Ethics - Issues Beyond 'The Usual Suspects'

March-April 2011

BY: FR. THOMAS NAIRN OFM, Ph.D.

What will the future of Catholic health care ethics look like? As we gaze into our crystal ball, one of our colleagues in the field of bioethics might be of help. In 2009, Howard Brody, director of the Institute for Medical Humanities at the University of Texas, Galveston, wrote The Future of Bioethics. In that book he listed the number of pages the Oxford Handbook of Bioethics (Oxford University Press, 2007, ed. by Bonnie Steinbock) devoted to a variety of bioethical issues.1 Prominent were what he called the "usual suspects": 107 pages devoted to end-of-life issues, 97 pages to genetics, 52 pages to cloning and stem cell research, the same number to research ethics, 29 pages to organ transplantation.

He noted that the handbook had serious omissions. For example, it lacked citations for evidence-based medicine, cross-cultural issues, patient-centered care, race and religion. Brody's book challenged bioethicists to move beyond the normal clinical issues, the "usual suspects." As an alternative, he discussed 10 issues he believes will become prominent in the future:

  • Acceptance of the interdisciplinary nature of the field
  • Patient-centered care
  • Evidence-based medicine
  • Community dialogue
  • Bioethics and power
  • Cross-cultural concerns
  • Race and health disparities
  • Disability
  • Environmental and global issues
  • The rise of new technologies

Brody's observations of the present state and his description of an alternative future both apply to Catholic health care ethics. Catholic ethicists are fond of the same list of "usual suspects." Whenever CHA asks its constituent ethicists for suggestions regarding webinars or other programs, most want programs dealing with end-of-life care, the Ethical and Religious Directives for Catholic Health Care Services, research ethics and institutional review boards, organizational ethics and ethical discernment/decision models for health care institutions.

The similarities made me wonder what Catholic health care ethics would look like if we applied Brody's analysis to our own discussion of the future. I chose four of his areas: patient-centered care, community dialogue, disabilities and environmental and global issues to begin this inquiry.

PATIENT-CENTERED CARE
Writing before the passage of the Patient Protection and Affordable Care Act, Brody explained that the design of health care in the future, especially the development of the personal medical home, will demand truly patient-centered care.2 Part of this future will involve technological changes such as computerized medical records and evidence-based medicine.

Improved technology, however, is only part of the story. Patient-centered care will also demand that physicians and hospitals expand services, expand hours of service and re-design facilities, Brody said. Both the conduct of medical personnel and the "feel" of the patient's experience of medicine must change.3 Building on the understanding of a medical home, he suggested the term "home" responds to the "basic human need to be welcomed"4 and stressed the importance of hospitality as part of the patient-centered care model. He also explained that the role of the bioethicist in this area would be to ensure that patients are welcomed without the distractions that often accompany their encounters with medicine. He challenged bioethicists to see the ethical difference between a case being presented from the point of view of a patient and one presented from that of the physician.

Those of us in Catholic health care ethics will recognize that the Directives echo Brody's challenge.5 They explain that the relationship between the health care provider and patient should be based on "mutual respect, trust and honesty."6 Directive No. 2 maintains that "Catholic health care should be marked by a spirit of mutual respect among caregivers that disposes them to deal with those it serves and their families with the compassion of Christ, sensitive to their vulnerability at a time of special need." Although we ethicists truly believe what the Directives state, our analyses of bioethical issues tend to remain from the point of view of the health care professional rather than the patient. It will be interesting to see how Brody's challenge might shape the contours of Catholic health care ethics in the future.

COMMUNITY DIALOGUE
Brody spoke of the need for bioethics both to stimulate well-informed conversations where many voices are heard and to create forums where differing points of view can enter into respectful dialogue.7 In discussing the sort of dialogue that he envisions, he suggested that bioethicists ought to seek out community voices that are usually not part of bioethical discussions and might be discordant. He said, "We can learn things that way that we would never find out in dozens of hospital consultations,"8 keeping bioethics humble and connected.9

Brody's discussion of community dialogue fits with the Catholic social tradition's emphasis on the value of participation. According to our tradition, it is both a right and a duty, stemming from the person's responsibility to contribute to the common good according to his or her capacities.10

If in the future Catholic health care ethics emphasizes such participation and seeks out as many voices as possible, it will perhaps become more raucous but may also become more faithful to the social tradition of the church.

DISABILITIES
One particular dimension of this community dialogue involves persons with disabilities. Brody said the relationship between bioethics and the disabilities community has been "severely strained"11 in recent years due especially to statements by bioethicists — particularly discussing end-of-life choices and allocation of resources — which those in disabilities community see as discriminatory. Brody acknowledged that barriers to those who have impairments are often the outcomes of a community's social choices and actions. He suggested that for a person with disabilities, quality of life depends more on the extent to which society is willing to make accommodations than on the severity of the impairment itself.12 He uses the notion of dignity to suggest that a just society will seek to provide each person the opportunity to achieve reasonable use of his or her capabilities.13

Similarly, the Catholic Church in the U.S. has spoken out extensively regarding the issue of disability. As early as 1978, the U.S. bishops stated that the "defense of the right to life ... implies the defense of other rights which enable the individual with a disability to achieve the fullest measure of personal development of which he or she is capable."14 The bishops pledged to work for greater inclusion of persons with disabilities in parish life, diocesan life and to make ministry with persons with disabilities a special focus of the National Conference of Catholic Bishops (now, the United States Conference of Catholic Bishops). The bishops stated that their "concern for individuals with disabilities ... goes beyond their spiritual welfare to encompass their total well-being." If in the future Catholic health care ethics incorporates more fully the perspective of persons with disabilities into its purview, it may help build better bridges between pro-life advocates and social justice advocates within the church.

ENVIRONMENTAL AND GLOBAL ISSUES
Brody's challenge to "expand the network of affiliations and the network of well-being that is necessary for optimal human flourishing" brings together environmental and global issues.15 Looking to the environment, Brody spoke of a conscious decision early in the history of bioethics to exclude ecological issues. Emphasizing the problematic consequences of this decision, especially in the area of public health where the environment cannot be separated from human health, he stressed the need for an ecological bioethics that helps "care for a fragile and increasingly ailing planet."16 Turning to global issues, he said, "We are by nature beings that seek a common good and wish to live a life of sociability, in keeping with our native intelligence."17

Environmental and global issues increasingly have become part of Catholic health care ministry. Pope Benedict XVI recently stated, "There exists a certain reciprocity: as we care for creation, we realize that God, through creation, cares for us."18 Following the pope's example, many Catholic health care systems in this country have led the way in their communities regarding care for creation. Similarly, many Catholic health care systems acknowledge that their responsibilities go beyond national borders, and they accept the challenge of the U.S. bishops issued 25 years ago regarding expanding the "understanding of the moral responsibility of citizens to serve the common good to the entire planet."19 If in the future Catholic health care ethics moves beyond its comfort zone in clinical matters and pays more attention both to the environment and to global issues, it will likely become more robust than it is today.

Brody challenges bioethics to move from traditional clinical ethics to social morality. His incorporation of notions such as personal dignity, human flourishing and the common good could be taken directly from the Catholic social tradition. If the future does involve such a movement, then our Catholic social tradition will become more central to the understanding of health care ethics than it is today.

FR. THOMAS NAIRN OFM, Ph.D., is senior director of ethics, Catholic Health Association, St. Louis. Write to him at tnairn@chausa.org.

NOTES

  1. Howard Brody, The Future of Bioethics (New York: Oxford University Press, 2009), 7.
  2. Brody, 55.
  3. Brody, 56.
  4. Brody, 59.
  5. United States Conference of Catholic Bishops, Ethical and Religious Directives for Catholic Health Care Services, Fifth Edition (Washington, DC: USCCB Publications, 2009).
  6. Introduction to Part Three of the Directives, "The Professional-Patient Relationship."
  7. Brody, 90.
  8. Brody, 102.
  9. Brody, 99.
  10. Pope John XXIII, Pacem in Terris (April 11, 1963), par. 48.
  11. Brody, 158.
  12. Brody, 162.
  13. Brody, 164.
  14. USCCB, Pastoral Statement of the U.S. Catholic Bishops on Persons with Disabilities (Washington DC: USCCB Publications, 2001).
  15. Brody, 177.
  16. Brody, 180. Brody is quoting from J.D. Moreno, "In the Wake of Katrina: Has 'Bioethics' Failed?" The American Journal of Bioethics 5, 5 (2005), W18-W19.
  17. Brody, 186.
  18. Pope Benedict XVI, Message for the Celebration of the World Day of Peace (Jan. 1, 2010), par. 13.
  19. National Conference of Catholic Bishops, Economic Justice for All (Washington DC: United States Catholic Conference, Nov. 13, 1986), par. 322.

 

Copyright © 2011 by the Catholic Health Association of the United States
For reprint permission, contact Betty Crosby or call (314) 253-3477.