae: A Defense.
San Francisco: Ignatius Press, 1988; 129-155
18 Finnis, reference (16); 6-9
19 Ashley, Benedict M., O.P., and Kevin D. O'Rourke, O.P. Healthcare
Ethics: A Theological Analysis. 3rd edition. St Louis: Catholic Health
Association, 1989; 47-49, 197-199
20 Beauchamp, Tom L., and James F. Childress. Principles of Biomedical
Ethics. 3rd ed. New York: OUP, 1989
21 Hauerwas, Stanley. Vision and Virtue. South Bend: Fides, 1974
22 Hauerwas, Stanley, et al. Truthfulness and Tragedy. Notre Dame IN:
University of Notre Dame Press, 1981
23 MacIntyre, Alasdair. After Virtue: a study in moral theory. 2nd ed.
London: Duckworth, 1985
24 Thomas Aquinas. Summa Theologiae. 1a.[2]ae question 19 articles 5-6
25 Grisez, reference (13); 73-96
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Arguments. New York: Corpus Books, 1970; 155-184
26 Fisher, Anthony, O.P. IVF: The Critical Issues. Melbourne: Collins
Dove, 1989
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33 McCormick, Richard A. Health and Medicine in the Catholic Tradition.
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38 Kiely, Bartholomew, S.J. The Impracticability of Proportionalism.
Gregorianum 1985; 66:655-686
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41 Pius XII, Pope. Address to the St. Luke Union of Italian Physicians
(12.11.1944). Discorsi e Radio-messaggi 1944; 6:191; quoted in
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43 May, William E. Feeding and hydrating the permanently unconscious and
other vulnerable persons. Issues in Law and Medicine 1987; 3:203-17
44 Sacred Congregation for the Doctrine of the Faith. Jura et Bona
(Declaration on Euthanasia), 5.5.80. In
Flannery, Austin, O.P. (ed.). Vatican II. Volume II: More
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48 Gallagher, John, C.S.B. The Principle of Totality: Man's Stewardship
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of Double Effect. Ethics 1980; 90:527-538
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ABSTRACT
Morality identifies the basic reasons for human choices, and
articulates principles for making those choices compatible with openness to
integral human fulfilment. Many ethical approaches and many sorts of
choices are incompatible with this. Faith guided by church teaching offers
further and surer education for conscience, and deeper understanding of the
healthcare worker's vocation.
The 'four principles' have their grounding and proper meaning only
within such a fully developed ethic. Beneficence requires the promotion of
the life and good health of patients; non-maleficence forbids harming them,
or compromising any instance of a basic human good in deceptive moral
calculations and quality of life judgments. Autonomy directs respect for
human dignity and responsibility; it does not justify individualism
independent of God and community, or exterminative medicine. Justice and
mercy enjoin solidarity, subsidiarity, fair resource allocation, and
special care for the poor and helpless.
This Catholic approach is shown to have implications for abortion,
IVF, sterilization, euthanasia, withdrawal of treatment, and honesty in
medical communication.
'THE FOUR PRINCIPLES' -- A CATHOLIC VIEW
John (M.) Finnis
LL.B. (Adelaide), D.Phil. (Oxon.), M.A. (Oxon.), F.B.A.
Professor of Law and Legal Philosophy, Oxford University; Fellow and Tutor,
University College, Oxford University College, Oxford, U.K.
Anthony (C.) Fisher, O.P.
B.A. (Sydney), LL.B. (Sydney), B.Theol.(Melbourne), D.Phil. Candidate (Oxon)
Blackfriars, Oxford, U.K.
Address: Blackfriars, St. Giles, Oxford, OX1 3LY
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