Virtue is in the middle.

Contemporary Catholic Health Care Ethics David F. Kelly (Georgetown University Press, 2004, 336pp) 1-58901-030-2 $32.50

CONTEMPORARY CATHOLIC Health Care Ethics combines David F. Kelly's academic work in moral theology with his years of experience in Catholic health care. The merging of Catholic theology with Catholic procedural methodologies and his application of both to the most prominent issues in today's health care produces an ideal text for classroom use. Medical, nursing and ethics students will come away with an appreciation of their Catholic theological tradition and solid support for many of their common sense convictions about contemporary health care ethics.

Philosophy and theology departments in Catholic colleges and universities have always offered courses in ethics and moral theology. Today they also offer bioethics courses in which Catholic moral theology is applied to concrete problems in health care. These courses are of interest because the problems are ones with which the students either have some personal experience or at least have heard about. Who hasn't heard about the contraception question, the abortion debate, Jack Kevorkian, Terry Schiavo or the problem of providing decent health care even for the poorest citizens?

Kelly uses a Natural Law approach which seeks moral direction from anthropology. His perspective on human nature is theological, philosophical and juridical. He uses broad theological categories to discuss specific moral problems and their resolution. He moves away from the narrow physicalistic perspectives that pervade official moral teachings and includes the psychological, social and spiritual dimensions of the human. Theological principles like God's dominion over life and redemptive suffering also play a role in making moral evaluations of specific problems. With this broader understanding of the human condition, Kelly successfully moves Catholic medical ethics away from many of the official positions and rigid rules that are supposed to end all ethical questioning.

Instead of seeing theology as a solution to complex medical problems, Kelly sees theology's influence in terms of creative tensions between polarities: sanctity of life and quality of life, nature and grace, growth and decay in creation, created goodness and inherited sin. In the Catholic theological tradition it is the structure of created reality and especially the created human person which provides a background for making ethical judgments. But neither resource generates unchangeable solutions to complex problems. Kelly makes the point over and over that background theological beliefs are more likely to generate dialogue, openness to different views, and consensus among persons coming from different traditions. He thus avoids the alienating consequence of providing one and only one answer to complex problems and shows a sincere respect for the official church teachings on life and death issues but is not always an apologist for the moral stands of church authorities.

On the issue of birth control, for example, he is clear and unapologetic about his disagreement with official teachings. He reviews how present church teachings developed--a historical approach that helps readers understand current teachings as well as the difficulty experienced by church authorities in making changes. The last formal official teaching in Humanae Vitae was followed by attempts to explain and/or justify the teaching. The explanations all suffered from what Kelly refers to as "physicalism," or the theory that matter is the only reality. Throughout the book, he shows this perspective to be a completely inadequate way of understanding humanity and forming moral judgments about human actions. Kelly's work on this one issue reflects an important dimension of the whole book. It is first of all thoroughly catholic in its treatments of the ethics of health care. And yet the book provides alternate moral teachings which are thoroughly Catholic.

The few references that Kelly makes to abortion suggest that he is uncomfortable with official teachings on this topic as well. As is the case elsewhere, he uses his background theological categories for framing the abortion questions. He talks about abortion in terms of matter and form, body and soul. In his understanding of the theological tradition, there is every reason for hesitancy in coming to particular judgments about abortion. Kelly's theology does not permit easy answers to difficult questions like "when does life begin." Suggestions that human life begins at the moment of conception, he says, ignore the complexity and uniqueness of the human person. He stands equally strongly against denying all value to early human life. Here as elsewhere, Kelly provides solid theological support for moral teachings that all but the most extreme will find both academically respectable and socially responsible.

Arguing within the Natural Law tradition he looks to reality for moral guidance rather than to the autonomy of a decision maker. He rejects the idea that it is a woman's choice that alone makes something like abortion either right or wrong. Choice, freedom and autonomy are important ethical considerations, but the developing human life is the primary foundation of any moral decision about it. A developing human life does not acquire human status when the woman accepts it as a person. It is the developing human life itself that grounds its moral status.

Kelly rejects the position of conservative Natural Law thinkers who reduce personhood to the genetic structure of a fertilized ovum. He dissents therefore both from the view that personhood exists from the moment of conception and the view that the morality of an abortion is determined simply by choice. At the moment of conception the fertilized ovum is a reality which has moral value, but not yet the moral value of human personhood.

Kelly's middle ground position on the moral status of the embryo also supports his moderate stand on the issue of stem cell research. He makes a case for the advantage of totipotent embryonic stem cells rather than aduk stem cells. Because of the less than full human-person status of the embryo, the use of embryos, which otherwise would be discarded, he argues, "is not absolutely wrong." Whether on abortion, or stem cell research, or any other controversial issues, Kelly argues a position derived from Aristode and St. Thomas Aquinas: in media slat virtus. His ethics is rarely conservative but yet difficult to censure. That is an accomplishment in Catholic ethics.

When Kelly's background ethical theory is applied to clinical medicine, the gap between abstract theory and concrete problems is bridged by a carefully designed methodology. Kelly has a long personal experience with the Catholic health care system and with the problems that arise in health care settings. Students will learn from his book not just about current moral problems but also about the procedures for avoiding the worst errors and arriving at the most defensible concrete decisions.

KELLY ADDRESSES SPECIFIC MEDical issues from an historical perspective. He shows the inevitability of a certain evolution in Catholic moral teachings and the weakness of any argument that attempts to defend some earlier position simply on the basis of church authority. Finally, he provides his own arguments for what he calls a more adequate, personal, broad and humane perspective on the issue. Kelly is a committed Catholic moral theologian. He is also a defender of moral stands that not only are more respected in today's academic communities, but certainly more widely shared by today's Catholic laymen. Kelly is an example of an educated Catholic laymen assuming responsibility for Catholic moral teaching and subjecting the teachings of church authorities to standards provided both by classical theology and contemporary science.

In the final section of his book Kelly looks at the justice question: the allocation of health care resources. Because he intends the book to be used in hospitals as well as classrooms, he includes a chapter on hospital ethics committees and how they operate with references to and explanations of the major bioethics court decisions and notes that American legal rules and regulations are often the legalization of long established Catholic moral directives.

As the new pope starts his reign, there are more than a few signs that less conservative moral teachings are beginning to emerge, even from within the Vatican. John Paul II's opposition to all forms of contraception is showing signs of weakening. One Vatican theologian recently wrote a defense of condoms for protection against transmission of HIV. Others have done likewise. As this started while John Paul II was still officially in charge, one can only imagine the changes that can be expected if the next pope is more open and less committed to reversing the directions laid out in Vatican II. It still may be too early to tell, but maybe we are approaching a time when a more liberal approach in Catholic bioethics will not only not be censured, but perhaps be welcomed. If that happens Kelly's book may turn out to be mainstream, rather than alternative, Catholic bioethics.

JAMES F. DRANE, PH.D. is professor emeritus of Medical Ethics at Edinboro University of Pennsylvania and the author of More Human Medicine: A Liberal Catholic Bioethics.