bernard farrell-roberts director of diaconal formation (maryvale ecclesiastical institute) principal...

Bernard Farrell-RobertsDirector of Diaconal Formation (Maryvale Ecclesiastical Institute)

Principal Tutor: International Science and Ministry Baccalaureate,

University of Barcelona

Member of:

Catholic Bishops’ Joint Bioethics Committee

International Association of Catholic Bioethecists

COMECE Consultation Group on Organ Donation

Catholic Hierarchy’s Representative on Organ Donation Ethics to the Department of Health

Pastoral Healthcare Ethics

Objectives for today:Sessions One & Two

Love underpins Pastoral Healthcare & Ethics, and is essential to a full and correct understanding of holistic

pastoral healthcare

Session One

• Understand the need for a systematic ethic

• Take away a systematic ethic applicable to all ethical problems

Session Two

• Examine the principal issues in Pastoral Healthcare & Ethics

• Understand the importance of holistic healthcare


Objectives for today:

Not to exhaust you too much!

This subject is incredibly wide and complex – we have a few hours, but we could fill several weeks with useful material and knowledge!

I do not touch on areas such as pastoral care of children, of families, commencement of life issues, genetics, Marriage and sexual ethics, special needs, mental health, or numerous other very interesting and important areas – it simply is not possible. Perhaps in the future you could think of covering some of this. However, I do have a very heavy and packed agenda to get through today, so I hope you will not find it too much for you. I also apologise if I cover old ground for any of you as I clearly know nothing of your backgrounds or previous studies.


Objectives for today:

• Synthetic strand running through todays talks: understanding holistic pastoral healthcare is only possible in the light of God’s revelation of Divine love.

• Use of Pastoral Healthcare and Ethics self-study course book.


We first need to understand the significance of God’s love in the Holy Trinity, and the outpouring of the same in our lives.

“Man cannot live without love. He remains a being that is incomprehensible for himself, his life is senseless, if love is not revealed to him, if he does not encounter love, if he does not experience it and make it his own, if he does not participate intimately in it. This, as has already been said, is why Christ the Redeemer "fully reveals man to himself".”

Redemptor Hominis 10

Biomedical Ethics

We can then pass on this understanding to others.

Let us take suffering as our example, as this is at the centre of pastoral healthcare:

Biomedical Ethics

Let us use the following to help us understand and explain on a practical

level God’s love and what this means in our lives:

The Suffering of Christ

Human Suffering

How are they Connected?Brotherhood of the Holy Cross

What exactly do we mean by “suffering”?

What do we understand by it?

Brotherhood of the Holy Cross

Pope John Paul II explained in Theme 6 of «Salvifici Doloris» that humans suffer in many different ways, many of

these not always accepted by medical

authoritiesBrotherhood of the Holy Cross

He explained that suffering is bigger than

illness, and more complex.

Both physical and spiritual suffering exist, in both the

body and the soul.


Man suffers because of evil, a “lack of good”,

because he has deprived himself of this good through his sinful

actions.Brotherhood of the Holy Cross

“In order to discover why we suffer,we have to

turn our gaze to the revelation of divine

love.”

Pope John Paul IIBrotherhood of the Holy Cross

Revalation of Divine love: Old Testament relationship

and covenants; & Christ himself.

“God so loved the world that he gave up his own

son”

Jn 3,16Brotherhood of the Holy Cross

“Those who participate in the suffering of Christ posess a special part of the infinite treasure of the redemption of the

world.”Brotherhood of the Holy Cross

What do we mean by this? We mean that we can and do

participate in the suffering of Christ through which He saved

humanity!

How then can and do we share in the sufferings of Christ?

In order to understand this we need to understand “love” itself.


Why?

Because it is in love itself that we find the justification of all suffering.

What is love then, and how does it justify suffering?


Simply speaking, Love is God, and is therefore“Trinitarian”, and this helps us to understand it, as explained by St Bernard of Clairvaux.

He explained that the Holy Trinity can be understood as a relationship of love, and as such a concept with which we can identify as parents, family members, friends, as humans who love.


Father Son (Love)

Spirit

The Father loves the Son and Spirit totally

The Son loves the Father and Spirit totally

The Spirit loves the Father and Son totally

All freely give themselves to the others totally


The outpouring of love between Father, Son, and Spirit is then poured onto us freely by the Holy Spirit in the form of grace.


In this way we enter into this same loving relationship, called to love God as He loves us.

Remember: Love is the total giving of self for the other:

* Christ for us in his passion and death

* Us for our wives, families, friends

* And for Christ? Are we willing to love Him as He loves us? He loves us totally, and seeks total freely given love back from us


If we then understand the following in light of this, we can begin to understand their true reality better:

*Marriage*As an icon of the Trinity

*As the “Domestic Church”

*The FamilyBrotherhood of the Holy Cross

And suffering…..?


If your son or daughter is suffering, wouldn’t you do everything in your power to remove that suffering from him or her, even to taking their suffering on yourself?

This is what God did.Brotherhood of the Holy Cross

Noone has greater love than this: than to give up his life for his friends.

John 15:13Brotherhood of the Holy Cross

So what should we do?

Are we going to love God as much as He loves us?

He suffers for us. He died for us.

This is how much He loves us – and He wants us to love Him as much as He loves us.

And how can we do this? Can we take on some of His suffering, suffer for Him, and therefore lessen the suffering He must endure, by sharing in his suffering for us, for our sins.


Seen like this, freely offered up to Christ in order to “take away” some of His suffering, human suffering becomes our participation in Christ’s act of salvation.

It becomes our gift to our fellow humans, our act of love for them. True love for our neighbour, reflecting our love of God.


In our suffering we walk freely to the cross, we take Christ down, share in His suffering, cradle him in our arms, and calm His pain.

We share in His salvific act for humanity, in the salvation of the human race.

We unite ourselves to God in the love of the Trinity.


Suffering is not negative. It gives us the opportunity to unite ourselves to God in a way that is very specal to Him, to take our place at His side.

Suffering is a fundamental part of being human.

No suffering is pointless.

By understanding love and suffering in this way, we are able to better understand everything that underpins pastoral healthcare, discovering the light in which every ethical decision must be considered.

Now, back to our systematic ethic…


The need for a systematic ethic

How do we know that we have thought of everything we should have done?

We must:

Inform ourselves

Know where to look

Have a method to use

Apply it rigorously

Where do we look? Where do we get our information from?

Bioethics


In Bioethics we shall find our method and our sources of information.

What is Bioethics? “Bio” in Greek means life

Bioethics is the philosophical study of the ethical issues and controversies brought about by advances in biology and medicine. Bioethicists are concerned with the ethical questions that arise in the relationships among life sciences, biotechnology, medicine, politics, law, philosophy, and theology.

Pastoral Healthcare needs us to look at “Biomedical Ethics”


What is your first impression of Bioethics, and the ethical problems we must resolve?

COMPLICATED ?

It can get even more complicated than this! Let’s have a look:

Biomedical Ethics

Modern influences on ethical decision making:

Legal Positivism

Generally accepted by Western Society at the time of the 2nd World War.

The law of the state is all that is required for the moral guidance of society

No higher law exists

Biomedical Ethics

What happens if Society gets it wrong?

The Law states that Jews are a subhuman class

Result =

HolocaustBut then, having seen our error, we did it

again:

Biomedical Ethics

What happens if Society gets it wrong?

• Paracetamol or Abortion

• Japan - Diagnosis of death

• If organ donor – death = brain stem death

• If not – brain stem death is not death and life must be sustained

Biomedical Ethics

Some modern consequences of legal positivism:

• Abortion – now being considered a human right by the UN

• Euthanasia – already killing those with special needs

• 3rd world birth control – via additives, experimentation, free contraception, etc.

• Aids in Africa – putting commerce and population control first?

• How does this happen? What is missing?

Biomedical Ethics

“Universal laws of jurisprudence”

Samuel L Jackson, Judge

Or Natural Law, as we know it

Biomedical Ethics

Natural Law

Natural Law: made up of Self-evident truths that are not demonstrable e.g.

Do not kill other humans

Love your neighbour

All humans have rights

Biomedical Ethics

Natural Law

Supreme Principle = Good is to be done, and evil avoided.

“Good is the principal dictator of conduct, therefore the Supreme Principal of moral action must have Good as its central idea.”

St Thomas Aquinas I-II, Q, xciv,a.2).

Biomedical Ethics

What does Moral Theology add?

• Revelation of God by God

• Knowledge of God: Scripture, Tradition, Magisterium

• Knowledge of Man from knowledge of God

Questions?

Let us move on now to ethical or moral decision making in healthcare……..

Biomedical Ethics

Where are we now? We have:

•Intelligent ethicists

•Sound ethical methodology

•Sound ethical theory

•Just legal systems

•Genuine concern for the good of mankind

•Understanding of Natural Law

•Moral Theology

For these to be effective we need a fair means to evaluate the morality of human actions.

Biomedical Ethics

Case Study: To illustrate what we are up against!

Dr Thustra’s DilemmaBackground

Competence and Research on the sexual health of teenagers

Pelvic inflammatory disease (sometimes called PID), is a progressive infection of the fallopian tubes, uterus, cervix, or ovaries. It is a secondary consequence of infection with sexually transmitted diseases (STDs), such as chlamydia or gonorrhoea. It is estimated that each year more than a million women will develop PID in the UK, with the highest infection rate amongst teenagers. If PID goes untreated, it can lead to internal scarring that can result in chronic pelvic pain, infertility, or a tubal pregnancy.

Biomedical Ethics

Biomedical EthicsPID can cause severe symptoms, and if it is not

treated or goes unrecognized, the PID can continue to spread through a woman's reproductive organs and may lead to long-term reproductive problems: • PID can cause scarring in of the ovaries, fallopian tubes, and uterus, and widespread scarring may lead to infertility. A woman who has had PID three times (or more) has an almost 50% chance of being infertile. • If someone who has had PID does get pregnant, there remains a high risk of an ectopic pregnancy. • Untreated PID also puts the patient at risk for a tubo-ovarian abscess (TOA).

The sexual health unit at Metropolis Hospital, under the supervision of well-known Gynaecologist Dr Zara Thustra, proposes to study the connection between the development of PID and the occurrence of sexually transmitted diseases. They are particularly interested in whether intervention and treatment of advanced chlamydia and gonorrhea infections in teenage girls with a new-generation of drugs - FERTEX-C and FERTEX-G (already licensed for treatment of these infections) - can prevent or reduce the development of PID. They are interested in this issue and this 'treatment group' because it is Dr Thustra's experience that most teenagers who seek treatment at the clinic do so reluctantly and rather too late to allow effective prevention of PID. She is curious as to see whether the undeniable improved efficacy of the FERTEX drugs also increases the length of the window in which treatment can prevent PID.

Biomedical Ethics

They propose to do a randomized control trial using teenage girls between the ages of 14 and 19 who present at the hospital's clinic with symptoms of chlamydia or gonorrhoea and who are judged by medical staff to be in the advanced stages of infection. The trial will involve 4 distinct treatment groups :• Group A - Advanced stage chlamydia treated with best of old-generation drugs • Group B - Advanced stage chlamydia treated with FERTEX-C • Group C - Advanced stage gonorrhoea treated with best of old-generation drugs • Group D - Advanced stage gonorrhoea treated with FERTEX-G

Participants will take the medication as usually prescribed, this will be followed up by fort-nightly examinations at the hospital - involving blood-tests, urine-tests, vaginal-swabs and ultrasound scanning of the reproductive organs.

Biomedical Ethics

Dr Thustra and her team, however, face a serious difficulty - more than half of the young girls in the proposed treatment group fall below the age (18) at which they are considered able to unproblematically give informed consent to participation in research. Dr Thustra is familiar with standard procedures for consenting to medical treatment - Over the age of 18 years competence is presumed. In England, Wales, and Northern Ireland adolescents aged 16-18 can consent to treatment but cannot necessarily refuse treatment intended to save their lives or prevent serious harm. Adolescents under 16 may legally consent if they satisfy certain criteria - namely - the young person should be able to:

• Understand simple terms, and the nature, purpose, and necessity for proposed treatment

• Understand the benefits, risks, and effect of non-treatment

• Believe the information applies to them

• Retain information long enough to make a choice

• Make a choice free from pressure

Biomedical Ethics

There are three strategies that might be adopted :

1.Consent all subjects who are over 18 and, in the case of subjects under the age of 18, also get parental consent for participation 2.Consent all subjects who are over 16 and, in the case of subjects under the age of 16, also get parental consent for participation 3.Consent all subjects and seek no parental consent for participation

What should Dr Thustra do?

Biomedical Ethics

Conclusion: it is simply too complex to be able to work it out like this!

Ascertaining the acceptability of any specific human action may be very complex, with multiple influences & considerations in play.

How can we be sure we have considered all we should prior to making our decision about a course of action, and how can we evaluate & balance all the relevent harms and benefits?

We need a “systematic ethic”

Biomedical Ethics

What is our Systematic Ethic?

1.Ensure that all principal potential harms and benefits have been identified

2.Ensure that all principal ethical schools of thought have been applied and evaluated

3.Value all humans equally, respecting their rights as humans

4.Do the above always in light of God’s revelation

And how do we go about this?

Biomedical Ethics

Ensure we consider all the following:

All ethical schools of thought, starting with:

Principalism

Autonomy

Beneficence

Non-Maleficence

Justice

Then adding “Scope”

Biomedical Ethics

The other principal ethical schools of thought

Virtue Ethicist View

Catholic Ethicist View

Feminine Ethicist View

Consequentialist View

Relativist View

Why?

• Firstly to ensure you haven’t missed anything

• Secondly in order to be able to justify yourself in front of others. Apologetics.

Biomedical Ethics

Case Study 1

A married couple are concerned about the wife’s father. He has an advanced

degenerative illness, is in hospital unable to feed himself and may be in considerable pain.

The doctors attending him have recommended that he should be allowed to

die, as his quality of life is so poor, and he will die before too long. Due to the advanced

state of his illness it is not possible to know how effective his pain relief is.

Biomedical Ethics

*It is important here to explain to the couple that we are simply stewards of our lives. We had no choice in our births, nor do we have any choice in our time of death. Life is God’s alone to give, and His alone to take away. Intentional killing is evil and cannot be considered as an option. They are right to be opposed to euthanasia.

*As Evangelium Vitae tells us: "Nothing and no one can in any way permit the killing of an innocent human being, whether a foetus or an embryo, an infant or an adult, an old person, or one suffering from an incurable disease, or a person who is dying. Furthermore, no one is permitted to ask for this act of killing, either for himself or herself or for another person entrusted to his or her care, nor can he or she consent to it, either explicitly or implicitly. Nor can any authority legitimately recommend or permit such an action". EV No.57

Biomedical Ethics

Regardless of what the doctors may say, it would be wrong to remove food from her father. To do so would be to kill him by starvation, and we do

not have this right.

Parenteral feeding, if considered a medical procedure, is acceptable only as long as its benefit outweighs any burden being placed

upon her father.

However, if parenteral feeding is considered to be basic human care and a human right, then it

may only be withdrawn if the burden of administering it is considered unacceptable.

Biomedical Ethics

Case Study 2A car accident has left a sixty year old woman in a coma, life support machines are managing her breathing, and she is receiving parenteral feeding. The doctors have told her husband that she is medically brain dead. She carried a donor card and had always insisted that in the event of her death she wished her organs to benefit others. Her husband is unsure what to do. The doctors say that her organs must be used soon, but he is concerned that she may still be alive, and that to turn the machines off would equate to murder.

Biomedical Ethics

Firstly the husband needs to find out if his wife is actually dead. It is usual for organs to be used for transplant as soon after death as possible. Care needs to be taken as the doctors may have decided that her “quality of life” is so poor that it would be merciful to end her life, solely in order that her organs could be used for those who could benefit from them.

This issue was dealt with by Pope John Paul II in an address to a working group of the Pontifical Academy of Sciences in 1989, and later ratified in the Charter for Health Care Workers produced by the Pontifical Council for Pastoral Assistance in 1995 (No.129).

He emphasised the importance of being able to detect the moment of death, with particular reference to the donation of organs. The definition to be used is that death exists when there is an “irreversible loss of all capacity for integrating and coordinating physical and mental functions of the body.”

Biomedical Ethics

Pope John Paul II goes on to clearly state that it would be unethical to cause the death of an individual so that their organs can be used for the benefit of others.

The 1989 Working Group arrived at a clinical definition of death. They said that this had occurred when:

a. Spontaneous cardiac and respiratory functions had irreversibly ceased, leading rapidly to a total and irreversible loss of all brain functions, or

b. There has been an irreversible cessation of all brain functions, even if cardiac and respiratory functions that would have ceased have been maintained artificially.

Debate among ethicists continues as to whether this criteria is adequate.

The husband has the obligation of ensuring that one of the above is true of his wife before allowing the life support machines to be turned off, and her organs used. It would appear at first sight that (b) might apply in this case.

Biomedical Ethics

QUESTIONS?

The principal areas of ethical concern in

Bioethics:

Biomedical Ethics

Biomedical Field Plus:

Biomedical Ethics

“Bio” Issues:

• Using Animals for Human Benefit

• Animal experiments and drug safety

• The validity of animal experimentation

• The moral status of the experimenters

• Animal experiments and animal rights

• Justifying animal experiments

• Animal experiments and consequentialism (balancing benefits and harms)

Biomedical Ethics

Case Studies:

• Rape leading to pregnancy• Foetus with genetic

abnormality• Pre-implantation selection• IVF• Living Donors• Human Experimentation

Biomedical Ethics

More Case Studies:

1.Quality of life argument e.g. organ donorship

2.Slippery Slope e.g. euthanasia3.Red Biotechnology e.g. embryonic

stem cells4.White Biotechnology e.g. sun tan

lotion & nano-technology5.Green Biotechnology e.g. GM Crops,

gene splicing, cloning

Biomedical Ethics

We shall look more at elderly and infirm issues in the next

session.

Questions ?

End of Session One

Biomedical Ethics

Session Two

What care is needed?“The centre of care and attention of both

the health care system and of society must always be the person, considered in the concrete circumstances of his family, work, social context, and geographical

area. Reaching out to a sick person thus means reaching out to a person who is

suffering, and not merely treating a sick body.”

Pope John Paul II 2000

Holistic Pastoral Healthcare

“Experience teaches you that the sick person is asking for more than a mere cure of the organic pathologies affecting him.

To give the sick and their relatives reasons for hope in the face of pressing questions that beset them about suffering and death

is your mission. The Church shares this impassioned service to life with healthcare

professionals.”



Open minds, patience, and a listening ear are needed:

There is a surprising, even perplexing, accepting quality in the voices we attend to. People readily take on a passive role when they are ill, especially in hospitals.

“It is of course right to fight illness, because health is a gift from God. But it is also important to be able to listen to God’s plan when suffering knocks at our

door.”



Jesus himself accepted the suffering of his passion and death. But he also prayed for it

to be removed from him.

Our role is to help others come to this ultimate and deep acceptance of God’s will in their lives – whether this means suffering or

not. Whether their suffering is visible, or not.

Our role is to provide holistic healthcare, thus achieving the salvation of souls.


In recent times, ethical decision making has become much more difficult:

“Not only is the fact of the destruction of so many human lives still to be born or in their

final stage extremely grave and disturbing, but no less grave and disturbing is the fact that

conscience itself, darkened as it were by such widespread conditioning, is finding it

increasingly difficult to distinguish between good and evil in what concerns the basic value

of human life.”

Pope John Paul II, Evangelium Vitae 4


Now we have the “Culture of Death”

“Choices once unanimously considered criminal and rejected by

the common moral sense are becoming socially acceptable.”

Pope John Paul II, Evangelium Vitae 4


In 2004 Joseph Cardinal Ratzinger said:

Secularisation is no longer neutral…….it is beginning to transform itself into an ideology

that imposes itself through politics and does not leave room for the Catholic and Christian vision”.

How right he was!

Despite what modern secular society would have us believe, when it comes to end of life issues,

………


We know in our hearts that all humans have the Right to Life

“We must speak of man’s rights. Man has the right to live”

Pope John XXIII, Pacem in Terris 8

This is the most fundamental human right. Without life no other rights have any meaning!


Life …is a gift from God which must be respected in all its stages and can

never be regarded as disposable since…. the life of every individual, from its very beginning, is part of

God’s plan.”

Congregation for the Doctrine of the Faith, Donum Vitae, 1987


What do we need for Holistic Healthcare?

Spiritual and Religious Care

• Health is state of complete physical, mental, and spiritual wellbeing, not just absence of disease or infirmity

• Medical intervention is not enough. Patients’ needs include emotion, hope, fear, spirit, love, relationships, and environment.

• Everyone needs support systems. Ill health brings fears, isolation, loss of independence


An exercise on “Loss of Independence”

Write down the three parts of / things about your life you treasure most.

Let the person on your right cross off 1 of the three, any one they like

Now let the person on your left cross off another 1 of the three

Look at your list. How do you feel to think that you have suddenly been deprived of the two crossed off items?

The average person in hospital loses 2 of the three most important aspects in their lives while they are in-patients. Similar experiences accompany many illnesses and often

old age too. We must bear this in mind in our pastoral ministry.


Aspects of pastoral care:

Religion and Spirituality

Spiritual care is available from many sources, some more affective than others.

Religious care is available from faith groups. 75% of adults in the UK profess

to having a religious affiliation.

Spiritual care is associated with meaning and purpose, and is commonly linked in the elderly to the need for forgiveness, reconciliation, and affirmation of worth.



Accompanying the sick and infirm

A key role of those providing pastoral care to the sick or infirm lies in

accompanying the individual through the experience of illness and

healthcare, often when faced with a scaring world full of technology,

expert professionals, loss of independence, many personal issues and fears, and perhaps even the odd

skeleton or two!


In this situation a good pastoral healthcare worker can help the

individual gain some sense of control by being able to make an informed

decision, fighting their corner in conflict situations brought about by different value sets, protecting them

against coercive influences, and looking after their spiritual welfare.


This care should go beyond listening, advising, or even just talking about God. Care is most fruitful when it leads into experiencing God’s presence and love

through prayer, worship, and communion. In prayer both worker and patient

acknowledge their joint dependence upon the One who is mightier than them both.

It releases the patient to follow the path of all humans, towards full union with their Creator. It is the natural path, full of love,

and completely good.



Sacramental Care

CCC 1525 speaks of three sacraments that accompany us at the end of our lives:

Penance – through which we are forgiven

Anointing – through which are healed and comforted

The Lord’s Body and Blood – Viaticum: the provisions for the journey, joining our passing over with Christ’s Passover

Together with prayer, these are essential.



Dealing with Substance Abuse.

• Any behaviour which is repeated over and over again despite significant negative consequences

• Alcohol, drugs, cigarettes, gambling, sex, shopping

• All obsessions are similar

• Remember the do’s and don’ts


Practical Do’s and Don'ts

• Don’t treat the addict as a child

• Don’t check up on them continually

• Don’t search for hidden supplies

• Don’t dispose of supplies

• Don’t nag and don’t argue when they are under the influence or withdrawing

• Don’t preach, scold, reproach, or enter into quarrels.

• DO seek quality professional help and advice

• DO speak about God, encourage, pray, listen.



Near Death and Death

Common Emotional Pathway: Not sequential, or regular

• Anger

• Denial

• Bargaining

• Guilt

• Depression

• Resolution / Acceptance




• Permit the dying to “deal with business”

• Recognise “anticipatory grief” in the family: Depression; Extreme concern for the dying; preparing for death; adjusting to death.

• Recognise “Complicated Grief”: this may appear as absence of grief, delayed grief, conflicted grief, or chronic grief. Recognised by: avoiding all reminders of the deceased, constant thought or dreams about the deceased, fear or panic at any thought of the deceased. Can be treated with drugs, but this may interfere with grief process.




Pastoral Healthcare response:

• Listen

• Offer opportunities for space and grieving

• Support

• Encouragement

• Emotional, spiritual, and physical support by Church community and

ministry


In a Birmingham Hospital a patient was chronically ill and although unfailingly

polite to visitors from the Catholic Chaplaincy team he seemed uninterested in the practice of his childhood Catholic faith. However, one day he turned to a religious sister visiting him and said

“That’s it, I’m coming back”. She was taken aback and said “To what?” To this he simply replied “To the practice of my faith, Sister”. He was fully supported in

this by his non-Catholic wife.

Constancy is essential!


Aspects of pastoral care:Near Death and Death

Levels of Human Healthcare:

• The biological level - respiration, nutrition, excretion, movement, reproduction, temperature balance etc. Physicians treat malfunctions at this level.

• The psychological level - need for security, a sense of belonging, intimacy or love (in its emotional aspects) Psychologists and psychotherapists operate at this level.

• The social level encompasses the need for esteem and respect, for love and a sense of belonging (in their more developed cultured aspects). This includes the behaviour and self-control of the individual within society. It is the domain of law, politics, and the clergy as moral guides.

• The spiritual or creative level - persons criticise, transcend and re-create the culture around them in artistic and scientific endeavours. Religious activity extends to one‘s relationship with God and the ultimate meaning of life. The spiritual guide, artist, poet, and inspiring thinker operate at this level.

Healthcare must serve the whole human person, not only their biological functioning.

Let us look at who is responsible for our health….


Responsibility for Health

WE ARE! – but others are also involved:

Resource apportionment in Healthcare

Personal

Ethos, Ethical Code, and Morality of the Physician

Personal Responsibility




The Catholic Church takes its lead from Christ Himself, who taught his disciples to be compassionate to the ‘poor, the crippled, the lame, the blind’ (Luke 13:14). It is the Church’s belief that all human individuals are entitled to healthcare.

However, the provision of healthcare services is full of problem areas, most of these revolving around which individuals have a right to which services, and which services ought to be provided.




There is a link between what provision can be made, and how much money there is to pay for it, and this often leads to complex and difficult ethical issues. For example, should someone with a three month life expectancy receive a drug that may extend their life by a few days, or a week or two, but that is so expensive that it will cost the equivalent of three life saving transplantation operations?

These complex ethical issues differ in accordance with the area of responsibility held by an individual within the health service. Health service managers for example have to deal with funding limitations, and complex budgetary systems.



Personal

‘It‘s my body. I can do what I like with it.‘

We may all have heard others saying this. I certainly have! It is clearly true that the body belongs to the person in a more fundamental way than any external possessions. My body is me, or at least a dimension of me. More

accurate than ‘I have a body’ is ‘I am body (as well as soul)’. The body is not an instrument or tool but an integral aspect of my person.



Personal

It is here that the fundamental division opens up between those who recognise no creator,

and claim absolute dominion over his/her own life and sexual faculties, and those who

recognise God as Lord and Giver of life. This chasm runs through the middle of much modern ethical debate. Democratic society attempts to

straddle the abyss and reach a compromise between irreconcilable standpoints, in order to

maintain a pseudo-peaceful co-existence.



St Thomas Aquinas stated the Principle of Totality thus – ‘Since any member is part of the whole human body, it exists for the sake of the

whole as the imperfect for the sake of the perfect.

Mutilation without due cause is therefore immoral, but the donation of a kidney, say, to a relative undergoing thrice-weekly dialysis, is a pre-eminent form of Christian charity. A person

sacrifices part of himself to bring life to another. Hence Aquinas’ formula requires adaptation.



Personal

As Christians we believe that our existence is a gift from the Creator. He addresses us: ‘Be fruitful and multiply; fulfil the earth and subdue it. Have dominion over the fish of the sea, the birds of the

air, and all living things on earth.’ (Gen 1:28)

Fundamentally therefore we are stewards, not owners, of creation. One day we must give a

reckoning of our stewardship. We are responsible to God for our body-soul persons. Voluntarily we

align our wills with the will of the Creator. For God‘s laws, properly understood, do not destroy

but perfect human freedom.



Personal

The responsibility for one’s personal health lies with the individual alone and cannot be

off-loaded onto someone else. Sufficient exercise, work and rest, and a healthy diet

are a basic necessity and are our own responsibility. Modern medicine developed a tendency to focus more on curing diseases than on preventing them through a healthy

regimen at an early stage, although in recent years there has been some improvement in

this.



Personal

Numerous factors in our lifestyles today have led to the very high levels of stress experienced by modern society - and stress is a major killer in

modern western societies. Despite recent improvements in hygiene and diet such factors as

the erosion of the Sabbath rest, environmental pollution, junk foods, and the widespread lack of

physical work and exercise inevitably lead to illness. This situation is made worse by the

activities that some engage in so as to relieve that stress, such as excessive drink, drugs,

overeating, tranquillisers or sexual indulgence.



Morality of the Physician




The Hippocratic Oath is the most recognizable of the ethical codes adopted by physicians. It has four elements: an agreement between the physician, patient, and society; an agreement not to do harm; an agreement to respect patients and their families; and an agreement to maintain the highest possible standards so that these may be passed on to future physicians. This Oath is very similar to its Moslem, Hindu and Chinese counterparts.

This Oath has helped produce a long history of physicians able to benefit the patient with their experience in managing the relief of symptoms, in restoring health, and in always providing comfort.




Whereas the Hippocratic Oath formed a direct agreement as to standards and behavior between the

practitioner and the patient, the new bioethical standard relates to an impersonal relationship

between an individual and the healthcare system. The result of this is that medicine moved from a system

that always protected life and the dignity of the individual, to one that leaves the door open to

subjective judgments as to the quality of life of an individual who can have their lives ended early if this

is judged to be substandard. Concepts such as the absolute sanctity of life have no place in the new

bioethic.




Unfortunately, the Hippocratic Oath now appears to be fast disappearing from the scene, to be replaced with a principalist ethic based upon the current thinking in secular bioethics. In this ethic decisions are based upon the principles of autonomy, beneficence, non-maleficence, and justice. Major proponents of this method are Beauchamp and Childress (Beauchamp, T.L. & Childress, J.F., Principles of bioethics, 3rd ed., Oxford University Press, New York) . As already seen, these principles are able to provide a guide to the morality of a specific action, but are often unable to help the ethicist arrive at a clear decision in complex cases. However, despite this, they are widely used in this context.




A significant consequence of this is that it is no longer possible to be confident that your practitioner will share your views on the sanctity of life, end of life issues, or even the quality of care due to you.


Relationship between Patient and Healthcare Professional

Informed Consent

Voluntary, non-coerced, informed, written

Honesty and Confidentiality

Genetical information; commercial interests, etc.

Medical Profession

Depersonalization


Respect for Humans at or near the end of their lives

Sanctity of Life

‘Human life is sacred because from the very beginning it involves ‘the creative action of God’, and it remains forever in a special relation with the Creator who is its sole end. God alone is the Lord of life from its beginning to its end…’ (Donum Vitae intro.5)

The right to life of the innocent human being is the first and most important of all human rights, because all others depend upon it. What use is the right to free speech, to association, to decent living conditions, if the right of life is not secure? It is the prerequisite, the sine qua non of all other human rights. (c.f. Pacem in terris 11)



Pastoral Care

Unfortunately a dying or seriously ill patient can often find themselves isolated, especially if the healthcare

professionals are themselves unable to face mortality. They may be inclined to retreat from something beyond their professional control. When healthcare professionals are themselves controlled by unconscious fears, they may

deceive patients as to their true condition and neglect the need for understanding and comfort. Thus an occasion for personal spiritual growth is lost for both the dying person

and the healthcare professional. This is why good training in this area is so necessary, as otherwise doctors, nurses,

health visitors and pastoral healthcare workers themselves can be bruised by constantly having to face the dying

without having some inner spiritual resources to draw on.



Pastoral Care

Christian doctors, nurses, and support workers have a most valuable role to play. If they understand suffering and death in terms of the passion and resurrection of

Christ, then their example and hope in the face of death can inspire their colleagues who are without faith.

Hospital personnel may feel defeated and helpless when patients for whom they have tried their best

nevertheless deteriorate and die. Only Christian hope has an answer for such despair. The Christian doctor or

nurse can see beyond the suffering of the ward and resuscitation room, to trust that through it all ‘God is working his purpose out as year succeeds to year, and

calling souls home to Himself’.



Pastoral Care

Hospices

Patients are usually in hospital with a disease, which a doctor can diagnose; prescribe medication or surgery for; and which they hope to recover from. However they go into a hospice basically for tender loving care, with no more drastic surgery or painful chemotherapy. They can enjoy a good cup of tea (or glass of

whisky!), be cared for in peace and quiet, and have their symptoms controlled until they die. Hospice staff are much more specialised in palliative care, and in 99% of terminal cancer cases

pain is quite controllable. They have more time to spend with their patients, and because hospices are smaller, the carers are more personal. They bear witness to the value of every human life, especially the weak and the dying. The religious ethos of

hospices is usually much stronger than that of general hospitals, and chaplaincy much more in evidence.



Ethical Issues:

• Clinical criteria for judging the moment of death

• Nutrition & Hydration

• Burdensome treatment

• Suicide

• Ordinary and extraordinary means


Assisted Dying

• Euthanasia

• Living Wills

• Back-Door Euthanasia

• Advanced Directives…….


Assisted Dying

Advanced Directives

The ‘living will‘ or ‘advance directive’ is drawn up specifying what kind of medical treatment the individual wants or does not want used should he become incompetent and no longer able to decide rationally for him or herself. It is an expression of the demand for autonomy and freedom so prevalent in western society. In particular a living will may reject futile life-prolonging treatments, and - this is where it becomes morally problematic - request euthanasia in certain circumstances.

There is a positive aspect to advance directives. If we ever become incompetent it will be very helpful to those responsible for our care at that time to know our wishes regarding treatment. The advance directive affirms three fundamental points of sound bioethics: the doctrine of informed consent; the right to refuse extraordinary or burdensome treatment; the legal right of all competent patients to refuse treatment. Furthermore, the drawing up of an advance directive turns a person‘s mind to pondering the end of earthly life and questions of ultimate value.


Assisted Dying

Advanced Directives

Negative aspects of living wills: any advance directive may be revoked whilst the patient is

competent. Once he becomes incompetent, it is binding. One‘s views and attitudes in a

dramatically different situation may change. However, one‘s past assessments and directives now prevail over one‘s present desires, and over

any assessment of best interests made by family, friends, doctors or nurses. The

euthanasia enthusiast may lose a little of his ardour for extinction once death is close.


Spiritual and Pastoral Care of the Sick

Today we have far fewer priests available, and this has meant a significant reduction in the number of hospital priest chaplains. This shortage is partly being addressed by the steadily increasing number of permanent deacons. Although many of these are married and work full-time in the secular world, sometimes they can be more available to serve as pastoral care ministers for the sick and dying. Among the ranks of the Deacons an increased interest is being shown for professional training and preparation to serve as pastoral care ministers to the sick, the hospitalized, and those confined to home or other institutions for their care. Such solicitude on behalf of the sick and dying is certainly an appropriate expression of the life of service which characterizes the role of the Deacon in the Church today.


Spiritual and Pastoral Care of the Sick

However, it is very important to realize that the pastoral care of the sick and dying is not only the preserve of ordained clergy. The laity too has a very important role to play here. The witness of the existing lay involvement in pastoral care among Catholics should inspire faithful men and women to seek opportunities to be of pastoral service to their sick brothers and sisters in Christ.


And finally….!

Important areas to ponder in days to come:

• The reality of hospitals and hospital life for both patients and staff

• How use can be made of the communities in which we live: (town, village, age related,

activity related, etc.); & which provide care: (medical, pastoral, social, etc.)

• How best to employ ecumenical collaboration

• The crucial nature of prayer, liturgy, sacraments, and how to enhance their use.


bernard farrell-roberts director of diaconal formation (maryvale ecclesiastical institute) principal...

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