Problematic health care ethics guide.

In July 1993, Catholic Insight published a review of the Health Care Ethics Guide of the Catholic Health Care Association of Canada. Seven problems were identified: decision making, forming one's conscience, life-sustaining treatment, natural family planning, conflict, mercy killing, in vitro fertilization. Here are two more.

Family planning or contraception?

Article 39 of the Guide states: "Health care facilities are encouraged to foster responsible parenthood and to promote the various methods of regulation of conception that respect a woman's natural fertility cycles." What does this mean?

1. It could mean natural fertility regulation by one of several methods, the Billings, the Creighton Method, etc., which are morally acceptable and highly effective.

2. It could include all of the "various" methods used today. The word "various" is loaded and suggests (perhaps deliberately) the following: the use of the condom, spermicide, contraceptive pill (many of which are low dose and abortifacient), and the use of the intrauterine device (always abortifacient). What does "respect a woman's natural fertility cycles" mean? Does it imply that only natural family planning is acceptable or not? The answer is by no means clear.

The Health Care Guide states that professionals are to be well informed on natural family planning methods. They are to provide instruction honestly and objectively about these and other methods, so that couples can make free and informed decisions for responsible parenthood. The guideline then refers to Article 10 -- in which is mentioned the importance of the health care institution's recognizing its mandate to educate.

The Guidelines informs us that the Catholic hospitals are mandated to instruct the public in methods of "responsible parenthood" that involve actions and intentions which the Church itself teaches are morally sinful.

Sterilization: direct and indirect:

Article 42 of the Guide states that direct sterilization, whether permanent or temporary, may not be used for regulation of conception. Article 43 immediately goes on to refer the reader to Introduction, Principle #6, the principle of legitimate co-operation:

"Sometimes it may be an ethical duty to `co-operate materially' with an immoral act (one does not intend the evil effect, but only the good effects) when only in this way can a greater harm be prevented, provided 1) that the co-operation is not immediate and 2) that the degree of co-operation and the danger of scandal are taken into account."

The Guide states that "the principle of legitimate co-operation applies the principle of double effect to the situation where an act is performed by more than one person who have different intentions." The Guide admits that it is unethical to co-operate `formally' with an immoral act; i.e., one does not intend the evil effects but only the good effects. However, the principle of double effect applies only to actions which are not intrinsically evil. Since both contraception and abortion are intrinsically evil, the principle of double effect cannot apply.

Recently, one person in authority in a Catholic hospital has quoted Article 2297 of the Catechism of the Catholic Church as justifying sterilization for such conditions as heart disease and psycho-social reasons.

This article states that "Except for strictly therapeutic medical reasons, directly intended . . . sterilizations performed on innocent human beings are against the moral law." Nonetheless, this person confirmed that contraceptive sterilizations were carried out in the hospital using this moral justification.

The correct technical interpretation of #2297 is given in the Text of the Doctrinal Congregation -- Statement on Sterilization, 1977. In response to questions from the U.S. National Conference of Catholic Bishops, the Congregation stated,

"Any sterilization which of itself, that is, of its own nature and condition, has the sole immediate effect of rendering the generative faculty incapable of procreation is to be considered direct sterilization. . . . Therefore, notwithstanding any subjectively right intention of those whose actions are prompted by the care of prevention of physical or mental illness which is foreseen or feared as a result of pregnancy, such sterilization remains absolutely forbidden according to the doctrine of the Church."

Where confusion arises is in the interpretation of the Catechism phrase "strictly therapeutic medical reasons." Such reasons apply only to therapeutic sterilization; that is, sterilization that is not directly intended, merely foreseen. Following the issuing of Humanae vitae, some theologians misinterpreted directives 6 and 20 of Ethical and Religious Directives for Catholic Health Care Facilities (1971) in an erroneous attempt to justify directly contraceptive sterilization for clinical indications. (Ref. (1)) This confusion is widespread.

The morally acceptable rationale of indirect sterilization is to suppress the endocrine function of the generative organ, because it is detrimental to some other pathology (as in ovarian suppression or cancer of the breast). Other examples of indirect sterilization include removal of the ovaries, testes, or uterus due to cancer.

Sterilization and the principle of totality:

The Guide accurately describes the principle of totality, the principle that the parts of a human being are ordained to the good of the whole. This, in concrete terms, means that a diseased part; e.g., an infected appendix, a cancer of the breast, etc., may be removed. However, the Guide does not say that this principle cannot be legitimately used to justify direct sterilization.

They should have stated this and it is a serious error that they have omitted to do so. The application of the principle of totality to justify direct sterilization has been forbidden by the Statement of the Vatican's doctrinal Congregation, March 13, 1975 in regard to sterilization in Catholic hospitals:

"Neither can any mandate of public authority, which would seek to impose direct sterilization as necessary for the common good, be invoked, for such sterilization damages the dignity and inviolability of the human person." (Ref. (2))

"Likewise, neither can one invoke the principle of totality in this case, in which case interference with organs is justified for the greater good of the person: sterility intended in itself is not oriented to the integral good of the person as rightly pursued, the proper order of goods being preserved, inasmuch as it damages the ethical good of the person, which is the highest good, since it deliberately deprives foreseen and freely chosen sexual activity of an essential element." (Ref. (3))

The main rationalizations used by theologians and ethicists in support of directly contraceptive procedures in Catholic hospitals appear to include:

a) An erroneous interpretation of the words `strictly therapeutic medical reasons;'

b) A definition of the principle of totality which omits any mention that it does not apply to intrinsically immoral procedures;

c) The failure to state that the principle of double effect does not apply to intrinsically immoral procedures.

(1) ) Thomas J. O'Donnell S.J., Medicine and Christian Morality, Alba House, 1991.

(2) ) Cf. Pius XI, The encyclical `Casti connubii' in A.A.S. #22, 1930, 565.

(3) ) Text of the Congregation for the Doctrine of the Faith - Statement on Sterilization, May 1975-6, in Sterilization, Recent Declarations of Popes and Bishops, Toronto, Life Ethics Centre (53 Dundas Street East, Toronto, ON, M5B 1C6), second edition, 1995, pp 26, $2.00.