Typically Roman Catholic view of reproductive technologies is negative. In condemning cloning, the Roman Catholic Church stressed that every human has “the right to be born in a human way” and Pope John Paul II called for an unconditional worldwide ban on the use of cloning. As mentioned earlier, GIFT is one example of a compromise that has been made between Catholicism and technology. However, in examining an issue such as cloning, there are two traditional issues of importance. First, the Church tends to begin any argument by looking at God’s role, if any, in the process and how science changes His role. Secondly, the question of what it means to be human is central in this theological debate.
In the Instruction on Respect for Human Life in Its Origin and on the Dignity of Procreation, theologians agreed that although “science and technology are valuable resources for man when placed at his service and when they promote his integral development for the benefit of all. . . they cannot of themselves show the meaning of existence and of human progress.” Further, it was stated that “science without conscious can only lead to man’s ruin.” As laid out in Christian teachings, God is the originator of all life as we know it. Man is merely His steward and carries out His will. There is a certain “sanctity and inviolability under God of every human life which He has created.” However, man is endowed with free will and they are charged to look to God for guidance in all they undertake.
The Roman Catholic Church has deemed that the creation of a new life is only acceptable in one setting: through sexual intercourse between a man and woman who are married. Within this union, it is the “interpersonal love which serves as the human channel for the divine creative life-giving process.” Human life is considered to be unique and inviolable “from the moment of conception until death.” At the moment of conception, God endows each person with a soul and it is the union of the body and soul that make man special. As laid out at the Second Vatican Council: “Each human person, in his absolutely unique singularity, is constituted not only by his spirit, but by his body as well. Thus, in the body and through the body, one touches the person himself in his concrete reality. To respect the dignity of man consequently amounts to safeguarding this identity of man ‘corpore et animan unus.’”
In another example, the Roman Catholic Church sees the creation of clones as objectifying human beings. At the Senate Hearing on Ethics and Theology held June 17, 1997, one Catholic theologian expressed his concern that “a human is not a product, commodity, or something manufactured and subject to quality control.” Reproductive biotechnologies such as IVF and cloning subject the life of a yet unborn individual to the control of someone in a lab. The fear that any child born as a clone of another will not be endowed with a soul adds uncertainty and makes many question whether God is the one who is really controlling the act.
The U.S. Political Response to Dolly
When Dolly’s birth was announced in February of last year, there was what seemed to be decisive action on the part of President Clinton. He assembled a group of scientists, theologians and other experts to form the National Bioethics Advisory Commission (NBAC) to examine the ethics of cloning. Clinton allotted ninety days for the a NBAC to “undertake a thorough review of the legal and ethical issues associated with the use of this technology, and report back to [him]. . . with recommendations on possible federal actions to prevent its abuse.” The commission called for federal legislation that would prevent anyone from cloning humans. However, some feel that NBAC failed to take a true moral stance against cloning. Rather than call for a complete ban on cloning, the commission suggested that cloning be postponed until the technology becomes feasible. This seems to suggest that there is no one overarching view of cloning that can be applied to the United States as a whole. Simultaneously with the creation of the NBAC, Clinton called for an immediate memoratorium on any federal funding used in further research of cloning. The government seems to want to say that cloning is wrong, but they are unable to find a common ground for their accusations.
As of December 1998, no definitive federal legislation has passed regarding cloning.
Conclusion
There are conflicting ways to view cloning from the perspectives of religion, philosophy, and law, but the issue of cloning will most likely remain a much debated topic in the years to come. It is difficult, even on a personal level, to come to grips with what the idea of cloning, and in what many call the postmodern era, it is rare that one universal truth can be found. As such, it is the responsibility of the individual to seriously consider the options she is faced with as the cloning of humans becomes a very real prospect.
There are several reasons why it is so difficult to come to a consensus on cloning. First, it is difficult to divorce the idea of cloning other mammals from that of cloning humans. Human cloning is at a standstill for the present, at least in terms of government support. While someone somewhere may be devoting their research to human cloning, most of the work currently being done seems to be with those who are testing on animals. Advocates of cloning animals use arguments such as increased output from individual animals or the possibility of engineering animals that can produce much needed drugs in their milk. These scenarios might have positive results, but that that kind of analysis cannot be done with the small amount of information that we have in our grasps today. The problem that this presents is that as cloning techniques become more refined and easier to use, the temptation to clone humans will increase.
The problem we then face is whether or not we allow science to move from cloning animals to cloning humans. The benefits may not be as great, but if there is even one couple who longs for a child genetically identical to themselves, there will be someone who will be willing to try the procedure. Much of the literature that has been published on the subject of reproductive biotechnologies addresses the question: Just because it can be done, should it be done? There does not seem to be a clear-cut answer. In terms of benefits to humans, clones could provide children for those who cannot have one of their own, or assistance as donors for a genetic twin who has a life threatening disease. On the negative side, the social consequences and effects on the cloned child cannot yet be imagined. It is unclear whether or not this “uniqueness” will be a burden too large for any child to carry. There is also the possibility that the gene pool will become smaller as more of the same genetic person are born, thus decreasing natural variety.
A second reason for the lack of agreement on cloning can be attributed to fear of the unknown. Currently, we have no real idea what the results of cloning could be for humans. There are those who are willing to let science continue its search for knowledge and mastery over mankind. There are others, often those sharing religious views, who maintain that cloning is man “playing God,” and still others are inclined to feelings or revulsion or disgust at the mention of cloning. Following in the path of other reproductive biotechnologies, it is likely that more people would begin to see cloning as just another acceptable biotechnology, if it were proven to be completely safe. However, until the research is done this cannot be shown.
The consequences of cloning in general are impossible to foresee. However, most scholars and politicians remain tied to the idea that cloning is not simply a question of science, but rather one of ethics and religion. It is interesting to note is important to notice just how seriously we in the United States consider the role of organized religions to be. The inclusion of religious scholars of different faiths in the assembly of the NBAC is a step in the direction of true discourse and the consideration of the feelings of mankind.
It is responsible for individuals to be hesitant in the struggle to come to grips with what cloning means for all people. It seems to be the tendency of man to see science as an entity with a persona of its own, a body that attempts to leave no fact unknown and no technical possibility unexplored. While there may never be a real consensus on whether human cloning is right or wrong, it is important for man to think before he acts. If this does not happen, we may realize too late that this is a technology that produces more bad than good. Once it is agreed that human cloning is permissible, there will be no turning back. Perhaps the fear and sense of revulsion that cloning inspires in many people will allow us to keep science in check
6. What Judgment Should Be Made on Other Procedures of Manipulating Embryos Connected with the "Techniques of Human Reproduction"?
Techniques of fertilization in vitro can open the way to other forms of biological and genetic manipulation of human embryos, such as attempts or plans for fertilization between human and animal gametes and the gestation of human embryos in the uterus of animals, or the hypothesis or project of constructing artificial uteruses for the human embryos. These procedures are contrary to the human dignity proper to the embryo, and at the same time they are contrary to the right of every person to be conceived and to be born within marriage and from marriage. Also, attempts or hypotheses for obtaining a human being without any connection with sexuality through “twin fission,” cloning or parthenogenesis are to be considered contrary to the moral law, since they are in opposition to the dignity both of human procreation and of the conjugal union.
The freezing of embryos, even when carried out in order to preserve the life of an embryo — cryopreservation — constitutes an offense against the respect due to human beings by exposing them to grave risks of death or harm to their physical integrity and depriving them, at least temporarily, of maternal shelter and gestation, thus placing them in a situation in which further offenses and manipulation are possible.
Certain attempts to influence chromosomic or genetic inheritance are not therapeutic but are aimed at producing human beings selected according to sex or other predetermined qualities. These manipulations are contrary to the personal dignity of the human beings and his or her integrity and identity. Therefore in no way can they be justified on the grounds of possible beneficial consequences for future humanity. Every person must be respected for himself: in this consists the dignity and the right of every human being from his or her beginning.
THE FORMULATION OF THE CHURCH'S STAND
Throughout its history, the Orthodox Church has dealt with controversial issues by a process which addresses the "mind of the Church." When an issue arises for which there is no clear-cut, widely and readily acknowledged tradition, and about which there is honest divergence of opinion as to what view genuinely expresses the teaching of the Church, a process begins which may eventually lead to the formulation of an official Church teaching. A classical example from the early period of the Church is the formulation of the Church doctrines about the person of Jesus Christ, which began with the First Ecumenical Council in Nicaea (325) and concluded with the Seventh Ecumenical Council (787).
Over this four hundred and sixty-three year period, the Church clarified its understanding and teaching of the revelation regarding Jesus Christ. At the center of this process stood the Ecumenical Councils, which constituted the final and most authoritative agent for the formulation of doctrine, pending the acceptance of their decrees by the entire Church. For the Orthodox Church, this meant that such issues could not, and should not, be solved by appeal to a single bishop or leader, no matter how honored and respected he might be. It meant, rather, that the Church set its mind to resolving the issue through a corporate approach which drew on the whole tradition of the records of God's revelation.
In practice this meant reference to the Bible and to the living Tradition of the Church by persons seeking to comprehend how the tradition spoke to the new questions being raised. Questions were never raised just for intellectual curiosity nor for the sake of systematic organization. They nearly always were raised because in one way or another their outcome would bear on our salvation and the truths of the Faith. A response would be made whenever a new teaching seemed to be at variance with tradition in one way or another, and consequently not in harmony with the received tradition of revelation, even though the response might have to deal with yet undefined topics. Thus, the great Fathers of the Church, such as Athanasios, Basil, the Gregorys and Chrysostom, not only criticized the false teachings of heresiarchs such as Arius, but proposed formulations of the truth as well. These became the subject of study, debate, and finally, the decisions of Councils on every level - local, regional, provincial and ecumenical, all guided by the Holy Spirit.
THE PRESENT STAND OF THE CHURCH
Many controversial issues presented to us during these days of rapid change have reached the earliest stages in the process of dealing with controversial issues. People are beginning the search for answers - either with respect to attacks on the faith and practices of the Orthodox Church, or to new and previously unimagined problems - that can be formulated so as to preserve our salvation in Christ and to reflect the truths of the Faith. Often, since new issues arising from the rapid development of technology affect not only individual church members, but society as a whole, the attempt to answer the question for and within the Church also provides a basis for addressing these same questions on the public scene.
In some cases the controversial issues can be addressed from long-standing doctrinal, ethical and canonical traditions. Where this is the case, there is little or no debate in the Church. One example is the Church's position on the legalization of abortion on demand. Since the Church went through the same debate in the early fourth century, it is not difficult to determine "the mind of the Church" on this issue, and to apply it to the current discussion.
COMPLICATIONS FROM TECHNOLOGY
The process, however, is not so easy in reference to the many issues which deal with the concerns arising from the amazing development of medical technology. How, for example, would the tradition of revelation address the issue of artificial insemination? The first question it would ask is if there are any implications in it from the perspective of salvation and the truths of Faith. In this case, since it clearly impinges on marriage, family, the relation between spouses, and the lives of human beings, there is an obvious connection. In order to understand that connection, it is necessary to examine the whole tradition of revelation in the sources of the Church's teaching in order to clarify the impact of the new technologies. Then, solutions seeking to embody that tradition are offered to the "mind of the Church."
If the membership of the Church finds them in harmony with the tradition, and if they are not widely challenged, the formulation may remain at that level, and become part of the teaching ministry of the Church. If it is challenged and debated, it may become the subject of conciliar decision. Only very few topics would ever reach the level of consideration by a regional or pan-Orthodox council.
THE CONTENT AND THE STAND OF THIS ARTICLE
What follows in this section represents this process in dealing with controversial issues. It seeks to express "the mind of the Church" on these issues, either by defending against attacks on the Orthodox Church's teachings and practice, or by providing ethical guidance concerning issues that arise from our highly technological age. Very few claims to uncontroverted teaching can be made. Most positions of the discussion should be understood as the current consensus, sincerely and widely held, and representing the mind of the Orthodox Church on issues discussed. At this early stage, this is the most that can be presented. In practice, it serves today as the teaching of the Orthodox Church on these controversial issues:
Medicine, Morals, and Religion
By
HOSPITAL, hostel, hospice, hotel-all carry the meaning of shelter and care as well as treatment. The religious inspiration behind it all is an old story, going back to the first refuges for the sick, which were the temples of Babylonia, India, Egypt, and Greece. The earliest people who came anywhere near to being a guild or profession of nurses in Christian Europe were nuns. The Sisters of St. Augustine were the first to be specially dedicated-a kind of vocation within their vocation. But they were anticipated, in fact, by the men of the Knights Hospitallers, the Knights of St. John of Jerusalem. We have a growing number of men in nurses' training these days (a kind of unisex counterpart to the young women going into doctors' training), but like so many other so-called new departures, they really are only a return to ancient examples.
What is different, of course, is that in the old days the hospital was the hostel for the hopeless. Only the incurable and moribund went there. Physicians and surgeons did their work in their own or their patients' homes, and hospitals were caring programs rather than treating programs. The marriage of the two functions-care and treatment-is hardly more than a hundred years old.
But my focus is on the modern setting, on medicine as it functions within the hospital system. It might be of interest to explore the curious
Joseph Fletcher is Professor of Medical Ethics at the University of Virginia Hospital, Charlottesville, Va., and the author of Situation Ethics (1966) and Moral Responsibility (1967). This article has been adapted from his remarks during the dedication celebration of the new facility of St. Mark's Hospital in Salt Lake City, Utah, on May 6,1973. The St. Mark's Hospital is the earliest hospital in the city and is affiliated with the Episcopal Church. The speech was part of a continuing program connected with the dedication and was sponsored by the hospital's medical staff, headed by Dr. Roy E. McDonald.
fact that doctors are among our most conservative people, and therefore the very idea of collectivism is alien to their social values, therefore the very idea of collectivism is alien to their social values, but the hospital is obviously a radical collective. The success of modern medicine and medical care is a result of the interdependence of medical specialties; its secret ties in the "division of labor" and complex referral system between the primary care physician and his many medical colleagues. Medicine can no longer be practiced out of a little black bag. Medicine is at last a collective enterprise, no longer a private one. It has turned into far more than a place; it is a system.
The motive or inspiration behind medical care is still religion, as much as it always was in the past. To say so, however, is to use the word religion in Tillich's sense of one's "ultimate concern." Religion is what we hold to be our first-order value or highest good, the "imperative" that pushes us on to do what we do. This is not, of course, the meaning given to religion in general or popular use; most people mean by it a faith tradition of some kind (Christianity, Buddhism, or some other belief-system) or an outlook on health and human obligation which has its final sanction in the will of God. The French word for hospital, hotel Dieu, reflects this theistic religion, and service under God is its explicit obligation.
Theism is not the only worldview at work in hospitals; there is humanism too, which acts with some as a motivational faith. I feel, as many others do, that it makes no practical difference whether physicians and nurses put God or man at the center of their faith. Whether we believe with Protagoras that man is the measure of things, or with the Bible that God is, the virtues of compassion and fortitude can and do follow from both standpoints. In a good hospital there is no such thing as a theological or canonical test for orthodoxy.
What counts is what is called "love" in Christian ethics, loving concern for human beings. Professing Christians certainly have no monopoly of love or any kind of patent on it. For example, when Erich Fromm says that "love is the only sane and satisfactory answet to the problem of human existence," he speaks and describes love exactly as a Christian would-except that he does not bring God into it. He thinks Christianly but talks humanistically.
Humanists and theists are similarly humane. They may give different answers to the Why question (why we should bother to help the sick), but they have much the same answers for What we ought to do and How we can do it best. In short, our guiding principle is what is humane and rational, not what is revealed or authoritarian.
It is impossible to look closely into modern medicine without seeing some very thrilling and often troubling questions. Technically they are posed by medicine, but they immediately take a moral and religious shape. Let me list some, only by title. What are we to do or not do, morally regarded, about such matters as truthtelling in medical diagnosis and disclosures of medical records; voluntary sterilization; transplants and implants; intensive care and resuscitation; defective newborns and high-risk pregnancies; in vitro fertilization in embryology and in therapy; triage decisions about conditions like complicated hepatic coma; selective abortion in intrauterine diagnosis; abortion on request a la the Supreme Court's recent decision; genetic engineering?
Again without discussing them, what should we do or not do about behavior control by psychosurgery or chemotherapy; positive and negative euthanasia; cyborgs and prosthetic amplifiers; transsexual operations in cosmetic surgery; selection procedures for hemodialysis and other allocations of scarce life-saving resources; artificial insemination and enovulation; bypassing refusals of consent to medically indicated treatment; ghost surgery in teaching hospitals; the non-medicinal use of drugs; clinical experiments; fetologic interventions? The list is long and growing longer.
These are all agonizing questions, and they face us every day in hospitals across the land. The decision making in most other walks of life is picayune compared to what confronts the practitioners of good medicine these days.
These are success problems, not failure problems. They come about because of biomedical advances. The entrance of science into medicine at the Renaissance changed it from stop-gap fatalism to a real and effective control over illness and health. For example, when I listed the various historic meanings of the word hospital, I left one out- "spital." At one time, hospitals were places where the victims of pulmonary tuberculosis came to spit their lives out. That common killer is now a thing of the past.
But success has its price. One of our troubling problems is how to balance what we gain and what we lose when a new drug or therapeutic agent carries undesired side effects. We are only barely beginning to realize the extent of iatrogenic illness-diseases due to cures. The illnesses are the built-in consequences of the cures. Look at what the viruses have done since the polio vaccine went to work. Since all drugs have toxicity points, 15 to 20 percent of patients suffer adverse reactions; more than half of them are minor, but one to two percent are fatal. Steroids are more specific, but they increase susceptibility to some infections. It is an ominous fact that by saving the lives of babies with genetic diseases and anomalies, they reach reproductive age and further pollute our common gene pool.
By what moral calculus can we face and deal with such issues? No cost-benefit analysis can work without ethics, for ethics deals with values, and such trade-off decisions have to calculate the weight or worth of one value against another. The same problem arises in a more intense form at the clinical level. For example, which patients in renal failure will share in the available slots of time on artificial kidneys or in the short supply of cadaver tissue? How are we to choose sides in the argument about whether to put hard drug addicts on methadone? It too is addictive. Do its lower cost and its freedom from the narcotics pusher tip the balance? We lack what might be called a mathematics of mercy, but until we find one we are flying blind.
Another issue crystallizing lately is latent in the phrase "quality of life." It is said that quality of life is more important than quantity of life and that therefore in terminal illnesses patients should not be kept going beyond a reasonable point. At the other end of the human life spectrum, in prenatal or reproductive medicine, it is contended that a defective fetus should be ended by pre-emptive abortion. I am personally confident that this is indeed good medicine, i.e., humane, but to see it this way is to have chosen a quality-of-life ethics instead of the traditional sanctity-of-life ethics. The issue has its bearing on many other problems of medical management, such as the current National Institute of Health policy of bowing to the Right-to-Lifers. This agitational group denounces the research use of live fetuses even though such organisms cannot survive and the chances to study them might prevent many of the tragedies of genetic and congenital disorders. It is a typical success problem; in earlier times we had no knowledge or control over the quality of birth and death.
There are some who listen to us wrestling with the resulting problems of medical success and cry out, "Stop! You are playing God, and it is wrong to do it." As one of several explorers of biomedical ethics, I am at least persuaded that we should accept the charge. We should say, "Yes, we are playing God"-meaning that we are responsible, that we assume the burden and risks of decision making about many things which once were outside our powers to control, ameliorate, avoid, or cure.
The real question, however, is which God or whose God we are playing? It used to be thought that God has a monopoly control over life and health and death. This was the primitive God of the Gaps-the God whose role was to fill in the gaps in man's knowl-
2 J. Fletcher, "Ethics and Euthanasia," American Journal of Nursing, 73 (April, 1973),670-675.
3 Boston Evening Globe, April 13, 1973.
edge and ability to control things or make sense of them. God was an hypothecation of human ignorance and helplessness.
Medicine made the first attempt to "play God" by investigating and controlling health, either with the help of or in spite of nature, God's creation. Now, like health, birth and death-the start and stop of life-are becoming areas of human responsibility. Among believers we are turning from the God of the Gaps to a God who is the creative principle behind all things, who is behind the test tube and amniocentesis as much as the earthquake and the volcano. The old God is dead. A good definition of medicine is "interference with nature" or "playing God."
There are other such issues. On the social and political side we can see that at least three reforms in the delivery of health care are coming. They are insurance for everybody for both hospital and office visits, special protection against the catastrophic costs of serious illness, and an increase of Federal commitments both to more treatment funds and more governmental supervision. These things, plus the emergence of health maintainance organizations and prepaid medical care, are going to stretch the moral muscles as well as the "system" of conventional medicine. Another example, at the working level, lies in the American Hospital Association's recent "Patients' Bill of Rights," which is bound to upset physicians who like the medical mystique and the doctrine that "doctor knows best." The customer, the patient, is going to have more to say in the future.
We not only have to think again about man's notion of God's role in human affairs, if we believe there is a God; now we also have to think again about who or what man himself is. And we all believe that man exists. Tied to this question is the determination of when a new person comes into being and when a person is dead and gone. The ethical importance of the Supreme Court's abortion decision is its judgment that an embryo or fetus is not a person. Obviously it belongs to the human species, although even this in the first weeks of pregnancy is only determinable microscopically, and it is definitely alive in the sense that cell division is going on.
But the indicators of humanhood, the criteria for humanness or personal quality, are certainly something besides biological functions, important as they are. The word "vegetable" for ex-cerebral or pre-cerebral individuals is as old as Aristotle and Thomas Aquinas and moral theology, and as new as the lexicon of house officers in modern hospitals. The vitalistic idea that life itself is the summum bonum, regardless of its quality, has never passed muster with pagans, Christians, or humanists, and in our time this naive vitalism is the Achilles heel of the whole anti-abortion, anti-euthanasia movement. Commitment to life at any price comes into
collision with an ethics of loving concern. It is a question of the vitalistic versus the humanistic morality.
Granted that a person or a truly human being is more than merely biological functions, no matter how spontaneous the functions might be, what more and how much more is it? There is, as far as I can see, no neat or confident answer available. The fact is that all of our classical definitions of man have to be re-examined in the light of modern medical knowledge, just as we have to review our concepts of life and death. As these things stand, we take a spooky and cruel posture too much of the time.
Suppose we ponder an actual case. A little boy with a severe neuroblastoma of the lung is admitted late at night, with perhaps four to five hours of life left. The physicians order the nurses to keep the child sitting up, to hold death off by preventing the lungs from filling. The child cries, over and over, "Please! Let me lie down. I hurt." But the nurses, unhappily but obediently, obey their orders. (Nurses are the people that doctors leave their problems with.) The chaplain next morning, in the cafeteria, asks the young doctors on that service why another hour or two of semi-life was worth the little boy's suffering. They have no answer; they "stand mute," as lawyers might say, with a glazed look in their eyes. Uncomfortable. Stubborn. Now, what does this little scenario teach us?
Let me go back again to the non-clinical side. It may well be, and I believe it to be true, that the search for what I've called a "moral calculus" is the most crucial problem we have in medical ethics and medical care. Sophisticated discussion of public policy, health, medical care, and research-all social-ethical concerns-keeps popping with terms like systems analysis, value judgment, priorities, triage, allocation of scarce resources, cost-benefit balance, choice options, and distributive justice.
The scope and arena of decision making has widened enormously since the days when being one's brother's keeper and loving one's neighbor was a direct matter between you and a handful of people you know personally, often by name. The pastoral, rural-agrarian and village society in the Bible, for example, no longer exists in this country. No longer can we turn to the teachings of Jesus or Moses for direct moral guidance. Things are not that simple any more. Medical ethics therefore has to become truly a social ethics, not a simple interpersonal morality. The world is so tied together now that even the words "neighbor" and "stranger" have become archaic. We even need a new ethical language.
The problem of moral calculus-the daily headache of hospital administration-is what makes directors and managers in the modern world our unsung heroes or martyrs, as the case might be. It is seen in its simplest shape as triage; deciding what to do or not to do
when supplies, funds, and personnel are in short supply. Triage aims at the greatest good (i.e., the best treatment) for the greatest number (i.e., the most patients). On a city hospital's emergency service, swamped by referred and unreferred patients, if the triage officer (the physician in charge) cuts out pregnancy tests because they are not instantly urgent, he or she is doing two things which are supposedly non-medical-practicing utilitarian ethics and economics. Utilitarianism aims at spreading expectable benefits, and economics is a studied judgment about preference among competing choices.
All of this means that physicians, nurses, paramedical professionals, and hospital officials will no longer be able to live by the traditional but too-simple one-to-one medical ethics. The philosopher Hans Jonas said recently, "In the course of treatment the physician is obligated to the patient and no one else." Obviously Jonas sees the road through his rear-vision mirror. He is contradicted by quarantine, compulsory vaccination, and mandatory autopsies in mysterious epidemics. And these things are only minor complications of traditional medical piety, compared to what is coming. What medicine needs is a moral telescope, not a moral microscope.
Allow me to describe an actual clinical situation. A patient is 47, married, has a wife and two children. He is an industrial engineer. His son is 18, his daughter 16. His condition is polycystic kidney disease, a genetic disorder. His father died of the same illness at 44, before dialysis or transplants were available. He and his wife know that the disease is transmissible to and through their children, but they insist on keeping the facts from their children because it might frighten them and inhibit their social life and courtship hopes. In this case to preserve the professional confidence, which the parents insist on, could be to victimize the children, their spouses, and their offspring. If the patient remains unchanged in his attitude, a medical ethics of compassion would require the renal service staff to violate the medical convention against disclosures. This is an example of the telescope replacing the microscope.
But triage is a small-scale and easy version of our moral calculus. Here is a down-to-earth case of the real thing. The hyperbaric chamber at a famous uptown New York hospital cost $750,000 to install, $600,000 per year to operate. In five years the total dollar cost was $3,750,000; 900 patients were treated at a cost of $4,166.65 each. For the same amount 20,000 outpatients could have been treated per year, or 100,000 altogether. Or, a screening program could have been set up in East Harlem to detect lead poisoning and anemia in a million children-to keep their brains from being ruined.
How are we to use a moral calculus in the forum of conscience when we look at duty and obligation through the telescope? That seems to me to be the over-arching ethical problem in medical
4 Daedalus, Vol. 98 (Spring, 1969), p. 238.
ethics or any ethics that is sincere enough to be realistic and to take all of the factors into account as honestly as we can. I do not pretend for a second that I can provide the solution. Actually, I am convinced that the only good answers will have to come from the hospitals and the clinics, not from libraries and kibitzers like me. But still I like to think that even kibitzers can sometimes ask good questions.
Let me try to summarize four points about medicine, morals, and religion.
(1) Some people believe in God's existence; all of us believe that men exist. Our medical philosophy should therefore be humanistically, humanely motivated. If human compassion is reinforced by a theistic faith, all the better. But it is only better if the faith happens to reinforce the compassion. Alas, not all religions do.
(2) Patients are persons, not just bodies. A truly human being is mental and moral as well as physical. The physical side, physiology, spontaneous or artificially supported biological functions, by themselves do not make a human being. The practice of medicine can become the ministry of medicine only if we realize that the quality of life is more important than mere quantity. Our devotion is not to life but to human life.
(3) In order to be morally responsible we should not wear blinders, seeing only one patient at a time. We need a telescope to see our true obligations. In our society and culture there are so many of us and we are so interdependent that we need mathematical morality, ethical arithmetic, a statistical sense of obligation-not the first-come-first-served simple doctor-patient ethics of the horse-and buggy era.
(4)We shall have to learn to live without absolutes, such as "Our sole obligation is to the patient under care" and "Life must be prolonged as long as possible" and "We must not disclose what we have learned in professional confidence" and "No cost is too much to cure a human ill." Instead of moral norms or principles of such undiscriminating and universal application we must make medical decisions by a situation ethics; what is right depends on loving concern for persons and the variables in each case. Situation ethics is clinical ethics. No good clinician finds the answer to any patient's problem in a prefabricated form out of a book. He sees the patient.