Pastoral Healthcare Ethics

1. Pastoral Healthcare Ethics Bernard Farrell-Roberts Director of Diaconal Formation (Maryvale Ecclesiastical Institute) Principal Tutor: International Science and Ministry Baccalaureate, University of Barcelona Member of: Catholic Bishops’ Joint Bioethics Committee International Association of Catholic Bioethecists COMECE Consultation Group on Organ Donation Catholic Hierarchy’s Representative on Organ Donation Ethics to the Department of Health

2. Pastoral Healthcare Ethics Objectives for today: Sessions One & Two Love underpins Pastoral Healthcare & Ethics, and is essential to a full and correct understanding of holistic pastoral healthcare Session One Understand the need for a systematic ethic Take away a systematic ethic applicable to all ethical problems Session Two Examine the principal issues in Pastoral Healthcare & Ethics Understand the importance of holistic healthcare

3. Pastoral Healthcare Ethics Objectives for today: Not to exhaust you too much! This subject is incredibly wide and complex – we have a few hours, but we could fill several weeks with useful material and knowledge! I do not touch on areas such as pastoral care of children, of families, commencement of life issues, genetics, Marriage and sexual ethics, special needs, mental health, or numerous other very interesting and important areas – it simply is not possible. Perhaps in the future you could think of covering some of this. However, I do have a very heavy and packed agenda to get through today, so I hope you will not find it too much for you. I also apologise if I cover old ground for any of you as I clearly know nothing of your backgrounds or previous studies.

4. Pastoral Healthcare Ethics Objectives for today: Synthetic strand running through todays talks: understanding holistic pastoral healthcare is only possible in the light of God’s revelation of Divine love. Use of Pastoral Healthcare and Ethics self-study course book.

5. Biomedical Ethics We first need to understand the significance of God’s love in the Holy Trinity, and the outpouring of the same in our lives. “Man cannot live without love. He remains a being that is incomprehensible for himself, his life is senseless, if love is not revealed to him, if he does not encounter love, if he does not experience it and make it his own, if he does not participate intimately in it. This, as has already been said, is why Christ the Redeemer "fully reveals man to himself".” RedemptorHominis 10

6. Biomedical Ethics We can then pass on this understanding to others. Let us take suffering as our example, as this is at the centre of pastoral healthcare:

7. Letususe thefollowingtohelpusunderstand and explainon a practicallevelGod’slove and whatthismeans in ourlives: TheSuffering of Christ Human Suffering How are theyConnected? Brotherhood of the Holy Cross

8. Whatexactly do we mean by “suffering”? What do weunderstandbyit? Brotherhood of the Holy Cross

9. Pope John Paul II explained in Theme 6 of «SalvificiDoloris» thathumanssuffer in manydifferentways, manyof thesenotalwaysacceptedby medical authorities Brotherhood of the Holy Cross

10. He explainedthatsufferingisbiggerthanillness, and more complex. Bothphysical and spiritual sufferingexist, in boththebody and thesoul. Brotherhood of the Holy Cross

11. Mansuffersbecause of evil, a “lack of good”, because he has deprivedhimself of thisgoodthroughhissinfulactions. Brotherhood of the Holy Cross

12. “In ordertodiscoverwhywesuffer,wehavetoturnourgazetotherevelation of divinelove.” Pope John Paul II Brotherhood of the Holy Cross

13. Revalation of Divinelove: Old Testamentrelationship and covenants; & Christhimself. “God so lovedtheworldthat he gave up hisown son” Jn 3,16 Brotherhood of the Holy Cross

14. “Thosewhoparticipate in thesuffering of Christposess a specialpart of theinfinitetreasure of theredemption of theworld.” Brotherhood of the Holy Cross

15. What do we mean bythis? We mean thatwe can and do participate in thesuffering of Christthroughwhich He savedhumanity! Howthen can and do we share in thesufferings of Christ? In ordertounderstandthisweneedtounderstand “love” itself. Brotherhood of the Holy Cross

16. Why? Becauseitis in loveitselfthatwefindthejustification of allsuffering. Whatislovethen, and howdoesitjustifysuffering? Brotherhood of the Holy Cross

17. Simplyspeaking, LoveisGod, and istherefore“Trinitarian”, and thishelpsustounderstandit, as explainedbySt Bernard of Clairvaux. He explainedthattheHoly Trinity can be understood as a relationship of love, and as such a concept withwhichwe can identify as parents, familymembers, friends, as humanswholove. Brotherhood of the Holy Cross

18. FatherSon (Love) Spirit The Father loves the Son and Spirit totally The Son loves the Father and Spirit totally The Spirit loves the Father and Son totally All freely give themselves to the others totally Brotherhood of the Holy Cross

19. The outpouring of love between Father, Son, and Spirit is then poured onto us freely by the Holy Spirit in the form of grace. Brotherhood of the Holy Cross

20. In thiswayweenterintothissamelovingrelationship, calledtoloveGod as He lovesus. Remember: Loveisthe total giving of selffortheother: • Christforus in hispassion and death • Usforourwives, families, friends • And forChrist? Are wewillingtoloveHim as He lovesus? He lovesustotally, and seeks total freelygivenlove back fromus Brotherhood of the Holy Cross

21. Ifwethenunderstandthefollowing in light of this, we can begintounderstandtheir true realitybetter: • Marriage • As anicon of the Trinity • As the “DomesticChurch” • TheFamily Brotherhood of the Holy Cross

22. And suffering…..? Brotherhood of the Holy Cross

23. Ifyour son ordaughterissuffering, wouldn’tyou do everything in yourpowertoremovethatsufferingfromhimorher, eventotakingtheirsufferingonyourself? ThisiswhatGoddid. Brotherhood of the Holy Cross

24. Noone has greater love than this: than to give up his life for his friends. John 15:13 Brotherhood of the Holy Cross

25. So whatshouldwe do? Are wegoingtoloveGod as much as He lovesus? He suffersforus. He diedforus. Thisishowmuch He lovesus – and He wantsustoloveHim as much as He lovesus. And how can we do this? Can wetakeonsome of Hissuffering, sufferforHim, and thereforelessenthesuffering He must endure, bysharing in hissufferingforus, foroursins. Brotherhood of the Holy Cross

26. Seenlikethis, freelyoffered up toChrist in orderto “takeaway” some of Hissuffering, human sufferingbecomesourparticipation in Christ’sact of salvation. Itbecomesourgifttoourfellowhumans, ouract of loveforthem. True loveforourneighbour, reflectingourlove of God. Brotherhood of the Holy Cross

27. In our suffering we walk freely to the cross, we take Christ down, share in His suffering, cradle him in our arms, and calm His pain. We share in His salvific act for humanity, in the salvation of the human race. We unite ourselves to God in the love of the Trinity. Brotherhood of the Holy Cross

28. Suffering is not negative. It gives us the opportunity to unite ourselves to God in a way that is very specal to Him, to take our place at His side. Suffering is a fundamental part of being human. No suffering is pointless. By understanding love and suffering in this way, we are able to better understand everything that underpins pastoral healthcare, discovering the light in which every ethical decision must be considered. Now, back to our systematic ethic… Brotherhood of the Holy Cross

29. Pastoral Healthcare Ethics The need for a systematic ethic How do we know that we have thought of everything we should have done? We must: Inform ourselves Know where to look Have a method to use Apply it rigorously Where do we look? Where do we get our information from? Bioethics

30. Pastoral Healthcare Ethics In Bioethics we shall find our method and our sources of information. What is Bioethics? “Bio” in Greek means life Bioethics is the philosophical study of the ethical issues and controversies brought about by advances in biology and medicine. Bioethicists are concerned with the ethical questions that arise in the relationships among life sciences, biotechnology, medicine, politics, law, philosophy, and theology. Pastoral Healthcare needs us to look at “Biomedical Ethics”

31. Biomedical Ethics What is your first impression of Bioethics, and the ethical problems we must resolve? COMPLICATED ? It can get even more complicated than this! Let’s have a look:

32. Biomedical Ethics Modern influences on ethical decision making: Legal Positivism Generally accepted by Western Society at the time of the 2nd World War. The law of the state is all that is required for the moral guidance of society No higher law exists

33. Biomedical Ethics What happens if Society gets it wrong? The Law states that Jews are a subhuman class Result = Holocaust But then, having seen our error, we did it again:

34. Biomedical Ethics What happens if Society gets it wrong? Paracetamol or Abortion Japan - Diagnosis of death If organ donor – death = brain stem death If not – brain stem death is not death and life must be sustained

35. Biomedical Ethics Some modern consequences of legal positivism: Abortion – now being considered a human right by the UN Euthanasia – already killing those with special needs 3rd world birth control – via additives, experimentation, free contraception, etc. Aids in Africa – putting commerce and population control first? How does this happen? What is missing?

36. Biomedical Ethics “Universal laws of jurisprudence” Samuel L Jackson, Judge Or Natural Law, as we know it

37. Biomedical Ethics Natural Law Natural Law: made up of Self-evident truths that are not demonstrable e.g. Do not kill other humans Love your neighbour All humans have rights

38. Biomedical Ethics Natural Law Supreme Principle = Good is to be done, and evil avoided. “Good is the principal dictator of conduct, therefore the Supreme Principal of moral action must have Good as its central idea.” St Thomas Aquinas I-II, Q, xciv,a.2).

39. Biomedical Ethics What does Moral Theology add? Revelation of God by God Knowledge of God: Scripture, Tradition, Magisterium Knowledge of Man from knowledge of God Questions? Let us move on now to ethical or moral decision making in healthcare……..

40. Biomedical Ethics Where are we now? We have: Intelligent ethicists Sound ethical methodology Sound ethical theory Just legal systems Genuine concern for the good of mankind Understanding of Natural Law Moral Theology For these to be effective we needa fair means to evaluate the morality of human actions.

41. Biomedical Ethics Case Study: To illustrate what we are up against! Dr Thustra’sDilemma Background Competence and Research on the sexual health of teenagers Pelvic inflammatory disease (sometimes called PID), is a progressive infection of the fallopian tubes, uterus, cervix, or ovaries. It is a secondary consequence of infection with sexually transmitted diseases (STDs), such as chlamydia or gonorrhoea. It is estimated that each year more than a million women will develop PID in the UK, with the highest infection rate amongst teenagers. If PID goes untreated, it can lead to internal scarring that can result in chronic pelvic pain, infertility, or a tubal pregnancy.

42. PID can cause severe symptoms, and if it is not treated or goes unrecognized, the PID can continue to spread through a woman's reproductive organs and may lead to long-term reproductive problems: • PID can cause scarring in of the ovaries, fallopian tubes, and uterus, and widespread scarring may lead to infertility. A woman who has had PID three times (or more) has an almost 50% chance of being infertile. • If someone who has had PID does get pregnant, there remains a high risk of an ectopic pregnancy. • Untreated PID also puts the patient at risk for a tubo-ovarian abscess (TOA). Biomedical Ethics

43. Biomedical Ethics The sexual health unit at Metropolis Hospital, under the supervision of well-known Gynaecologist Dr Zara Thustra, proposes to study the connection between the development of PID and the occurrence of sexually transmitted diseases. They are particularly interested in whether intervention and treatment of advanced chlamydia and gonorrhea infections in teenage girls with a new-generation of drugs - FERTEX-C and FERTEX-G (already licensed for treatment of these infections) - can prevent or reduce the development of PID. They are interested in this issue and this 'treatment group' because it is Dr Thustra's experience that most teenagers who seek treatment at the clinic do so reluctantly and rather too late to allow effective prevention of PID. She is curious as to see whether the undeniable improved efficacy of the FERTEX drugs also increases the length of the window in which treatment can prevent PID.

44. Biomedical Ethics They propose to do a randomized control trial using teenage girls between the ages of 14 and 19 who present at the hospital's clinic with symptoms of chlamydia or gonorrhoea and who are judged by medical staff to be in the advanced stages of infection. The trial will involve 4 distinct treatment groups : • Group A - Advanced stage chlamydia treated with best of old-generation drugs • Group B - Advanced stage chlamydia treated with FERTEX-C • Group C - Advanced stage gonorrhoea treated with best of old-generation drugs • Group D - Advanced stage gonorrhoea treated with FERTEX-G Participants will take the medication as usually prescribed, this will be followed up by fort-nightly examinations at the hospital - involving blood-tests, urine-tests, vaginal-swabs and ultrasound scanning of the reproductive organs.

45. Biomedical Ethics Dr Thustra and her team, however, face a serious difficulty - more than half of the young girls in the proposed treatment group fall below the age (18) at which they are considered able to unproblematically give informed consent to participation in research. Dr Thustra is familiar with standard procedures for consenting to medical treatment - Over the age of 18 years competence is presumed. In England, Wales, and Northern Ireland adolescents aged 16-18 can consent to treatment but cannot necessarily refuse treatment intended to save their lives or prevent serious harm. Adolescents under 16 may legally consent if they satisfy certain criteria - namely - the young person should be able to: • Understand simple terms, and the nature, purpose, and necessity for proposed treatment • Understand the benefits, risks, and effect of non-treatment • Believe the information applies to them • Retain information long enough to make a choice • Make a choice free from pressure

46. Biomedical Ethics There are three strategies that might be adopted : 1. Consent all subjects who are over 18 and, in the case of subjects under the age of 18, also get parental consent for participation 2. Consent all subjects who are over 16 and, in the case of subjects under the age of 16, also get parental consent for participation 3. Consent all subjects and seek no parental consent for participation What should Dr Thustra do?

47. Biomedical Ethics Conclusion: it is simply too complex to be able to work it out like this! Ascertaining the acceptability of any specific human action may be very complex, with multiple influences & considerations in play. How can we be sure we have considered all we should prior to making our decision about a course of action, and how can we evaluate & balance all the relevent harms and benefits? We need a “systematic ethic”

48. Biomedical Ethics What is our Systematic Ethic? Ensure that all principal potential harms and benefits have been identified Ensure that all principal ethical schools of thought have been applied and evaluated Value all humans equally, respecting their rights as humans Do the above always in light of God’s revelation And how do we go about this?

49. Biomedical Ethics Ensure we consider all the following: All ethical schools of thought, starting with: Principalism Autonomy Beneficence Non-Maleficence Justice Then adding “Scope”

50. Biomedical Ethics The other principal ethical schools of thought Virtue Ethicist View Catholic Ethicist View Feminine Ethicist View Consequentialist View Relativist View Why? Firstly to ensure you haven’t missed anything Secondly in order to be able to justify yourself in front of others. Apologetics.