BY: SR. NUALA P. KENNY, OC, MD, FRCP
As a Sister of Charity of Halifax and a physician, I have found the gospel of Jesus' healing and reconciling ministry to be crucial in my life and in my ministry. It has been a source of inspiration, direction and consolation in many of the demanding and difficult situations that all who work in health care face. However, these days the Old Testament prophets, particularly Jeremiah and his lamentations, better match my mood and experience. In the mysterious path of vocation, I have become a highly visible Roman Catholic in the very public world of medical education and health care ethics in Canada. After completing 34 years as a professor of pediatric medicine and physician-bioethicist, I felt drawn to more formal faith-based ethical reflection and now serve as ethics and health policy adviser to the Catholic Health Alliance of Canada.
I felt a compelling need to make this shift, in part because the public bioethics enterprise, with its focus on the principles of respect for autonomy, beneficence, non-maleficence and justice, had become increasingly limited for me in answering the deep ethical and spiritual issues inherent in health care. I also felt a personal need to root my ethical reflections and analysis more intentionally and more rigorously in Scripture and in spirituality. I came to appreciate how shockingly few resources are available to support faith-based ethics in Canada, even as the need for this kind of reflection and analysis grows and the issues become increasingly complex.
I thought I could assist in this ministry, reflecting more deeply on the ethical and moral issues in health care from my comfortable home within the family of the faith. It is no easy matter today to work in public health care and bioethics as an identifiable Roman Catholic, and I eagerly anticipated doing faith-based ethics within a shared spiritual and theological tradition.
But, a year into this move I easily identify with the woeful Jeremiah, asking myself, "What have I gotten into?" Previously, although I was engaged as a Catholic in health care ethics in medical education and health policy in Canada, I was not doing "Catholic ethics" nor was I ever employed by a Catholic institution. However, I was aware of the issues and controversies in moral theology and health ethics. I know now that my awareness was quite limited. As I formally studied to update my moral theology and Catholic bioethics, participated in the revision of the Canadian Health Ethics Guide, assisted in advocacy against a Canadian federal bill proposing legalization of assisted death and followed closely the health reform debate in the United States, I learned just how fractured and fractious Catholic bioethics has become. Indeed, it was a revelation of sorts to see that this family of the faith seems to be a dysfunctional one when it comes to witnessing to the gospel of healing and reconciliation in modern health care.
So, I find myself identifying more and more with Jeremiah and his lamentations. Not to over-dramatize, but I have groaned like Jeremiah over some of what I have read and heard. I have felt my heart turning over at dissension and division within the church. My gut has certainly shuddered in response to angry, painful situations. And in keeping with the plaintive and questioning element of the genre of lament, I have silently and publicly asked,"Why have we come to this?" and "How can we retrieve our Gospel vision and restore our intellectual tradition of nuanced moral reasoning?"
"Make us come back to you, Yahweh, and we will come back." (Lamentations 5:21)
THE MISERIES OF THE PEOPLE
"Oh how lonely she sits, the city once thronged with people, as if suddenly widowed" (Lamentations 1:1)
Jeremiah's lament over the destruction of the temple and the people's loss of faith seems to mirror the state of the church's voice in the moral arena of our time. I am in anguish over the marginalization of this voice when our world needs the good news of healing and reconciliation more than ever before. As a believing physician, I have groaned at the failure to understand that a health care encounter is a place of moral meaning, a teachable moment, a time for evangelization and re-evangelization. Questions of fundamental meaning about life, death, suffering, dignity, dependence, fidelity, care and justice are inherent in health care decisions, whether for oneself or for one's loved ones. Even the most non-reflective, non-religious persons cannot avoid these fundamental questions as they respond to the birth of a baby with a life-threatening condition, hear the diagnosis of cancer, rush to the emergency room where a teenager lies unconscious, care for a parent with dementia or accompany a dying spouse. Whether a health care encounter results in physical cure or improvement or not, it is an opportunity to experience the healing and reconciling ministry of Jesus Himself.
"People respected the priests no longer, they paid no attention to the prophets." (Lamentations 4:16)
The broader and deeper understanding of ethical concerns as they are experienced by patients, families and caregivers across the full continuum of health need seems to have been lost. In morality in general, and in health care ethics, in particular, Catholics appear to be obsessed by sexual and reproductive morality. This is ironic if not tragic, given that issues such as priestly sexual abuse and the ongoing failure of appropriate and adequate hierarchical response have profoundly weakened the church's influence in general, and in the area of sexual morality specifically. It is all the more of concern when the issue of birth control has fractured the faith community for more than 40 years and many, if not most, of the practicing faithful judge the church's teaching on contraception to be irrelevant. As a consequence, there is neglect of conscience formation in this area of reproductive sexuality and failure to attend to the full scope of the gospel of life and its demands. Despite its prominence and importance, Catholics are not effectively dealing with educating the faithful on the separate and distinct issue of abortion. Further, as the recent American health reform debates demonstrated all too vividly, Catholics hold widely divergent understandings of the appropriate strategies to respond to the issue of abortion in our pluralist world.
I weep at the confusion of Catholics today regarding end-of-life care and the loss of the long and proud tradition of a "good death." The public perception today is that Catholics are vitalists who favor prolonging biological life at all and any costs. The meaning of being a resurrection people is lost to the faithful and to society.
I am "sick at heart" (Lamentations 5:17) over the dissension and divisions within our own church on ecclesiology, theology and moral issues in health care. This dissension is even at the highest levels. When members of the Pontifical Academy for Life can't agree and accuse the president of that academy of failing to show "absolute respect for life," we are in serious trouble. No bishop or theologian is safe from criticism for not being "pro-life" enough. Indeed, some bishops appear to live in fear of these allegations. This dissension and judgment is rampant in websites and blogs that are "holier than the church," even as they are often written by people who appear to be ignorant of the moral and intellectual tradition of the church. We Catholics seem to lack respectful ways of dealing with differences and loyal dissent. When we disagree, we move rapidly to ad hominem arguments in which disagreement brings negative judgments of character, of sinfulness, disloyalty and condemnation.
Recognizing the long and proud intellectual tradition of Catholic moral theology, why does Catholic bioethics today appears to be an act-centered, rule-based deductive process focused on a narrow range of "life" issues rather than on a faith-filled search and formation of the heart and mind? Morality is focused primarily on rules rather than on the moral development of the persons we are and are becoming. The formation of Christian/Catholic conscience is overlooked or ignored. The catechetical and pedagogic response appears to be louder and more specifically focused on magisterial edicts, insensitive to and distant from the actual experience of uncertainty, fear, pain and suffering, and in contradiction to all we know of adult learning and faith formation. Why is this? How can it be that Catholic moral theology evokes a vision of negatives and harsh judgments rather than the compassionate, open, merciful responses of Christ himself?
The pastoral challenge is to be faithful to fundamental beliefs and principles while applying them with "the mind of Christ" to particular cases so that the encounter results in healing and compassion. This does not mean there are no hard truths. It does mean that the pastoral challenge is fulfilled; the full message experienced as truly good news only when the encounter is an experience of the just and merciful God.
THE SINS OF THE PEOPLE AND ACTS OF GOD
"Even their prophets receive no further vision from Yahweh" (Lamentations 2:9)
Jeremiah recognizes that the "miseries" experienced by the people are a result of both the sins of the people and acts of God. The prophet's role is to lay open the sins and connect them to the afflictions. Certainly, much of the anguish of those who work in health care is connected to the sins of modern health care. These sins, which are many, include rampant individualism and unlimited demand for individual benefit, inordinate dependence upon and belief in technology, even extending to technologic answers to social and spiritual issues (e.g. birth control to remedy poverty, the medicalization of all sadness as treatable depression, demands for unlimited access to technology to avoid death, assisted death to avoid suffering.) These sins also include a lost understanding of the common good and a failure of commitment to solidarity in response to health needs locally and globally. Other sins are the result of our limited focus on the moral and ethical issues in health care, our profound differences in moral methodology and — perhaps the most pervasive — a disconnect between moral principles and their pastoral application.
North American Catholics appear to be no different from nonbelievers in their demands for unlimited potential benefit for themselves and their loved ones and in their belief in technology and in technologic answers to spiritual and social issues. From the vanity of cosmetic medicine and surgery to the selfish refusal to accept the limits of medicine and the inevitability of death, we do not stand out as counter-cultural. We are failing to be a resurrection people, in contrast to death-denying, death-defying society around us. Our use of health technology, even when all "reasonable hope of benefit" is lost, is no different from that of nonbelievers. This is far from the notion of "prudent care" for our body and health, "taking into account the common good," as our catechism calls us to do. At a deeper level, it is contradictory to the teaching that "life is not an absolute good" but a penultimate one. Moreover, our relationship to technology is inconsistent. We reject technology for birth control and infertility treatments but are enthusiastic about intensive care, ventilators, organ transplantation and medically assisted nutrition at the end of life. This is inconsistent with Cardinal Joseph Bernardin's challenge to develop a "consistent ethic of life." It is inconsistent with the full understanding of the gospel of life as well.
While North Americans spend more and more money and human resources on individual health benefits for some, basic care is unavailable across the globe. When the average daily cost of a single hospitalization in North America for non-emergency care is more than the average annual per capita total health expenditure in many of the undeveloped nations of the world, something is seriously amiss. We have lost in health care the stellar social justice tradition of our church. We fail to understand the notion of the common good and fail to demonstrate real commitment to solidarity, whether locally or globally. The contentious health care debate in the United States and the creeping privatization of the Canadian universal, publicly (tax)-funded system bear witness to the weakness of Catholic notions of solidarity and the common good.
Some of the miseries arise from within the church itself. Why have we narrowed our understanding of moral issues, failed to focus on adult faith formation and restricted the sources of moral wisdom we use to discern the faith-filled response to the complex issues of modern health care? We have lost sight of the fundamental reality that morality is about the kind of people we are becoming. It is about virtue and character and not primarily about rules and regulations. We have become concerned about protection of conscience for health care workers without adequate attention to the formation of that conscience.
"Joy has vanished from our hearts; our dancing has been turned to mourning" (Lamentations 5:15)
Clearly, our ecclesiology, our understanding of the church, is crucial to our moral understandings and moral methodology. From the humble church of Vatican II searching for moral truth with a central role for the laity (the sensus fidelium) and a focus on collegiality to the present retrenchment church of self-confident possession of moral truth, dominated by a limited understanding of magisterium and a hierarchical governance model that rejects collegiality and subsidiarity, we see a concomitant reshaping of moral theology. Yet, humility in the face of the human frailty of sickness and death seems indispensable.
We see profound and divisive differences in moral methodology within our church. We see moral theology's "intrinsically evil" versus "proportionate reasoning" approaches as almost armed camps. And, while something important is being taught in the natural law tradition regarding creation, and finding within it reflections of the Creator's intent, some versions of natural law no longer seem to fit. It is difficult to find moral norms in nature in a world where very little is natural any more, especially in health science and technology. Moreover, the "new natural law" has developed independent of divine revelation or Scripture. It is dependent on the authority of reason alone. This seems to ignore the corruption of reason through original sin, our need for healing and reconciliation and our dependence on a merciful God.
More importantly, for ordinary Catholics, the values inherent in Christian responses to the ethical and moral issues in health care are found in the gospel messages about Christ, the divine physician, and his ministry to the sick, and in the lives of believing persons (the sensus fidelium). While we have always had a history of different theological approaches to moral reasoning, the differences today, in the context of a retrenchment ecclesiology, provide little help and much confusion for those who strive in the trenches of health care to continue the healing and reconciling ministry of Jesus Christ. Indeed, Catholic health care ethics is a high-risk profession!
HOPE IN YAHWEH
"Brooding on my anguish and affliction is gall and wormwood. My spirit ponders it continually and sinks within me. This is what I will tell my heart, and so recover hope; the favors of Yahweh are not all past, his kindnesses are not exhausted; every morning they are renewed; great is his faithfulness. 'My portion is Yahweh' says my soul, 'and so I will hope in him'." (Lamentations 3:19-24)
It is the nature of lament that it does not lead to clear, logical, practical solutions. There is a kind of emotional release that comes from groaning and weeping, but groaning takes a lot of energy. The danger is allowing it to deplete us. Jeremiah finds his way to a kind of consolation in his hope and trust in Yahweh. I, too, tell my heart that "the favors of Yahweh are not all past."
The health care encounter is a place of moral meaning and so, presents an enormous opportunity for evangelization and re-evangelization. My own hope is that we can find a new way forward, focus on formation of conscience and develop that conscience with attention to all of the pillars of moral wisdom: Scripture, tradition, especially magisterial teaching, experience and reason. Healing and reconciliation come from a lived experience of the ongoing ministry of Christ himself in ever more complex situations of human pain and suffering. There is only one way forward:
"Let us examine our path, let us ponder it and return to Yahweh." (Lamentations 3:40)
SR. NUALA P. KENNY, OC, is emeritus professor of bioethics, Dalhousie University, Halifax, Nova Scotia, and ethics and health policy adviser at the Catholic Health Alliance of Canada.
GUIDED REFLECTIONS
Editor's note: Sr. Nuala Kenny's article raises critical concerns related to the intersection of Catholic bioethics and the Catholic health care ministry. In order to encourage individuals and groups within the ministry to reflect more deeply on these issues and discuss their implications, we offer the following starting points:
- Sr. Kenny asserts that Catholic bioethics is cut off from its spiritual and theological tradition and therefore unable to adequately address the deep ethical and spiritual issues inherent in the health care ministry. Do you agree? Disagree? In what ways have you or others you know experienced the disunity Sr. Kenny describes?
- Describe a health care encounter in which you participated that might be described as an "opportunity to experience the healing and reconciling ministry of Jesus himself," whether or not it resulted in physical cure or improvement.
- What are some of the imbalances Sr. Kenny describes that interfere with a deeper understanding of ethical concerns as they affect patients, families and caregivers across the continuum of health care?
- Do you agree with Sr. Kenny's assessment of "the sins of modern health care?" Is there anything you would add to her list?
- What does it mean to say Catholic bioethics as practiced today is "insufficiently nuanced" and lacks gospel vision? In what ways have you personally experienced a "disconnect between moral principles and their pastoral application"?
- What does it mean to say that the work of Catholic health care does not stand out as counter-cultural, that "we are failing to be a resurrection people," and that we have "become concerned about protection of conscience for health care workers without adequate attention to the formation of that conscience." Do you agree with Sr. Kenny's assertions? Why or why not?
- How does Sr. Kenny link different understandings of ecclesiology to Catholic bioethics and its application to health care?
- What does it mean to say that "moral theology's 'intrinsically evil' versus 'proportionate reasoning' approaches [are] almost armed camps"?
- Do you think the "natural law" tradition in Catholic moral theology is well understood? What problems does Sr. Kenny see with the relationship between natural law and Catholic health care today?
- Sr. Kenny ends on a note of hope. What strategies would you propose to address the problems she describes and "find a new way forward"?
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