Text: Health Care Ethics USA

The Vocation of the Healthcare Ethicist

Jun 9, 2021, 17:33 PM
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Feature Article

Archbishop Anthony Fisher, OP, Ph.D.

Editor's Note: This article is based on a presentation by Archbishop Anthony Fisher, OP, Ph.D., of Sydney, Australia, at CHA's Theology and Ethics Colloquium, March 10, 2021.

Thank you and greetings from Sydney, Australia. Let us consider the vocation of the healthcare ethicist by first examining current dilemmas of health ethics and various perspectives on healthcare ethics from secular, Jewish and Christian traditions. We will also examine viewpoints on the role and need for ethicists in the context of contemporary health care and moral principles of the Catholic Church.

Current Health Dilemmas: Which Ethic Applies?

  • A young man dies in the ER after a car accident; his widow wants his sperm collected immediately so she can have his children. The emergency team is unsure of their options and responsibilities. What do you advise?1
  • An elderly lady from an aged care facility who has been febrile for days and is now short of breath, coughing, and tachycardiac. She has hypertension and early dementia, and has previously been treated for pneumonia, but is otherwise relatively healthy. There is dispute over what is medically indicated, what the patient wanted, and what her family is demanding. You are contacted by the director of nursing. What do you advise?2
  • A ten-year-old biological male diagnosed with Asperger's Syndrome and gender dysphoria is referred by a GP to your hospital for assessment and prescription of 'puberty blockers' followed by other 'gender affirming' pharmacological and surgical interventions. The child is already dressing as a girl and the child's parents, teachers and psychologist are divided on how to respond. The matter is referred to the hospital ethics committee and the members all turn to you. What do you advise?3

These cases are examples of the thousands of enquiries referred each year to medical associations, healthcare institutions and ethicists for advice. Thousands more people access the codes and online ethical resources of these bodies,4 or go trawling the net and the blogsphere for counsel. Others get their ideas from such reliable sources as General Hospital, Grey's Anatomy or one of the 73 American TV series so far, all set in medical or hospital settings and combining soap opera and ethical consult.5 For every one of these cases in the professional literature or the pop media, there are thousands more real life examples that you and your colleagues could add to the catalogue of human experience.

The COVID-19 pandemic has multiplied people's ethical dilemmas, and there is already a burgeoning literature around these.6 Issues have included the limitation of public freedoms, access to tests and treatments, sharing of test results with civil authorities, principles of triage for overwhelmed systems, and maintaining family integrity amidst quarantine and social distancing. While many have put their hope in vaccines, these too have raised questions regarding the use of fetal cell-lines, the testing and effectiveness of vaccines, priority of access to vaccines, whether there is a strong duty to be vaccinated and what encouragement or coercion is appropriate, and the responsibilities of 'big pharma' and the richer nations towards poorer countries under COVID. For many people the pandemic has forced a re-examination of the meaning of life, their own priorities, ethics in a time of crisis, and their attitude to healthcare.7

Addressing the coronavirus crisis, the Vatican has offered several reflections upon our common vulnerability and interconnectedness along with some principles for responding to such an emergency.8 These documents have also challenged the reduction of the ethics of healthcare to certain 'neuralgic issues' as John Glaser has pointed out, and we can become fixated on a narrow range of 'moral' concerns while ignoring issues of access, equity, waste and the like that touch on the lives of many more people, often more drastically.9

Which is not to trivialize for a moment the seriousness for people's personal lives, and for the character and mission of practitioners and institutions, of controversies over care at the beginning or end of life,10 sterilizing or 'gender-affirming' interventions, the conscience rights of practitioners and institutions;11 nor to minimize the anxiety many feel about the direction of government policy in recent years or in the years to come.12 The theological anthropology, Gospel of life, and freedoms of religion proclaimed in the Catholic tradition are surely non-negotiables for any Catholic ethicist, practitioner or institution, but it will take courage and prudence to hold fast to these things at a time when they are increasingly counter-cultural.

Into these myriad issues the bioethicist “enters where angels fear to tread.” What are the rules of engagement? In a world with multiple, rival, fragmented moralities, and where some think there's no more to ethics than personal preferences, loyalty groups, and power games, which way do we go for the inspiration, even vocation, of the ethical adviser in Catholic healthcare?

Wisdom Traditions on Health Ethics

'Secular' Wisdom on Health Ethics
One obvious place to start is the Hippocratic tradition, which evolved from the fifth century BC onwards,13 and was long regarded as the model of medical conduct. Suffice it here to say that the 'Hippocratic Oath' is topped and tailed with a vow and prayer to the gods of health; it briefly articulates the intrinsic goals of medicine and character proper to its practitioners; and it lists some dos and don'ts which give a sense of how those vows, goals, and character might play out in practice. There's no hint here, however, of the need for ethics expertise: moral philosophy, like medicine, was in its infancy in the Hippocratic era and the doctor still knew best.

I won't trace here the evolution and influence of the Hippocratic tradition thereafter. Much of it survived in the 1948 Declaration of Geneva and subsequent declarations of the World Medical Association (WMA). Here, the medical profession worldwide, recovering from the catastrophic malpractice of the Nazi era, sought to recover and translate the oath for modernity.14 Though more coy about god language, Geneva joined Athens (and Jerusalem) with talk of a “solemn pledge”, “consecrating my life” to service, maintaining “utmost respect” for human life from conception, and being ready “even in the face of threats” to observe “the higher laws of humanity”. In just a few verses, the WMA commended pietas toward teachers and profession, a dignified professionalism and good conscience, and strict observance of patient confidentiality, non-discrimination and non-maleficence.

The Hippocratic tradition suggests that bioethics can be grounded in the internal logic of the practice of medicine and a morality 'natural' or 'common' to humanity. It marks a deeply humane and spiritual concern at the heart of good medicine. But in modernity, medicine can be market-driven and even cynical: how is the best of the Hippocratic tradition to be recovered and advanced?

Jewish Wisdom on Health Ethics
What does biblical wisdom offer? In the 38th chapter of the Book of Ecclesiasticus in the Catholic and Orthodox bibles, we have the nearest ancient Jewish parallel to the ethics of Hippocrates. Written by a Hellenistic Jew, Ben Sirach from Seleucid-occupied Jerusalem in the second century BCE (it opens by telling the sick to honor the physician and the pharmacist as well). Why? For his knowledge of medicinal herbs and his service of humanity; for diagnosing accurately, preserving life, prescribing the right medicine; and for healing effectively and relieving pain (vv. 1-8,14). The physician can hold his head high, knowing he is a credit to God and a contributor to the world (vv. 3,6,8). But he must also acknowledge that his hands and learning are God-given gifts, and so pray to the God from whom all healing comes (vv. 1-2,4-7,12,14).

The 'patient', for her part, must be patient rather than defiant, cleanse body and soul, pray and sacrifice for a cure, and “then let the doctor take over” (vv. 9-12). As if an advertisement for the American Medical Association (AMA), Ben Sirach declares that no sensible person will reject the physician's advice, and that life and health may depend on it! (vv. 4,12-14) But then, as if to counter-balance the praise of doctors, Ben Sirach quotes a popular aphorism of the ancient world: “Let the wicked fall into the hands of a physician”! (v. 15)

Christian Wisdom on Health Ethics
The parable of the Good Samaritan in Chapter 10 of the Gospel of Luke is the text that most influenced Christian healthcare and health ethics. Suffice it here to say it is the story of a 'carer' cradling a wounded man, binding up his wounds, pouring lineament, giving pain relief, and ensuring institutional care and funding for as long as needed. Here we find themes of:

  • Compassion and active mercy
  • An ethic of rescue (save-heal-care), without discrimination, calculus, blaming
  • Charge to “Go and do likewise”.

Jesus' own healing ministry, his self-description as a physician of bodies and souls, and this story with its concluding mandate, were springboards for Christian healthcare, pastoral care of the sick, and health ethics. Thereafter, came a sacrament of the sick and rites for the dying; monastic pharmacies and hospices for pilgrims and the infirm; hospitaller orders of religious men and nursing orders of religious women; hospitals, orphanages, clinics and other Church-sponsored care services; and centers for training physicians and nurses. In the process, the Catholic Church became the oldest and largest healthcare provider in the world!

Why Do We Need Health Ethicists?
Despite tell-all interviews with Oprah Winfrey, Americans may be mystified regarding the role of the monarch in the Westminster system. The queen clearly has great symbolic authority and some surviving royal prerogatives as the parliament, executive and judiciary all act 'in her name'. But the British monarch does not make the decisions. When she acts, she acts on the advice of her government. She does, however, have three rights vis-à-vis her government: to be consulted, to encourage, and to warn.15 You might say that the role of the ethical adviser in healthcare is rather similar. But why have them at all? Why not just leave it to the republic of common sense and its fine citizens, health professionals and patients?

'Secular' Wisdom On the Need for Health Ethicist
The latest AMA Code of Ethics (2016) claims continuity with the Hippocratic tradition and insists that health professionals must not only be technically competent but ethically principled in their practice (1.2, 1.3, 3.1.6). This includes being professional (1.1, 3.1), trustworthy (1.5), patient-focused (2.1.1 etc.), confidential (2.2), and respectful of patient dignity, rights, and boundaries (1.5, 2.1.1, 2.1.5, 3.1.8, etc.).16 Amongst those with whom the Code envisages health professionals collaborating are ethics committees and consultants.

The AMA conceives of these as:

  • Supporting informed, deliberative decision-making by patients, families, and the healthcare team
  • Offering assistance in addressing ethical issues that arise in individual cases, clarifying issues and values, and facilitating sound and respectful decisions
  • Facilitating discussion that promotes respect for the values, needs, and interests of all participants, especially when there is disagreement or uncertainty
  • Providing ethics-related educational programming and policy development within their institutions.17

These are important tasks, but they have their risks and need to be contextualized with their goals and substance carefully articulated.

Jewish Wisdom On the Need for Health Ethicists
In a previous section, I noted that in Ecclesiasticus Chapter 38 we have the nearest thing in the Old Testament to a healthcare ethic. There, we find advice both for health professionals and for patients, about the calling and inspiration of medicine, its goals, the spiritual attitudes proper to the participants, and the conclusion that we should follow our physician's advice. In the very next chapter of Ecclesiasticus, we are told to seek the advice also of the philosopher or wise person. She is one who meditates on the Law of the Lord, researches the wisdom of the ancients, ponders the meaning of stories and proverbs, and is upright and grateful. She also explores less familiar territory, sifts good from evil, and prayerfully contemplates divine wisdom as much as human (Sir 39:1-14).

God blesses her with wisdom, but she doesn't hoard it for herself: she counsels the great and the good, appears before the authorities, and pours forth words of wisdom for all (vv. 4,6,9). “Many shall praise this one's wisdom,” the text continues, “and it shall never be forgotten. The memory of the wise shall not fade away, and their wisdom shall be honored” from generation to generation, in the nation and the Church (vv. 12-14). Though Ben Sirach doesn't say explicitly that this advice is as important for moral and spiritual health as medical advice is for physical health, he declares the faithful should meditate on this sage's advice (v. 16).

The positioning of these two chapters of Ecclesiasticus – about the advice of the physician and the advice of the philosopher – right up against each other, invites reflection on the intersection between medicine and ethics, and the possibility of someone being a wise counsellor when it comes to healthcare decisions.

When the great Jewish philosopher-physician Moses Maimonides (1135-1204) offered his medieval ideas on the medical arts and ethics, such sentiments were omnipresent. After the model of Ben Sirach, he presented the philosopher-physician as a wisdom figure and friend of humanity, a lover of science and of neighbor, without avarice or vanity.18 But does the wise physician really need ethical advisers?

The words the Bible uses for 'advise' or 'counsel' – in Hebrew יעץ (ya'ats) and עצה ('etsah), in Greek βουλἡ (boule), συμβουλεὑω (symbouleuo) and γνώμη (gnome) – have some interesting qualities. Advice in the Bible is never merely feeling or opinion: it is expected to be well-considered and taken from a reliable source. It is usually very practical, advising on plans, strategies, what is to be done. And it is never neutral. To give counsel is not just to outline a range of options. Rather, it is to commend the right course of action, and so it implies guidance and obligation.

There are many advisers and much advice given in the Bible – the terms יעץ and עצה appear 168 times. God is, of course, the best of advisers and the most prudent choice is that which conforms to his plan;19 indeed God's revealed plan is His counsel.20 The Prophets confirm that right counsel comes from the Lord, or the Spirit of the Lord.21 The Psalms and Wisdom literature personify Wisdom as a divine adviser.22 In this tradition, Christ is presented as the 'Wonderful Counselor',23 wisdom incarnate24 and wiser than Solomon,25 and the Holy Spirit as 'the Counselor'.26 Throughout the Old Testament, patriarchs and kings had regular advisers,27 and the Wisdom literature recommends that people more generally take broad advice, from one of more quality advisers and heed that advice.28 So Christians are taught to seek the wisdom 'from above' and give and take counsel from each other.29 To be a wise bioethicist in the Biblical sense, therefore, would be to be one who is in tune with the wisdom of God and who assists others with the practical application of that wisdom.

Christian Wisdom On the Need for Health Ethicists
This brings me to Christian attitudes on the idea of a health ethicist. With the gradual development of Catholic healthcare and pastoral care of the sick, there developed parallel traditions of thought about the ethics of life and death, sickness and health, self-care and health-care, professions, institutions and systems. This stretched from the Gospel generation, the fathers and scholastics, through the casuists and manualists, to the Catholic 'medico-morals' texts and secular bioethics of modernity.30 One could easily identify some key influencers and monuments of that evolution: Augustine, Aquinas, Alphonsus, the neo-Thomists, Pius XII, John Paul II in Evangelium Vitae, Elio Sgreccia and his Pontifical Academy for Life, Paul Ramsey, Beauchamp and Childress, Edmund Pellegrino, Ashley and O'Rourke, the Ethical and Religious Directives to name a few.31

One monument along that winding path was the publication in 1994 of the Charter for Health Care Workers by the Pontifical Council for Pastoral Assistance to Health Care Workers. It was revised and reissued in 2016,32 just before that council was absorbed into the Dicastery for Promoting Integral Human Development. The original charter elaborated an ethic for healthcare workers, beginning with a description of their vocation as “Ministers of Life” and elaborating their duties, especially with respect to procreation, life and death.

The New Charter follows the same structure but now includes some key magisterial pronouncements of the past two decades, and some reflection upon advances in technology, professional practice, healthcare law and ethics in the meantime. There is a rather 'Franciscan' emphasis on social justice in the new text.33 Another difference is the addition of a section on ethics committees and clinical ethics counseling.34 Here at last, we have a magisterial document that recognizes the existence of the hospital, system ethicist and ethics committees, and favors these because they can:

  • Supply for deficits in the experience and sensitivity of the individual health worker faced with an ethical dilemma
  • Articulate the values and principles at stake
  • Assist where there are areas of conflict or ethical doubts on the part of clinicians, patients and relatives, as well as policy-makers, managers, insurers and the like
  • Enable more reasonable clinical decision-making “within the framework proper to medicine and ethics”.

The Charter, like the secular, Jewish and Christian bioethics of the two and a half millennia before it, presents healthcare as a calling and self-gift; ethical advisers share in that vocation by supplying, articulating, assisting and enabling in the ways identified. Ethicists are wise advisors, teachers and mentors, who help form the consciences of health practitioners and managers, always challenging them to more and better. As even the AMA recognizes with respect to ethics committees that serve faith-based or mission-driven heath care institutions, these are expected to “uphold the principles to which the institution is committed” and “make clear to patients, physicians, and other stakeholders that the institution's defining principles will inform the committee's recommendations”.35

Not-so-good Reasons for Health Ethicists
Having explored some of the good reasons in the philosophical, biblical and magisterial traditions for having ethics advisers, consults and committees, we might consider some of the risks of these 'experts' and practices.

First, modernity tends to bifurcate the medical and ethical, as the know-how of two distinct groups. It takes years of specialized studies to master a discipline, and so those engaged in the one have only limited knowledge of the other. The upside is that there is rigorous research, academic discipline, debate and progress in each field; the downside is that the two disciplines float further and further apart. Then the ethicist may think, teach and advise from a position so theoretical as to be ill-informed, irrelevant or unintelligible, and the practitioner may pay lip-service to professional ethics, but in fact be guided by personal preference, professional fashion, civil law, and/or income maximization, and not much more.

Secondly, there is a danger of individuals or whole institutions outsourcing conscience and moral decision-making to some expert or committee of experts whose 'job it is' to deal with ethical matters.36 This has several related but distinct risks: that the ethicist, who scores higher on 'moral reasoning' – whatever that means37– becomes the ethical know-all in the minds of others or in her own mind; that patients and families are disabled in favor of the 'expert' opinion of the ethicist; and that medical professionals abrogate their own personal moral responsibility, especially in the face of vexing issues.38 As the late, great Jewish ethicist, Lord Jonathan Sacks, observed in his Templeton acceptance speech:

You can't outsource conscience. You can't delegate moral responsibility away. When you do, you raise expectations that cannot be met. And when, inevitably, they are not met, society becomes freighted with disappointment, anger, fear, resentment and blame.39

Thirdly, at the other end of the spectrum, are those ethicists who, avoiding shouldering such grave responsibilities, become so vague or evasive as to be unhelpful. Interviews with a number of clinical neuroscientists over a seven-month period revealed the perception of a boundary between the 'real' work of practitioners and the 'ideal' work of ethicists.40 As one participant put it: “I've been to conferences where there was a talk on bioethics It's too philosophical what they say, not tangible, and they all talk and talk, and by the end of it, you don't remember anything.”41 Well, that might tell you more about the inattention of that particular practitioner than the quality of the talk itself. But it is clear in the three traditions I have explored today that ethical advisers are expected not to offer grand theories, or speculate about the range of options, but to guide choices and actions. Bioethicists must assist in good healthcare decision-making and in the sound education of professional or institutional consciences, rather than confusing everyone, making them unconfident about the way forward, or unconcerned about the ethical implications of their choices.

Fourthly, some imagine that a person might gain expertise as a bioethicist by doing a course or conference here and there, but with no serious grounding in one or more of the relevant disciplines of moral philosophy, moral theology, biology, healthcare or pastoral theology.42 If people are free to erect a shingle announcing themselves as a health ethicist without serious credentials, so too individual practitioners may imagine themselves well formed in ethical matters after very little formal study of ethics or formation in the application of ethics to their behavior. Asking medical and nursing students to undertake some classes in principlism so that they can recite the Georgetown mantra, or requiring healthcare managers to read and sign onto the Ethical and Religious Directives, is just not enough.

A fifth danger of which bioethicists and those who seek their advice must be aware is that consciously or not the ethicist can be 'tamed' by their institution. We all want to get along with our comrades at arms in a healthcare setting; to be a team player, not a naysayer who gets in the way of technical progress, fiscal responsibility or current practice. We don't want to be branded as a 'hard-liner' or a 'difficult person'. The risk here is that the ethicist's desire to get along with or within the institution blunts her willingness to ask hard questions and press for limits. In such a case, the ethicist loses purpose or, worse, ends up as window-dressing for ethically dubious decisions. Here the Vatican's New Charter is right to warn that ethics committees can become 'merely administrative supervision' ticking various boxes when it comes to research or clinical practice for legal or professional purposes, but not addressing the ethical values at stake.43

Finally, if ethicists risk being tamed by their institutional affiliation, they must be equally watchful of their surrounding culture. Some aspects of the contemporary West are supportive of sound ethics, but we can also experience pressures to secularize and accommodate, or to so elevate medicine that it colonizes the whole of reality. Like the anathemas against witch-doctors in the Old Testament and against the pharmacists in the New,44 ethicists as practitioners of true religion must always be ready to call out unethical behavior or systems, as well as medical idolatry.45

Profession and Vocation: How Ethicists Serve Health Care and the Church

The Profession of Health Ethicists
The three traditions that have informed my paper today all present health-carers – and by extension health ethics advisers – as engaged in more than a job or career. Some prefer the terms profession and professionals. Leon Kass and Alasdair Macintyre have explained that 'profession' is an ethical notion entailing:46

  • A conviction on the part of practitioners about the importance of their particular service to others and their suitedness to it
  • Immersion of newcomers in that practice, calling forth devotion of character and life
  • Appropriate apprenticeship or education in knowledge, skills, mission, practical principles and virtues
  • Public recognition by the community and public 'profession' by the practitioner of this tradition of practice
  • Self-regulation by the practitioners of their own professional standards according to the internal goals of their activity and their inherited but evolving ethic
  • Readiness to be public advocates for that professional ethos and for the needs of those they serve.

As an example of this last matter, the COVID-19 pandemic has served to highlight the inequities in access to tests, treatments and preventative measures within our communities and between countries. There are some big questions here about the allocation of social resources, and especially healthcare resources, and widening gaps between haves and have-nots in healthcare. Here, health ethics and social ethics intersect and the Christian preferential option for the poor and powerless will play out not just in willingness to do the unprofitable but charitable thing, but in public advocacy for social change.

If the idea of a medical or nursing 'profession' is itself an ethical notion, then the 'profession' of the bioethicist (at least in part) is to support his or her medical colleagues in being faithful to their 'profession'. When patients, relatives, colleagues, insurers or others press the health worker to act contrary to sound ethics and professional conscience, the ethics adviser can both support them in their resolve and advance education and discussion with those promoting a contrary agenda.

The Vocation of Christian Healthcare and Health Ethics
For Christian carers and those who advise them, however, talk of being 'professionals' – while better than talk of job or career – still limps somewhat. They reach for a word like 'calling' or 'vocation' to describe their sense of a transcendent mission to save, heal and care for or to assist others to do so. Hence the use of religious language in the Hippocratic, Jewish and Christian traditions of health ethics, and of a kind of sacred seriousness even in the contemporary codes and declarations of the WMA and the AMA. The Vatican Charter characterizes the activity of health-carers and their colleagues as guardians and servants of human life, health and dignity.47 They serve human beings respectfully at their most fragile, and thereby contribute to the common good of their community, and give witness to moral norms and the spiritual life.48 They know their task to be one of Christian witness and mission, 'a response to a transcendent call that takes shape in the suffering face of the other', a prolongation of the charity of Christ the Physician, and a reflection of his 'Good Samaritan'.49 Theirs is a participation in the pastoral and evangelizing activity of the Church.50

Beyond the moral elements of profession for healthcare and health ethics, there are spiritual dimensions of vocation, that include:

  • A sense of divine calling, building upon any natural suitedness, so that one expects to find purpose, fulfilment, even sanctity, through the appropriate pursuit of that activity
  • Willingness to cultivate character and mores not only through professional studies and immersion, but also through personal prayer, study of the sacred word, and reception of the sacraments
  • Desire to pursue the goods of this vocation even if this will not maximize income or kudos51
  • Public profession of that willingness, if not in religious vows, then by attachment and fidelity to a Church institution, its magisterium and directives such as the ERDs
  • Integration of the role of bioethicist with other elements of one's personal and spiritual life, e.g., the service of one's family and the worship of one's God. Thus, one would expect a Catholic health ethicist to be a faithful Mass-goer, not out of tribalism or legalism, but because she finds inspiration and sustenance for her vocation there
  • Prophetic willingness to call out cultural, economic or political forces that press practitioners (or even ethicists themselves) to conform to the values 'of this world' rather than of the kingdom of God
  • Involvement in a Christian “community of concern” that assists the ethicist with discernment and supports them through challenging times.52

Conceiving of bioethicists as missionaries to their institutions, systems and surrounding cultures does not mean adopting a posture of imagined superiority or permanent opposition. Christians are called to be instruments of peace, and health ethicists can be so in a polarized Church and society, or when patients, family members and carers have opposing views. Even in the face of intractable issues like abortion, euthanasia, sterilization, sex-change or vaccine hesitancy, bioethicists can share with people to a broader historical, cultural, and spiritual vision and invite them into a conversation that is at once candid about basic norms yet respectful of those who think differently. As Ron Hamel argued, ethicists “should also seek to form communities of moral discourse, places where ethical issues are acknowledged and taken seriously, where conversations can take place about ethical concerns and issues, and where ethical discernment can take place.”53

Conclusion
There are today some powerful pressures to abandon the three streams of sound health ethics that I have followed today, or to diminish the senses in which health-carers and their advisers are engaged in an ethical profession, even a God-given vocation, or to disallow Catholic institutions to be different in some ways. Buzz words like 'compliance', 'efficiency' and 'transparency'; 'discrimination', 'anti-discrimination', 'homophobia' and 'transphobia'; 'reproductive health' and 'the full range of services'; 'separation of Church and state' and more – have been weaponized, as have some laws and policies addressing these matters. People are dismissed, de-platformed, trolled and otherwise threatened with ruin if they do not conform. In turbulent times like these, as several CHA ethicists have pointed out, ethics is critical to preserving the identity and integrity of Catholic healthcare, in assisting people in dealing with ethically complex matters, in challenging some individual behavior and organizational culture, and in engaging in the ongoing formation of leaders and staff.54

In this paper I began by identifying some examples of contemporary ethical issues, including ones raised by the COVID-19 pandemic, that call for sound ethics and reliable ethical advisers. I asked which healthcare ethic should inform our practice, and proposed as authoritative the 'secular' wisdom of the Hippocratic tradition through to the WMA declarations, the Jewish wisdom of Ben Sirach through Maimonides and since, and the Christian wisdom beginning with Jesus' Good Samaritan via great theologians and health practitioners through to the contemporary magisterium and theological reflection. I then probed why health ethicists, consults and committees are desirable, and identified some good reasons in the three traditions, as well as some dangers. Finally, I considered the how of the service of health ethicists and proposed that it is more than a career, or even profession, and more like a religious vocation, and I identified some of the marks of ethics advisers so understood. I suggested that in times such as these the missionary or evangelical role of the bioethicist comes to the fore but is also very challenging.

And so I leave the last word to that Biblical wisdom with which I began this talk. “In an abundance of counselors there is safety” (Prov 11:14; 24:6), so “Listen to advice and accept instruction, that you may gain wisdom for the future” (Prov 19:20). But as “All counselors think highly of their own counsel” but not always deservedly (Sir 37:7-11), esteem most highly the counsel that is most like “consulting the oracle of God” (2Sam 16:23). God bless health ethicists!

Archbishop Anthony Fisher, OP, Ph.D.
Bishop of Sydney
Syndey, Australia

ENDNOTES

  1. Adapted from Daniel Sokol, 'Meeting the ethical needs of doctors: We need clinical ethicists in addition to other measures', British Medical Journal 330(7694) (Apr 2005) 741-2, at p. 742.
  2. Adapted from case reworks one offered in David Fleming, 'Responding to ethical dilemmas in nursing homes: Do we always need an ethicist?' HEC Forum 19(3) (2007) 245-59, at p. 245.
  3. Adapted from Annie Pullen et al., 'The experiences of gender diverse and trans children and youth considering and initiating medical intervention', International Journal of Transgenderism 20(4) (2019) 371-87.
  4. BBC News, 'Doctors make ethical plea', 2 December 2003, http://news.bbc.co.uk/2/hi/health/3253786.stm
  5. 'List of medical drama television programs', Wikipedia https://en.wikipedia.org/wiki/List_of_medical_drama_television_programs.
  6. For example: E. Azoulay and N. Kentish-Barnes, 'A 5-point strategy for improved connection with relatives of critically ill patients with COVID-19', Lancet Respiratory Medicine 8(6) (2020); Ezekiel Emanuel et al., 'Fair allocation of scarce medical resources in the time of Covid-19', New England Journal of Medicine 382(21) 2049-55; T. Farrell et al., 'AGS Position Statement: Resource Allocation Strategies and Age-Related Considerations in the COVID-19 era and beyond', Journal of the American Geriatric Society 68 (2020) 1136-42; T. Farrell & L. Francis, 'Rationing limited healthcare resources in the COVID-19 era and beyond: Ethical considerations regarding older adults', Journal of the American Geriatrics Society 68 (2020) 1143-49; Joanna Hart et al., 'Family-centered care during the COVID-19 era', Journal of Pain and Symptom Management 60(2) (2020); J. Lai et al., 'Factors associated with mental health outcomes among health care workers exposed to coronavirus disease', JAMA Netw Open 2 March 2020; R.C. Maves et al., 'Triage of scarce critical care resources in COVID-19', Chest 11 April 2020; Franklin Miller, “Why I support age-related rationing of ventilators for Covid-19 patients”, Hastings Centre Bioethics Forum, 9 April 2020; Rene Robert et al., 'Ethical dilemmas due to the Covid-19 pandemic', Annals of Intensive Care 10(84) (2020); L. Rosenbaum, 'Facing COVID-19 in Italy – Ethics, logistics, and therapeutics on the epidemic's front line', New England Journal of Medicine 382(20) (2020) 1873-75; R.D. Truog et al., 'The toughest triage: allocating ventilators in a pandemic', New England Journal of Medicine 382 (2020) 1973–5; M. Vergano et al., 'Clinical ethics recommendations for the allocations of intensive care treatments, in exceptional, resource-limited circumstances', Critical Care 24(1) (2020) 165; D.B. White & B. Lo, 'A framework for rationing ventilators and critical care beds during the COVID-19 pandemic', Journal of the American Medical Association 323(18) (2020) 1773-4.
  7. Seren Boyd, “Doctors Wrestle with Ethics of Clinical Decisions,” British Medical Association News, 9 December 2020https://www.bma.org.uk/news-and-opinion/doctors-wrestle-with-ethics-of-clinical-decisions
  8. E.g. Pope Francis, Fratelli Tutti: Encyclical on Fraternity and Social Friendship (2020) 7, 32-6, 54, 168; Meditation in a Time of Pandemic, 27 March 2020; Address to the Banco Farmaceutico Foundation, 19 September 2020; Message to the 75th Meeting of the United Nations General Assembly, 25 September 2020; Message for the 54th World Day of Peace, 1 January 2021; Congregation for the Doctrine of the Faith, Note on the Morality of Some Anti-COVID19 Vaccines (2020); Dicastery for Promoting Integral Human Development, Message in Time of Coronavirus (2020); Dicastery for the Laity, Family and Life, In Loneliness the Coronavirus Kills More, 7 April 2020; Pontifical Academy for Life, Pandemic and Universal Brotherhood (2020) and 'Humana communitas' in the Age of Pandemic (2020); Pontifical Academy for Life and the Dicastery for Integral Human Development, Old Age = Our Future: the Elderly after the Pandemic (2021); Pontifical Academy of Social Sciences, Responding to the Pandemic (2020).
  9. John Glaser et al., 'Reflections on the role of ethicists in the Catholic health ministry', Health Care Ethics USA, Spring 2010, 8-18.
  10. For my thoughts on some of these matters see: A. Fisher, Catholic Bioethics for a New Millennium (CUP, 2012).
  11. For my thoughts on this matter, A. Fisher, 'Freedom of conscience and institutional integrity', in Helen Alvaré (ed.), The Conscience of the Institution (South Bend: St Augustine's Press, 2014), 1-28.
  12. See the National Catholic Bioethics Center's Bioethics Public Policy reports of recent weeks: https://www.ncbcenter.org/bioethics-public-policy-reports.
  13. See Helen Askitopoulou & Antonios Vgontzas, 'The relevance of the Hippocratic Oath', European Spine Journal 27(2) (2018) 1481-90; T.A. Cavanagh, Hippocrates' Oath and Asclepius' Snake: The Birth of the Medical Profession (OUP, 2017); Robin Fox, The Invention of Medicine: From Homer to Hippocrates (Basic Books, 2020); Raphael Hulkower, 'The history of the Hippocratic Oath; Outdated, inauthentic, and yet still relevant', Einstein Journal of Biology and Medicine 25 (2010) 41-44; Leon Kass, Toward a More Natural Science (Simon & Schuster, 2008); Howard Markel, 'I swear by Apollo – On taking the Hippocratic Oath', New England Journal of Medicine 350(20) (2004) 2026-9; Steven Miles, The Hippocratic Oath and the Ethics of Medicine (OUP, 2005).
  14. World Medical Association, Declaration of Geneva – The Modern Hippocratic Oath (1948, as revised 1968, 1983, 1994, 2005 and 2006): https://www.wma.net/what-we-do/medical-ethics/declaration-of-geneva/
  15. Walter Bagehot, The English Constitution (1867), ed. Paul Smith (CUP, 2001), p. 75
  16. American Medical Association, AMA Code of Ethics 2004, as revised 2006 and 2016.
  17. AMA, Ethics Committees in Health Care Institutions: Code of Medical Ethics Opinion 10.7 https://www.ama-assn.org/delivering-care/ethics/ethics-committees-health-care-institutions and Ethics Consultations: Code of Medical Ethics Opinion 10.7.1 https://www.ama-assn.org/delivering-care/ethics/ethics-consultations. See also AMA Journal of Ethics, May 2016, special issue devoted to health care ethics consultation.
  18. E.g. in The Guide to the Perplexed and in the Oath of Maimonides. See Abraham Heschel, Maimonides (Farrar, Straus & Giroux, 1984); Moshe Halbertal, Maimonides: Life and Thought (Princeton University Press, 2015); Corey Miller, In Search of the Good Life: Aristotle, Maimonides and Aquinas (Pickwick, 2019); Fred Rosner, 'The life of Moses Maimonides – a prominent medieval physician', Einstein Q J Biol Med 19(3) (2002), 125-8; Kenneth Seeskin (ed), The Cambridge Companion to Maimonides (Cambridge University Press, 2005).
  19. Ex 18:19; Dt 32:18-20,28-29; 1Kings ch.12; Pss 5:10; 81:12; 107:10-14; Jer ch. 24; Prov 21:30.
  20. Exod 18:19; Num 24:14; 1Kings 1:12; 12:6; 1Chr 26:14; 27:33; 2Chr 20:21; 30:23; Isa 8:10; 19:11; 28:29; Jer 32:19; Ezra 7:28; Ps 33:10; 119:24; Job 3:14; Prov 8:14; Mt 26:4; Lk 7:30; 23:51; Jn 18:14; Acts 2:23; 4:28; 5:38; 13:36; 20:27; 27:12; 42: 1Cor 4:5; Eph 1:11; Heb 6:17
  21. Isa 11:2; 28:29; 40:13-14; Jer 32:19.
  22. e.g. Ps 16:7; 19:20-21; 32:8-11; 33:8-11; 73:24; 106:13; 107:11; 119:24; Prov 1:25,30; 8:14; Wis 8:9; 9:13-17; Sir 24:29; 42:21; Job 12:13; 26:1-4; 38:1-7; 42:1-6.
  23. Isa 9:6.
  24. Mt 7:24; 13:54; Mk 6:2; Lk 2:40,52; Jn 1:1-18; 1Cor 1:18-31; Col 2:3; Rev 5:12.
  25. Mt 12:42.
  26. Jn 14:16,26; 15:26; 16:7; cf. Mt 17:5; Jn. 3:16-17;
  27. Amongst those with regular or at least occasional advisers are Abimelech (Gen 26:26), Pharaoh (e.g. Gen 41:14-45; Ex 6:28; 10:7 etc.; Isa 19:11), Moses (Ex 18:17-19,24), David (2Sam 15:12,31; 16:9-12,23; 1Kings 12:13-14; 1Chr 26:14; 27:32-3), Absalom (2Sam 15:34; 16:15,20-23; 17:4-23), Rehoboam (1Kings 12:6,13; 2Chr 10:6-8,13-14), Jeroboam (1Kings 12:28), Jehoshaphat (2Chr 20:21), Ahaziah (2Chr 22:3-5), Amaziah (2Chr 25:16-17), Hezekiah (2Chr 30:2), Zedekiah (Jer 38:4), Shecaniah (Ezra 10:2), Haman (Esther 5:14; 6:13), Artaxerxes (Ezra 7:14-15,28; 8:25), Ahasuerus (Esther 1:21; 3:13), Nebuchadnezzar (Dan 3:2-3,91-4; 4:27,36; 6:7) and others (e.g. Jud 20:7; 2Kings 6:8; 1Chr 12:19; 26:14; Judith 14:1; Jer 18:18; 49:7). Herod, too, assembled the chief priests and scribes to advise him: Mt 2:3-6.
  28. Job 38:2; 42:3; Prov 1:5; 8:6,10; 11:14; 12:15,20,26; 13:10; 15:22,31-33; 19:20; 20:5,18; 24:6; 27:9; Eccles 4:13; Sir 6:6; 21:13; 37:7; 40:25; 44:3-4; Tob 4:18-19; 1Macc 2:65.
  29. Mt 18:15-17; 23:3; cf. Mt 5:38; 7:7-8; Gal 5:22-23; 6:1-2; 1Cor 15:33; 1Thess 5:21; Col 3:16-17; Jas 1:5; 3:17; cf. 2Tim 3:16-17.
  30. Robert Baker, Before Bioethics: A History of American Medical Ethics from the Colonial Period to the Bioethics Revolution (OUP, 2013); Jeffrey Bishop, The Anticipatory Corpse: Medicine, Power, and the Care of the Dying (University of Notre Dame Press, 2011); John Evans, The History and Future of Bioethics: A Sociological View (OUP, 2014); Nancy Jecker, Bioethics: An Introduction to the History, Methods and Practice (3rd edn, Jones & Bartlett, 2011); Albert Jonsen, A Short History of Medical Ethics (OUP, 2008); Christopher Kaczor, Defense of Dignity: Creating life, Destroying Life, and Protecting the Rights of Conscience (University of Notre Dame Press, 2013); Sana Loue, Case Studies in Society, Religion and Bioethics (Springer, 2020).
  31. On the history of Christian/Catholic bioethics see: Stanley Hauerwas, 'How Christian ethics became medical ethics: the case of Paul Ramsey', Christian Bioethics 1(1) (March 1995) 11-28; Dianne Irving, 'Quid Est Bioethics?'https://www.catholicculture.org/culture/library/view.cfm?recnum=3320; Louise Mitchell, 'A brief history of Catholic bioethics', Ethics & Medics 41(7) (2016) 3-4; Kevin O'Rourke et al, 'A brief history of the development of the Ethical and Religious Directives for Catholic Health Care Services', Health Progress 82(6) (2001), 18-21; Kevin O'Rourke & Philip Boyle, Medical Ethics: Sources of Catholic Teachings (3rd edn, Georgetown University Press ,1999); Edmund Pellegrino & Martin D'Arcy, 'The Catholic physician in an era of secular bioethics', Linacre Quarterly 78(1) (2011) 13-28.

    Key texts include: Benedict Ashley, Jean deBlois and Kevin O'Rourke, Health Care Ethics; A Catholic Theological Analysis (5th edn, Georgetown University Press, 2006); Nicanor Austriaco, Bioemedicine and beatitude: An Introduction to Catholic Bioethics (Catholic University of America press, 2010); W.J. Eijk et al, Manual of Catholic Medical Ethics (Connor Court, 2014); William E. May, Catholic Bioethics and the Gift of Human Life (3rd edn, Our Sunday Visitor, 2013); Edmund Pellegrino and David Thomasma, Helping and Healing: Religious Commitment in Health Care (Georgetown University Press, 1997); Elio Sgreccia, Personalist Bioethics: Foundations and Applications (National Catholic Bioethics Center, 2012); Nicholas Tonti-Filippini, About Bioethics, 5 vols (Connor Court, 2011-17), US Conference of Catholic Bishops and CHA, Ethical and Religious Directives for Catholic Health Care Services (6th edn, 2018)https://www.usccb.org/about/doctrine/ethical-and-religious-directives/upload/ethical-religious-directives-catholic-health-service-sixth-edition-2016-06.pdf.
  32. Pontifical Council for Pastoral Assistance to Health Care Workers, Charter for Health Care Workers (1st edn, 1994; 2nd edn, 2016). The first edition is available athttps://www.vatican.va/roman_curia/pontifical_councils/hlthwork/documents/rc_pc_hlthwork_doc_19950101_charter_en.html. The New Charter for Health Care Workers was translated into English and published in Philadelphia by the National Catholic Bioethics Center in 2017 and is available online athttps://www.scribd.com/document/431501363/The-New-Charter-for-Health-Care-Workers#from_embed. The Council ceased operation in 2017 and its responsibilities were transferred to the new Dicastery for Promoting Integral Human Development.
  33. See Cathleen Kaveny, 'Pope Francis and Catholic healthcare ethics', Theological Studies 80(1) (2019) 186-201.
  34. New Charter §140.
  35. AMA, Ethics Committees in Health Care Institutions: Code of Medical Ethics Opinion 10.7 https://www.ama-assn.org/delivering-care/ethics/ethics-committees-health-care-institutions
  36. Cf. Sokol, 'Meeting the ethical needs of doctors'. AMA, Ethics Consultations: Code of Medical Ethics Opinion 10.7.1 https://www.ama-assn.org/delivering-care/ethics/ethics-consultations notes that “Whether they serve independently or through an institutional ethics committee or similar mechanism, physicians who provide ethics consultation services should… serve as advisors and educators rather than decision makers. Patients, physicians, and other members of the care team, health care administrators, and other stakeholders should not be required to accept the consultant's recommendations. Physicians and other institutional stakeholders should explain their reasoning when they choose not to follow the consultant's recommendations in an individual case.”
  37. D. Self, J Skeel & N. Jecker, 'A comparison of the moral reasoning of physicians and clinical medical ethicists' Academic Medicine 68 (11) (1993) 852-5.
  38. Thus AMA, Ethics Committees in Healthcare Institutions, observes that “To be effective in providing the intended support and guidance in any of these capacities, ethics committees should: (a) Serve as advisors and educators rather than decision makers. Patients, physicians and other health care professionals, health care administrators, and other stakeholders should not be required to accept committee recommendations. Physicians and other institutional stakeholders should explain their reasoning when they choose not to follow the committee's recommendations in an individual case.”
  39. Jonathan Sacks, 'Acceptance speech for Templeton Prize', Templeton Foundation, 26 May, 2016https://www.templetonprize.org/laureate-sub/sacks-acceptance-address/
  40. Caragh Brosnan and Alan Cribb, 'Between the bench, the bedside, and the office: The need to build bridges between working neuroscientists and ethicists', Clinical Ethics 9(4) ((2014) 113-19.
  41. Brosnan and Cribb, 'Between the bench, the bedside, and the office', p. 115.
  42. Thus AMA, Ethics Consultations: Code of Medical Ethics Opinion 10.7.1 notes that “Whether they serve independently or through an institutional ethics committee or similar mechanism, physicians who provide ethics consultation services should… have appropriate expertise or training—for example, familiarity with the relevant professional literature, training in clinical/philosophical ethics, or competence in conflict resolution—and relevant experience to fulfill their role effectively.”
  43. Pontifical Council for Health Workers, New Charter, 140, para 2.
  44. Lev 20:27; Dt 18:10-14; 1Chr 10:13-14; Acts 13:6-12; Rev 21:8; 22:15.
  45. cf. Hauerwas 1985; Meilaender 1995., see
  46. Kass, Toward a More Natural Science; Alasdair MacIntyre, After Virtue: A Study in Moral Theory (3rd ed., University of Notre Dame Press, 2007).
  47. Pontifical Council for Health Workers, New Charter, 1.
  48. Pontifical Council for Health Workers, New Charter, 2-6.
  49. See: John Paul II, Evangelium vitae (1995), 27; Pontifical Council for Health Workers, New Charter, 8; J.A. Di Noia, “The virtues of the Good Samaritan: Health care ethics in the perspective of a renewed moral theology”, Dolentium Hominum 31 (1996), 211-14.
  50. New Charter, 9. See also Congregation for the Doctrine of the Faith, Samaritanus Bonus: On the Care of Persons in the Critical and Terminal Phases of Life (2020).
  51. Alan Astrow, Is medicine a spiritual vocation?' Society, 50(2) (2013), 101-105; Philip Bochanski, 'Professing faith, professing medicine: Physicians and the call to evangelize', Linacre Quarterly, 81(1) (2014), 1-11; R.A. González, 'The vocation to serve: Cornerstone of healthcare', MEDICC Review, 14(2) (2012); Germain Grisez, 'Healthcare as part of a Christian's vocation', in Luke Gormally (ed.), Issues for a Catholic Bioethic (London: Linacre Centre, 1999), 151-58; S. Hinohara, 'Medicine and religion: the spiritual dimension of health care', Humane Health Care 1(2) (2001), E2; Margaret Mohrmann, Medicine as Ministry: Reflections on Suffering, Ethics and Hope (Cleveland: Pilgrim Press, 1995); Daniel Sulmasy, The Healer's Calling: A Spirituality for Physicians and Other Healthcare Professionals (New York: St Paul, 1997) and A Balm for Gilead: Meditations on Spirituality and the Healing Arts (Georgetown University Press, 2006); etc..
  52. Glaser, 'Reflections on the role of ethicists', p. 20.
  53. Ron Hamel, 'Strengthening the role of ethics in turbulent times', Health Progress May-June 2010, 60-61, at p. 60.
  54. See the several articles collected together in CHA, The Ethics Role in Catholic Health Care https://www.chausa.org/docs/default-source/general-files/cha_ethicsrole-pdf.pdf?sfvrsn=2.

Reflection Questions

  1. If you are an ethicist, how do you see your part in the ministry as a peacekeeper?
  2. Everyone has a vocation, a calling. Where have you seen yourself called this past year?
  3. The Archbishop sees ethics as a part of Catholic identity. How do you see our moral teaching shaping the way we provide care in today's world?
Categories:
  • HCEUSA
Authors:
  • Archbishop Anthony Fisher, OP, Ph.D.

Issues