Pastoral Healthcare Ethics

Pastoral Healthcare Ethics
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 self-study course book.

Biomedical Ethics
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".” RedemptorHominis 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:

Letususe thefollowingtohelpusunderstand and explainon a practicallevelGod’slove and whatthismeans in ourlives: TheSuffering of Christ Human Suffering How are theyConnected? Brotherhood of the Holy Cross

Whatexactly do we mean by “suffering”? What do weunderstandbyit? Brotherhood of the Holy Cross

Pope John Paul II explained in Theme 6 of «SalvificiDoloris» thathumanssuffer in manydifferentways, manyof thesenotalwaysacceptedby medical authorities Brotherhood of the Holy Cross

He explainedthatsufferingisbiggerthanillness, and more complex. Bothphysical and spiritual sufferingexist, in boththebody and thesoul. Brotherhood of the Holy Cross

Mansuffersbecause of evil, a “lack of good”, because he has deprivedhimself of thisgoodthroughhissinfulactions. Brotherhood of the Holy Cross

“In ordertodiscoverwhywesuffer,wehavetoturnourgazetotherevelation of divinelove.” Pope John Paul II Brotherhood of the Holy Cross

Revalation of Divinelove: Old Testamentrelationship and covenants; & Christhimself. “God so lovedtheworldthat he gave up hisown son” Jn 3,16 Brotherhood of the Holy Cross

“Thosewhoparticipate in thesuffering of Christposess a specialpart of theinfinitetreasure of theredemption of theworld.” Brotherhood of the Holy Cross

What do we mean bythis? We mean thatwe can and do participate in thesuffering of Christthroughwhich He savedhumanity! Howthen can and do we share in thesufferings of Christ? In ordertounderstandthisweneedtounderstand “love” itself. Brotherhood of the Holy Cross

Why? Becauseitis in loveitselfthatwefindthejustification of allsuffering. Whatislovethen, and howdoesitjustifysuffering? Brotherhood of the Holy Cross

Simplyspeaking, LoveisGod, and istherefore“Trinitarian”, and thishelpsustounderstandit, as explainedbySt Bernard of Clairvaux. He explainedthattheHoly Trinity can be understood as a relationship of love, and as such a concept withwhichwe can identify as parents, familymembers, friends, as humanswholove. Brotherhood of the Holy Cross

FatherSon (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 thiswayweenterintothissamelovingrelationship, calledtoloveGod as He lovesus. Remember: Loveisthe total giving of selffortheother: Christforus in hispassion and death Usforourwives, families, friends And forChrist? Are wewillingtoloveHim as He lovesus? He lovesustotally, and seeks total freelygivenlove back fromus Brotherhood of the Holy Cross

Ifwethenunderstandthefollowing in light of this, we can begintounderstandtheir true realitybetter: Marriage As anicon of the Trinity As the “DomesticChurch” TheFamily Brotherhood of the Holy Cross

And suffering…..? Brotherhood of the Holy Cross

Ifyour son ordaughterissuffering, wouldn’tyou do everything in yourpowertoremovethatsufferingfromhimorher, eventotakingtheirsufferingonyourself? ThisiswhatGoddid. 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 whatshouldwe do? Are wegoingtoloveGod as much as He lovesus? He suffersforus. He diedforus. Thisishowmuch He lovesus – and He wantsustoloveHim as much as He lovesus. And how can we do this? Can wetakeonsome of Hissuffering, sufferforHim, and thereforelessenthesuffering He must endure, bysharing in hissufferingforus, foroursins. Brotherhood of the Holy Cross

Seenlikethis, freelyoffered up toChrist in orderto “takeaway” some of Hissuffering, human sufferingbecomesourparticipation in Christ’sact of salvation. Itbecomesourgifttoourfellowhumans, ouract of loveforthem. True loveforourneighbour, reflectingourlove 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”

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 = Holocaust But 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 needa fair means to evaluate the morality of human actions.

Biomedical Ethics
Case Study: To illustrate what we are up against! Dr Thustra’sDilemma 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).
Biomedical Ethics

Biomedical Ethics
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? Ensure that all principal potential harms and 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?

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.

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 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. Biomedical Ethics

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: Quality of life argument e.g. organ donorship Slippery Slope e.g. euthanasia Red Biotechnology e.g. embryonic stem cells White Biotechnology e.g. sun tan lotion & nano-technology 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

Holistic Pastoral Healthcare
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 terris11)

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.

Pastoral Healthcare Ethics