Impact and Challenge: 25 Years of Bioethics
Issue 20, November 2006
Where There Is No Vision, The People Wander (Proverbs 29:18)
Let me begin by expressing my immense gratitude to Archbishop John Dew and to Father Michael McCabe for inviting me to deliver the Catholic Foundation Lecture on the occasion of its Silver Jubilee. I am truly humbled and honored, especially given those who have preceded me in giving this lecture. I would also like to thank all of you for being here this evening.
The title of this evening's lecture is Impact and Challenge: 25 Years of Bioethics. However, I have also sub-titled this reflection using a text from Proverbs: Where There Is No Vision, The People Wander (Pv 29:18), because I believe that much of what I will be speaking about this evening has to do with vision an inadequate vision in much of bioethics and a corrective vision that can be offered by elements of the Catholic faith and theological tradition. By the way, I should mention that the text from Proverbs is sometimes translated more ominously as: Where there is no vision, the people perish. I will leave it to you to choose the translation you prefer!
What I wish to do this evening is to reflect with you on some of the major contributions of bioethics toward enhancing dimensions of human life, as well as some of the more trenchant challenges it poses to all of society, but particularly to the community of faith. For better or worse, I do this out of my own social location, namely as an American theologian and bioethicist, for I can only speak of the bioethics that I know and experience. My genuine hope is that something I have to say will resonate with your experience of bioethics in New Zealand either your experience of American bioethics (what you read or hear about), or of New Zealand bioethics, or both.
Before proceeding with the main portion of the lecture, let me say a word about what bioethics is. I would describe bioethics as a multidisciplinary field of study that examines various ethical dimensions of developments in medicine and the life sciences at the individual, organizational, and societal levels. The ethical dimensions I am referring to are threefold. First is the question "What should we do?" This is the domain of conduct or action and is concerned with whether we should proceed with or employ x, y, or z technology. Much of bioethics is concerned with this dimension of ethics. It is generally the most interesting. Second is the question "Who should we be?" This is the domain of character. What kind of individuals, organizations, or societies are we becoming in and through our decisions, practices, and policies? This is less of a concern to bioethics, unfortunately. And, third is the question "How do or should we see?" — This has to do with the beliefs, values, attitudes, intentions, and motives that we bring to any issue. — These shape our vision and vision affects what we see. Vision is critical, but most often neglected. It is that dimension of ethics and bioethics that I will be focusing on this evening.
In 1981, when the Foundation was first established, bioethics was still something of a fledgling field of study, approximately 13 years of age, depending on when one dates the birth of bioethics. As young as it was, bioethics had already addressed a wide range of issues prompted by relatively rapid advances in medicine and the life sciences. Among these issues were abortion, new reproductive technologies (e.g., in vitro fertilization and embryo transfer), genetic engineering (e.g., gene therapy, recombinant DNA research), genetic counseling and screening, prenatal diagnosis, research on human subjects (including the mentally ill, prisoners, children and embryos), organ transplantation and the definition of death, allocation of scarce medical resources (e.g., dialysis machines) psychosurgery and behavior control e.g., electronic stimulation of the brain (ESB) and electroconvulsive therapy (ECT), the right to refuse life-sustaining treatment as well as the right to execute advance directives, euthanasia, and, finally, the health professional-patient relationship (e.g., the right to self-determination, informed consent, confidentiality, and truth-telling). This is an impressive array of issues for a field that was so young and unformed. With regard to many of these issues, bioethics succeeded in forging a social consensus, often enshrined in laws or guidelines. These in turn, together with the on-going discussions, altered thinking and practice in health care delivery and research, most often, but certainly not always, for the better.
Twenty-five years after the inception of the Catholic Foundation, the field of bioethics has reached some degree of maturity. It is a flourishing area of study worldwide with its own practitioners, its own journals and extensive body of literature, institutes and centers around the world (such as The Nathaniel Centre), degree programs, courses in educational institutions, national and international conferences. It has a presence in and to many governments (in the form of Commissions and the like, such as the Toi te Taiao — The New Zealand Bioethics Council) as well as in a vast number of health care institutions and research organizations around the world (in the form of ethics committees or ethics consultants). It is a very frequent topic of media attention. Bioethics has truly become a powerful presence and force in many societies.
In addition to its expansive growth and to its continued work on many of the issues noted above, bioethics in the past twenty-five years has had to grapple with major advances in science and medicine. Perhaps most significant, because of their implications for the future, have been the completion of the Human Genome Project, stem cell research, and cloning. Other issues also stand out—the AIDS epidemic, physician assisted suicide (PAS) and euthanasia, terminal sedation, futile treatment, artificial nutrition and hydration, especially for patients in a permanent vegetative state, xenotransplantation, genetic modification of food, and the threat of pandemics. Indeed, bioethics touches almost every dimension of human life and, in some way, the lives of almost every person on this planet. It is difficult to imagine any other field of study that is so pervasive in scope and that deals with such fundamental dimensions of human life and, hence, that is so potentially influential. What are instances of that influence? What has been the impact of bioethics?
The Impact of Bioethics: A Few Examples
There can be little doubt that bioethics in its nearly 40 years of existence has had a significant impact on social beliefs, practices and policies around the world. In very many instances, this has been a positive impact. In other instances, however, its influence raises serious concerns and challenges. I wish to begin with what I see as a few of the positive impacts of bioethics (though even these have their shadow side).
First, bioethics has had a significant impact on the way in which health professionals and patients relate, at least theoretically and, to a considerable degree, actually. The change is often characterized as a shift from paternalism, where the physician is the primary decision maker, to patient autonomy, where the patient is the primary decision-maker. Patient autonomy recognizes the individual's right to make decisions about his or her health and life in accord with that person's beliefs and values. It places the patient at the center of health care and research decisions, bringing some greater balance to the relationship. Ideally, patient autonomy fosters a more collaborative relationship where health professionals and patient work together for the patient's healing and health. At times, however, it can foster an adversarial relationship where the patient pits his or her will against the physician's.
Several other considerations follow from this emphasis on patient autonomy. If the patient is the prime decision maker, then he or she needs to be adequately informed about his or her medical condition (and, hence, truthfulness is necessary) as well as the potential benefits and burdens of various treatment alternatives. In addition, the patient's consent is required, a consent that must not only be informed, but also be free of undue influence and coercion. Patient autonomy or self-determination requires that patients take more responsibility for their health and their health care. This is a positive good, an important development.
While secular bioethics frames this in the language of liberalism, the fundamental concepts are not foreign to our religious beliefs. We might approach this from the perspective of respect for inherent human dignity and what is required to respect that dignity in the professional patient relationship. Or we might approach it from the perspective of stewardship. Human life and the human body are entrusted to us for our use, our care, and development. One's health is the responsibility of the individual. In the words of the Australian Code of Ethical Standards (1.2): The primary responsibility for safeguarding and maintaining one's health so far as that is reasonable belongs to each person in his or her own right. It follows that each person is primarily responsible for making decisions concerning his or her own health.
I believe that recognizing the responsibility of the patient for his or her health and the centrality of the patient in health care decision making, together with the accompanying notions of informed consent and truth-telling, is one of the most significant and positive contributions and impacts of bioethics.
A second positive impact of bioethics has been its transformation of the way in which people die, particularly in those countries with high tech medicine. To a large degree, bioethics was born in response to rapidly developing medical technologies that were capable of prolonging life ventilators, dialysis machines, organ transplants as well as cardiopulmonary resuscitation and new drugs and surgeries. While in some instances, these new developments saved lives, in other instances they merely prolonged the dying process, sometimes to the point of subjecting dying patients to something close to torture. Too often medical technology at the end of life was doing something to patients instead of doing something for them.
Gradually it came to be realized that dying patients or those who represent them ought to be the ones making decisions about what life-sustaining treatments should be employed and for how long. At least in the American context, it was the combination of respect for patient autonomy or self-determination, together with the Catholic principle of ordinary and extraordinary means that lead to the moral and legal recognition of a dying patient's right to refuse life-sustaining treatment. The right was often tested in the courts and almost each time the courts affirmed and re-affirmed it. While there are still abuses of life-sustaining technology and some disputes about what is morally and legally permissible (e.g., the Terri Schiavo case), there generally is a more tempered use of measures at the end of life. Together with the hospice movement and the spread of palliative care, dying has become more humane. Bioethics has contributed to significant advances in end-of-life care.
The shadow side of this contribution, however, is that the right to refuse treatment has become for some the right to demand specific treatments (e.g., "I want everything done") or, conversely, the right to end one's life (PAS) or to have one's life ended (euthanasia).
A third impact of bioethics in the past 25 years in particular is that it has popularized advances in medicine and biotechnology. What I mean by that is that it has brought these issues into people's homes and schools and churches and places of employment. What might have remained unknown or little known now becomes the subject matter of news reports and table conversations. Bioethics over the years has succeeded in bringing the issues to light and in generating conversation and debate about them. People are generally better informed about these issues that are vital to their own lives and, often, they are engaged in debates about policies, laws or practices. This too is a positive impact.
There are many other areas that we could point to where bioethics has had a significant impact—protection of human subjects in research and organ transplantation, for example. But at this point, I wish to turn to a different kind of impact, those that are less positive, those that pose challenges for individuals and societies and, in a particular way, those that pose challenges for the church, the community of faith, and for theological bioethics going forward. These challenges all in one way or another have something to do with how we see, with our vision. How we see very much determines what we do. The concern is not that the people have no vision (to return to the sub-title of this reflection), but rather that the vision they do have is faulty or inadequate. Such visions lead to practices that are harmful or destructive of individuals and societies. I believe that the future of our societies will depend greatly on how successfully we address these challenges.
Twenty-Five Years of Bioethics: Some Challenges
There are very many challenges which bioethics poses to our societies and to our communities of faith. I wish to highlight only a very few, none of which is particularly new to you, but which I increasingly find to be troublesome as I scan the horizon of issues with which bioethics is engaged. I will consider four: attitudes toward human life, an overemphasis on autonomy, an inability to accept finitude and limits, and a marginalization of religion and theology.
Attitudes toward Human Life
The first is societal attitudes toward human life. Here I fear two extremes. On the one hand, are those who have diminished respect for human life, at least at some stages (usually the beginning and the end). This is evidenced in the high rates of abortion worldwide and in increasing efforts in many countries to legalize PAS, euthanasia, or both. These developments are surely of grave concern. But what I find even more troubling and potentially dangerous is the devaluing of human life in debates about embryonic stem cell research and cloning. Proponents of these technologies either accord no value to beginning human life or not enough value as to prohibit it from being destroyed. Of further concern is that proponents of these technologies are willing to destroy early human life for our purposes. Early human life is considered to have little or no value in itself, but is accorded instrumental value. It is or may be useful for us. It can be destroyed to benefit us (and in the case of cloning, it can be created and destroyed to benefit us). This attitude seems to cross a new threshold.
The other development that is troubling moves in the opposite direction in the direction of vitalism (i.e., life itself is considered to be the highest value and must be sustained at all costs). This is evidenced particularly in several statements made over the past thirty years by a few bishops, local bishops' conferences, and Vatican offices about medically administered nutrition and hydration (MANH). It was further evidenced in the address of Pope John Paul II in March, 2004 and in subsequent responses to the papal allocution.
As you may know, John Paul II's remarks were directed at patients in a permanent vegetative state. Among other things, the Pope stated his belief that medically administered nutrition and hydration are "In principle, ordinary and proportionate, and as such morally obligatory, insofar as and until it is seen to have achieved its proper finality, which in the present case consists in providing nourishment to the patient and alleviation of his suffering." Since the allocution, at least in the United States, we are seeing some people extend — the Pope's remarks to all patients unless those patients are imminently dying (i.e., death is a few hours away). We are also just beginning to see the application of this approach beyond MANH to other life-sustaining measures, e.g., cardio-pulmonary resuscitation.
This is a troubling development for a number of reasons. It is a departure from the Catholic tradition around forgoing treatment, a tradition that has been in place and has remained constant for almost five hundred years. It accords physical, biological life a status that is not consistent with the Catholic tradition where we consider human life to be sacred, but not absolute. It medicalizes the dying process and plays into the hands of the technological imperative (i.e., if we have the technology, we must use it). It will dramatically reshape the way we care for the dying and move us back to where we were in the early days of bioethics. It will create enormous problems for Catholic health care and place Catholic health care where it exists at odds with the standard of care and with the law, at least in many countries. It will inadvertently foster PAS and euthanasia. And it seems to contradict our belief in the resurrection.
For centuries, the Catholic tradition of forgoing treatment has walked a middle path between prolonging dying and hastening death. As the Australian Code of Ethical Standards states (5.3): [T]wo extremes should be avoided: on the one hand, an insistence on futile and overly-burdensome treatments which merely obstruct death, on the other hand the deliberate withdrawal of treatment in order to bring about death. Since good medicine treats a person rather than a condition, respect for persons requires that they neither be under-treated nor over-treated; rather, when people are dying they should have access to the care that is appropriate to their condition. The two developments I have noted, if they take hold, would likely shift this balance with potentially unfortunate if not tragic consequences.
Overemphasis on Autonomy
Another challenge spawned by bioethics, at least in the United States, is an excessive emphasis on the individual, on individual rights, and on individual choice. Autonomy is a cornerstone of much of the bioethics literature and bioethical analysis. The emphasis on autonomy has had a profound impact on the development of bioethics as well as the practice of medicine. I wish to point to a few consequences of this emphasis (which, by the way, represents a particular way of viewing the human person) and the challenges they raise.
First, this conception of human beings is at minimum truncated and more probably deficient and even false. It leads people to think and act as if they were isolated and detached entities, self-sufficient islands as it were, and fails to recognize that social life is an essential dimension of the human person. In fact, we are social by nature and we are able to exist and flourish only in relationships with others. Relatedness to others is not a matter of autonomous choice, but an intrinsic dimension of what it means to be human. Because of this inherent sociality, we not only have individual rights, but also responsibilities to others. The exercise of individual rights and the pursuit of individual goods must always be balanced by social considerations. A sense of connectedness to others, together with a concomitant sense of responsibilities to them is seriously underdeveloped in much of contemporary bioethics.
Second, the emphasis on the autonomous individual elevates choice as the defining characteristic of the person, and gives individual choice a status that is extremely problematic. The choice of the autonomous person is often regarded as trumping all other considerations. In other words, the very act of choosing something makes it right regardless of what is chosen. We see this most clearly exemplified in some arguments regarding abortion, PAS, and euthanasia. What is chosen is not central to the choice, the decision making process, or the moral argumentation (if there is any). The fact of choosing eclipses all else. This leads inevitably to relativism and to a privatization of issues—relativism because idiosyncratic preferences and the choices based upon them are all that matter, and privatization of issues because there is little or no consideration of the consequences of one's choices upon immediate others and upon the common good (e.g., euthanasia).
Third, and very problematic, the emphasis on individual autonomy has curtailed the scope of bioethics. So much of bioethics has to do with individual rights and their protection. Issues tend to be addressed almost exclusively from this perspective—individual problems to be addressed on an individual level. It is largely patient-focused. For example, in the early days of the AIDS epidemic, the central questions had to do with whether it was necessary to obtain informed consent to test an individual, whether test results could be passed along to public health authorities, maintaining the privacy and confidentiality of those with AIDS, and whether health care professionals could refuse to care for a patient with HIV-AIDS. What has been missing from so many discussions in bioethics is attention to questions of social justice that go beyond the individual. As Catholic moral theologian Lisa Cahill has noted in her book, Bioethics and the Common Good:
[W]hen AIDS first came to the attention of Catholic moral theology, its analysis was closely connected to the morality of personal sexual behavior. Gradually, awareness grew that the impact of AIDS on the health of populations around the world is dire.
AIDS began to move out of the category of a sexual problem and into that of a global health problem. It is also a problem of appropriate medical and social responses to suffering and death. Broader social issues began to be examined, including more effective means of preventing transmission (the debate about the use of condoms), the inequities of wealth and power that contribute to the spread of AIDS, the need of resource redistribution to treat all those with AIDS with antiretroviral drugs, and the obligation to care for communities afflicted by AIDS (especially AIDS orphans) as falling on the international community, especially its wealthiest members. AIDS has become a problem of bioethics and the global common good. (Lisa Sowle Cahill, Bioethics and the Common Good, 2004, pp. 67-68).
What Cahill suggests is that an overemphasis on autonomy and the individual has resulted in a lack of concern for the common good, and a neglect of the social dimensions and implications of developments in medicine and biotechnology. Hence, what is needed, and this can be a major challenge, is a reorientation of perspective, a transformation of vision. It means seeing the nature of human beings and approaching developments in medicine and the life sciences differently, with different assumptions, different categories, and different questions. This re-orientation entails not only the individual, but the individual-in-community; not only choice and individual rights, but also justice and responsibilities to the common good, including the global common good; not only the questions relevant to the developed world, but those as well relevant to the third world, or the two-thirds world.
Such a reorientation would likely bring to the forefront the reality that much of the world does not benefit from the advances in medicine and biotechnology. In the words of John Paul II:
[There is a] very serious and unacceptable gap that separates the developing world from the developed in terms of the capacity to develop biomedical research for the benefit of health care assistance and to assist peoples afflicted by chronic poverty and dire epidemics— It is essential to realize that to leave these peoples without the resources of science and culture means to condemn them to poverty, financial exploitation and the lack of health care structures, and also to commit an injustice and fuel a long-term threat for the globalized world (Address to the Pontifical Academy for Life, 2003).
The challenge here is enormous. It is especially pressing for Catholic bioethics, which is not immune from a focus on issues as they affect individuals. It is critical that we do more bioethics from the perspective of Catholic social ethics bringing to bear our fundamental commitments to human dignity in the context of community, the common good, solidarity, and justice.
Finitude and Limits
Another critical challenge is the need to recover or, perhaps, acquire a sense of finitude and limits. We are finite beings, pure and simple. We will all die. Our lives are marked by pain, suffering, disease, disability, and countless other limits. We will never fully overcome our finitude and all that that entails. This reality does not mean that human beings ought to be passive before the various manifestations of finitude. That is simply not human nature. In fact, human history can be viewed at least in part as an on-going attempt to overcome limits of various sorts. We would be remiss if we did not employ our God-given intelligence and creative abilities to improve upon our lot and to bring ourselves and creation to fuller development.
But are there limits to this effort? Or can anything and everything be justified in the process of curing disease and delaying death? The latter very often seems to be the case among the scientific community as well as the general population. There seems to be a sense that with adequate time, money, and effort, particular diseases can be conquered and death itself can be overcome. The American philosopher and bioethicist Daniel Callahan puts it this way:
Medicine, I believe, has implicitly defined its central purpose as an all-out fight against death. [E]very cause of death is taken to be contingent, a matter of chance. By contingent and chance I mean that it need not exist, that there is in principle and in medical theory no reason why any particular disease cannot be overcome. Death is in some sense biologically programmed, but not particular causes of death. Just as smallpox was eliminated and diphtheria and typhoid and typhus all but eradicated, so cancer and Alzheimer's can also be done away with. This is the abiding faith of scientific medicine. No cause of death has been declared beyond hope; none could be. All of the known causes of death can, in principle, be picked off, one by one. All of the wars against disease can eventually be won, not only those that kill us but also those that weigh us down our aging (Daniel Callahan, The Troubled Dream of Life, 1993, pp. 74-75).
The belief that all diseases and even aging can be conquered along with death is often coupled with a belief that there is a moral obligation to use whatever means are possible to pursue this goal. Again, in the words of Daniel Callahan:
The advent of effective medicine, the kind that can save and extend life, changed the perspective on death as an evil. As it became increasingly possible to manipulate the conditions of dying, fatalism was rejected and a moral dimension was added. That dimension soon took the form of a simple principle: since death is an evil in human life, we have a moral obligation to use medical means to combat it. What can be done to struggle against death ought to be done. (Daniel Callahan, The Troubled Dream of Life, 1993, p. 75).
Those who choose not to do everything possible to overcome disease and stave off death are considered to be blameworthy. This is the kind of rhetoric, for example, that we hear, at least in the United States, with regard to the pursuit of embryonic stem cell research. One proponent of the research puts it this way: What excuse will we offer this young woman should we fail her now? What might we tell her children? Or the millions of others who suffer? That when given an opportunity to help, we turned away? That facing political opposition, we lost our nerve? That even though we knew better, we did nothing No, no, we owe this young woman and all those who suffer we owe ourselves better than that.
Part of what fuels such thinking seems to be a belief that there are no limits to human ingenuity and to medical progress. Again, in the words of Daniel Callahan:
[W]e must understand that it [the dream of medical progress] is, in modern hands, open-ended and expansionist. The dream of medical progress does not have any logical or obvious endpoint or any intrinsic constraints. Nor is it at all clear just what would count as a full realization of the dream. The eradication of all suffering? The cure of every disease? An endless old age? Immortality?
Precisely because modern medicine's unspoken goal is simply more, there are no limits to what can be hoped for and sought. The very absence of any more clearly and precisely articulated goals fuels the entire enterprise. In modern medicine's dream of progress, there are no set boundaries to what societies and individuals can desire, nor to what may be done to satisfy those desires. (Daniel Callahan, False Hopes, 1998, p. 52).
The challenge here it twofold: we need to recognize that not everything is justified in the attempt to cure horrible diseases that plague the human condition and, second, we need to learn to live with our finitude and some of the limitations that we encounter. We need to understand that we are creatures and not God. The maddening reality that we must accept is that we can never fully overcome ourselves. This is what it means to be finite. While we can and should strive to overcome human limitations, a complete transcendence of them through technological means will never be possible. Yes, we should attempt to alleviate human suffering and its causes and even seek to prevent premature death, but within limits, recognizing that there are other needs and other goods to be pursued, that there are moral constraints, and that there are realities called the common good and the global common good. Viewing human endeavors in biotechnology against the backdrop of our finitude can help us temper unrealistic expectations and use our creativity more constructively. Again, we need to see differently, we need to correct our vision, and then perhaps we will choose differently.
Recovering the Voice of Religion and Theology
A further challenge (and this is the final one I will address this evening) posed by much of contemporary secular bioethics and many practitioners within the field is the marginalization of religious and theological contributions to bioethics. This may be a challenge more troubling in the United States than elsewhere because of my country's strong tradition of the separation of Church and state, the reality of religious pluralism, and concerns over the views and tactics of the religious right. However, I suspect the problem may exist elsewhere, but for somewhat different reasons (such as secularism, anti-clericalism and the like).
It is well known that the first practitioners of modern bioethics were theologians. It is also well-known that there is a long history of attention to medical-moral matters within Catholicism. For a variety of reasons, however, shortly after the birth of bioethics in the late 1960s and early 1970s, philosophy and law came to dominate and define the field. It was then that the "Georgetown mantra" came to exist the four principles of autonomy, beneficence, non-maleficence, and justice that originated at Georgetown University. Each of these was understood individualistically and focused on protection of individual rights. These philosophical concepts were seen as offering a more neutral and objective mode of moral analysis in a pluralistic society, especially with regard to the formation of public policy. Religion was deemed to be partisan and as imposing solutions upon society derived from a religious perspective that was not shared by the general populace. Within a very short time, religious and theological voices were relegated to the margins of bioethical debates and policy formation. In response, in order to —remain in the game,— many theologians began to adopt the language and categories of secular bioethics abandoning their own theological traditions, concepts, and symbols. They began to function as philosophers, employing the Georgetown mantra, focusing on the individual, individual autonomy, and individual rights.
This development, I believe, has lead to a great impoverishment of secular bioethics. Deprived of religious and theological voices, bioethics has operated out of a very inadequate notion of the individual, society, and justice. It has resulted in a narrowing of the scope of bioethical concerns. It has permitted bioethics to focus excessively on the impact of new technologies on individuals primarily, as well as on individual choice and individual rights. And it resulted in many of the underlying meaning questions not being addressed, such as, the meaning of finitude, limits, dependency, parenthood, procreation, health, medical progress, life and death and the like.
In recent years, the place of religion and theology in bioethics has improved somewhat, but there is still much room for improvement. Going forward, I believe that communities of faith and theological bioethicists have a critical role to play. I would like to suggest six ways in which religion and theology can contribute to bioethics. First, and rather obviously, it can provide a far richer understanding of what it means to be human than what is currently operative in much of Anglo-Saxon bioethics and public policy formation. An understanding of the human person that has breadth and depth that goes beyond an emphasis on the individual, on autonomy, on choice, and on individual rights could lead to a bioethics and a public policy that will better contribute to the flourishing of individuals and society.
For example, in the embryonic stem cell debate, the moral status of the embryo is surely a primary consideration. But this is not the only consideration. A fuller theological understanding of the human person would also want to underscore our social nature and the duties we have toward and responsibilities we have for one another, including nascent human life and those who suffer from disease and disability. This includes what we become as individuals and as a society in and through the choices we make. What will be the impact on us and on those who come after us if we accept the destruction of nascent human life? What will be the impact on us if we acquiesce to using nascent human life for our purposes? — We would want to consider what we owe one another in our various social interactions, that is, what justice requires of us. Who will benefit from the cures, if any, developed from embryonic stem cells? Who will have access to such treatments? Will we ensure fair access and equitable distribution?
Such a theological understanding of the human person would likely consider the fact that human beings are finite, that limitations of various kinds are an ultimately inescapable part of our life experience. It would also likely consider human sinfulness, that fact that so often we pursue and choose to do what is contrary to respect for human dignity and human flourishing . It would underscore the fact that often we pursue the wrong goals, or the right goals for the wrong reasons or in the wrong ways. Power, greed and hubris are powerful forces that can lead us off the mark.
A second and very much related contribution is that religious and theological voices in bioethics can lead to an expansion of the considerations that enter into discussions of developments in biomedicine and public policy. As previously mentioned, bioethics discussions often become narrowly construed, focusing on rights, for example, individualistically understood, or procedures to ensure non-interference, or the pragmatic results and benefits of particular technologies. The embryonic stem cell debate is focused on the moral status of the embryo, the hoped-for benefits of the research, a presumed obligation to pursue this research for the benefit of others, and an unfettered pursuit of knowledge. These are undoubtedly all critical considerations. But there are more, as was suggested above in identifying some aspects of a theological understanding of the human person and some of their implications for embryonic stem cell research. By broadening our considerations, by paying attention to more of what is at stake, one would hope for public policies that have taken account of the complexities of these situations and, hence, become a more fitting response for the good of society.
Third, theological approaches to bioethics of necessity raise questions of meaning. In bioethics and public policy discussions, questions of meaning are there invariably, but they are most often not recognized or, if recognized, are not engaged. Cultures marked by classical liberalism and a hyper-sensitivity toward pluralism are not inclined to take on questions of meaning. But this is to the detriment of public policy and society. It results in thin discussions, inadequate readings of what is going on and of what is at stake, and, often, responses to biomedical developments and public policy that reflect this. Part of this broadening of the agenda and considerations of bioethics is, as Lisa Cahill observes, "to make sure the debate addresses the needs and concerns of all, to ensure that the needs of the voiceless are given voice, and to ensure that the marginalized are protected and thus enabled to make their contribution to society" (Cahill, Theological Bioethics, p. 20).
In the embryonic stem cell debate, the meaning questions go beyond the moral status of the embryo. They encompass such other things as how we understand illness, disability and death, our finitude and how we deal with limitation as well as the drive to overcome it, our obligations to others and to future generations to seek and provide cures for disease and disability, the common good, scientific progress, and the pursuit of knowledge. Attending to these issues could result in richer more adequate deliberations, responses and policies.
Fourth, theological approaches to bioethics could serve a prophetic function in bioethical discussions and with regard to public policy. They could remind society of critical dimensions that are not being considered; challenge beliefs and values that ultimately do not contribute to human flourishing; point to the consequences for individuals and society of certain values, conviction and choices; and call society to be and become more. Theology, for example, could invite society to reflect on its attitude toward nascent human life and its obligations toward that life and all the vulnerable in our midst. It might call into question a mentality and a practice that is willing to sacrifice the most vulnerable for the benefit of many and, concomitantly, the use of a utilitarian calculus in the development of public policy. It might call for examination of the assumption that we must pursue every avenue available to us in the great desire to relieve pain and suffering. In their prophetic role, religion and theology might challenge the technological imperative and might raise up for consideration the variety of motives behind the drive to make use of embryonic stem cells, including profit, prestige and power. They might hold up for reflection and debate the possible impact of our choices about this issue on our very humanity and upon the kind of society we become.
Fifth, theological approaches to bioethics have the potential for transforming the community of believers. All of us operate out of a particular world view, a particular way of seeing and interpreting reality. That worldview affects what is seen and not seen, what is valued and not valued, what is valued more and what is valued less. All of us bring these values, beliefs, dispositions, intentions, motives and sentiments to our deliberations and our judgments. One of the primary contributions of religion and theology to bioethics is to influence the worldview of members of the faith community who in turn can influence public debate and influence the shaping of public policy.
This contribution of religion and theology, however, hinges on at least two things. One is education or formation, the gradual shaping of the character of individual believers. How is this done and done deliberately, consistently and successfully? The other is dialogue, communities of believers functioning also as communities of moral discourse, exploring moral issues in light of their faith and their theological understanding of what it means to be human. If these two things can occur successfully, it is more likely that theology will have some effect on bioethical deliberations and the formulation of public policy.
Sixth, and finally, theological bioethics should lead to action, to the transformation of those situations related to advances in medicine and biotechnology that are unjust. In the words of Catholic moral theologian Lisa Cahill:
[T]heological bioethics is not just about talk. It is about action. The 'truth" and viability of the vision of Christian theological bioethics is warranted not just by cogent theory or argument but by the emergence of transformative practices that join with other movements in global civil society to encourage human solidarity, empower "the poor," and motivate the powerful to change.
[B]ioethics in the twenty-first century must in every case be social ethics, not just as theory but as engagement. This is particularly true in light of globalization.
[T]heological biooethics must go beyond decrying injustice, beyond taking a "prophetic" stance against social practices that commercialize human beings, the human body and its processes, or important human relationships. It must even move beyond painting a vision of a more egalitarian and solidaristic future. Theological bioethics must critically reflect on and make normative judgments about, theoretically account for, and ultimately take part in a global social network of mobilization for change. (Lisa Sowle Cahill, Theological Bioethics, 2005, pp. 2, 3).
The challenge to theological bioethics as well as to people of faith is to enter bioethical debates true to their own theological convictions, bringing them to bear in appropriate ways to the issues at hand, while, as Lisa Cahill suggests, "seeking common cause and building a common language with all who are similarly committed to health care justice" (Cahill, p.18).
Looking back on twenty-five years of bioethics, there is much to be pleased with. It has accomplished much for the benefit of individuals and, to a considerable extent, for the good of societies as a whole, though less so for some of the marginalized, especially in underdeveloped countries. In pursuing and bringing about these benefits, however, bioethics, at least in some of its expressions, has contributed to beliefs, values and attitudes that seem not to contribute to the ultimate flourishing of individuals and communities. It has contributed to a vision of human beings and human purposes that in some cases is inadequate and in others, harmful. If I might paraphrase the text from Proverbs: "Where there is a faulty vision, the people wander, and they might perish." Or, in the words of Father Michael McCabe:
In exploring the possibilities of biotechnology there is an ever-present danger of losing our way, of taking ourselves and future generations into territory or an environment which is fundamentally harmful to human life. The irony is that we are most likely to do this as we search for ways of sustaining life, relieving suffering and improving our quality of life" (Michael McCabe, "Bioethics and Decision Making," The Nathaniel Report, April 2001, p. 3).
As we begin the next twenty-five years of bioethics, it is critical for people of faith and for theologians who do bioethics to attend not only to the advances in medicine and biotechnology, the dilemmas, but also to the vision or visions that accompany debates about them. It is perhaps here that communities of faith and theological bioethics can make their greatest contributions and where their contributions are most needed. — As Joseph Cardinal Bernardin pointed out in a talk to the United States Conference of Catholic Bishops on health care reform:
[This is] a time of testing and a moment of opportunity for the Church. We will be tested on how our teaching contributes to the moral framework for reform. Our tradition can illuminate important aspects of the debate, illustrating the potential of the Catholic social vision for contemporary issues" (Joseph Cardinal Bernardin, "The Right to Healthcare: A Test and an Opportunity for the Catholic Community," 1993).
Ultimately, the vision ought to be a transformational vision. Our vision of the person-in-community, the common good, solidarity, justice, and the option for the poor is inherently oriented toward change, change in personal attitudes and behaviors, change in social attitudes, policies, practices and structures, change in how we view and deal with old and new developments in medicine and biotechnology. This will lead to a different kind of bioethics. The vision that grounds it, however, is difficult to achieve and realize in so many respects. But that is our challenge as we take bioethics into the future.
The Catholic Foundation Silver Jubilee Lecture was delivered by Dr Hamel at St Joseph's Catholic Church, Mount Victoria, Wellington on October 18, 2006.
Ron Hamel, PhD, is Senior Director, Ethics, for The Catholic Health Association of the United States of America