Health Ethics Guide
HEALTH ETHICS GUIDE
Catholic Health Association of Canada
The full introduction to the "Health Ethics Guide" includes a summary of the basic principles that shape Catholic medical ethics. This 2000 "Health Guide" replaces the 1991 "Health Care Ethics Guide."
The Catholic Health Organization
The ministry of Catholic organizations is one of the visible expressions of the ministry of Christ. As creatures of body and spirit, we need visible, tangible human institutions to assist us to live as a believing community bearing witness to the Good News as expressed in the Catholic faith. Catholic organizations fulfil this important role by being present to people at the critical points where life can be fostered, where people are born and die, where they learn and are taught, where they are cured and healed, and where they are assisted when in trouble. Catholics see this concrete involvement as a sacramental presence, an encounter with Christ.
Catholic health organizations have a distinct spiritual vision and culture that directs them to attend to the needs of the poor and vulnerable with compassion and dignity. It is that vision which defines the quality of their relationship with those in need of care.
Our distinctive vocation in Christian health care is not so much to heal better or more efficiently than anyone else; it is to bring comfort to people by giving them an experience that will strengthen their confidence in life. The ultimate goal of our care is to give those who are ill, through our care, a reason to hope. (Joseph Cardinal Bernadin, "What Makes a Hospital Catholic—A Response," America, Vol. 174, no. 15 (May 4,1996), 9.)
Among the tangible signs that should identify Catholic organizations are the following: Catholic sponsorship and management; quality care; proper stewardship of resources for the community served; a culture that supports Christian ethical values and spiritual beliefs; recognition by the bishop of the diocese as an integral part of the apostolate; promotion of spiritual/religious care; mission and values integration; just working conditions; the availability of the sacraments, and the prominence of various Christian symbols.
The work of Catholic health organizations is a particular expression of the healing ministry of Christ. The physical, emotional and spiritual healing experienced by those cared for within these organizations is a sign of the presence and compassion of Christ the healer. Such organizations offer a privileged opportunity to provide the best possible care in a manner and atmosphere fully inspired by the gospel.
The basic orientation of Catholic health organizations and their personnel is respect for the dignity of every person and concern for the total well-being of persons receiving care. These organizations affirm the importance of family, friends and the community in the promotion of health. They also strive to provide for their personnel a milieu that is conducive to personal fulfillment.
As part of the history of health care institutions in Canada, religiously-based organizations have earned their rightful place in our country through their pioneering efforts, often undertaken in very demanding circumstances. Such centres continue to make a distinctive contribution to health care in Canada.
Ethical Reflection and Decision-Making
To witness to the teachings and values of Jesus Christ requires sound moral reflection and judgement. This is especially true in our technological world where there is an ever-increasing danger of reducing persons to objects. Judgements of what is right or wrong are ethical or moral decisions. Especially when rights, duties, or values appear to conflict, ethical reflection and discernment can assist everyone concerned.
The quality of ethical decisions depends not merely on abstract reasoning, but also on the lived faith, prudence and virtue of the decision-maker. The Catholic moral tradition is the fruit of an on-going dialogue between our understanding of human nature and our experience of God as revealed in Jesus Christ. It develops through prayer, study, reflection and the recognition of the Holy Spirit at work through various sources. Such sources include health and social service providers, the experience of the Christian community, moral theologians, ethicists, pastoral care workers, the local bishop, church teachings, and especially Sacred Scripture. No source of knowledge pertinent to the issue at hand should be neglected in the making of moral decisions.
The Catholic moral tradition presents a number of theological foundations that guide ethical reflection. These include a belief in the presence of God in human experience; the conviction that all of creation is to be regarded as a gift of God's love; an awareness that we have a responsibility to work to eliminate sickness and suffering; an acknowledgement that, at times, there can be growth through suffering; and the recognition that the moral dimension of human existence requires that we act from an informed conscience.
The local bishop has the responsibility to provide leadership and to collaborate with the mission of Catholic organizations. In fulfilling his role as the primary teacher and pastor of the community, with the assistance of specialists in different disciplines, he has the task to ensure that the teaching of the church is reflected faithfully in the context of rapidly developing medical advances and of the increasing complexity of the human sciences. In order to truly respect dignity, promote justice and foster trust, the church must itself witness to these values.
Since the Christian moral tradition is a living tradition, our formulations of it are necessarily the product of a grasp of reality that is constantly being refined, of historically conditioned attitudes, and of limited philosophical concepts and language. At any given time in history, a particular formulation is only more or less adequate. Continued faithfulness to this living tradition presupposes growth in understanding of moral principles and their implications. It is also important to remember that Catholic teaching maintains a hierarchy of truths and values. This means that specific teachings have varying degrees of importance concerning one's faith and moral life.
The tradition is not always clear or unanimous concerning all moral issues. In such cases, it is the teaching of the Catholic Church that obligations are not to be imposed unless they are certain. Thus, in moral questions debated by moral theologians in the church, Catholic tradition upholds a person's liberty to follow those opinions that seem to be consistent with the wishes of the person receiving care and with the best standards of good care.
Christian Moral Values
Christian ethical reasoning is based upon a world view contained in the gospel as interpreted by the church. This world view gives rise to values and principles that direct ethical decision-making and that enable us to respond to the call to respect dignity, promote justice and foster trust.
Two fundamental values underlie the discussion of values in this guide.
DIGNITY OF EVERY HUMAN PERSON— All persons possess an intrinsic dignity and worth that is independent of what any other person thinks or says about them. (Pastoral Constitution of the Church in the Modern World, Vatican Council II: Constitutions, Decrees, Declarations, Austin Flannery (ed.), New York, American Press, 1996, nos. 27, 29.) The basis for this dignity, in the Judeo-Christian tradition, is the belief that every human being is made in the image of God.
THE INTERCONNECTEDNESS OF EVERY HUMAN BEING —Human persons are social beings and cannot live or develop their potential outside of human relationships and community. (Ibid., nos. 12, 25.) This fundamental value affirms the interconnectedness of every human being with all persons, with all of creation, and with God. From these two fundamental values flow a number of related values.
STEWARDSHIP AND CREATIVITY— The scriptures present a view of creation as both gift and responsibility. We share a responsibility to respect, protect and care for all of creation and for ourselves. We are to use our own free and intelligent creativity to fashion a better world while respecting its true nature, appreciating its benefits and accepting its limitations.
RESPECT FOR HUMAN LIFE— Human life is sacred and inviolable in all of its phases and in every situation. (Pontificia Academia Pro Vita, Final Declaration, 5th General Assembly (February 24–27) 1999, no. 1.) Human life is a gift of God's love and the basis for all other human goods. Nevertheless, human bodily life is not an absolute good but is subordinated to the good of the whole person.
THE COMMON GOOD— Every individual has a duty to share in promoting the well-being of the community as well as a right to benefit from being a member of the community. Respect for human freedom necessitates that society seeks to enable men and women to assume responsibility for their own lives, and to encourage them to cooperate with each other in pursuit of the common good—the building of a just and compassionate social order in which true human growth for all persons is encouraged. By extension, the common good includes environmental concerns that have a direct relationship to the good of individuals and of society.
CHARITY OR SOLIDARITY— Charity is the Christian virtue urging us to respond to the needs of others. Solidarity (which includes empathy and compassion for others) is a contemporary way to express our interconnectedness to all human beings and our obligation to respond with love to their needs. This response is even more explicitly articulated in church teaching which exhorts individuals, organizations and those who develop public policy to a preferential option for the poor and marginalized.
Christian Moral Principles
TOTALITY AND INTEGRITY— All our physical and psychological functions are to be developed, used, and cared for to protect our human dignity. Therefore, no human function can ever be sacrificed except for the saving or better functioning of the whole person. Basic human capacities may not be sacrificed if more harm than good would result to that person.
DOUBLE EFFECT— When an action may have both beneficial and harmful consequences, such as pain relief treatment for a terminally ill person—treatment that might shorten life—the action may be pursued if the following conditions are fulfilled: (i) the directly intended object of the act must not be intrinsically evil, i.e. contrary to one's fundamental commitment to God, neighbour or oneself; (ii) the intention of the agent must be to achieve the beneficial effects and to avoid the harmful effects as far as possible (i.e. the harmful effects should not be wanted, but only allowed);(iii) the foreseen beneficial effects are not achieved by means of the foreseen harmful effects; rather, the beneficial effects are inextricably and unavoidably linked to the harmful effects; (iv) the foreseen beneficial effects must be equal to or greater than the foreseen harmful effects.
LEGITIMATE COOPERATION— This principle applies to situations where an action involves more than one person, and sometimes when the persons have different intentions. It is unethical to cooperate formally with an immoral act, i.e. directly to intend the evil act itself. But sometimes it may be an ethical duty to cooperate materially with an immoral act, i.e. one does not intend the evil effects, but only the good effects, when only in this way can a greater harm be prevented. Two provisions must be considered, namely, (1) the cooperation is not immediate and, (2) the degree of cooperation and the danger of scandal is taken into account. (Refer to Appendix II, "The Principle of Legitimate Cooperation")
SUBSIDIARITY— According to this principle, decisions should be taken as close to the grass roots as possible. As applied to health needs, the principle suggests that the first responsibility for meeting these needs resides with the free and competent individual. Individuals, however, are not self-sufficient. They can achieve health and obtain health care only with the help of the community. The responsibility of fulfilling those needs that the individual cannot achieve alone must be assumed by larger or more complex groups, e.g. community organizations and different levels of government. (Refer to John Paul II, Centesimus Annus, no. 12)
FREE AND INFORMED DECISION-MAKING— The person receiving care is the primary decision-maker. No service or treatment is to be provided without his or her free and informed consent. For those not capable of making an informed decision, a proxy shall act for the person in accordance with their personal care directives. If an advance health care directive is inapplicable or unavailable, a proxy shall act for the person in accordance with their known needs, values and wishes. In emergency situations where the person receiving care is not capable of making an informed decision and a proxy is unavailable, the care provider may act in the proxy's stead.
CONFIDENTIALITY— Respect for the dignity of persons insists that persons receiving care be treated with trust, honesty and confidentiality. This includes privacy of personal information and freedom from unnecessary intrusions by others.
In this introductory section of the guide, we have highlighted the values and ethical principles of the Christian tradition that direct our efforts to enter into relationships that respect dignity, promote justice and foster truth. In the remainder of the guide we apply these values and ethical principles to seven key areas related to care in the fields of health and social services.
The Communal Nature of Care
Health and social service organizations operate in societies that are organized into complex networks of social groups, from the smallest family to local, national, international and global systems. These different social structures are contemporary expressions of the basic and diverse social needs of all persons. The interconnectedness of all human beings is a fundamental value.
While each person is unique, no one could exist for long or fulfil their potential apart from the human community. The community gives people opportunities to provide and obtain resources such as food, clothing, shelter and culture that are required to live a truly human life. Through sharing and communicating with others in community persons grow in knowledge and love. They achieve human fulfillment by serving others, since each one receives from and contributes in some way to the individual personal development of others. Indeed, every society in a certain sense is "personal," so that the person is the beginning, the subject and the aim of every social institution. (Pastoral Constitution of the Church in the Modern Work, Vatican Council II: Constitutions, Decrees, Declarations, Austin Flannery (ed.), New York, American Press, 1996, no. 25.)
The individual and social needs of people always must be kept in balance within a social order "founded on truth, built on justice, and animated by love.… Every social group must take account of the needs and legitimate aspirations of other groups, and even of the general welfare of the entire human family." (Ibid., no. 26.) This is achieved through cooperative activity and through social structures that seek to guarantee equity and to overcome domination of one group by another. Through such an approach, individuals and groups contribute to the well-being of others and receive from others what is needed to meet their own particular needs.
Christian tradition uses the images of the human body and of the family to emphasize that human beings function often as organs of the greater civil society, united by common ends and using common means. Every person shares responsibility for our society and society has a responsibility for each of its members. As Christians, we also live in society as members of a community of faith. The faith life of the Christian community is shaped by our baptismal call to share God's life and to work for the common good of all peoples. The fundamental law of this community is such that love of self, love of neighbour and love of God should not be separated.
Health care and social support are two of the responsibilities and benefits of society. It is therefore necessary that (governments) give wholehearted and careful attention to the social as well as to the economic progress of the citizens, and to the development […] of such essential services as […] housing, public health, education […] (John XXIII, Pacem in Terris, April 11, 1963, no. 63.)
Catholic health and social service organizations function in civil society with a particular identity and mission. The specific way in which this mission is carried out distinguishes the service of Catholic care providers. This service is designated as "ministry" because it is motivated by the gospel and is part of an enduring faith tradition. Such an understanding of ministry challenges any system which might treat a person merely as a case, number or statistic. All those who are engaged in this ministry seek to create a community of compassion. They are dedicated to the care of persons in need, especially the most vulnerable, to the promotion of health in all its dimensions, and to forming healing relationships.
In society at large, Catholic health and social service organizations are a voice expressing a vision of life based on the moral and religious values of the Roman Catholic tradition. The care provided by these organizations is one expression within the local church of the healing ministry of Jesus Christ.
The Dignity of the Human Person
A fundamental value underlying ethics in health care and social services is respect for the dignity of each human person. This value aspires to protect the multiple interests of the person—from bodily to psychological to spiritual to cultural integrity. This respect for the dignity of each human person has been acknowledged and enshrined in the United Nations' Universal Declaration of Human Rights.
Human dignity is based on the physiological, psychological, social and spiritual uniqueness of being a person. Persons are created with intelligence and free will, with a moral consciousness and a potential for self-fulfillment. They possess the radical capacity to know, to love, to choose freely and to determine the direction of their lives. Each person is irreplaceable, with an intrinsic value and purpose in life. All persons are equal in dignity and, therefore, are to be treated with equal respect.
Our Christian faith holds that all persons are created in the image and likeness of God, and are called to know, love and be in communion with God, with all other persons and creation for all eternity. We believe that God became human in Jesus Christ, enabling all human beings to share the dignity of being daughters or sons of God, sisters or brothers of Jesus Christ.
Respect is due to every person. In light of gospel values, differences of age, sex, race, religion, social and cultural background, health status, sexual orientation, intelligence, economic status, employment, or other qualitative distinctions do not take away from the dignity shared by all persons, whether or not they are aware of their dignity.
Human sexuality is a personal aspect of our identity that gives beauty, pleasure, power and mystery to our lives. Because we are created in the image and likeness of God, human sexuality is good in all its dimensions: physical, psychological, spiritual and social.
Human sexuality has an interpersonal purpose. It is rooted in our basic human need to love and be loved, to live and grow through human relationships, to preserve and perpetuate society. The wonders of sexuality and birth are best shared in the family setting, and should be supported by instruction in both the parish and school.
Human sexuality is meant to nurture and sustain a woman's and a man's free gift of themselves in a permanent, loving and fruitful commitment of marriage. For Christians, this covenant of human love is a symbol of that faithful love existing between Christ and the church.
The love between a woman and a man is experienced in a unique way and completed through the marital act of sexual intercourse. This act can deepen the union of love, enabling the couple to share with God in the creation of human life. Men and women are called to be responsible stewards of God's gifts, always treating each other with loving respect. The unitive and procreative aspects of sexual intercourse are not to be separated.
Responsible parenthood requires that decisions about having children be made in a prayerful and discerning manner, considering what is most loving and life-giving and what is best for the overall welfare of the family.
Christianity looks upon the beginnings of human life with particular wonder and reverence. Catholic health care providers, therefore, are to surround obstetrical and perinatal care with an atmosphere respectful of human life, mindful of the parents' special circumstances and needs.
Organ and Tissue Donation and Transplantation
Human beings live and grow in mutual dependence with other members of the human community. Advances in medicine have made organ, blood and other tissue transplants a way to improve health and to give new life to countless people. Organ and tissue donation is an expression of respect for the dignity of persons, solidarity with other members of the human community, and charity in response to the needs and suffering of others.
From a Christian perspective, as members of the human community, we are co-creators and stewards of God's creation. We are to use our gifts to benefit ourselves, other individuals and the common good. In honouring the sacredness of every human life, Christians are encouraged to be generous in their response to God's call to love through the self-giving that comes from volunteering to be an organ donor. (John Paul II, Evangelium Vitae, no. 86.)
In applying its ethical principles to the issue of organ and tissue donation and transplantation, the church teaches that transplanting organs and tissues from a dead person to a living person, and transplanting organs and tissues from a living person to another, are ethically acceptable, provided that the following criteria are met: there is a serious need on the part of the recipient that cannot usually be fulfilled in any other way; the functional integrity of the living donor as a human person is not impaired; the risk taken by the living donor as an act of charity is proportionate to the good resulting for the recipient; the donor's and the recipient's consent are free and informed.
Many Catholic health care organizations provide a crucial link in the donation and transplantation of organs and tissues. They have a responsibility to provide this service with respect. Health care professionals are ideally suited for promoting organ donation and for educating the public about the subject.
Schools, parishes and community organizations should highlight the merits of organ and tissue donation and transplantation. Such activities would help to bring this issue into peoples' homes and encourage them to express their wishes to family and care providers.
Care of the Dying Person
Because of the inherent dignity and value of the person, all human beings are to be respected at every stage of life.
Sickness, suffering and dying are an inevitable part of human experience. Although the harshness of these realities can be eased by medical and psychological advances, nonetheless, they are a reminder of the limits of human existence and they lead human beings to ask more profound questions about the meaning of life and the mystery of death.
Dying can be a time of deeper self-awareness and not merely an inevitable process to which persons must passively submit. It can be a time in which persons freely and consciously affirm the meaning of their lives. It can also be an occasion of profound reconciliation with family and friends. In the time between the diagnosis of a terminal illness and death many losses occur which affect both the dying person and family members. These losses may be physical, psychological, social, or spiritual in nature. Grief is an important dimension of the dying process. Spiritual and religious care, therefore, is an essential element of care for those who are dying.
As Christians, what may seem meaningless takes on new meaning when we walk with Jesus Christ in faith through his life, death and resurrection. Death is the end of life on earth and the beginning of an eternal life with God. This conviction has moved Christians throughout history to regard death with awe and profound respect. When suffering and sickness do occur, they can have a positive meaning in a person's life. They do not represent a punishment or curse. On the contrary, accepted as a means of drawing closer to Christ, they can be an aid to spiritual growth.
Advances in science and technology are dramatically improving our ability to cure illness, ease suffering and prolong life. Concerted efforts must be taken to alleviate sickness and suffering.
These advances also raise new ethical questions concerning end-of-life care, particularly around life-sustaining treatment. There are occasions when prolonging life by artificial means places onerous burdens on dying persons and their families. In the face of such issues, it is necessary to maintain a balance between two important obligations. We are obliged not to intentionally kill someone; assisted suicide and euthanasia are not acceptable options. At the same time, we are not obliged to use life-sustaining procedures which would impose burdens out of proportion with the benefits to be gained from such procedures.
Catholic health and social service organizations, along with local parish communities, should surround dying persons and their families with all the care resources available.
Research on Human Subjects
Research in the human sciences provides significant benefits for the human community. New knowledge and understanding in health care, the social sciences and technology help alleviate human suffering, improve treatments for illnesses and enhance health status. The findings of research involving human subjects can offer creative solutions and hope for research subjects, particular groups and society as a whole. The participation of individuals in research studies, as investigators or as subjects, is an affirmation of solidarity with others. The way research is carried out must always respect the dignity and integrity of the persons involved and serve the common good.
Our Christian faith gives us an increased awareness of solidarity with others and challenges us to exercise leadership through participation in research. As co-creators with God, we are to use our gifts of intelligence and freedom to improve our bodies and to develop health care and social services that will benefit humankind, including medical technologies, methodologies and basic sciences.
Catholic health and social service organizations, as well as educational institutions engaged in research involving human subjects, have a responsibility to communicate and foster a respectful ethical attitude toward such research.
Governance and Administration
Catholic health and social service organizations are communities of service, united through collaborative activities and inspired by Roman Catholic moral principles for the purpose of providing an optimum level of care for those who are sick or in need, and promoting a healthy society. At the same time, they are occupational communities providing for personnel a means of personal and professional fulfillment and a means of earning a living.
To meet these obligations, the organization is called upon to act as a moral community by addressing the ethical dimension of decisions related to governance and administration, and by striving for effective communication and consultation with all members of the organization.
As a community of service that receives funds from the public to carry out its mission, the organization acts to meet obligations that correspond to its several roles:
- as an agency commissioned to provide services to the public;
- as a human community of service expressing solidarity with those in need of care;
- as a Christian community acting as a careful steward of God's gifts;
- as a church community committed to a preferential option for those who are poor and marginalized.
Work is a dimension of a person's creativity; it provides a community and a sense of meaning and purpose. As a community of work, the organization seeks to create an atmosphere within which work is viewed as more than an economic function. The personnel, in turn, are expected to carry out the mission of the organization. In their life and work personnel are guided by personal values that go beyond their role as employees. Personnel should be treated accordingly.