Death by qualification

On August 1, the CDF issued a responsum about the use of "artificial nutrition and hydration" (ANH) for patients in a "permanent vegetative state" (PVS). Given the controversy surrounding the case of Terry Schiavo in 2005, and Pope John Paul II's controversial 2004 allocution on the broader topic, I was surprised that the responsum went largely unnoticed outside the Catholic professional circles most closely concerned with such matters. In my own post on the document, where I revealed my personal as well as intellectual interest, I argued that the teaching conveyed by the responsum is not a matter of opinion but a logical corollary of the settled, ordinary teaching of the Church. It should be received as such by all Catholics. But I am not at all surprised that what is not a matter of opinion in principle is becoming one in fact. The document's reception seems to be killing the teaching with qualifications—the kind of qualifications that can be and are used to justify killing the most vulnerable of patients.

A very good example of what I'm referring to is an article in the December 7 issue of Commonweal by a Franciscan brother, Daniel P. Sulmasy, who "holds the Sisters of Charity Chair in Ethics at St. Vincent’s Hospital in New York City" and is "also professor of medicine and director of the Bioethics Institute of New York Medical College." This man is well-placed to influence Catholic clergy as well as health-care professionals, and I have no doubt he does so. He is concerned, at least prima facie, to uphold orthodox Catholic teaching. Yet whether by design or merely in effect—I don't know, and it hardly matters—Sulmasy's article reduces the responsum's utility to next-to-nothing. It does so by how he interprets the Vatican's motives and how he reduces the teaching's scope of application.

First we are told that the responsum must be read in its cultural and political "context." That seems fair enough; after all, even the dogmatic definitions of the Church can be adequately interpreted only by taking their original contexts into account. Thus:

The Vatican’s interest in PVS is also driven by its reaction to utilitarianism-especially in English-speaking nations and particularly in Australia, where philosophical utilitarian ethics is perhaps most radical. Utilitarian philosophers have argued in scholarly journals that it would be more morally appropriate to conduct painful experiments on human beings in PVS than on dogs or porpoises, since those in PVS cannot feel pain and have ceased to be persons. This is not a view that is congenial to Catholic thinking and a group of very influential prelates has pressed for doctrinal responses to such utilitarian claims.

That is true and important. To understand the teaching's value, it's important to know what sort of prevalent moral philosophy the teaching's premises oppose. But Sulmasy goes on to observe, at some length, that the Vatican's stance is motivated partly by both "pro-life extremists" within the Church and by a European culture of health care that is supposedly more "paternalistic" than the American. Now even supposing for argument's sake that such motives were at work, their relevance to the question of the responsum's truth and value is at best dubious; for in general, the truth of a rationally argued-for proposition is independent of the motives one might have for asserting the proposition. Yet Sulmasy actually adduces such motives as part of a critique, as though they somehow undermined the value, if not actually the truth, of the responsum's teaching. And by lumping the latter two motives—if in fact they are among the motives—together with the first as part of the document's "context," the first is conditioned by rhetorical association with them. Hence the difficulty: Sulmasy insinuates, without actually claiming, that the CDF stance is just a matter of opinion—one that might well have been left unexpressed by Vatican officials, and might even have been different from what it is, if the motives he cites had not been present. While that might not be the message Sulmasy wants to convey, he ought to know that it's the message many will readily hear. That's both because it is what they're disposed to hear and because there's nothing to discourage such a disposition in Sulmasy's discussion of "context." So this kind of writing is irresponsible on the part of a man in his position.

Sulmasy also reduces the teaching's scope of application not by denying what it says, but by giving such weight to exceptional cases as to make it seem purely a matter of judgment, on the part of those responsible for a PVS patient's care, whether or not ANH could constitute unduly burdensome and thus "extraordinary" or "disproportionate" treatment. To see the difficulty, contrast the last two paragraphs of the CDF's own nota (commentary) on the responsum with Sulmasy's conclusion.

The nota says (emphasis added):

When stating that the administration of food and water is morally obligatory in principle, the Congregation for the Doctrine of the Faith does not exclude the possibility that, in very remote places or in situations of extreme poverty, the artificial provision of food and water may be physically impossible, and then ad impossibilia nemo tenetur. However, the obligation to offer the minimal treatments that are available remains in place, as well as that of obtaining, if possible, the means necessary for an adequate support of life. Nor is the possibility excluded that, due to emerging complications, a patient may be unable to assimilate food and liquids, so that their provision becomes altogether useless. Finally, the possibility is not absolutely excluded that, in some rare cases, artificial nourishment and hydration may be excessively burdensome for the patient or may cause significant physical discomfort, for example resulting from complications in the use of the means employed.

These exceptional cases, however, take nothing away from the general ethical criterion, according to which the provision of water and food, even by artificial means, always represents a natural means for preserving life, and is not a therapeutic treatment. Its use should therefore be considered ordinary and proportionate, even when the "vegetative state" is prolonged.

Not much wiggle room there. Now, zeroing in on the used of the phrase "in principle" by both the responsum and the nota, Sulmasy begins thus:

...the CDF statement ratifies the views of an international group of Catholic bioethicists who in July 2004 argued that the words “in principle” in the papal allocution did not mean “exceptionless,” but rather the opposite. This is crucial because in the ordinary/extraordinary-means tradition, one cannot make an a priori exceptionless declaration that a particular treatment is ordinary. A treatment that is ordinary in one set of circumstances may be extraordinary in another. The CDF’s response and accompanying commentary declare that its teaching about feeding tubes in PVS must be located squarely within this tradition.

Again, that is true. But in response to concerns about whether Church teaching about using ANH in PVS patients has "changed" to a confusing extent, Sulmasy says (I have added the bullets and accompanying syntactical changes—ML):

What, then, has changed? It seems to me that the proper way for clinicians, hospitals, and families to interpret the CDF statement is to understand it as saying that IF

• a patient is in the rare state known as PVS
• has not left any advance directive
• is otherwise young and healthy
• the government or an insurance carrier is paying or one is independently wealthy
• it is not reasonable to construe that the patient is suffering
• and if there are no apparent complications

then, other things being equal, one cannot justify the removal of the feeding tube merely because one is morally certain that the patient cannot recover. In such a “thick” description of the circumstances, the believing community’s authoritative voice has judged that this treatment should be considered ordinary. I suspect that previously many of us would have taken a good-faith determination by the family that the patient would not want to live if unable to recover as sufficient to judge the feeding tube extraordinary. The Vatican has now declared that more justification is required.

The irony here is exquisite. In the very course of affirming that the Vatican has clarified the full rigor of the teaching, Sulmasy so qualifies the teaching's scope that, if his analysis is broadly accepted, the teaching will make virtually no practical difference to current clinical practice in Catholic or any other institutions. Other paragraphs, especially his closing ones, continue in the same vein. Thus, a CDF document meant as a reaffirmation of the strongly-worded doctrinal clarification issued by the previous pope is reduced to a wan reminder that a bit more justification than some have found enough is required for dehydrating and starving a PVS patient to death.

This is how the Enemy uses theologians despite their best intentions. Cynicism and subtlety choke off the Spirit of life. Intelligent Catholics, beware.

The issues behind the issues

In an article on the First Things blog last week, Prof. Robert P. George wrote (emphasis added):

There are many profound respects in which our culture is in need of transformation. Work is needed in every sphere. There are two issues, however, that are so central to our future and, indeed, to the future of mankind that they must, surely, be given a certain priority. Both are on the table now and will be resolved—for better or for worse—in the next decade or so. Critical (possibly irreversible) decisions will be made in the next year or two. I speak of the issue of marriage and the complex set of issues sometimes referred to compendiously as “bioethics.” In respect of both matters, things will go one way or the other depending on the posture and actions of Catholics.

Having once briefly worked under Robby, and having continued to follow his work with stupefied admiration, I am obliged to agree with him that the political difference will be made by Catholics—if, that is, a difference is going to be made. But I am far from convinced that there is still time to make a difference. That is because the issues behind the ones he identifies as top-priority seem largely to have been decided—and decided wrongly.

In the case of marriage, the "developed" world as a whole has firmly adopted the premise that marriage is only what people collectively decide it is. That holds of the Anglosphere, which includes the United States, in particular. What is still understood to be "traditional" marriage—a lifelong union between a man and a woman, ordered to the transmission and maintenance of new life—is no longer assumed by our legal and cultural norms to be divinely instituted. To be sure, many tradition-minded believers of all major religions still maintain that assumption. Some even act accordingly. But in the public square, traditional marriage is now treated as just one option among others, just like one's choice of religion. Marriage as an institution is thus becoming something we may adapt at will, on the basis of ideas, preferences, and goals that make no necessary reference to a divine or even a natural law. That is the main reason why intentionally sterile marriages, no-fault divorce, serial divorce-and-remarriage, and even cohabitation without the formality of marriage are now more widespread than at any time since the pagan Roman Empire. That is why same-sex "marriage," currently opposed by the majority of Americans—who are, after all, still formed by the residual sentiments of tradition—is slowly spreading among nations and states. Ineluctably, it will gain well-nigh universal acceptance. So long as our legal and cultural norms assume that it is human choice, not "the laws of nature and of nature's God," that determines what marriage is to be, then what is called "marriage" will become more and more elastic, stretched to fit more and more forms of moral and spiritual absurdity defended by the buzzwords of "freedom" and "equal rights."

As for the array of bioethical issues that keep arising with the advance of science and technology, we can raise all the "ethical" objections we like to this-or-that practice made newly possible; but in the end, such objections cannot of themselves make much difference. I need not discuss specifics, such as pre-natal screening or human cloning; for the underlying problem is that there is no longer any common religious or philosophical framework in which to discuss such issues, and to which appeal could successfully be made to resolve them. The very terms of discussion reinforce the default impression that this array of issues is a matter of adjudicating democratically among competing ideas and beliefs—many of which have a certain plausibility, but none of which are ultimately more than just matters of opinion. So, amid the cacophony of competing opinions and Weltanschauungen, the irrefragable fact of what can be done ensures that all of it, eventually, will be done. And once such things are done, they develop too much of a constituency to make banning them politically realistic. Just look at what's happened with IVF.

All of this is the fruit of what I call "autonomism": the idea that human freedom entails the freedom to decide what the most fundamental norms of life are to be, a freedom constrained only by obvious considerations of physical reality and social utility. Now if autonomism could still be effectively reversed, Catholics would indeed be best placed to do the job. The pope and the bishops say all the right things, in theory; and they do have allies among the Orthodox, conservative Protestants, observant Jews, even Muslims. The Catholic Church is certainly pivotal here. But as Robby seems implicitly to recognize, the most the Catholic bishops can realistically do is "encourage, exhort, and cajole." That is not just because the political sphere is the province of the laity, which of course is true; it is because the bishops confront, among the Catholic laity themselves, the same autonomism that has gained purchase in the culture at large.

Among those Catholics who care enough to even understand Church teachings about marriage and bioethics—and such Catholics, in my observation, are not the majority—many regard such teachings as reformable, and thus as "take-it-or-leave-it." In other words, the teachings are treated as matters of opinion. That, I believe, is the most likely reason why why more American bishops do not withhold the Eucharist from Catholic politicians who support a so-called "right" to abortion. If they were to get tough about that particular matter, the ensuing storm of controversy would rightly raise the question why they don't get equally tough about other moral issues on which many Catholics, in theory or in practice, treat settled Church teaching as a matter of opinion and thus as optional. Marriage is quite high on that list of other moral issues: the divorce rate among Catholics roughly matches that of the general population, and many divorced-and-remarried Catholics receive the Eucharist without qualm or question. And of course there's contraception, a matter on which the vast majority of Catholics reject, in both theory and practice, a teaching of the Church which has not varied for as far back as we have records on the subject. I don't hear any bishops suggesting that loyalty to such teaching be made a litmus test of good standing with the Church. So, if they can't crack down on those issues, how are they going to energize Catholics who aren't already loyal to join forces with other religous believers about the issues Robby sees as so crucial? Even leaving aside the aftershocks of the sex-abuse scandal, the de facto moral authority—the street cred, if you will—just isn't there.

None of this is to say that I wouldn't want to join forces with people like Robby on such matters. I'd be on the side of light and truth, after all; in fact, this blog is my own small way of doing it. And if, in careerist fashion, I got a job out of the whole business, I'd have an interesting life to boot. But I believe that, in the end, only radical divine intervention will make much difference. Things have to happen that will shock people back into a sense of spiritual reality. I hope it won't have to be a combination of natural disasters, wars, and economic dislocations that would reduce us to a peasant-style existence; but I wouldn't be at all surprised if that's what it takes. In the meantime, let us keep saying what needs to be said; but above all, let us pray, do penance, and love one another. Drawing people back to God depends above all on his grace, light, and joy shining in our hearts and faces. In short: on our holiness.

Excuses are running out: amniotic stem cells

It has been known for some time that adult stem cells have proven to be more successful therapeutically than embryonic stem cells. Far more, in fact. The excuse usually given for government funding of research into the latter is that, if only scientists could extract lots more stem cells from embryos, thus killing the embryos, the usefulness of ESC therapy could, and probably would, improve dramatically. Of course, only if you're a utilitarian at heart would you think that such a result would solve the moral problem; but then, most Americans are indeed utilitarians at heart, else we wouldn't have legal abortion. Yet now the usual excuse for embryonic stem-cell research is weakening.

It appears that stem cells gleaned from the amniotic fluid of the placenta have great potential. Since obtaining them involves no killing, the U.S. bishops' pro-life spokesman and the Vatican have acclaimed the new avenue of research. Of course the drumbeat for ESCR remains. Some scientists say that amniotic stem-cells aren't a "one-size-fits-all" shoe, so that there can and must remain a place for ESCR. That allows the political momentum for ESCR, renewed by Speaker of the House and "Catholic" grandmother Nancy Pelosi, to continue. To any objective observer, however, it seems that the excuses for forcing all of us to fund ESCR are starting run out. But the excuse that persists will remain powerful despite its objective weakness.

The momentum for ESCR funding is about the same thing as what motivates much other legislation: butt-covering. Most politicians, including nearly all Democratic ones, don't want to be blamed for the deaths of visible people that, it is thought, could be avoided if only the right laws, with the right funding level, were passed. The same goes for other issues, such as domestic violence. Congress recently renewed the Violence against Women Act, with its considerable price tag and outrageously sexist assumptions, so that it wouldn't have to deal with women who get angry whenever a woman is badly injured or killed by a male significant other. Men of course enjoy no similar protection even under state laws, which are mostly gender-neutral as written but far from gender-neutral as applied. There is no political cost to pretending that male victims of domestic violence don't matter, because the near-universal assumption is that men can "take it" on what is falsely imagined are the rare occasions when such violence occurs. Neither is there any political cost, in most jurisdictions, to pretending that embryos don't matter. With legal abortion, embryos are killed every day so that their mothers' lives won't become as difficult as they would be if they were allowed to develop to term and be born. That is now taken as a constitutional entitlement by the majority of women; one moral excuse given for that legal status quo is that unwanted pre-born children are better off dead. More important, however, is that if efforts to make most abortions illegal ever were to succeed temporarily, an army, mostly of women, would descend on state capitals and even Washington screaming bloody murder about deaths from back-alley abortions. All branches of government know that, which is why, despite considerable and growing pro-life sentiment, abortion will not be substantially limited by law anytime soon. And then there's in vitro fertilization and pre-natal genetic "testing." Because much-desired babies result from using those techniques, most politicians care no more than most parents do that their price includes the destruction of many embryos. And so nothing will be done about such practices, save to find ways of funding them at everybody's expense. Politically, there's far less of a downside to the killing of embryos for the benefit of others than there would be to forbidding it. That, after all, is why it isn't forbidden.

Long-term, the only solution to such problems is spiritual. Respect for the sanctity of life must grow to the point that there's a greater political cost to permitting, even funding, such things than to forbidding or discouraging them. That seems to be happening among young people regarding abortion, and may eventually happen regarding ESCR if present scientific trends continue. But the basic problem is the prevailing assumption that it's up to us to decide, for reasons that seem good to us, who among the most vulnerable should live and who should die. I'm not optimistic that such an assumption of godhood will be overturned. And if it is not, our society will eventually self-destruct from hubris.

Mutilating Ashley: from parenthood to pet ownership

Diogenes at Off the Record has some biting commentary about the case, and a touching photo, of Ashley Peters, the mentally disabled nine-year-old whose parents have had various surgeries done to prevent her from becoming more difficult to care for as she grows older. Understandable though their motives may be, what her parents have done is mutilate a child for their own future convenience. Not that they would care, but the CCC (§2296) condemns that. Is this still another disturbing precedent for the future, or just an anomaly?

I hope the latter and resign myself to the former.

The brave new world looms ever closer

The debate over embryonic stem-cell research is already being overtaken by events. One hears periodic reports that it delivers far less than promised even as other, less ethically objectionable techniques yield results. But we now face something still more deadly: prenatal genetic diagnosis, or "PGD" for short. You might ask how anybody can object to mere "diagnosis." You'll see.

Last week NPR did a two-part radio report on PGD. The first, whose transcript is available here, was a story about the Magliocco's, a Connecticut couple whose first child died within weeks of birth from a rare genetic disorder. Wanting more children, but not children like that, they went in for PGD. Essentially, it involves producing an array of embryos by IVF, finding out which have the defect, eliminating them, implanting one healthy one in the mother's womb, and freezing the rest for thawing when convenient.

Read the segment for further details of what's involved. I strongly suspect this couple are cafeteria Catholics, given their name and location. Figures.

The second segment was an interview with Eric Cohen, director of the Bioethics and American Democracy program at the Ethics and Public Policy Center. I heard it all on the radio, but you can't get the transcript on the NPR website, just a podcast. I'll sum up his wise words.

First, PGD is a case of "eliminating the disease by eliminating the patient." That's Cohen's phrase; I couldn't have put it better myself. Second, PGD is now used by some couples for gender selection and, in one case, by a deaf couple to produce a deaf child. Eventually, Cohen speculated, PGD could be used to select genetically for children with all and only the qualities desired by their parents. Children produced to order like commodities. The way Dell builds people's computers, I would add.

I am revolted by all of this. But it will march on, inexorably. As it does so, those who heed the voice of the Catholic Church will find themselves an ever-shrinking minority. Perhaps the "ecclesial movements" will be the only way for faithful laity to provide the mutual support needed to maintain the light in the encroaching darkness.