The ethics of life: medical advances have exposed inconsistencies in the roman catholic hierarchy's position on life.

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WHAT MADE IT SO DIFFICULT FOR MUCH OF TERRI Schiavo's family to accept the decision to let her die was the remembered person, an actual social and personal existence that had been; its permanent loss was something with which they were unwilling to come to terms.

The late Cardinal Bernardin described the new approach to the sanctity of life that had permeated the official pronouncements of the post-Vatican II church as a "consistent ethic of life." The adjective "consistent" was an acknowledgement that the Roman Catholic church had historically fallen into the glaring contradiction of preaching the sanctity of life while supporting such violent and inhumane practices as slavery. A "consistent life ethic" sought to provide a single moral framework for looking at a wide range of issues: contraception, abortion, euthanasia, capital punishment, war, social welfare. It provided an intellectual basis for Catholic progressives to support both social justice and the restriction of women's reproductive rights. The cost of keeping and getting some Catholic progressives in the antiabortion camp was the admission that life issues were complex. If the consistent ethic of life were absolutist, then it would be difficult to explain why the church was not, for example, radically pacifist. But amid complexity and the accompanying acceptance that individual Catholics might in good conscience disagree, the consistent ethic of life began to unravel. The bishops of the United States, like the hierarchical church elsewhere, wanted and were compelled by the Vatican to remain absolutist on abortion while avoiding such an uncompromising position on war and even capital punishment. So the intended consistent life ethic has been frequently criticized for its inconsistency.

What has frequently gone unnoticed, however, is that the earlier consistent life ethic has been replaced by a hierarchy of two realms of life issues. The lower one contains the social justice concerns with capital punishment, war and matters of social welfare. The higher one comprises an abstract view of the human biological lifespan. The latter is characterized by the ubiquitous language in official church statements about the protection of life "from the moment of conception until natural death." Over against the supposedly more complex life issues of social justice, the church hierarchy contends that there is a simple and absolute duty to protect human life in any and all its biological stages. Abortion and euthanasia are therefore the two threats, at the beginning and the end of human life, respectively, that deserve utter opposition and moral condemnation. But are the moral issues surrounding the biological life of human individuals really as simple as the church suggests? Are the moral decisions about continuing or terminating pregnancy equivalent to those that we make at and about the end of human life?

THE RETREAT OF NATURAL DEATH

In the second half of the 20th century, rapid advances in medical technology made it increasingly possible to keep people with serious injury and illness alive by artificial means. Alongside respirators and kidney dialysis machines, new drugs, organ transplants and other medical interventions prolonged life--but often with substantial losses to its quality. In this new situation, the poet Arthur Hugh Clough's dictum came readily to mind: "Thou shalt not kill; but need'st not strive officiously to keep alive." A distinction was made between euthanasia and the refusal of medical treatment to prolong life. The Roman Catholic church recognized this distinction and accepted that quality of life was as important to being a human person as biological existence. Yet treating a human fertilized egg as a human person will have repercussions for what decisions one would allow actual human persons to make about prolonging life through medical treatment. In the Catholic "seamless garment of life," abortion and euthanasia become morally undistinguishable--with the result that the definition of euthanasia is broadened. End-of-life issues are collapsed into an ethical framework designed to preserve the continued physical existence of embryos and fetuses, where no arguments about quality of life are admissible.

The danger here is that Catholic teaching will begin treating persons faced with decisions about life-prolonging medical treatment as though they were fetuses. One indication that this is already happening is the disturbing case in which the Catholic church in Italy refused Christian burial to Piergiorgio Welby. Italian law has a very broad definition of euthanasia for a Western society, one that includes withdrawal of artificial life support (although this is changing as a result of the Welby case). In December 2006, after an unsuccessful battle in the courts, Welby, who was terminally ill with muscular dystrophy, persuaded his doctor to unhook him from the artificial respirator that was keeping him alive. Italians, who are generally opposed to euthanasia and assisted suicide, nonetheless sympathized in large numbers with Welby's plight. One sympathizer was Cardinal Carlo Maria Martini, the former archbishop of Milan, who criticized not only the church's pastoral response to Welby but also the Italian law.

In an interview with a Milan newspaper, Martini defended the right of a mentally competent patient to refuse treatment when it imposes a burden disproportionate to its benefit, quoting the Universal Catechism of the Catholic Church in support of his view. In its rejoinders, the Vatican cast its previous sanction of patients' refusing medical treatment as severely limited. Diocese of Rome vicar general Cardinal Camillo Ruini, who had denied Welby a Christian burial, told a meeting of Italian bishops the day after Martini's article appeared, "The rejection of aggressive treatment may not be allowed to reach the point of legitimizing what are more or less disguised forms of euthanasia"--a thinly veiled attack on Martini. Ruini defended his decision on Welby's funeral, regretting that many would misunderstand it, "including believers, who were moved by sentiments of human pity and solidarity toward the suffering person, although they were perhaps less conscious of the value of every human life, of which not even the sick person is free to dispose." Bishop Elio Sgreccia, president of the Pontifical Academy for Life, rebutted Martini in an article in the newspaper Corriere della Sera. Interpreting Pope John Paul II's encyclical Evangelium Vitae, Sgreccia defined "euthanasia by omission" to include the refusal of artificial means of life support. Both Ruini and Sgreccia advocated an abstract value of human life that can be attributed equally to a fetus or a terminally ill 60-year old man like Welby. In contrast to this abstract view, Martini weighed the concrete conditions of actual persons. He realized that "new technologies demand greater wisdom in order not to prolong treatments when they are no longer of benefit to the person."

The Welby case and the Vatican's response to it could erode the church's teaching on the right of a patient to refuse treatment at the moment when practically, and therefore pastorally, it is most important: when medically prolonging life means a severe diminution of its quality. It is by no means the case that all of the Catholic hierarchy wants to move in that direction. The bishops of England and Wales, where new legislation allows for living wills to determine end-of-life treatment, in July 2007 released a draft of guidance for Catholics on the issue. To the question, "Do I always have to have life-prolonging treatment?" the bishops reply:

   No. Though we each have a duty to care for our health, you do not
   have a duty to prolong your life at all costs. How we spend our
   time on earth is more important than the length of our life, and a
   treatment which prolongs your life may impose burdens such that you
   consider the treatment is not worthwhile.

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When it comes to specific means of artificial life support, the English and Welsh bishops do not demand that artificial nutrition and hydration be always maintained, as Sgreccia did. Their wording leaves much more flexibility to the individuals making the decisions in concrete circumstances. "As refusing food and fluids by tube is likely in some cases to lead to a person's death, this could be a dangerous step," the bishops write. "However, it is sometimes appropriate not to give food and fluids by tube, especially in the last few days of life."

Cardinal Martini and the Catholic bishops of England and Wales are facing up to a reality that the Vatican and conservative Catholics choose to ignore. The rapid advance of medicine will have the consequence that most of us will be faced, for many of us more than once, with the decision whether to prolong life through medical treatment. These medical advances may not, after serious illness or injury, enable doctors to restore a patient to a reasonable quality of life. The elderly will be especially affected as the most common causes of death--cancers, cardiovascular failure--become increasingly treatable: Life will be prolonged, but aging and the extreme frailty that it often brings will not stop. The prospect for many is a vastly extended period of advanced age and frailty. In such circumstances, some of us will reach a point at which miracle cures seem more a curse than a blessing. Should we feel morally obliged to undergo them?

Recent advances in genetics have enabled us to dismantle human aging mechanisms, but even in the most optimistic medical scenarios, the issues around a consistent life ethic and an ever-expanding concept of euthanasia are not solved. On the contrary, they become dramatically worse: Would it be ethically wrong for a person to forgo anti-aging treatments because he or she did not want to live indefinitely? The church might say so; but on the other hand, it might condemn anti-aging treatments on the grounds that they abolish natural death. Even medical advances that are less dramatic will pose acute moral dilemmas. When treatments become available that are based directly on embryonic stem cell research, will the church ask faithful Catholics to forgo them on the basis that they were achieved through the destruction of human life? One fears that in the not-too-distant future, another case like Welby's could lead the official church to oppose the removal of an artificial respirator as euthanasia by omission but also to contend that a cure based on embryonic stem cell research should be refused because it is "anti-life."

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PERSONHOOD, THE BRAIN AND DEATH

End-of-life issues pose in an acute way the question of the relation of human personal life to a biological location in the human body. When we seek the basis of our personhood, we find it in the higher functions of the human brain. When those parts of the brain where higher functions occur are damaged or destroyed through injury or disease, there is a loss of personal life. We find painful evidence of this in the slow erosion of the person as brain tissue is destroyed in a disease like Alzheimer's. The consistent life ethic prefers to ignore or downplay how personhood is constituted by the physical activity of our brains, because this reality does not support its central claim of a "seamless garment of the life from the moment of conception until natural death."

The potential for the higher brain functions that make personhood possible does not emerge in the human fetus until the third trimester of pregnancy. After birth, the brain continues to develop, and social experience strongly influences the physical formation of the brain. There is no sharp division between nature and nurture in the neurological processes through which the potential for personhood is converted into the contours of an actual person, a unique individual like you and me. In actual living persons, the physical and social bases for personhood are inextricably combined. Because end-of-life issues affect such persons, they have a closer ethical association with the social-justice concerns of capital punishment, war and welfare provision than with abortion. The concrete contexts of life in human society demand our reflection on how human persons can best flourish within them and on what to do in extreme circumstances in which it is impossible for the human person to flourish. An ethic that abstracts human biological existence from our neurologically based social selves is going to serve the born very badly.

There are a few instances in which the status of human beings at the end of life is comparable to (but not the same as) human fetal life before the development of higher brain function. Such circumstances exist when severe brain damage has removed the basis of higher brain functions. In the widely reported case of Terri Schiavo, only the brain stem survived, enabling nothing more than autonomic functions such as breathing. Schiavo's higher brain functions, and with them her person, had been irretrievably lost. The Florida courts that allowed her removal from artificial life support recognized this. What made it so difficult for much of her family to accept this decision was the remembered person, an actual social and personal existence that had been. The permanent loss of this person was something with which they were unwilling to come to terms. Most of us find troubling the realization that physical vulnerability extends to the core of our selves. A consistent ethic of life tries to get around this uncomfortable truth by arguing that if we preserve human biological life in every form and circumstance, then maybe some disembodied spark of personhood will remain unscathed. This is an illusion, a theologically unworthy one. It denies how we become who and what we are and--in Christian belief--how God has created us. We cannot protect human physical life by fetishizing it. We need to accept that our personhood is utterly dependent on our body and its brain. We feel pain, we fear death, and we try to make sense of our embodied existence in even the most reduced physical conditions. Valuing human life requires that we recognize the physical fragility of our personhood and face difficult and complex end-of-life issues with wisdom and compassion.

SHEILA BRIGGS is an associate professor of religion at the University of Southern California and a board member of Catholics for a Free Choice.