Autonomy and Community Care: Are They Compatible in Aged Care?
Michael McCabe
Issue 6, April 2002
"What occurs at the cellular level inevitably affects the structures of which the cells are the basic unit, and their physiological performance, with consequent effects at all levels of human existence. Accordingly, the process of aging manifests itself in the body, the behaviour, the attitudes, the feelings and the self-image; it has large social consequences on social relations, performance and on the economic condition of the individual and the community in which he or she lives."
—Abbot John Bamberger
Xenotransplantation: Issues and Challenges
Anne Dickinson
Issue 6, April 2002
In Rome the Pontifical Academy for Life has given qualified approval to xenotransplantation. In New Zealand the Ministry of Health has declined approval for an Auckland company to carry out clinical trials involving xenotransplantation. What are the issues raised by this emerging form of biotechnology?
Editorial: Ethics and Trust
Michael McCabe
Issue 7, August 2002
"Trust is most problematic when we are in states of special dependence – in illness, old age, or infancy or when we are in need of healing, justice, spiritual help, or learning. This is the situation in our relationships with the professions that circumstances force us to trust. We are forced to trust professionals if we wish access to their knowledge and skill. We need the help of doctors, lawyers, ministers, rabbis, priests, chaplains, or teachers to surmount or cope with our most pressing needs. We must depend on their fidelity to trust and their desire to protect rather than exploit our vulnerability."
—Edmund Pellegrino and David Thomasma [1]
The concept of community is a central motif in bioethics. It is based upon the belief that the human person is fundamentally a social and cultural being who lives in relationship, and finds meaning in and through those relationships. The term "the common good", for example, illustrates the belief that the welfare of the individual is inextricably connected with the welfare of others.
A profession can be viewed as a "community" which exists for the purpose of meeting a human need, and which is based upon a body of knowledge and a particular set of skills. Professions have unique educational and socialisation processes, together with codes of ethical practice, which help to guarantee and shape the integrity of relationships both within the profession and between the professionals and those they serve. Professional codes of ethics help to establish accountability and to preserve the ethical boundaries within which the nurturing and continuation of trust can happen. When professional obligations are neglected or exploited by some members of a professional community, the sense of belonging can be undermined for others in the community. Members of a profession can feel isolated and let down by the unethical actions of fellow professionals.
Recent experiences in the medical and teaching professions and in the Church could lead to a deep-seated ambivalence about involvement with professionals in various fields, and relationships in general. Because people require the services of the caring professions when they are at their most vulnerable, a betrayal of trust exacerbates this sense of vulnerability, eroding a sense of security for the injured individual, the community and the particular profession itself. This feeling of heightened vulnerability, the consequence of very real hurts and grave injustices, may lead us to become even more cautious and diffident in our relationships with others, and possibly deter us from seeking professional help when it is needed. In these circumstances such diffidence in relationships becomes a form of self-protection.
When trust is removed or lacking in human relationships the ability to live fully in society and the ability to attain the essentials of a satisfying life are diminished. Possibilities of growth and fulfillment are restricted. Loss of trust inevitably impacts on the transcendent dimension of life for individuals and for communities, namely, in the ability to be creative and in the ability to anticipate the future in a hope-filled manner. Ultimately, the withdrawal of trust removes the very possibility of healthy community life.
Trust entails risk. As Pellegrino and Thomasma note, to trust and entrust is to become vulnerable and dependent upon the goodwill and motivations of those we trust. In times of conflict and hurt, such as in the betrayal of professional trust, whether individually and/or institutionally, the ability and willingness to risk trusting requires even greater courage. While the withdrawal of trust can be justified as a form of self-protection, personal growth is only fully achieved within community and will always involve taking risks.
The restoration of trust cannot be achieved without the building and maintenance of clear boundaries. Neither can it be restored without fulfilling the requirements of justice. In the Catholic tradition justice is prior to charity, which means relationships cannot be fully restored while any injustice remains.
It is possible that talking about the betrayal of trust may only further erode an already battered professional confidence, and threaten the fragile relationships between professionals and those they serve. That is a risk for those involved, and it is a real risk. But the damage that will ultimately be done by silence or concealment is a much greater risk. Renewed wisdom and potential healing can only emerge with honesty and with courage. Silence prevents both reconciliation and growth and provides conditions for multiplying the harm. That has been the lesson at the heart of recent events in the Catholic Church.
In recent months the actions of medical personnel at Green Lane Hospital provide an illustration of how trust can be rebuilt. Following revelations of organs being retained without consent by hospitals in Great Britain and in Australia, Green Lane Hospital initiated its own self-review of procedures. Subsequently, they accepted responsibility for the fact that certain actions of hospital staff, the result of both individual decisions and systemic processes, were both unacceptable and unethical. Most importantly, in the face of uncertainty over the current laws in New Zealand relating to post mortems, they have not sought to hide behind legal ambiguities but have acknowledged the need to do things differently. Significantly, the ability to move ahead and the potential that now exists for trust to be re-established between the caregivers and patients at Green Lane Hospital is a result of the honesty and courage to name and discuss the issues. Painful as this process has been, the openness with which the discussions have taken place has allowed both the deep hurts and pain to be expressed and a more ethical practice to emerge. In my view this is a wonderful example of rebuilding trust so that patient care and respect, high quality research, and professional practice are all enhanced.
Rebuilding trust has profound implications for those who have broken a trust, be they individuals in the professions, or within the institution itself. Even after this has been achieved, and it will inevitably be a very painful process, the rebuilding of trust will also have implications that are personal, communal and institutional. Nevertheless, to rebuild trust is to reinvest in a hope-filled future.
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[1] Pellegrino, E., Thomasma, D. (1993) The Virtues in Medical Practice. New York: Oxford University Press. p. 65.
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Rev Michael McCabe, PhD
Director
The Nathaniel Centre
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2002
The Restoration of Trust
Bishop Peter Cullinane
Issue 7, August 2002
Introduction
The relationship between professionals and those they serve implies of its very nature a certain need, and therefore vulnerability, on the part of those who seek help. It is this vulnerability and sense of dependency that can become deep hurt and insecurity when trust is betrayed by the professional. To whom does one go when those that one trusted have become the threat and the danger?
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The Principles Revisited
Anne Dickinson
Issue 7, August 2002
In June 2002 Anne Dickinson was a participant in the Kennedy Institute of Ethics 28th annual Intensive Bioethics Course (IBC XVIII) at Georgetown University, Washington DC. Here she writes about the part of the course which focused on the principles of bioethics.
Surveying a Catholic Approach to Bioethics
John Kleinsman
Issue 7, August 2002
"Healthcare ethics is about the medical art of curing where possible, and the human art of caring always."
--Richard C. Sparks
The Catholic moral tradition emphasises that life is a free and totally unsolicited gift from God. An appreciation of this fact engenders an attitude of profound gratitude and thanksgiving. When we look at life like this, Christian morality is nothing other than our response to the unconditional and amazing love of God: 'How ought we who have been so gifted by God to live?' Like any special gift, we instinctively feel that life is something to be treasured and to be used in a responsible way. This is the starting point for any Catholic approach to bioethics.
The absolute dignity accorded human beings in Catholic teaching reflects the biblical message that each person is created in the image and likeness of God (Genesis 1:26-31). The belief that human life is a reflection of God's own nature means that personal worth and human dignity are inherent or innate characteristics; that is to say, our worth comes from 'inside' the human person rather than from anything 'external'. Human dignity is absolutely independent of our value to others, our ability to function, our age, health, gender, race or economic status. The belief that dignity is innate explains why the Catholic moral tradition upholds, absolutely, the teaching that persons may never be used by others as a means to an end, no matter how worthwhile the end may be.
Acknowledging God as the author and giver of all life calls us to recognise the sacredness of, and our interconnectedness with, all of creation. In other words, human persons are fundamentally relational beings. The person is always person in relation to the totality of reality; self, other people, all created reality and God. Due recognition of this highlights the responsibility we have of living in "right relationship". Often expressed in the biblical terminology of "stewardship", our interconnectedness is not, however, to be confused with "absolute dominion". Instead, the interconnectedness of all life demands recognition of, and respect for, the fact that there are limits to what we as humans should do. Our responsibility to protect and enhance the integrity of all relationships is the key to identifying what the limits are.
These limits have been, and continue to be, well traversed (even if not always agreed on) in regard to our responsibilities towards other human beings. That we are fundamentally social beings means that the human person, adequately considered, is a cultural person. Our ability to function in autonomous ways and to develop as individuals is always dependent upon our identity with a particular cultural group. Such a perspective nurtures a broad vision of the human person as called to live within caring communities. We find our fulfillment as committed individuals bound in kinship, friendship, and fellowship to our families and our neighbours. Yet the Gospel reminds us that we owe loyalty not only to those whom we readily choose as friends, but also to strangers and even to enemies. In Catholic language the term "common good" is used to describe the fact that our individual welfare and flourishing is inextricably connected with the welfare of others.
At the very heart of Catholic respect for human life is a special and persistent advocacy for those who depend on others for survival itself. Indeed, Jesus Christ teaches that the moral heart of any society may be measured by how well it provides for those who are most vulnerable and dependent. The beginning and end of life are areas of special interest and concern in bioethics because people are particularly vulnerable at these stages of their life journey.
The limits of human freedom have perhaps been less well delineated in regard to the relationship between humans and the rest of the created order. As recently as 1999, Pope John Paul II, in an address given to the WTO Conference in Seattle, Washington, has talked about the need to address the ecological crisis: "Faced with the widespread destruction of the environment, people everywhere are coming to understand that we cannot continue to use the goods of the earth as we have in the past ... [A] new ecological awareness is beginning to emerge ... The ecological crisis is a moral issue."
Our own New Zealand Bishops have also written that it is "in keeping with the traditions of the Māori of Aotearoa that we need to respect the sacredness of creation, as partners in life with the earth, the oceans, the lakes, the animal world, the mountains, the fish of the sea and the birds in our forests and gardens. From such sources, balanced by the infinite hand of God we draw all life and nourishment." [1] The integrity of all creation needs to inform our bioethical discussions with regard to the lengths to which we humans are prepared to go in order to delay death or to improve the quality of our life.
Recognition of the need to respect limits itself calls for a certain approach to understanding personal freedom, one that may be at odds with the way in which freedom is sometimes understood. Freedom can never mean the experience of simply exercising choices or options for action. A Catholic-Christian approach upholds an understanding of autonomy (the idea that we are the authors of our own fate) that includes the notion of our inter-dependence with others. We act freely when we act in ways that help us to flourish according to our deepest needs and yearnings, including our need to be in caring community. "Human nature" is a term sometimes used in Catholic teaching to refer to that which is in keeping with our deepest human yearnings.
A further principle that underpins a Catholic-Christian approach to bioethics is the belief that faith informed by human reason can discern the good. This means that, in their endeavour to determine what is appropriate human conduct, Catholics are committed to dialogue with all the sciences. In the words of John Paul II: "Faith and reason are like two wings on which the human spirit rises to the contemplation of truth."
From the above broad and general vision of the goodness and sacredness of the created order the following set of key moral and ethical principles inform a Catholic-Christian approach to the interdisciplinary science of bioethics:
- The sanctity of life
- The dignity of human persons
- The relief of suffering
- The duty to care for one's own health
- The duty to care for those who are sick – in body and in spirit
- The existence of limits, including the limit to provide treatment
- The promotion of the 'Common Good'
- Respect for culture
- A preferential option for those who are most vulnerable and deprived
- Respect for the integrity of all creation
- Justice – the equitable distribution of risks and benefits
- A commitment to truth telling
- A consistent ethic of life
- Respect for autonomy
While the above principles are identifying of a Catholic-Christian approach, it will be obvious that they are not uniquely Catholic and that they resonate with the values of all other people of good will. That this is so is not at all surprising since the Gospel values of Jesus Christ, upon which these principles are based, ultimately point us to what is most truly and deeply human and to what will lead the whole of the created order to flourish: "I have come that you might have life and have it in abundance." (John 10:10)
(Previous editions of the Nathaniel Report have explained the implications of some of these principles as understood in the Catholic moral tradition.)
For further reading see:
Beauchamp, T.L., Childress, J.F. (1994). Principles of Bioethics. Fourth Edition. New York: Oxford University Press.
Brody, H. (1989). Transparency: Informed Consent in Primary Care. Hastings Centre Report 19:5, pp.5-9.
De Dios Vial Correa, J., Sgreccia, E. (Eds.) (1998). Human Genome, Human Person and the Society of the Future: Proceedings of Fourth Assembly of the Pontifical Academy for Life. Vatican City: Libreria Editrice Vaticana.
De Dios Vial Correa, J., Sgreccia, E. (Eds.) (1999.) The Dignity of the Dying Person: Proceedings of Fifth Assembly of the Pontifical Academy for Life. Vatican City: Libreria Editrice Vaticana.
Gormally, L (Ed.). (1999). Issues for a Catholic Bioethic. London: The Linacre Centre.
The Hastings Center. (1987). Guidelines on the Termination of Life Sustaining Treatment and the Care of the Dying. Bloomington: Indiana University Press.
New Zealand Catholic Bishops' Conference. (1997). A Consistent Ethic of Life – Te Kahu-O-Te-Ora. Wellington: Catholic Communications.
O'Rourke, Kevin D. & Boyle, Philip. (1993). Medical Ethics: Sources of Catholic Teachings. Washington, D.C.: Georgetown University Press.
The Pope John Center. (1989). Conserving Human Life. Braintree, Massachusetts: Pope John XXIII Medical-Moral Research and Educational Center.
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John Kleinsman teaches Moral Theology at the Catholic Education Centre in Wellington and is also a part time researcher for The Nathaniel Centre
©
2002
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[1] New Zealand Catholic Bishops' Conference. (1997). A Consistent Ethic of Life – Te Kahu-O-Te-Ora. Wellington: Catholic Communications.
Exploring the Role of Health Professionals in Truth Telling: A Nursing Perspective
Debbie Wise
Issue 7, August 2002
Introduction
Truth telling (veracity) is a key factor in the relationship between patients, their families and health professionals. The Oxford dictionary defines truth as: a quality or state of being true, genuine, loyal, faithful; in accordance with fact or reality, exact, accurate.