Bernard Farrell-Roberts
Director 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
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 selfstudy 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
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:
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 authorities
Brotherhood 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.
Brotherhood of the Holy Cross
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 II
Brotherhood 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 3,16
Brotherhood 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.
Brotherhood of the Holy Cross
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?
Brotherhood of the Holy Cross
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.
Brotherhood of the Holy Cross
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
Brotherhood of the Holy Cross
The outpouring of love
between Father, Son, and
Spirit is then poured onto us
freely by the Holy Spirit in
the form of grace.
Brotherhood of the Holy Cross
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
Brotherhood of the Holy Cross
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 Family
Brotherhood of the Holy Cross
And suffering…..?
Brotherhood of the Holy Cross
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 15:13
Brotherhood 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.
Brotherhood of the Holy Cross
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.
Brotherhood of the Holy Cross
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.
Brotherhood of the Holy Cross
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…
Brotherhood of the Holy Cross
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:
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
What happens if Society gets it
wrong?
The Law states that Jews are a
subhuman class
Result =
Holocaust
But then, having seen our error, we did it again:
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
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?
“Universal laws of jurisprudence”
Samuel L Jackson, Judge
Or Natural Law, as we know it
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
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).
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……..
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.
Case Study: To illustrate what we are up
against!
Dr Thustra’s Dilemma
Background
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.
PID 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.
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 oldgeneration 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.
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
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?
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”
What is our Systematic Ethic?
1. Ensure that all principal potential harms and
2.
3.
4.
benefits have been identified
Ensure that all principal ethical schools of
thought have been applied and evaluated
Value all humans equally, respecting their
rights as humans
Do the above always in light of God’s
revelation
And how do we go about this?
Ensure we consider all the following:
All ethical schools of thought, starting with:
Principalism
Autonomy
Beneficence
Non-Maleficence
Justice
Then adding “Scope”
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.
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.
* 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
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.
Case Study 2
A 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.
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.”
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.
QUESTIONS?
The principal areas of
ethical concern in Bioethics:
Biomedical Field Plus:
“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)
Case Studies:
•
•
•
•
•
•
Rape leading to pregnancy
Foetus with genetic abnormality
Pre-implantation selection
IVF
Living Donors
Human Experimentation
More Case Studies:
1. Quality of life argument e.g. organ donorship
2. Slippery Slope e.g. euthanasia
3. Red Biotechnology e.g. embryonic stem cells
4. White Biotechnology e.g. sun tan lotion &
nano-technology
5. Green Biotechnology e.g. GM Crops, gene
splicing, cloning
We shall look more at elderly
and infirm issues in the next
session.
Questions ?
End of Session One
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
“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.”
Pope John Paul II 2000
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.”
Pope John Paul II 2000
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.
Aspects of pastoral care:
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.
Aspects of pastoral care:
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.
•
•
•
•
Aspects of pastoral care:
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.
Aspects of pastoral care:
Near Death and Death
Common Emotional Pathway: Not sequential, or
regular
• Anger
• Denial
• Bargaining
• Guilt
• Depression
• Resolution / Acceptance
Aspects of pastoral care:
Near Death and Death
•
•
•
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.
Aspects of pastoral care:
Near Death and Death
•
•
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
Responsibility for Health
Resource apportionment in Healthcare
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.
Responsibility for Health
Resource apportionment in Healthcare
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.
Responsibility for Health
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.
Responsibility for Health
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.
Responsibility for Health
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.
Responsibility for Health
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.
Responsibility for Health
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.
Responsibility for Health
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.
Responsibility for Health
Morality of the Physician
Responsibility for Health
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.
Responsibility for Health
Morality of the Physician
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.
Responsibility for Health
Morality of the Physician
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.
Responsibility for Health
Morality of the Physician
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)
Respect for Humans at or near the end of their lives
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.
Respect for Humans at or near the end of their lives
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’.
Respect for Humans at or near the end of their lives
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.
Respect for Humans at or near the end of their lives
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.