ETHICAL PRACTICES

IN
HEALTH AND DISEASE
A Primer on Health Care Ethics
Michael A. Monge
Sinag-tala Publishers, Inc.
Manila
Contents
Prologue xiii
Introduction XV
Notion of Professional Ethics XVll
Part I
BASIC ETHICAL QUESTIONS
1. Human Acts 5
The principle of double effect 5
2. Man, the Moral Subject:
A Synthesis of Anthropology 9
3. Conscience 13
Mode of action
13
Proximate norm of morality 14
Conscience versus law 15
4. Natural Moral Law 19
Law which man has not laid upon himself 19
Contents of natural law 20
Its characteristics: universal and immutable 22
Can the natural law change? 24
5. Human Freedom 25
Various concepts 25
Its existence 26
6. Moral Determinants of Human Acts 29
Object, end and circumstances 29
Moral principles 30
7. Cooperation with Evil 33
Am I responsible only for my own action? 33
Notion and types of cooperation 34
Criteria for judging the morality of cooperation 35
Some examples 36
Part II
CONCRETE ETHICAL PROBLEMS
1. Duties Toward the Unborn 45
Life: a fundamental good of the person 45
Rights and duties towards human life 46
Attempts against human life 48
2. Abortion 49
Notion 49
Forms 49
Techniques of induced abortion 52
Abortionist arguments and their criticism 54
Church teaching 65
Licitude of the so-called "indirect" abortion 68
Administering baptism to the aborted fetus
and premature newborn 69
viii
3. Respect for the Suffering Patient
The nature and meaning of pain
Fatigue
Illness
Obstetric analgesia
Painless delivery (childbirth)
Induction of labor
4. Drugs
The therapeutic use of drugs
Non-therapeutic use
Effects of "soft" drugs
The ethical evaluation of drugs
5. Duties Towards the Dying Patient
71
71
74
78
81
81
83
85
85
86
87
91
93
The terminal patient 93
Disthanasia or employing "disproportionate"
means for therapy 99
Euthanasia 102
Vital testament 107
6. Bodily Integrity
Principle of totality
Plastic surgery
Organ transplants and donation
Determination of death
Nature of the cadaver
Sterilization
7. Sexuality: At the Service of the Person
Sexuality in human beings
The purpose of sex: unitive and
procreative aspects
Responsible parenthood
Regulation of birth
Artificial contraceptive techniques
Therapeutic use of "pills"
ix
109
109
109
110
115
118
119
125
125
128
133
136
140
143
8. Artificial Fertilization 145
Artificial insernina tion 145
Ethical evaluation 146
In vitro fertilization 147
Other aspects 148
Ethical evaluation 149
9. Eugenics 155
Historical background 155
Positive eugenics and negative eugenics 156
Prohibition of marriage 157
Pre-nuptial certificate 158
Genetic counselling and prenatal diagnosis 159
Ethical evaluation of amniocentesis 160
10. Human Experimentation, Medical Progress
and Research 165
Ethics of scientific experimentation 166
11. Telling the Truth to the Patient 169
Patient's right to the truth 170
Healthcare professionals must not lie 171
Dilemma: will the truth hurt? 173
The truth need not hurt 175
Practical guidelines 176
Medical team as moral support to the patient 178
12. Professional Secret 181
Some difficulties 181
Notion of Professional secrecy 183
Scope and rationale for medical secrecy 184
Who are obliged to maintain secrecy? 185
When does a secret cease to oblige? 186
Whom must the physician inform? 187
X
13. Integral Approach to Patient Management:
Humanizing Medicine 189
The whole person affected by illness 189
What does "total patient care" mean? 190
Aspects of integral approach to patient
management 190
Qualities of health care professionals 193
Special patients 196
14. Spiritual Care of the Patient 199
Spiritual care: rights, duty and necessity 199
How to render spiritual care 203
Bibliography 213
Index 221
Xl
Prologue
In Spain, there are not many books written on Healthcare
Ethics. Other European countries are actually experiencing vivid
reflections, teaching activity and discussions on ethical prob-
lems related to human health and disease. In contrast, in Spain,
many still believe that these problems are more apparent than
real. According to their opinion, one need not study profes-
sional ethics to act uprightly; it is enough to use one's moral
intuition or do what others do. As they say, why bother to
improve on the established routines? Such effort, they reply,
neither merit appreciation nor sympathy of other colleagues,
since majority of them have lost the vocational dimension of
the healthcare profession.
This book-"Ethical Practices in Health and Disease" - is
written by Miguel A. Monge, physician and priest. His many
years of personal experience, direct contact with physicians,
nurses, the sick and their families, enabled him to be both a
spectator and concerned party when confronted with ethical
and pastoral problems that arise frequently from the intense
and vibrant life of a modern hospital. His style is influenced
by both moral theology and medical studies. After ordination,
he has been exercising his pastoral ministry and, with prudent
discretion, has become the "advocate of the sick."
We are, therefore, dealing with a book whose author talks
not from hearsay but after having been confronted with real
problems, taken a stand, and offered, justified, or analysed their
solutions. He offered these solutions to those in need, with due
respect and affection, whenever they asked for it, while always
following the paths of Christian Anthropology and Morals, as
taught by Catholic Magisterium. The book is systematic and
explicit; it does not get lost in complex critical discussions. In
dealing with almost all the questions which confront today' s
Healthcare Ethics, it tries to give relevant facts, while avoiding
ambiguities.
Books of this sort will always be a must in our pluralistic
society, precisely because of this pluralism. The book will serve
both believers and non-believers. It imparts knowledge with
simplicity and sincerity. It likewise serves as a clear, unequivo-
cal profile of catholic moral wisdom. It will help some to take
decisions and contribute to the divine plan of salvation. Others
it will help in practising respect for persons, make known to
them the richness that Christian Ethics has in relation to
healthcare professions.
DR. GONZALO HERRANZ
Department of Bioethics, University of Navarre
President, Central Commission of Deontology of
the General Council, College of Physicians of Spain.
Introduction
There are many instances when healthcare matters require
an ethical approach. We cannot follow the principle: "Every-
thing that can be done ought to be done." Medical practice is
subject to certain ethical limitations.
The following pages contain a compact synthesis of the Basic
Ethical Principles intended for healthcare professionals and for
whoever finds the topics to be of interest. It will serve them
in their professional work or when confronted with some of
these problems. It will provide fur them answers. Thus, it will
guide them in their actuations by -sure ethical criteria.
To condense in such a small space everything related to
the ethical practice of Medicine is quite difficult. Notwithstand-
ing, I have tried to expound in a clear and accessible manner
a series of basic moral norms which ought to direct the task
of nursing. As a profession, it is becoming a more important
one by the day. Now a university career in Spain and long
before in other countries like the Philippines, it is called to
have an enormous transcendence in the conservation and pro-
tection of human life and health.
1
Perhaps it would help if I explain how the book was planned.
I must admit that in the beginning I wanted to entitle it, "Ethics
for Christian Nurses," since these pages were initially addressed
to nurses and written from a christian viewpoint. That is why
I often referred to Catholic Doctrine, and to the judgement of
1
H.A. COHEN. La enfermera y su identidad. (The Nurse and Her Identity) Grijalbo,
Barcelona 1988.
Church Magisterium. This latter sheds abundant light on many
of the topics treated here.
But I refrained from using the title because I would like
to address the book to all classes of persons, be they nurses
or not, christians or otherwise. I would like to stress the latter
point since majority of the topics need not be supported by
the witnessing of the Catholic faith. Human reasoning, alone,
can already answer completely the various questions presented
here, from abortion to drugs, euthanasia to genetic engineering.
But as today, a lot of topics are seen from other points of view
by reason of what others term as ethical pluralism, it has seemed
to me advisable to forewarn.
In summary, although the arguments-of anthropological,
scientific nature derived by natural reasoning, are the foun-
dation of this book, however, references to the Catholic
Magisterium are included when opportune.
I am encouraged to make two considerations:
a) The healthcare professional (physicians, nurses, etc.)
cannot limit himself to the fulfillment of a technically perfect
job, achieving what we can call neutral or aseptic. All the more
reason when one is a Catholic, since faith, if it is genuine, is
projected on to one's life, including one's professional work.
The christian professional cannot be a spiritual schizophrenic
who forgets the religious dimension of his existence, ignoring
the duties subsequent to his Faith.
b) Besides, those who work in health care professions,
whether christians or not, will meet people who have faith,
whose illness will make them feel more strongly the religious
dimension of their life. These patients hope for and seek the
necessary help in this matter, and not only from the Chaplain
of the hospital.
Nevertheless, whether it is a question of living one's faith
(if one is a christian) or helping a patient who has faith, one
needs to master the ethical criteria on certain important questions
that arise in our work. Virginia Henderson, one of the promi-
nent figures in Basic Nursing, wrote: "The greater the religious
formation of the nurse, her confidence in the therapeutic effects
of religion, her spiritual formation and her tolerance for other
creeds the better service she will render to the sick."
2
2
VIRGINIA HENDERSON, Principios basicos de los Cuidados en enfermeria. (Basic
Principles in Nursing Care), published by the International Council of Nurses. Geneva
1971, pp. 53-54.
xvi
I hope that these pages will be useful to all the components
of that "Great Medical Profession," as Fox calls it, each one
according to his specialty, but all united in a continuous
dedication to the care of the patient, trying to cure or alleviate,
safeguard his life and health, while improving whatever can
be improved.
xvii
Notion of Professional Ethics
DEONTOLOGY or Professional Ethics or Morals, is the
science which considers the specific ethical obligations arising
from the exercise of one's profession. Any professional work,
by the mere fact of being performed by a human person, is
subject to general ethical criteria: to work well with profes-
sional competence, sense of responsibility, loyalty and solidar-
ity with one's colleagues and so forth. Moreover, concrete ethical
problems are encountered in every profession; these require
a special formation. This is what is properly called PROFES-
SIONAL DEONTOLOGY, Professional Ethics or Morals (for
physicians/ lawyers, nurses
2
and others).
Today, needless to say, the medical profession (physicians,
nurses, midwives, nurse aides, etc.) demands a highly specific
professional competence and profound ethical dimension.
Certain controversial issues can be dealt with only after receiving
good formation and possessing sure criteria. The following
example is an excerpt of The Code of Deontology for Nurses
published by the International Committee for Catholic Nurses
and Medico-social Assistants (CICEAMS) in 1973:
"The particular sociological and ideological conditions of
the present world urges nurses to struggle to acquire a unique
formation as regards problems related to human experimen-
tation, special surgical operations, birth control, abortion,
1
Cfr. Code of Medical Ethics and Deontology, approved by the College of Physicians
of SfJain. April 1990.
2
Cfr. Code of Deontology of Nurses in Spain, May 18, 1990.
euthanasia, sterilization, artificial fertilization, drugs, narcotics,
and so forth."
Obviously, these problems and many others require an
ethical approach. An approach in accordance with certain values
and a specific point of reference is needed whenever one has
to judge the ethical or non-ethical dimension of these acts.
Therefore, in this book, we begin by analyzing the so-called
basic ethical realities. We include a synthesis of basic anthro-
pology by discussing human acts, freedom, how to determine
the morality of human acts, and so forth.
Part II, which comprises the major portion of this book,
is mainly composed of the ethical analyses of various matters
in health care activities.
We dwell on those questions which are relevant not only
to the medical profession, but also to ordinary men and women:
abortion, the right to life, euthanasia, artificial prolongation of
life, transplants, eugenics, in vitro fertilization, sexuality, arti-
ficial contraception, human experimentation, genetic engineer-
ing ... and other minor topics: the right of the patient to know
the truth regarding his illness, or dignified humane treatment
and spiritual attention, medical secrets, etc.
XX
Part I
Basic Ethical Questions
Unlike Sociology, Ethics does not limit itself to
the description of human behaviour. It evaluates and
judges it as either good or bad, appropriate or in-
appropriate. It acts through human reason which is
capable of determining the degree of goodness or malice
of human acts. Human reason, then is capable of
making value judgments.
But one may ask: "What is the point of reference
in judging acts as good or evil?" That is, what norms
or criteria determine the goodness or malice of human
acts? The answer is: The so-called "Moral Law" is
the norm of human acts.
In this way, we arrive at certain fundamental
ethical realities which merit description. We refer to
the following:
Human Acts
Man, the Moral Subject
Conscience
Natural Moral Law
Freedom
Determination of the Morality of the Human Acts
Cooperation with Evil
1 Human Acts
Although all acts performed by man (thinking, speaking,
eating, etc.) can be called human acts, this term is usually
reserved for human acts which proceed from a deliberate will,
i.e., rational and voluntary, and therefore, free. If one of these
elements is lacking, (for example, acts performed when drunk,
drugged, or forced, etc.) a human act properly speaking does
not take place.
Three elements of a human act are described: advertence,
volition and execution. For a human act to be responsible, these
three elements are necessary. In the first place, one needs to know
what one is doing, whether good or evil, appropriate or inap-
propriate. When someone acts inadvertently ("I did not realize
what I was doing.'') or through ignorance, the hunan act may
not be imputable. This is because in culpable ignorance does
exist as in a nurse whose knowledge of her profession is defective.
Secondly, one has to will or to want to act. In order to act
responsibly, the act should be willful, voluntary. Acts can have
multiple effects, some of them "wanted, others unwanted." One
seeks the good effect but does not want at the same time the
undesirable effects. This is the case of the so-called actions with
double effect which we will analyze shortly. It is a question
of utmost importance in resolving many moral problems which
usually come up today as "conflict of values."
The Principle of Double Effect
We are dealing with an important question in relation to
voluntary human acts. This principle has frequent and mul-
tiple applications in the moral life; concretely, in relation to
the imputability of the effects of human acts.
When a human act has only one effect, it is not difficult
to pass a moral judgment. The object, end, and circumstances
of the same act can be adequately evaluated. Things, however,
are not always this simple. Human life is often beset with
conflicts of values because there are actions, which, aside from
producing a good effect, cause an unwanted evil effect which
accompanies the former inseparably. The problem presented
is: "Can one carry out such acts? Is it licit to perform a good
or an indifferent act, from which proceed also evil consequences?
These acts are described to have a double effect, which presents
the question of direct or indirect voluntary."
An object may be willed directly when it is the explicit object
of an act of the will that tends to it as an "end" or a "means
to an end." However, something may be indirectly willed when,
although not the object of the intention, is an effect precisely
because of a resolution of the will executed for another "end;"
this act is not willed in itself but is foreseen and permitted
as a consequence of something directly willed and from which
it cannot be separated.
Morals then teaches that, exceptionally, an action may be
performed in order to obtain a good effect, foreseeing that evil
effects will necessarily result with more or less -certainty, and
more or less necessarily, without being directly intended by
the agent. The following conditions must be present however:
a) The action must be morally good or at least indifferent
in its object, end and circumstances; it must not be evil
in itself (to kill, to lie, to steal, etc.).
b) The good effect must immediately follow the action, or
at least, be simultaneous with the evil effect in the order
of causality. It cannot be the consequence of the evil
effect in as much as "the end does not justify the means"
(cfr. Romans 3:8).
c) The intention of the agent must be morally good, i.e.,
that he intends only the good effect. The evil effect is
foreseen and permitted but not wanted. The evil effect
cannot be intended, not even through the good effect.
Nor can the agent want both effects. He must will
exclusively the good one, and with displeasure permit
the evil effect due to its absolute inseparability from
the good effect.
d) A proportionately grave reason must exist in order to
justify the evil effect. In other words, there should be
reasonable proportion between the good intended and
6
the evil permitted. The judgment of this decision
corresponds to the conscien-:e of the subject, which ought
to be enlightened by the objective moral norm and, as
the case may be, with the advice of a prudent and upright
person. At times it can be the most difficult principle
to apply in practice.
In doubtful cases, one has to consider various aspects, by
virtue of which one has to judge the morality of a similar action:
certainty or uncertainty of both the good effect and the evil
effect, necessity or degree of advisability of this act, in the order
of the good effect; more or less influence and relation of the
same with the evil effect, etc.
In moral life, we apply this principle constantly. Man cannot
always achieve the ideal of the pure good. He frequently
encounters situations wherein he needs to act, while accepting
and suffering the negative consequences of the acts which are
in themselves good; otherwise he would have renounce these
acts. We shall come across many examples, and we shall have
to recourse to this principle in order to explain the licitude
of the so-called "indirect" abortion.
Finally, apropos execution, the subject who acts should do
so freely. He should not be subjected to any type of coercion,
whether physical or moral. Therefore, it is important to know
the obstacles or difficulties (called impediments) which are
frequently encountered in moral actuations, namely: ignorance,
passion/ fear, violence, habits, customs and so forth. The so-
called remote impediments can also have some repercussion
albeit indirectly, in the free human act. Included are tempera-
ment, age, sex, biologigal heredity, and some pathological
conditions (neurosis, epilepsy, etc.). Doubtless, all these have
a bearing on the moral behavior of the individual.
1
We are referring here to passions as possible impediments to human acts. But
one must not forget that passions can also 'Je outlets for expressing one's freedom.
Ethically speaking, passions are neither good nor bad, in so far as they emanate from
the involuntary affectivity. When however they are accepted or rejected freely, they
become subject to moral evaluation. In this sense, they can be utilized to obtain the
good. St. Thomas Aquinas says: "It corresponds to the moral perfection of man to
act, not only according to his will, but also according to his sensible appetite, as Psalm
83:3 reads: "My heart and my flesh rejoiced in the Living God." (Summa Theologiae,
1-2, q. 24, a. 3). For a detailed psychological analysis of the passions: cfr. E. ROJAS.
El Laberento de Ia Afectividad (The Labyrinth of Affectivity) Espafia-Calpe, Madrid 1987.
7
2 Man, The Moral Subject:
A Synthesis of Anthropology
We have said that human acts are acts performed by man.
Let us pause and consider the subject of human acts. If our
point of departure is: "Medicine is at the service of man," it
is necessary to explain what man, the recipient of this service,
is.
The basic concepts of "true" anthropology or the study of
man are not easy to bring up. Here, we are before a "mystery"
about which many opinions have been given. Some of them
have been contradictory. Nevertheless, with the help of Christian
Revelation we will try to do so.
Man can know what he is, through reason alone. However,
the best guarantee of knowing himself is by adhering to what
God has revealed: "For Sacred Scripture teaches that man was
created 'to the image of God,' with a capacity to know and
love his Creator. And made him master over all earthly creatures
that he might govern them and make use of them, while
glorifying God" (Vatican Council II, Past. Const. Gaudium et
Spes, no. 12).
Man is the most noble of all creatures. Since part of his
"being" pertains to the animal world, he participates in its bless-
ings and limitations, undergoes biological development, has
instincts and senses, etc. But another aspect of that same "being,"
transcends the material world and is independent from it.
Through his rational soul, man participates in that other world,
that of the spirit. Man is not simply a highly evolved animal
(a naked monkey, as described by a popular editorial published
many years ago), according to Darwinism or Materialistic
Evolutionism. Man is a marvelous unity of rationality and
animality. "Man is not deceived when he regards himself as
superior to bodily things and as more than just a speck of nature
or a nameless unit in the city of man. For by his power to
know himself in the depths of his being (i.e., through reflection),
he rises above the whole universe of mere objects. When he
is drawn to think about his real self he turns to those deep
recesses of his being where God who probes the heart awaits
him, and where he himself decides his own destiny in the sight
of God. When he recognizes in himself a spiritual and immortal
soul, he is not led astray by false imaginings that are due to
men;ly physical or social causes. On the contrary, he grasps
what is profoundly true in this matter" (Gaudium et Spes, no.
14).
Man's spiritual nature is manifested by rational thought and
the free, voluntary tendency towards his final end. Therefore,
human nature is a dynamic reality characterized by:
a) A natural tendency towards an end. Man fulfills himself
by reaching out, serving a cause higher than himself,
loving others ... That end is objectively found only in
God. On account of sin and the bad use of freedom,
it may be sought in other things.
b) A rational knowledge of that end. To this end, he freely
directs himself. Man freely accepts or rejects it. There-
fore, he is not enslaved by his nature, let alone by his
instincts.
Natural Law includes these two properties, as we will see
later. The essential characteristics of Christian Anthropology are
synthesized as follows:
a) Man is a living being, composed of matter and spirit,
body and soul. The soul, with its intellect and free will,
is superior to the body. The substantial union of body
and soul constitute one bemg, individual or person. By
virtue of this union, the human body cannot be reduced
to a mere complex of tissues, organs, and functions; nor
can it be equated to an animal body. We have to
remember this when we study human experimentation
or artificial fertilization.
1
1
John Paul II addressed the participants of the 35th General Assembly of the
World Medical Association, October 29, 1983.
"Every human person, with his irrepeatable and unique singularity, is composed
not only of the spirit, but also of the body. And thus in the body and through the
body is the person itself reached in its concrete reality. Consequently, respect for the
dignity of man, demands the safeguarding of his identity as man, corpore et anima
unus, as affirmed by Vatican Council II," (Gaudium et Spes, no. 14). The fundamental
criteria for making decisions should be based on this anthropologic vision. The text
may be found in the "Documentacion Palabra" 1983/295.
10
b) Man, being a corporeal and spiritual creature, is rational
and free. He is endowed with such dignity that he should
never be considered nor treated as an "object." He is
not "something" but "someone."
c) The individual human soul is immortal. God created
it immediately out of nothing.
d) Everything on earth should be ordained to man as its
center and summit. God has given him dominion over
all his works.
e) Man is a social being. He cannot live nor perfect his
qualities if he does not enter into relationships with
others.
f) Man is a creature made according to the image of God. But
because of original sin, man ell from his primordial
greatness. This explains the suffering and anguish of
the present life. Nevertheless, man is called to cooperate
with God to obtain his salvation.
g) The human person is sacred: it is the origin of his human
rights and duties. It is the basis for equality and fraternity,
surpassing any consideration of sex, race, social status,
culture, etc.
h) Jesus Christ has redeemed man, and destined him for
a Supreme End: the eternal possession of God in the
other life (Cfr. Gran Enciclopedia Rialp, see "Hombre").
11
3 Conscience
A person who acts ethically, is said to be acting in conscience.
Conscience judges a concrete act as good or evil. We all can
distinguish a person with good conscience from another with
a bad one. Conscience is a fact of life.
Whenever man acts, he judges whether he is actually doing
good or evil. Conscience praises him when he does good and
blames him when he does evil. This is because the human
intellect has a practical knowledge of the so-called first prin-
ciples of the moral order: "Do Good and Avoid Evil." "Do not
do unto others what you do not want others to do unto you."
In the light of these principles, conscience judges the acts
about to be performed. We can say that conscience omits a
judgment in which those principles are applied to concrete acts.
What happens, however, is that those first principles are still
too general. Human reason itself must go about developing
them in order to know more concretely where good and evil
lie. Here natural law links up, since conscience does not
determine arbitrarily what is good or evil. Rather, it judges
in accord with a norm of morality given to it. This norm is
Natural Law.
Mode of Action
Conscience is the meeting point of the Moral Law, objective
and universally valid, and the individual personality. The fact
that the law is objective does not excuse man from getting to
know the law through personal effort, reflection and active
search for the plan of God for each individual. Likewise, man
is responsible for applying the law to concrete acts.
"Acting according to one's conscience" does not merely
signify certainty and firm decision (certain conscience). Above
all it confirms the judgment of conscience to the moral norm
(correct or true conscience). For example, Vatican Council II
explains the moral norms regarding marriage: "Married people
should realize that in their behavior they may not simply follow
their own fancy but must be ruled by their conscience-and
conscience ought to be conformed to the law of God in the
light of the teaching of the Magisterium of the Church, who
is the authentic interpreter of the Divine Law in the light of
the Gospel" (Gaudium et Spes, no. 50).
Christians can know the Moral Law through faith and
reason. This law ought to direct all human acts. For this purpose
God has endowed human nature with "a spiritual faculty which,
in particular cases directs to the will itself acts that conform
to the Divine Will in order that man may choose and deter-
mine" (Pius XII, Discourse, March 23, 1952). This spiritual faculty
of man is called his moral conscience.
"By means of conscience, man knows not only Divine Law
in general, but also its singular and concrete applications to
each case of his personal life" (Gaudium et Spes, no. 16).
Proximate Norm of Morality
Catholic Theology affirms that the immediate and proxi-
mate norm of human acts is the judgment of conscience: no
objective norm nor law can serve as norm of action if man
does not know and apply it in his life.
The judgment of conscience for each concrete act is the
expression of the commands of the Moral Law. Therefore, man
is obliged to follow his conscience faithfully in all his activities
in order to reach God, such that "he who disobeys his conscience
has deviated from the right path" (Romans 14:23).
However, "conscience in itself is not the arbiter of morality
of the acts that it suggests. Rather, it is the interpreter of an
interior and superior norm which it did not create. Neither
is conscience the source of good and evil" (Paul VI, Address,
February 13, 1969).
These words of Pope Paul VI are a serious warning of a
misunderstanding that lamentably nowadays is very wide-
spread. Imperceptibly the error that establishes the individual
conscience as ultimate judge of one's own acts has spread.
Obviously, a per-son who acts against his conscience would
act wrongly. This, however, does not make conscience the
supreme norm. The supreme norm of morality is the Divine
Law. In the aforementioned same address of the Pope quoted,
14
he tells us that for conscience "to be a valid norm of human
actions, it has to be correct, i.e., true and sure of itself, and
not doubtful nor culpably erroneous."
"The more a correct conscience prevails, the more do persons
and groups turn aside from blind choice and try to be guided
by the objective standards of moral conduct. Yet it often happens
that conscience goes astray through ignorance which it is unable
to avoid, without thereby losing its dignity. This cannot be said
of the man who takes little trouble to find out what is true
and good, or when conscience is by degrees almost blinded
through the habit of committing sin" (Gaudium et Spes, no. 16).
Conscience Versus Law
What happens if conscience erects itself as the norm of
morality? Some persons resort to the judgment of conscience
in order to justify their actions, while disregarding or defying
the moral law. "I act according to the dictates of my conscience."
"I cannot go against the dictates of my conscience."-these are
statements of half-truths. Certainly, it is necessary to be guided
by one's conscience for he who acts against his conscience goes
astray (St. Paul asserts this in Romans 14:23). But it is insuf-
ficient. Since conscience is not the source of good and evil,
it does not create the law but rather judges the correct application
of the norm to a concrete action.
It is erroneous to consider the law as antagonistic to
conscience because this reduces the law to a simple exterior
norm and conscience to being representative of man's auton-
omy. In the measure that man wants to be himself he will try
to achieve the greatest possible independence from the law;
and if ever the law were vague, ambiguous, or fail to adapt
to the individual mentality, his conscience would be happy to
recover his complete freedom.
In a similar way, it is erroneous to consider the moral law
as proceeding solely from the will of God or from his vicars,
even from the vicars' whims or caprices. Likewise, it is very
wrong to consider conscience as exclusively representing man.
Some people forget that the Law of God is not founded solely
upon His Will, but also upon His Wisdom. Conscience reflects
Divine Wisdom on the creature. Conscience and law must com-
plement rather than oppose each other.
15
If conscience were the immediate, supernatural voice of God,
therefore, it would not err. However, it receives data from fallible
and human sources. "Only the knowledge of the first moral
principles is exempt from error."
Pope Paul VI said: "The voice of conscience is not always
infallible nor objectively supreme. In certain aspect of super-
natural action reason alone cannot indicate the good, but needs
the help of faith which dictates the norm of justice willed by
God through Revelation." It is necessary to educate one's
conscience. This is done by practising diligence in order to know
the moral laws, seeking opportune advice, removing obstacles
(passions, egoism .. . ) which impede the knowledge of the truth.
At times, why does conscience seem to contradict the Moral
Law? These are those who say, "I cannot accept in conscience
the Encyclical Hurnanae Vitae;" "I do not understand the illic-
itness of the so-called therapeutic abortion;" "I do not see the
need to go to Mass on Sundays;" and so forth. In these situ-
ations, a christian must adapt his conscience to the law as
interpreted by the Magisterium of the Church.
The German Bishops issued a statement in 1966, in defense
of the Moral Law: "Whoever thinks that he can have personal
ideas and that he has more profound future information
regarding the Church with regard to a specific point of
theological doctrine ought to ask himself, before God and his
conscience, dispassionately, whether in that particular point he
has the breadth and depth of necessary doctrine in order to
deviate, in theory and in practice, from Church Magisterium.
Such a case is conceivable but the presumptuous and arrogant
person also thinks he knows everything better and will have
to render an account to God one day."
The subject may also suffer from invincible error. Whoever
acts with an invincibly erroneous conscience does not commit
a sin even if he does what he should not do. He deserves
compassion rather than justification. However, some invincible
errors suffered at present could have been corrected in the past.
Therefore, this conscience is responsible before God for not
having placed the means tb get out of error then.
In certain instances, a christian is obliged to go against the
law (only as regards human laws). This is when the law
contradicts a moral norm. Moral norms never excuse man from
his responsibility. Some Bishops* have unceasingly reminded
"Spanish Bishops.
16
Catholics of their duty to reject the law on abortion because
it is an unjust law. Medical personnel should refuse such cases
on grounds of conscience.
To sum up: although we have to decide in the "inviolable
sanctuary of our own conscience" which reflects the dignity
of the human person, it is wrong to appeal to conscience in
order to evade the duty of adapting to objective moral norms,
which we may ignore yet ought to know. To say: "it's because
I ought to listen to my conscience," asserting one's independ-
ence from God and the Magisterium, is equivalent to saying:
"It's because I am responsible for whatever I do." Needless
to say, when we accept something which, in principle, did not
originate from us, we DO SO responsibly because we want
to, in conscience. For this reason, it is not enough to follow
one's conscience, even if we are sure of our decision. Conscience
(subjective and proximate norm of morality) has to be correct,
well-formed, and in agreement with the Moral Law (objective
norm of morality).
17
4 Natural Moral Law
Law Which Man Has Not Laid Upon Himself
"Deep within his conscience man discovers a law which
he has not laid upon himself, but which he must obey. Its voice,
ever calling him to love and to do what is good and avoid
evil, tells him inwardly at the right moment: do this, shun that.
For man has in his heart a law inscribed by God. His dignity
lies in observing this law, and by it he will be judged" (Gaudium
et Spes, no. 16).
This law, which man has not laid upon himself, is a divine
design for rational creatures. It is called the NATURAL LAW.
It constitutes the totality of duties imposed by God upon man,
which man can know through human reason.
Man, even pagan man, has always felt his dependence upon
the Creator. The following text is taken from the classic Greek
Tragedy, wherein Antigone, the protagonist, answered Creonte,
by appealing to unwritten laws, not found in books but learned
and expressed in his very nature: "I cannot imagine how your
decrees can have such strength that I, a poor mortal, will be
able to trespass these unwritten but immutable laws of the gods.
These laws were not promulgated yesterday; they are valid
for all times and no one knows when they were written"
(Sophocles, Antigone).
Nevertheless, Christianity has been the one developing this
teaching with more depth.
Experience shows that God need not communicate directly
to man these principles of moral life. These principles are
grasped and understood by man through his own intellect since
they are inherent in his nature.
The fundamental principle of moral life known to all men
is: Do good and avoid evil. But one may ask: What is good
and what is evil? What are the criteria that distinguish good
from bad behavior? Can one by any chance, follow an arbitrary
rule of conduct? In other words, can any man choose to act
arbitrarily following his own conscience? This is far from true,
to man on account of his being a substance, an animal being
and a rational being, respectively.
a) Man, in as much as he is a corporal substance, tends
to conserve his existence, to maintain himself in being.
Whatever is directed towards the preservation of life
and avoiding its obstacles is considered good. Conse-
quently it is good to look for the means necessary for
subsistence (food, shelter, etc.) and evil to take one's
life or endanger it (e.g., homicide, or torture).
b) Because of that natural inclination which he has in
common with animals, man tends towards sexual
communication for reproduction. Therefore, whatever
accords with his animal nature is good (the right use
of sex, formation of a family, education of children, etc.).
On the contrary, whatever deviates from or incapaci-
tates sexuality (homosexuality and in general, all sexual
perversions) is evil.
c) Being a rational creature, man seeks to know God, seeks
the truth, lives in society together with other men,
perfects himself in the image of God, and so forth.
Therefore, to adore God (religion), serve others, culti-
vate the spiritual faculties, practice virtues ... , are good.
On the other hand, to reject God, tell lies, hate, be selfish,
give in to vices, remain in ignorance ... , all these are evil.
As these principles are quite general, it is necessary to
concretize and derive more proximate and immediate conclu-
sions. This requires the collaboration of the so-called moral
science. This science deduces without resorting to complex
reasoning concrete basic principles known as primary principles
of natural law.
Thus, for example, logically deduced from the universal
principle of conserving life or avoiding harm to anyone, are:
not to kill the innocent, not to do violence, not to steal, helping
the needy, not to covet the neighbor's wife, and so on. Obviously,
these are concrete cases to which the general principle is applied.
Uninfluenced by prejudice, human reason can deduce them
easily.
These derivations show that the primary principles of the
Natural Law coincide substantially with the contents of the
Decalogue revealed to Moses on Mt. Sinai (Ex 20:2-17; Deut
21
and in itself is immutable. Its precepts have a perma-
nent value, independent of the circumstances of time
and place.
"The basic obligations imposed by the moral law
are based on the nature of man and its essential re-
lations. Consequently, it is valid everywhere, wherever
man is found" (Pius XII, Alloc. April 18, 1952). That
is why, for example, some things will always be evil
"in the essential relations between God and man,
between men, between couples, between parents and
children; in the essential relations within the commu-
nity, in the family, in the Church, in the State. Therefore,
among other things hatred of God, blasphemy, idolatry,
apostasy, perjury, homicide, false witness, slander, adul-
tery, fornication, wrong use of matrimony, solitary sin,
stealing and robbery, deprivation of basic necessities of
life, unjust wages (Jac 5:4), hoarding of goods and
overpricing of basic commodities, fraudulent bankruptcy,
unjust manipulation in the act of speculation-all these
are gravely prohibited by the Divine Legislator" (ibid).
The Second Vatican Council, after having enumerated a host
of similar acts (abortion, euthanasia, mass suicide, torture,
arbitrary detention, slavery, white slavery, subhuman working
conditions, etc.), concludes forcefully: "These and other similar
acts are in themselves dishonorable, degrade human civiliza-
tion, dishonor the perpetrators as well as their victims and are
contrary to the honor due to the Creator'' (Gaudium et Spes,
no. 17).
The immutable character of the Natural Law has been
recently recalled by John Paul II: "the law which is inscribed
in the heart of man expresses the immutable demands of his
personal being, as created by God ... , it does not solely contain
general orientations and its specific applications as conditioned
by distinct and changing historical situations. It also contains
moral norms with precise, immutable and unconditional
contents. "
2
2
Cfr. John Paul II, Speech at the International Congress of Moral Theology. (April
7-11, 1986) L'Osservatore Romano, April 11, 1986.
23
Can Natural Law Change?
This question is proposed by many today. Many argue that
human progress is constant in order to limit the universality
and immutability of the Natural Law.
Twentieth century man insists that he is quite different from
his medieval counterpart. Thus, the norms that govern his life
ought to be different. Man, indeed, has progressed. He is an
intelligent being undergoing continuous formation. But nature
does not change. Man remains the same with the passing of
time. The man who invented fire or the wheel is the same
substantially as the man who pertains to the atomic era. Love,
loyalty, veracity ... hatred, treason, deception ... are attitudes
constantly found in human nature. Cardinal Danielou said
during the VII International Thomistic Congress that what
distinguishes men of different eras is accidental. It would be
silly to say that modern man is more intelligent than Plato,
more ingenious than Dante, or more holy than Augustine of
Hippo. Although the external differences are enormous, what
is specifically human-the intellect and the will-is permanent,
and accounts for this continuous progress since ten centuries
ago.
Nevertheless, man's historical character also affects the
Natural Law. The Natural Law, in itself, does not change. What
may change are the conditions for its application. Man's
understanding of this Law may also change. In fact, there may
be deletions (some principles are forgotten) as well as additions
(e.g., moral conscience acquires a greater depth) . For example,
remember that for a long time, slavery was reputed to be
something natural (a result of the obscuring of the natural law
by original sin). On the other hand, interest on loans was
condemned because it was confused with usury. In this latter
case, there was a change in the subject matter of the Natural
Law. However, these events are not really serious obstacles
to the Natural Law as long as they are properly understood.
It simply confirms that even if the Natural Law is immutable,
its knowledge can still be obscured. Nor does its immutability
contradict its historical character in so far as it is destined to
be applied constantly universally to all men of all times (Cfr.
Instruction of the Congregation of the Doctrine of the Faith, February
2, 1956).
24
5 Human Freedom
It is presumed that one admits the existence of human
freedom whenever one talks about human acts, conscience,
morality, etc.
Perhaps human freedom has never been discussed so much
as in our time. We refer to it in order to justify any mode
of action, no matter how foolish it may appear.
But this, in itself, induces us to think that not all definitions
of freedom are correct.
Various Concepts
Some authors, past and present, even negate the existence .
of freedom. Man, for them, always acts by necessity. Freedom
as we call it is none other than man's awareness of that necessity.
With this supposition, man would be bereft of freedom and
would then be determined by:
mechanisms, common to all material beings, particularly
the neurophysiologic process
economics
the dominant culture
the language structure
the socio-political structures, etc.
This hypothesis envisions man from a materialistic perspec-
tive. It reduces human behavior to the analysis of responses
to certain stimuli (Nee-Behaviorism Theory).
Other modern theories on freedom are summarized as
follows:
a) Freedom is reduced to the capricious spontaneity of the
instincts. According to this theory, one has to negate
the conscious control of behavior since the rational
motives that seek to direct cond'.lct are merely super-
ficial.
b) Freedom consists in doing what one wants, as long as
one does not violate the freedom of the others. Norms
or objective valid ends are negated if these are superior
to the "I."
c) Freedom is the capacity to choose at every moment any
possibility even if it contradicts previous choices.
Therefore, to feel free can also mean withdrawing from
commitments that bind or limit freedom.
Consequently, any commitment of self-giving would mean
a loss of freedom.
Its Existence
To deny freedom is to deny moral duty and responsibility.
When one does not accept freedom, it becomes useless to talk
of guilt, crime, delinquency, punishment, repentance, respon-
sibility, etc. The truth is that man possesses freedom as a
distinctive characteristic of his nature. Experience shows man
to know that he is master of himself. He has the capacity to
decide whether to act this way or that. This is exactly what
freedom is.
As to the rest, faith confirms what personal experience
undeniably demonstrates: "God created man free. He left him
to his free decision," says Scripture (Eccl 15:14). Church
Magisterium teaches that freedom is "truly an exceptional sign
of the image of God in man" (Gaudium et Spes, no. 17); it is
"the highest good of human nature" (Pius XII, Alocution, April
10, 1958) and that "human dignity, therefore, requires that man
act according to his conscience and free will" (Gaudium et Spes,
no. 17).
1
The following statement is made whenever confronted with
false theories on freedom:
a) Freedom exists as proven by the immediate experience
of our free acts. In fact, man can make decisions that
transcend time and place, or that modify economic, socio-
political, cultural systems, etc.
1
Cfr. Instructions of the Congregation for the Doctrine of the Faith. Christian Freedom
and Liberation. March 22, 1986. This makes for a profound analysis of the matter.
26
b
b) Freedom is not pure, whimsical spontaneity. It is related
to man's acquired knowledge of things. According to
his greater or lesser knowledge, man can be more or
less free. Therefore, he who is bereft of reason cannot
act with freedom. He, therefore, is not responsible. This
group includes infants, the insane, the hypnotized, and
so forth. Likewise, the ignorance of those who do not
know the good that ought to be done or the moral law
is opposed to moral freedom. Nevertheless, culpable
ignorance does exist. There are persons who do not want
to know so as not to feel responsible.
c) Moreover, freedom is more than the capacity to choose
spontaneously with creativity, self-possession, self-
control, and self-mastery. All these aspects are quite
important. But freedom, properly speaking, consists in
the dominion of the will over its acts. In fact, freedom
is defined as the capacity of man to act or not to act,
to act this way or that way. Therefore, freedom is one
of the properties of the human will.
d) Although man is a temporal being immersed in time
his free decisions transcend time. Therefore, he can
determine the future (i.e., keep promises), and modify
the past (e.g., repent).
e) Freedom is closely related to responsibility, i.e., to
account for the things that we do. Responsibility is not
an external limitation of freedom. On the contrary, every
free decision ought to be responsible. There is mutual
correspondence between the two; they cannot be iso-
lated from one another. Morally speaking, therefore, one
cannot demand responsibility where there is lack of
freedom. Neither can freedom exist without responsi-
bility.
f) Though human freedom is not absolute, it nevertheless
exists. Indeed, in order to be completely free, the human
individual needs the help of others, most especially God.
This is what is meant by the expression: freedom
is conditioned.
Therefore, one can say that man is a "complete" being
or a being with an "end," a destiny, given by God. That
end is summarized as: TO LOVE GOD AND ALL MEN.
The fullness of freedom is only reached when one accepts
the plan that God has designed for him. On the contrary,
27
man is not free when he directs himself to his egoistic
end. This is because it negates the transcendental
meaning of his life. He may rebel-man is the only
creature who can do so-against God's plan. This would
be a sign of freedom, but it leads to damnation.
"In fact, man decides for himself whether or not to
obey reason, seek the moral good, direct himself to his
ultimate end. He may choose the opposite direction,
deceived by an apparent good. In this way, he disrupts
the natural order and voluntarily plunges himself into
an inevitable ruin" (Leo XIII, Enc. Libertas Praestatis-
simum).
g) According to some philosophers, another dimension has
to be added to the concept of freedom as something
granted to us. It is that which accompanies nature (free
will)- it is the so-called "MORAL FREEDOM." It is that
freedom which man acquires with the practice of moral
virtues. One achieves self-mastery after struggling to
acquire the moral virtues (prudence, loyalty, optimism,
joy, generosity, ... ) It is also the result of mastery over
one's passions. This does not signify suppression,
because that would be impossible. It means not allow-
ing oneself to be "carried away" by his passions. Self-
conquest, i.e., having greater moral freedom, demands
an innate capacity for self-determination which pertains
to the faculty of the will. Moral freedom is impossible
without free will. Relying on the free will, possessing
it naturally as man does (in the most adequate and logical
sense), we naturally exert the effort to achieve and perfect
moral freedom. To proceed otherwise is to exercise
freedom in a certain way. However, it would not be
the best way nor the most intelligent way of exercising
freedom.
2
In fact, even with God's help, human freedom is
confronted with grave psychological obstacles and
external influences (fear, violence ... ). These could
diminish in some way or even eliminate human respon-
sibility. In the course of medical practice, the so-called
limit-situations or the "limits of freedom" in some
situations could arise.
2
A. Millan Puelles. Lexica filos6fico. (Lexicon of Philosophy). Rialp, Madrid 1984,
p. 405.
28
6 Moral Determinants
of Human Acts
Morality constitutes a peculiar dimension of human acts.
It is a prerogative of the dignity of our nature as spiritual and
free. For example, one can never qualify the behavior of animals
as moral or immoral. Whenever one talks of morality, one always
considers someone who can plan and direct his behavior freely.
Nevertheless, this does not mean that man creates the moral
norms.
Anyone can easily understand what is meant by the state-
ment that a person is good or bad. He is a good professional.
He is a bad person ... But, how do we determine whether an
act is good or bad?
Morality is usually defined as the conformity or disagree-
ment of the human act with the moral norms. The norm pertains
to reason (as we have already seen, when we studied the natural
law). For a christian, it is known as the Law of God, the Law
of Christ or the Evangelical Law.
Object, End and Circumstances
Human acts are composed of different elements. These are:
the act itself, the end pursued by the subject or the intention
that moves him, and finally, the circumstances that surround
the action which can modify the other two elements.
Thus, there are three elements to consider whenever judging
the goodness or malice of a human act. They are the object,
the end, and the circumstances. Some authors term them as "sources
of morality."
a) The object is the primary and essential element. It is what
is actually pursued by the act itself. For example, to
take possession of another's property is the object of
stealing. To shorten the life of a patient is the object
of euthanasia. To honor God is the object of the cult
of religion, etc.
By their object, acts can be good (to work, to build
friendship ... ), evil (to take possession of another's
property, to abandon a dying patient...) or indifferent (to
walk, to sleep, to read ... ). Indifferent acts are converted
to good or bad acts depending on the intention of the
subject.
b) The end of the moral act is the objective proposed by
whoever acts. It is the principal intention of the subject
who acts. Without it the act will not be carried out.
Whenever one does something, one always does it for
a motive. Thus, one can serve the others or work for
one's own personal glory.
c) The circumstances are those accidental aspects of the object
or of the intention of the subject that affect in some way
the goodness or malice of the act without modifying
its substance. Some affect the moral object (time, place,
quantity or effects); others, the subject who acts (who
he is, in what manner, the means used, the motives).
Moral Principles
From what we have just said, the fundamental moral
principles of greater interest are summarized as follows:
a) The object is the primary and essential element of the morality
of an act. It is independent of the intention of the subject
at the moment of acting. For example, to help an accident
victim is good in itself, regardless of the intention of
the helper. To give alms, in itself, is good even if done
out of conceit. To shorten the life of the patient is bad
in itself, though motivated by pity. Therefore, the first
condition for an act to be considered good is that the
object must be good. Some think that what is truly impor-
tant for the morality of an act is the rectitude of intention,
understood as a principle that does not influence the
object. In this way, one who performs abortion with
a good intention (to save the life of the mother) believes
that his action is morally good. This erroneous doctrine
is called "the morality of intentions." It is a doctrine
which sustains that the good intention of a certain act
is a sufficient reason to qualify the act as something
good.
30
This means that the morality of acts which are good
or bad, in itself, cannot change with the intention of
the subject. Pius XII refers to this type of acts in his
well-known text (cfr. immutability of the natural law).
b) When the object is morally indifferent, the morality of the
act is determined primarily by the intention and/or by the
circumstances.
What is in itself indifferent (to take a walk, to read)
will receive its morality from the intention or the
circumstances that accompany it.
c) The principal end or intention of the subject can convert an
act whose object is indifferent into a good or bad act. An
act which is good in its object can become more or less good,
or even bad. And a bad act can become worse or better, but
never good.
"The end does not justify the means" is a funda-
mental moral principle based on the Apostle Paul's
affirmation: "Let us not do evil in order to obtain the
good" (Romans 3:8). Therefore, stealing with the "good"
intention of giving to the poor is illicit. So is steriliz-
ing a woman that she may not have more children to
feed.
d) The circumstances cannot convert a good act into some-
thing bad or vice-versa. They, however, can increase or
decrease, per accidens, the goodness or malice of an act.
Thus, to steal is always evil. The sin, though, is pro-
portionate to the amount stolen. The gravity of slander
depends on the person who slanders and the extent of
its spread.
e) From what has been said it follows that for an act to
be good, its object, end and circumstances have to be
good. Nevertheless, an act is evil if any of these ele-
ments, namely, object, end or circumstances is evil.
31
7 Cooperation With Evil
Am I Responsible Only For My Own Action?
Man is a social being. He acts within a network of inter-
personal relations because he needs others to perfect and develop
his personality and improve his work. Therefore, he is morally
responsible not only for his actions but also for the good or
evil influence of his actions upon others. The primary principle
of the natural law, "Do good and avoid evil" can be considered
in its wide sense. Do good and do not influence others to do
evil. Help others to do good.
In this regard, we refer to the obligation of everyone to
cooperate with the good, to help others in their work and in
the practice of virtue, etc. For example, a healthcare profes-
sional who works well, gives good advice to and encourages
a patient in crisis is exercising positive cooperation. The duty
to cooperate in a good action ought to lead christians to
contribute with all their might in making the vivifying prin-
ciples of the Gospel become present and imbue all fields where
they act. This includes their professional work (cfr. Vatican
Council II, Apostolicam Actuositatem, no. 16). They must flee from
positions limited to personally avoiding bad actions and
distancing themselves from the influence that those deeds can
have on the rectitude of other people's actions.
An honest professional man ought to ask himself if he is
doing the right thing when he cooperates in another's sin. In
other words, he must ask if there are circumstances in which,
without ceasing to act rightly, he can allow his actions to be
used by someone for a bad purpose. That is why it is good
sometimes to pray with the Psalmist: "Forgive the fault of your
servant in the sins of others" (Ps 18:13).
But specific situations can also arise in which a professional
man- willingly or unwillingly, directly or indirectly-can be
cooperating in the evil that others perform.
For example, christian nurses work in private clinics or
government hospitals where their colleagues disregard the
ethical norms on procreation, right to life, etc. and perform
tubal ligation, vasectomy, abortion, etc. This would also apply
to medical, paramedical and non-medical personnel (nurse aides,
public relations officers, maintenance personnel, etc.) who work
in medical centers.
The immediate question is: should all forms of cooperation
be denied? Or under what conditions can some type of coop-
eration be allowed? This is a classical topic in morals.
Notion and Types of Cooperation
The notion of cooperation in evil is broad. It includes all help
given to the evil act of another. It includes different modalities:
for example, to command or advice another to commit an illicit
act; to sell a good object which will be used for an evil act.
Cooperation with evil is classified according to various
criteria:
a) Positive and Negative Cooperation
Positive cooperation signifies a voluntary act which
contributes to the evil act of another (for example, an
instrument nurse assisting in a sterilization procedure).
Negative cooperation consists in an omission (like
allowing another person to do an evil one could and
ought to have done something about to stop him, either
by restraining, warning, denouncing, a thief's act of
stealing).
b) Formal and Material Cooperation
Cooperation with an evil act is termed "formal"
when one wills or consents to the evil act of another
in its ethical malice, whether or not the agent of the
evil action knows about it. It is termed "material" when
cooperation with the evil act of another is through a
physical act, without willing or consenting to it.
Therefore, in the latter, one cooperates with the evil act
but not with the evil intention.
34
)
d)
' terL
Firs

:.....::ctt. I

Sec<
p erc:
::::.1en ti 0
-- Paul
_ -ot onl
_ seeir
WhE
cersons
::::'e IDOl

Thir ,
_e mu
Decific
order
:laiiD.
c) Immediate (or Direct) and Mediate (or Indirect) Cooperation
Cooperation is immediate or direct when it coincides
in the same act as the one committing the evil act. For
example, to assist a robber to load a stolen object, or
to act as first assistant to a surgeon performing a steri-
lization operation.
Cooperation is mediate when one provides the means
utilized by another person to do evil. However, in itself
the means does not have any necessary relation with
such act. For example, to sell weapons which are later
used in committing homicide, or to hand over a syringe
which is used by another to "inject himself."
d) Proximate and Remote Cooperation
One may also speak of proximate and remote coop-
eration according to a greater or lesser physical or moral
proximity between the act of cooperating and the evil
act of another.
Criteria For Judging the Morality of Cooperation
First, every cooperation which directly influences the evil
intention of the person with whom one cooperates, is always
illicit. In fact, it is a scandal to incite others to do evil, and
should never be done.
Second, formal cooperation is always illicit. The reason:
cooperation not only affects the evil act; it also affects the evil
intention by approving the mode of action of the other person.
St. Paul teaches: "He who does such things are worthy of death.
Not only those who do it; likewise, those who find pleasure
in seeing it accomplished" (Romans 1:32).
When cooperation is given simultaneously by different
persons, all are culpable. However, the principal cooperators
are more culpable than the secondary or accidental coopera-
tors.
Third, in general, simple material cooperation is also illicit.
One must not help any one to do evil. Nevertheless, in certain
specific circumstances it may be licit to cooperate materially
in order to obtain the necessary good or to avoid a more serious
harm.
35
Ethical judgment regarding the licitude of material coop-
eration in the evil act of another has to be made in each case.
One has to take into account the principle governing acts with
side effects (Principle of Double Effect) (cfr. above).
One encounters many situations in daily life in relation to
cooperation with evil. Here are some examples:
cooperation in political activities (citizens who support
political parties that violate human rights, defend
abortion, etc.; delegates who vote in favor of civil laws
which contradict the natural law ... )
cooperation in the sale or marketing of weapons, drugs;
cooperation in tax crimes
cooperation in the entertainment world, press, maga-
zines, ownership of moviehouses, attendance to lewd
shows, etc.
But those which are of more interest to us are those which
arise in the health care professions. We shall cite some of these.
Nevertheless, we forewarn that with a view to resolve them,
it would be wrong to present them by seeking but a minimum
of fidelity to moral principles (the value of human life, the real
meaning of sexuality, etc.). Such attitude would be ab initio
vitiated, because one is obliged to positively defend life, the
truth and the good, etc. and avoid anything that could go against
these values. With this caveat, let us indicate some specific
examples, pointing out also the moral principles apropos possible
cooperation in each case.
Some examples
a) Materially writing down some prescriptions:
What happens when a nurse, by doctor's order, writes down
prescriptions for contraceptives upon request of patients who
do not want to have more children? This is a case of material
cooperation, which is remote and mediate, that could be licit
in certain circumstances.
1
Nevertheless, it would be advisable
1
A. Peinador, Moral Professional. (Professional Ethics). BAC. Madrid 1969, nos.
445, 755 and 757.
36
:.u.
of
_-\. siJ
~ r i o n
- ed,
" gtl
nly
Jl thE
.::: ST:
~
...::. _-oN
that the nurse, though she cannot argue it out with the doctor
show her disapproval of the matter, remove all possible scandal,
etc.
b) I.U.D. insertion:
In some hospitals, the IUD is inserted by the physician
assisted by a nurse. As previously mentioned the device prevents
pregnancy by the mechanism of reaction to a foreign body in
the uterus. (Cfr. p. 140) Pregnancy is prevented by causing
abortion within the few hours or days after fertilization by
impeding the implantation of the embryo into the uterine wall.
The abortive effect is added to the contraceptive one. This is
why a christian nurse must not contribute to this end with
her cooperation. One is dealing with an act that is exclusively
directed at sterilization, which, besides, results in the destruc-
tion of life.
c) Sterilization:
A similar thing happens during the performance of ster-
ilization procedures (e.g., vasectomy, tubal ligation) in the
operating room. Another physician or a nurse is often asked
to assist. Frequently, they are asked to assist in a normal
caesarean operation. Now some gynecologists abuse the
procedure by proceeding routinely to bilateral tubal ligation
when they have performed more than one caesarean operation
on the woman. Clearly, a christian nurse cannot be an assisting
instrument in such sterilization procedures. However, the nurse
may find herself assisting, for not having been previously
notified, a surgeon who proceeds to perform tubal ligation
during the caesarean operation. In this case, the nurse would
be only unethically cooperating.
In these cases, it is important to emphasize that "PREVEN-
TIVE STERILIZATION"- for the purpose of preventing any
pregnancy which could definitely aggravate some diseases-
is NON THERAPEUTIC. Pregnancy and the subsequent
aggravation of the disease are not consequent to the abnormal
functioning of the reproductive organ, but to the VOLUNTARY
AND RESPONSIBLE ACT of conception. A document of the
37
Congregation for the Doctrine of the Faith (L'Osservatore Ro-
mano, December 12, 1976) regarding sterilization in Catholic
hospitals affirms that PREVENTIVE STERILIZATION IS
DIRECT, and therefore, absolutely prohibited.
With regard to material cooperation, the document recalls
the traditional doctrine which makes a distinction between
necessary and free cooperation and proximate and remote
cooperation, which ought to be applied in the most prudent
way, as the case may be. In the case cited, it is quite clear
that even if direct sterilization were imposed in an official way,
or were included in the statutes of the hospital, one may and
ought to refuse even immediate material cooperation. The reason
is that it deals with something intrinsically evil.
Nevertheless, one may encounter cases wherein presumed
material cooperation may be permitted. The obstetrician may
decide on his own to perform tubal ligation during routine
caesarean section without previously informing the nurse or
the patient's husband. The nurse thus finds herself assisting
in the operating room. In these cases, too, she has to avoid
scandal as well as the danger of doctrinal confusion by
explaining to the obstetrician her moral stand.
d) Infertility Studies:
In infertility studies, the male patient is often advised to
collect his semen through illicit means (commonly by mastur-
bation). The nurse collaborates by explaining the procedure to
the patient.
The Magisterium of the Church has made clear her stand
in this regard. It does not present any moral objection to the
study of infertility, i.e., the analysis of the semen, per se. What
prompted the intervention of the Magisterium is the way of
obtaining the semen. She declares the following methods as
illicit, namely masturbation, onanism and contraceptive tests.
In the July 24, 1929 document, she affirms that directly caused
masturbation in order to get sperm for diagnostic and thera-
peutic purposes is not licit. Pius XII reaffirmed this doctrine
in an address to the International Congress on Fertilization and
Human Sterility in 1956. Recent Magisterium has maintained
the same stand-against the opinion of some theologians. In
view of all this, a catholic evidently cannot cooperate by advising
38
or explaining the procedure of obtaining the semen through
illicit means.
e) Abortion:
The evil of abortion (i.e., unjust deprivation of the life of
an innocent being, cfr. p. 49 ff) is of such gravity that in practice
it is very difficult to justify whatsoever any cooperation in the
act. Proximate cooperation is always illicit. For example, to
collaborate in its performance in the operating room (anesthet-
ist, the instrument assistant). Indirect material or mediate coop-
eration may be considered licit only in those truly exceptional
cases. This would be the case in countries where abortion is
allowed by civil law while the right of objection of conscience
is denied. In some the right is recognized only in theory but
in practice the person who refuses to cooperate suffers grave
consequences. The Cardinal Vicar of Rome issued a note in
this regard on June 6, 1978: "Mediate material cooperation in
the preparation and performance of abortion may be permitted
if and only when the refusal of collaboration upon invoking
the objection of conscience on the part of the members of the
health personnel (i.e., medical staff, paramedical personnel, other
persons involved in the health care) results in harm propor-
tionate to the cooperation required."
The seriousness of abortion demands that the harmful con-
sequences be definitely serious, and that it is not possible or
becomes very burdensome to find a solution after. Otherwise,
that possible cooperation should not even be entertained since
one can and ought to have recourse to lawful means in order
to clearly and openly oppose cooperation in the crime of
abortion.
39
Part II
Concrete Ethical Problems
Duties Toward the Unborn
Abortion
Respect for the Suffering Patient
Drugs
Duties Towards the Dying Patient
Bodily Integrity
Sexuality: At the Service of the Person
Artificial Fertilization
Eugenics
Human Experimentation, Medical Progress
and Research
Telling the Truth to the Patient
Professional Secret
Integral Approach to Patient Management:
Humanizing Medicine
Spiritual Care of the Patient
1 Duties Toward the Unborn
The medical profession is always at the service of life. The
Hippocratic Oath reads: "I will not accede to pretensions that are
directed to the administration of poison nor induce to anyone
suggestions of the same kind. I will abstain from administering
abortifacients to women."
The defense of life is a problem of pressing relevance. If
one considers the constant aggression on life that we witness
today, life about to be born (abortion), life that is already
consolidated (violence, terrorism, war), life that is on the decline
(euthanasia), one immediately appreciates that we are dealing
with a subject of utmost importance.
Life: A Fundamental Good of the Person
In the natural order, human life is a gift that is so great
and so full of possibilities that everyone values it. For a person
with faith, "Human life is sacred from its inception as it comes
directly from the creative power of God."
1
It can then be affirmed
that the cornerstone of a society humanized by christianity is
built on the affirmation of the primacy of life under all circum-
stances (cfr. Paul VI, Alloc. July 12, 1972). Life is a fundamental
good of every man converting him into an owner, a possessor
of a fundamental right. Man is not the absolute owner of life;
he is but its steward. That is why he cannot take it away from
himself; thus, suicide is illicit. However, in the eyes of men,
man has dominion over his own life. This means that neither
the State nor society nor any individual has the right to attempt
against it.
The Fifth commandment of the Decalogue-Thou shall not
kill-is the synthesis of those duties referring to life and to
the integrity of the human body; it has much to teach. Until
such time when a man becomes culpable, his life is "untouch-
1
John XXIIT, Enc. Mater et Magistra, May 15, 1961, no. 194.
able." Consequently, all acts that tend directly to its destruction
are illicit, whether such "destruction" is an end or solely a means
to an end, or whether it deals with embryonic life in its full
development or life reaching its terminal stage.
2
Only when an individual becomes a real threat to the life
of others, that is, when he is found to be in a situation ju-
ridically called "Unjust Aggressor," is it justified to eliminate
his life in defense of one's own in the absence of other effective
means. This is the "Principle of Legitimate Defense," some-
thing universally accepted. Regarding those cases of "Capital
Punishment" and the so-called "Just War," authors customarily
find the justification in the demands of the common good and
when it is the sole means of defending one's own existence.
As regards the moral justification of these exceptions and the
problems that they bring up today, we will not discuss them
because this does not enter into the sphere of this book.
Nevertheless, we would like to point this paradox: at a time
when the abolition of the death penalty or capital punishment
considered justly as an achievement of human progress and
war meets with aversion everywhere; when those data seem
o tify that the conscience of contemporary man has become
more sensitive to actions against life, we witness a fact that
radically contradicts this: we refer to the death penalty decreed
against an innocent person by definition: the unborn. Abortion
is, in fact, quantitatively (as we will see it right away) the gravest
attempt against human life.
Rights and Duties Towards Human Life
From the moment of its conception, human life is the subject
of rights and duties united inviolably to the person. The "right
to life" is at the same time an obligation. From both derive
other rights and duties which are translated into demands of
the dignity of human life. Let us consider firstly the obligations
of man towards his own body.
2
Pius XII, Alloc .. o v ~ -- --:- ~ _ - _ , Pio XII y los Medicos (Pius
XII and the Ph:y"Sician
1
. ~ :- . 23-24.
~ e
refi
Ad
::
At
e
c::: Sui
oh
ad
as
Tht
an<
~
Tht
ace
me
In
COt
foe
ph
ize
- _. :J.S tifie
Thed
=nfessior
=- ; or at1
- edical a
:: is al
_ eir faitl"
a) Obligation with Respect to Corporal Life
The duty of bodily care comprises a set of specific obli-
gations and corresponding rights. In summary they are:
1) Healthy and sufficient nutrition in order to conserve and
refurbish bodily energy.
2) Adequate clothing.
3) A dignified dwelling place which is at the same time
the field and center of one's home.
4) Sufficient hours of sleep and rest, in order to restore
physical and mental strength. Rest is also achieved by
a change of activities, e.g., hobbies, physical exercise such
as walking, gymnastics, sports, games, reading, etc.
5) The obligation of observing hygienic practices to avoid
and prevent health hazards and diseases.
6) The obligation to obey traffic regulations to prevent road
accidents. This is one of the most frequent causes of
mortality in the developed countries.
7) In general one should avoid all forms of excess that
could be detrimental to health like over indulgence in
food and drink, use of drugs and substances that have
physical and psychiatric side-effects (abuse of tranquil-
izers, narcotics, tobacco, etc.).
b) Justified Risks to Life or Health
The duty to preserve and protect life is not absolute. At
times, it is subordinated to the fulfillment of higher duties, for
the glory of God and the service of others, i.e., non-transferable
professional obligations. In these cases, there exists the right
and also the duty to accept death or gravely risk one's health
or even life. Such is the case of the exercise of some high-risk
professions (firemen, policemen, and so on); mountain rescu-
ers; or attending physicians, nurses, and so on when giving
medical attention to contagious patients during epidemics, etc.
This is also the case of christian martyrs when they profess
their faith.
47
Attempts Against Human Life
The Fifth Commandment known through Natural Law and
promulgated by Divine Revelation on Mount Sinai, affirms
emphatically: "Thou shall not kill" (Exodus 20:13). This precept
includes all attempts against human life whether it be one's
own (suicide) or another's (homicide). Abortion and Euthanasia
are qualified forms of homicide. We will discuss them later.
All interventions which endanger life without a just cause,
likewise, constitute a negative attempt against it. One may
certainly have grave reasons which justify the risk to one's life
or health as we have already enumerated. In order to evaluate
adequately, one must consider the need for taking action, its
end, the contingencies and gravity of the foreseen risks, and
so on. This may justify the licitude of some surgical operations
or transplants.
48
2 Abortion
Notion
Abortion is defined clinically as the expulsion of a non-viable
fetus before the twenty-eighth week of gestation, i.e., when
survival outside the maternal womb is impossible. This period
has been reduced today because medical advances have lowered
the limit of viability. There are already cases of 20-week fetuses
born alive with favorable evolution. When the fetus is already
viable, we call it premature delivery. But what really charac-
terizes abortion from the moral standpoint is not so much the
premature expulsion of the fetus but its death. Logically, when
the fetus is not viable, its expulsion is always followed by death.
Forms
It is interesting to know the terminology used when consi-
dering abortion from the medical, legal or moral point of view.
a) From the medical standpoint
1) Spontaneous, accidental or involuntary abortion is that which
occurs during the first few days of gestation (also termed
ovular abortion) or later. It is usually secondary to
maternal or ovular pathology which cause alterations
leading to a defective development, even death of the
ovum. This is then expelled spontaneously. It does not
present any moral problem because, as we have said,
it is involuntary.
2) Induced abortion is that which is caused voluntarily.
We will discuss it here.
3) In medical parlance, the term "Therapeutic Abortion" is
sometimes used to refer to that which aims to eliminate
a real or presumed risk for the mother precipitated by
pregnancy. It is an inappropriate terminology. Some
authors confuse it erroneously v.ith the so-called indirect
abortion, from the moral standpoint, which we will
discuss later.
b) From the legal standpoint
What was solely of interest until recently was the so-called
criminal abortion, considered a grave crime in Penal Codes.
Today with the legalization and positive authorization of
abortion in some cases, things have changed.
A review of the legal proceedings of those countries which
have legalized abortion show some differences in modalities,
which can be observed upon reading the World Health
Organization (WHO) Chronicle of 1976. This chronicle sum-
marizes the situations in which the legislation of different
countries authorize the practice of abortion:
when abortion is authorized to safeguard the physical
and mental health of the mother;
when pregnancy is the consequence of rape or incest,
or occurs in minors;
when the mother contracts rubeola during a critical stage
of gestation (with consequent risk of congenital mal-
formation of the baby) or has been exposed to other
risks (e.g., certain drugs or ionizing radiations) which
can lead to defective fetal development;
when Down's Syndrome or other chromosomal abnor-
malities are diagnosed by amniocentesis;
when the parents are mentally-deficient and considered
incapable of adequately rearing a child.
Besides these indications, presumptuously based on medical,
eugenic or medico-social considerations, some legal organiza-
tions authorize abortion for socio-economic or simply economic
reasons. Having arrived at this point, it is interesting to retrace
the legal path that abortion laws have followed. They habitu-
ally and always start-this has been the initial entry in almost
all countries-by allowing abortion in certain, very exceptional
cases. These are the so-called "therapeutic abortion" (when the
physical or mental health of e mother is endangered);
embryopathies (when they foresee o sible lesions or malfor-
::::1atior
Girnin
Bu
::rreach
::-eason
_g-il
-=rus i1
All
::: ents.
:.: that
. m t<
e th
..: e m
Alt
:.."-l.at fr,
e stE
::: e elli
1
Fro
In
- indl
rr.direct
ThE
On
ght
bab
_: a cc:
pic

_...... e a
=- dy,
mations in the fetus), and when pregnancy is the result of a
criminal act: rape or incest.
But in reality with these apparently reasonable motives a
breach is caused in the legislative mechanism. Through it other
reasons are easily added. Finally, as what is actually happen-
ing-interruption of pregnancy is left for the mother to decide.
This is where the loophole in the law finally ends up.
All abortionist campaigns seek support in these lamentable
events. They seem to forget however that the "ordinary" abortion
is that which is practiced against a baby that would have been
born totally normal, fruit of a freely-willed sexual relation and
one that would not cause serious problems to the health of
the mother.
Although it may seem exaggerated, it is important to stress
that from legal interruption of pregnancy, sterilization is only
one step away, as is also euthanasia from sterilization. Then,
the elimination of being considered useless is not many more
steps farther away. Only time will tell if this won't be so.
c) From the moral standpoint
In this respect, what is only of interest is the classification
of induced abortion into direct abortion (directly induced) and
indirect abortion.
The first type is directly willed as the principal end. It
includes all types of induced abortion, in whatever presenta-
tion, from the evil called "therapeutic abortion" to criminal
abortion. Here, abortion is sought as an end or as a means
to an end: health of the mother, prevention of the birth of an
abnormal child, the need to uphold one's honor, etc.
On the other hand, indirect abortion is not wanted nor
sought directly. It is rather the consequence-accidental and
probable-of an operation intended to cure a gynecological
lesion, independent of pregnancy. For example, the extirpation
of a cancerous uterus in a pregnant woman, intervention for
ectopic pregnancy, or in general, what could follow the
application of medical therapy to the mother in order to directly
cure a serious disease. We will explain it later. In our present
study, we will refer to directly induced abortion.
51
Techniques of Induced Abortion
It is quite important to be acquainted with the techniques
currently employed to directly induced abortion. These tech-
niques are discussed below.
1) Abortion by Dilatation and Curettage (D&C) . Dilatation and
Curettage is an abortive technique of long standing. It
is still widely used in clinics. D&C is accomplished in
the period between 7 to 12 weeks of gestation, utilizing
a carved blade introduced through the vagina into a
previously dilated cervix until it reaches the endometrial
wall. The endometrium is then scraped carefully and
thoroughly until all embryonic or fetal remains and
surrounding placental tissues are removed. The proce-
dure is then completed with a detailed counting of fetal
parts. This eliminates the risk of infection or hemorrhage
for the abortant mother, should any tissue remain. D&C
is performed under general anesthesia.
2) Abortion by Caesarean Section or by Abdominal Hysterec-
tomy. Abortion is carried out in a similar fashion as in
any caesarean operation by which abdominal incision
is followed by extraction of the fetus from the uterus.
However, there is one radical difference: after the
umbilical cord is cut, the neonate is left to die without
resuscitation. Abortion of this type is undertaken during
the last trimester of pregnancy since no other technique
is available at this stage.
3) Abortion by Suction Technique. The communist abortion-
ists pioneered in this technique of abortion by utilizing
the suction apparatus. Later, the western abortionists
adopted it. Abortion is carried out by aspirating the
substances adherent to the wall and contained within
the uterine cavity by means of a potent vacuum suction
machine. The powerful suctioning force dismembers the
minute body of the fetus, detaches it, and mangles the
surrounding placental tissue. These lacerated tissues
easily pass through the rubber tubing and are then
collected in a glass bottle. Similar to curettage, the
abortion is completed by counting one by one all the
parts sucked out because retention of any tissue can
lead to infection or hemorrhage of the abortant mother.
52
a
~
- ..!i
in
or
0
it
be
to
th
hy
in
Abortion is easily accomplished within two minutes, a
factor which permits operation on a commercial scale
in the so-called "abortion" clinics. The suction tech-
nique guarantees death of the fetus at whatever moment
during the first to the 12th week of gestation (or 3
months). During this time its skimpy volume will permit
passage of the mangled parts through the 11, 12 or 13
mm. diameter of the cannula utilized, as the case may
be.
4) Abortion via Intra-amniotic Infiltration. About 10 to 300
cc of amniotic fluid is first extracted through an
abdominal puncture. This is followed by infiltration of
a 20% hypertonic saline solution or 50% dextrose of water
into the amniotic sac. This causes necrosis of the placenta
and saline intoxication of the fetus. The fetus eventually
dies within an hour. Abortion is completed with the
expulsion of the fetus at about 36 hours post-infiltration
of hypertonic solution. This technique carries a certain
risk of uterine perforation, not excluding the death of
the abortant mother on account of the passage of the
saline solution into the blood of the abortant. However,
it guarantees the death of the fetus of about 16 weeks
(4 months) gestation, period during which the amniotic
sac contains sufficient fluid to permit the lethal injec-
tion.
5) Abortion via Intravenous Infusion of Prostaglandin. Certain
classes of prostaglandins exert powerful effects upon
the contractibility of uterine muscles, whenever these
are infused slowly using the intravenous route. It
virtually takes effect within a few hours causing the
expulsion of the fetus. This procedure supersedes the
above method (4).
When one considers the ideal period when perform-
ing abortion by suction or by intra-amniotic infiltration,
one observes a brief interval from 12 weeks (3 months)
to 16 weeks (4 months) age of gestation-during which
it is difficult to abort. During this period, the tiny human
being has acquired sufficient mass, making it difficult
to suction as the mangled parts may not easily pass
through the tubing. Nor can one abort by infiltrating
hypertonic solution because there is not sufficient liquid
in the amniotic sac. Therefore, slow intravenous infu-
53
sion of prostaglandin is used by those bent on getting
rid of the unborn baby at this time.
Recently, a "new contraceptive pill," the so-called
RU-486 has been launched in the market. RU-486 is a
hormone antagonist which opposes the action of
progesterone, the hormone which initiates and sustains
pregnancy. Associated with prostaglandin, which
provokes uterine contraction, it expels the embryo from
the womb of the mother. Thus, we are dealing with
an authentic abortion. While the above technique is not
yet widespread, some abortionists advice the abortant
mother to wait until 16 weeks of gestation, when the
amniotic sac contains sufficient amount of fluid to allow
infiltration.
Abortionist Arguments and Their Criticism
The evil of abortion is universally admitted. No sane and
upright man would consider it as good in itself. However, the
question arises in cases where abortion may offer a possible
solution to the problems of a pregnant woman.
a) Pathological Conditions Affecting the Embryo
From the medical point of view, induced abortion may at
a glance, seem most "reasonable" in cases of fetal abnormality,
diagnosed intrauterine, with certainty, using modern technol-
ogy, e.g., biopsy of the chorionic villi, amniocentesis, or ultra-
sonography.
This dilemma creates a greater impact today compared to
the past when accurate diagnostic methods were lacking. The
parent's reaction is understandable in the face of a possibly
abnormal offspring, diagnosed with certainty, near certainty
or high statistical probability. The suppression of a new life
because it is defective is not the proper course of action. From
the medical point of view, one could resort to a good pro-
phylaxis, pre-natal or intrauterine therapy, where feasible, and
in extreme cases, rehabilitation. One can never directly induce
the death of an innocent being.
In a similar way, the outright rejection of the handicapped
person supposes a kind of racism of the "healthy," or in the
54
.:
phrase of Lejeune, "chromosomic" racism. This attitude could
bring grave consequences for humanity. (Hitler, prior to
extermination of the six million Jews, had been previously
convinced that they were inferior human beings.)
Christian doctrine casts new light on these dramatic cases.
Let us read an interesting text:
"The case is also difficult when one confronts the risk of
giving birth to a baby with grave congenital anomalies. We
cannot minimize the tragedy of the situation. But one cannot
claim for himself, even during these dramatic circumstances,
the right to suppress human life, no matter how defective the
child might be. Life is valued not for its normality nor future
productivity but for its intrinsic dignity. It has been repeatedly
affirmed that the presence of these unique beings in the midst
of a dehumanized and utilitarian society can and should help
in basing mutual relations upon due respect for all human
beings, which is more important than what they give or produce.
The competent authorities must create specialized educational
institutions for the education of these type of individuals, whose
needs exceeds the capabilities of their own families. We must
remember that during these circumstances, as in many others
during the course of our life, we will find ourselves face to
face with the mystery of suffering and evil, what is the mystery
of the Cross of Christ, which according to our firm hope leads
to the splendor of the Resurrection. The Christian attitude should
be to take up the cross of each day, led by the hand of the
heavenly Father."
1
b) Physical or Mental Health of the Mother: Therapeutic Abortion
It is quite surprising that the current permissive legislature
considers as an indication for abortion any pregnancy which
endangers the life of the mother. lt is quite clear that the
authorities, knowing the rarity of such circumstances, usually
include as "risks" to life anything that affects the physical or
even psychological health of the mother.
In fact, if ever the evil called "therapeutic" abortion were
justified in the past, it was only justified clinically. It was never
morally. Today, this eventuality no longer exists in as much
'Spanish Episcopal Conference. Note no. 17, October 4, 1974.
55
as medicine has advanced in strides. Those cases which present
the dilemma of saving the life of the mother at the cost of
the baby's life are now exceptionally rare. It will be enough
to cite two eloquent testimonies:
"Undoubtedly, pregnancy can occasionally aggravate the
maternal health to such a degree as to endanger her life.
Although frequent in the past, it has now become nil. Intensive
obstetric care has allowed many pregnancies to continue inspite
of complications."
2
With the passing of years and consequent progress in
Medicine, this statement has been reaffirmed frequently. Dr.
Botella in his declarations to the afternoon daily "Informaciones"
(January 27, 1983) assured that: "THERAPEUTIC ABORTION
NO LONGER EXISTS."
"The remarkable progress recorded by the medical sciences
in the last years has practically eliminated the dramatic clinical
dilemmas accompanying high-risk pregnancy, which confronted
the husband and the physician the mother's life or the child's.
Today, in fact, faced with these rare cases wherein there are
two imminent dangers, of death and sure complication of the
conditions of saving both, it is now possible to perform cardiac
surgery or use artificial kidneys without endangering the
concomitant pregnancy. This shows the inconsistency of many
arguments that are often adduced to support the Law on
Therapeutic Abortion, in cases, where they have no health
motive to effectively justify it" (Prof. Bompiani, Director of
Obstetric Clinic of the Universidad del Sacra Cuore de Roma,
1973).
Even in cases wherein pregnancy endangers the life of the
mother, it is never licit to perform abortion. Pope Pius XII made
the following declaration when the problem was presented to
him in the early 50's: "All human beings, therefore, including
the baby in the womb of the mother, receive the right to life
directly from God, and not from his parents, nor from his society,
nor from any human authority.
"Nobody, no human authority, no science or medical
indication, nor eugenics, social, economic or moral indications
can grant a valid juridical right to dispose of an innocent human
life directly and freely. Neither can anyone take a stand in favor
2
J. Botella Llusia. Cuestiones Medicas Relacionadas con el Matrimonio (Medical
Questions Related to Marriage), "Cientifico-Medica," Madrid 1965, p. 30.
56
= eli
an e1
direc
_?=:miss
The
ght
en
-=- nev
that
-:he
""5?ain
=-<
=-. l
of its elimination, if it were permissible, as an end or as a means
to an end. To save the life of the mother is a lofty goal, but
to directly kill her baby as means to achieve this is not
permissible" (Address, October 29, 1951).
3
The address provoked strong reactions such that somebody
thought that the Church could sacrifice in cold-blood the life
of the mother in favor of the child. This is not true. The Pope
immediately corrected this false interpretation: "The Church
has never taught that the life of the unborn child is preferable
to that of the mother. It is wrong to present the problem in
the alternative form: either the life of the mother or the life
of the child. No. Neither the life of the baby nor the life of
the mother can be suppressed directly. In either case, there is
but one requirement, namely to exert all efforts to save both
lives: that of the mother and that of the child.
4
The Pope stated quite clearly, Catholic doctrine that holds
that no one can directly attempt against the life of the fetus
in order to save the mother's life. This would be direct homicide
and is always illicit. An Episcopal Conference of a European
country* states it this way: "Catholic morals considers legiti-
mate any medical intervention even if it indirectly causes the
loss of one of the two lives. However, it can never allow the
direct killing of the fetus. Moreover, from another point of view
and with a christian outlook, the gift of maternity and the spirit
of faith has frequently given the mother sufficient confidence
in God in order to generously sacrifice her own life to give
birth to a new one" (Commentary on Abortion by the Spanish
Episcopal Conference, 1974, no. 16). To justify abortion for the
sake of the psychological well-being of the mother has little
basis. Psychiatrists know quite well that modern therapy can
solve any psychiatric problem precipitated by pregnancy.
Besides, they know that abortion has caused a lot of mental
disturbances. The World Health Organization has said: "The
women for whom abortion is justified are the very same ones
who carry the highest risk of mental disorders once abortion
is performed."
'Spain.
3
Cfr. S. Navarro, Pius XII and the Physician, Conclusa, Madrid 1964.
4
Cfr. ibid. p. 153. .
57
c) Freedom to Decide for One's Body
"My body belongs to me!;" "Our abdomen is our posses-
sion!" is the outcry of the feminists who consider the fetus
as a mere appendage of the mother's body which can be
extirpated according to her free decision.
The argument merely demonstrates a crass ignorance of
biological facts. The new human being in the maternal womb
possesses its own genetic apparatus distinct from that of the
mother. She may have the right to her own body but not over
the unborn who is already another being and not just a part
of her own. The rights and freedom of each individual end
where the rights of another begin.
d) Rape or incest
In cases of rape or incest, what is often adduced and stressed
to justify abortion is that the victim has been traumatized for
life. This may be true in some cases. Nevertheless, it has been
observed that conception seldom occurs following rape. Besides,
abortion does not necessarily remove nor reduce the trauma;
on the contrary, it increases it. But above all, to kill the innocent
child to atone for the fault of the father is always illicit. Referring
to this topic in a conference in front of a big audience (in the
auditorium of the College of Physicians of Madrid), Dr. Wilke
challenged his audience: "Who among you thinks or agrees
that the rapist should be punished by death?- No one answered.
"Then, why kill the innocent child?"
e) Birth Control
In order to curb the growth of the population, some do
not hesitate to advise abortion. They have gone to the extent
of shuffling demographic data to show that population growth
is catastrophic to the planet. We are dealing with a complicated
matter which can..11ot be discussed here. Suffice it to say that
including abortion in politics" makes it an
aberration at the very least. Logically, in the same way and
with the same materialistic assumption, one can also present
the possibility of "eliminating" old people when they cease to
58 .
be active and productive, incurable patients, the insane, the
abnormal, etc.
But most of all, the most recent studies of economists and
demographers, have banned-from the purely scientific point
of view-the Neo-Malthusian presumption that population
growth is an obstacle to development. Although some inter-
national organizations (The United Nations, FAO) remain
obstinate in this presumption, many authors have affirmed that
today "demographic growth and the economy are united to
common structural mechanisms such that in practice, the growth
of the population becomes a factor for economic developrnent."
5
Statistics show an alarming decline in the population of
the West for some years now. A journalist describes the situation:
"We are heading towards a Europe without children." It is a
well-known fact that many countries have gone below the
threshold of renewing their generations due to the decline in
fertility rate.
The involutive process started around 1964 in Northern
Europe and the Western Hemisphere. It has become acute since
1975 to present. The following statistics prove this reality.
It is calculated that to replace generations, the fertility rate
(average number of children per female) should be 2.1. 1987
data show many European countries actually below this index:
Germany, 1.5; Italy, 1.57; France, 1.82; Spain, 1.79.
Many demographers, economists, sociologists and others
have voiced their alarm. Appropriate measures should be taken
to ensure the growth of the European population. Otherwise,
we will all sink with the reduced number of young people;
Europe will be converted into a huge horne for the aged. And
it would not be strange that those who have pushed for so
selfish demography politics be the same ones to lobby for
euthanasia in order to cushion the aging that their own
rnalthusian policy had caused.
5
J. Chenais, La revancha del tercer mundo (The Revenge of the Third World). Planeta,
Barcelona 1988; Cfr. J.L. Simon, El Ultimo Recurso (The Last Resort), Dossat, Madrid
1986; A. Sauvy, Los mitos de nuestro tiempo (The Myths of Our Time), 2nd Edition,
Labor, Barcelona 1972; Id., Crecimiento Cero (Zero Growth), Dopesa, Barcelona 1973;
P. Chaunu, El Rechazo de Ia Vida (The Rejection of Life), Espana, Madrid 1979; J.M.
Casas Torres, Poblacion, Desarrollo y Calidad de Vida (Population, Progress and the Quality
of Life), Rialp, Madrid 1982.
59
f) The Risks of Clandes:ir."' Abor:ion
The argument is orrnulated this way:
Premise 1: Unfortunately, the cases of clandestine abortions
have increased to alarming proportions.
Premise 2: This is something the law can no longer ignore.
Conclusion: Therefore, it has become a necessity to legal-
ize this situation so that mothers "who need to abort" will have
access to sanitary facilities and therefore, avoid the "enormous
dangers" arising from clandestinity (substandard sanitary
facilities, poorly trained personnel, etc.).
Commentary: Except for a few cases, the latter is not true,
since clandestine abortion is usually performed in adequate
localities by highly trained personnel (physicians, nurses or
midwives).
It is important to know that, if the law ought to take into
account social reality, neither reality nor law itself are the
supreme instance. There are other laws superior to positive law,
e.g. law against murder or against arbitrary disposal of another's
life. Moreover, following the same logic, an ironical situation
could arise in which one has to legalize robbery, delinquency,
tax evasion and other existing crimes in society. Yet, once
legalized, their accompanying dangers would disappear only
for the authors of the law.
But, irony aside, one has to affirm that a government that
renounces the protection of the most important common good,
the right to life of the most unprotected beings (the unborn)
is totally incompetent. We are not confronted here with a law
of tolerance nor simple legalization but with a positive authori-
zation of evil.
On the other hand, it is quite surprising that in countries
where abortion has been legalized, it is observed that its
legalization has not at all diminished the incidence of clan-
destine abortions. We transcribe what the French sociologist
Alfred Sauvy affirms:
6
"The incidence of clandestine abortions has not diminished
according to the proportions forecasted by the proponents of
6
Mas datos acerca del aborto (More information regarding abortion), "Tribuna
Medica," July 9, 1971.
60
_-:;eat,
::::IlO\
:::.5eS I
- tim
.._ OSJ
pl
::ecaus1
info
- an t
As
e

:..andes
roxi
nun
3,60
:-000 c
::erlorrn
e 14
The
Som1
al
::::.e stron
:::egnan
trary,
- :-ell-kno
::Lght ct
:"<e lasH
=-.fuough
= "dB: "S-
G. Ca1
BL. Ho1
legal abortion; at times, it even has increased. This phenome-
non, already observed in Denmark, Sweden, and Japan, is now
repeated in the United States. This fact is explained by the
'removal of guilt.' Upon authorizing abortion in certain social
cases (limited salary, inadequate housing), it seems almost
legitimate to resort to the sa'me solution in quite similar
circumstances. Besides, when abortion is generally practiced
in hospitals, many women p r ~ f r to remain anonymous." For
example, in the United Kingdom, clandestinity is increasing
because of the required conditions. The wife would not want
to inform the husband of her pregnancy which is the result
of an extramarital relation, etc.
As a matter of fact, clandestine abortions do not always
decline with legalization. There are some revealing data. "In
Hungary, in 1950, there were 1,700 legal abortions and 34,300
clandestine ones. In 1965, with the permissive legislation, the
number rose to 180,300 and 33,700 respectively. In Japan, where
abortion has been legalized since many years ago, from 1950
to 1970, there were about 50 million abortions, of which
approximately 30 million were clandestine. In Czechoslovakia,
the number of legal abortions increased in ten years from 2,100
to 73,600, while clandestine practices remained stable at about
30,000 annually."
7
In France, in 1979, 155,000 abortions were
performed "officially" although the real number was 300,000
since 145,000 were- clandestine.
8
g) The Unwanted Baby
Some claim pregnancy by "mistake" as another motive to
justify abortion: Why keep an "unwanted baby"? Let us consider
the strong remarks of Alfred Sauvy: "The concept of "unwanted"
pregnancy does not always signify unwanted birth. On the
contrary, pregnancy could be the result of an unconscious will,
well-known to psychologists. On the other hand, the sentiments
might change consciously during the course of the pregnancy.
The lastbom, so-called the "Benjamins" are frequently spoiled,
although the majority of them were the least wanted." Sauvy
adds: "Studies comparing maternal relations with the wanted
7
G. Caprile, "Civilta Cattolica," March 6, 1976.
8
L. Homme Nouveau, November 16, 1980, p. 5.
61
and unwanted offspring, show that 90% of those maltreated
were products of a planned and desired pregnancy." Dr.
Lenoski-author of the study cited by Sauvy-selected 500
maltreated children and concludes that, after the discovery of
the "pill" (which logically reduced the incidence of unwanted
pregnancies), the number of abused children has increased
threefold. Besides, to impose as a condition on a human being-
to be loved or neglected in order to claim the right to life-
is indeed a dreadful idea because it follows logically that
someone who is "unwanted" can be eliminated."
h) Delayed Inception of Human Life
In order to justify abortion, many people still base their
arguments on what they consider as the "uncertainty of the
inception or beginning of human life." If in these initial phases
of embryonic development there is no certainty of th._e existence
of human life, what impedes its elimination when there are
motives for doing so?
We can call this position as medieval. Let us briefly review
history. In the Middle Ages, the Scholastics introduced the
question that was philosophical-theological in nature. It dealt
with the moment of the infusion of the soul into the body.
Two theories emerged: immediate animation (the fetus is ani-
mated at conception); and retarded animation. Basing it on
Aristotle, St. Thomas Aquinas defended this theory affirming
that the soul was infused into the body at a later moment:
40 days in the male and 80 days in the female. Thus, there
would be a phase in the development of fetus wherein it is
considered inanimate and therefore, not a person. If in case
its life is suppressed, the act would not be considered homicide.
This was the theory of progressive spiritualization. It was then
believed that the human spirit, or personhood was created at
40 to 80 days after fertilization.
It is important to remember that this distinction was a
question of a purely philosophical order: concretely, whether
the body was a "suitable" matter to receive the soul on the
first day of conception or later, as St. Thomas and the other
philosophers who followed Aristotle thought. It is then a
question for philosophical discussion of which the moral reason
is independent for two reasons:
62
: )
7e
:cept
'-I
- -OW
1) Even if retarded animation were assumed, human life
already exists. This life prepares and demands the soul's
infusion. This then will complete the nature received
from . the parents.
2) On the other hand, the probable existence of the soul
(the contrary will never be demonstrated) is sufficient
to consider taking away of life as accepting the risk of
killing a man-to-be, one already provided with a soul.
The moment of the infusion of the soul into the body is
not empirically demonstrable; it is a theological question.
Although the Magisterium of the Church has no solemn
definition regarding .this topic, nevertheless, we can say that
the doctrine on "immediate animation" is indirectly contained
in the definition on the human soul by the Lateran Council
IV in 1215 and in a Brief of Pope Alexander VII (1661) which
was used in the dogmatic definition of the Immaculate
Conception of the Blessed Virgin (1854).
However, in our case, it is enough to know what Vatican
Council II affirms, namely, that "HUMAN LIFE BEGINS AT
THE MOMENT OF CONCEPTION" (Gaudium et Spes, no. 51).
This is no longer a philosophical question but a biological,
genetic truth. If human life begins then, logically, it is assumed
that the infusion of the soul takes place at that moment.
9
This
is the opinion of the great majority of the Catholic theologians.
Setting aside the theological question, it is sufficient to know
that if life begins at fertilization, then, this life demands absolute
respect. Furthermore, it is modem science and not theology
that affirms the inception of human life at fertilization. From
the fertilization of the ovum until birth-and the same until
death-it is one and the same individual who develops. One
cannot split into two the development of this new human being
without contradicting embryology- as if, at a certain moment
mutation were to occur capable of changing it completely,
causing its transformation from animal to human nature It is
not therefore scientifically admissible to think that the product
9'fhis idea is expressed in a document of John Paul II about the Virgin Mary-
who as Catholic faith teaches- has been preserved from the inheritance of the original
sin. "In this way- says the Pope-from the first moment of her conception, that is,
her existence-she is Christ's" (Enc. Redemptoris Mater, March 25, 1987, no. 10). We
have emphasized the words that identify "the moment of conception and human
existence."
63
of conception be in those first moments what is called only
a general matter in order to form later by means of a new
transition to human life. We shall cite some scientific testimo-
nies:
"Setting aside theology, there are many more solid biolo-
gical arguments which can establish the inception of a new
being at fertilization. We all know that the genetic code of the
fertilized ovum is distinct from that of the father and of the
mother. Likewise, we know that the subsequent development
of a human being, with all its hereditary characteristics are
already transcribed into the code by the invisible finger of he-
redity."10
The French geneticist Jerome Lejeune, whenever asked:
"When does life, at the biological level, really begin?"
responds in this way: "What an amusing question. Nobody,
before legalizing abortion in any country anywhere in the world,
has ever asked himself in this respect. Only about 5 or 6 years
ago, all physicians and geneticists agreed in saying that: 'Life
begins at the beginning, that is, at fertilization.' Besides, this
is what is actually taught in all Faculties where Genetics is
taught. What professors universally teach does not refer
exclusively to man, but encompasses the beginning of life of
the crocodile or of the rat. The question: 'Does human life begin
much later?' -has been proposed simply to convince the
population to accept the elimination of certain individuals. If
you wish, there is in this some kind of schizophrenia. It is well-
known to all scientific experts that man begins 'to be' from
the beginning. There is no doubt about it. A great number of
intellectual contortions have been utilized to say that: 'Life begins
only after a week, after a month, or after 2 months, after 3
months or, after 9 months ... ' and this simply permits public
opinion, which repudates the killing of a baby, believe that
what is killed is not yet a baby. This is true schizophrenia in
that reality is negated. Because, the truth is that in whatever
abortion, a very young human being is eradicated and that's
all. Here, there is no scientific ambiguity."
11
The most recent advances in Cytology, Genetics and Mole-
cular Biology have demonstrated the truly dynamic character
10
Cfr. J. Botella Llusia, Noticias Medicas, Sunday Supplement, May 9, 1976.
11
M undo Farmaceutico (The Pharmaceutical World), December 1974, Madrid. More
data can be found in Se fabrican hombres (Human Beings are Manufactured) by F.
Anson, Rialp, Madrid 1988, pp. 193-223.
64
'11ag1
ce i
This
~ t o n
' al
og
ute
- .ilizat
ce c
-- nei
elo
- once
urch
The 1
m stic:
-_ t tht
"
'" no.
of the nature of individual life. The life of any living organism,
whether animal or plant species-we know today- is the
development of a meticulous program of the DNA, in coded
language. One of the most outstanding achievement of Modern
Science is precisely the discovery of this code, the genetic code.
This program is immediately activated at the moment of fer-
tilization in multicellular organisms, including man. This unique,
original program is distinct from the program of the father and
of the mother. It will henceforth function without interruption
until the senile death of the individual. It dictates orders for
organogenesis and sets in motion the functions according to
a precise chronology.
12
Strangely, the recent experience with in-vitro fertilization
lead to the same conclusion.
Doctors Edwards and Steptoe succeeded in transferring the
minute Louise Brown-that first baby conceived by artificial
fertilization-into the uterus of Mrs. Brown because the entire
science of Genetics and Biology assured them that the tiny being
was neither a tumor nor a parasite but a human being,
marvelously young, the same offspring of Mr. and Mrs. Brown.
Lejeune arrives at a definitive conclusion: "After thousands of
babies conceived in the same manner, it can already be
concluded that, as an experimental evidence, human life begins
at conception."
13
Church Teaching
The Church firmly maintains its position (which cannot be
otherwise) that human life in gestation must be defended at all costs.
It does this in the face of all attempts to justify abortive practices
in many countries which have legalized abortion.
Christian authors of antiquity rejected abortion. For instance,
"Christians marry and beget children. They do not get rid of
what they conceived," affirms the second century author of
the Letter to Diognetus, Chapter 5. Atenagoras, a Christian
apologist of the same century, defended Christians against
accusations of murder and cannibalism. These were pagan
12
A. del Amo, Manuscript, 1985.
13
Sentido Humano de Ia vida, (The Human Dimension of Life), "Dolentium Hom-
inurn," no. 7, Rome 1988, p. 20.
65
practices. He affirms: "How can we kill if we do not even want
to see killing (in the arena) so as not to stain ourselves wi'th
such impurity? On the contrary, we affirm that those who
commit abortion commit homicide and they have to account
for it before God." Many councils, both provincial and uni-
versal, have maintained the same criterion as another conse-
quence of the biblical commandment: "Thou shall not kill. "
Vatican II considers abortion as an "abominable crime." In 1973,
Pope Paul VI reaffirmed it in a message on French television:
"Recently the Council has vigorously reminded that ALL LIFE
IS SACRED. Except in legitimate defense, nobody can ever
authorize a man to dispose of another's life or of his own even
at the cost of contradicting, if necessary, what is said and thought
at times in our surroundings. We untiringly repeat that like
abortion, euthanasia is a crime."
It is enough to recall the most recent declaration of Church
Magisterium in this respect. Bishops' Conferences of different
countries have all given their pronouncements: they have made
forceful condemnation of those attempts to legitimize abortive
practices. This has been done in France, Italy, Germany, Swit-
zerland, United States, Spain and so forth. The Holy See, through
the Congregation of the Doctrine of the Faith, has published
a Declaration on Procured Abortion (November 18, 1974)
reminding that: "The Eternal Law and the Natural Law exclude
any right to kill an innocent man. Nevertheless, if the reasons
adduced to justify an abortion were clearly unfounded and lack
weight, the probkms would not be that dramatic. Its serious-
ness rests on the fact, that in some cases, perhaps quite
numerous, the rejection of abortion could harm important goods
which are normally held in esteem and rright even apparently
have priority. We do not ignore the great difficulties: it cC'uld
be a serious problem of health, oftentimes a question of life
or death for the mother; or the burden of having another child;
or above all, when there are good reasons to fear abnormality
or retardation of the child. Different social environments give
varying importance to considerations of honor or shame, the
loss of position or rank, etc. We ought to proclaim absolutely
that none of these reasons can ever objectively grant the right
to dispose of the life of another, not even at its inception. And
whatever refers to the unhappy future of the child, not even
the father nor the mother can substitute and decide on its
behalf, even if it is still in the embryonic state-whether to
66
prefer life or death. But neither the child himself, once matured,
could ever claim the right to suicide; while not of age to decide
for himself, neither can the parents choose, in any way, death
for him. Life is a fundamental good that is so essential that
it cannot be placed on the scale with other difficulties, includ-
ing grave ones."
John Paul II, since his election as Roman Pontiff, has not
ceased condemning abortion: "It is the obligation of the Church
to reaffirm that induced abortion is death: it is the assassination
of an innocent creature. Consequently, the Church regards
legislation in favor of induced abortion as a very grave offense
against fundamental human rights and divine conunand: 'Thou
shall not kill!" (Allocutions, May 10, 1981).
One can recall the forceful words of John Paul II during
his visit to a European country* on November 2, 1982: "There-
fore, whoever refuses to defend the most innocent, weakest
human person--conceived yet unborn would seriously trans-
gress the moral order. The death of the innocent can never
be authorized.
"Is there any sense in speaking of the dignity of man, of
his fundamental rights, if the innocent is left unprotected, to
the point of even facilitating means or service, whether public
or private, to destroy defenseless human life?"
Finally, we remind that the Catholic Church has reserved
the canonical penalty of excommunication for those who induce
abortion. In cases of successful abortion, the penalty also applies
to the so-called necessary accomp!.ices, i.e., those who helped
accomplish abortion, without which it could have not been
successful (Cfr. Code of Canon Law, Canons 1398 and 1329).*
*Spain.
*The Teaching of the Spanish Episcopal Conference (SEC)
In what refers to Spain, the Bishops have expressed their rejection in several
collective documents. We recall the following:
a) Note on Abortion: by the Episcopal Commission for the Doctrine of the Faith
(October 4, 1974), which reminds that abortion has always been condemned
by the Church and that exceptions to justify abortion even in the most difficult
situations do not exist.
b) Declaration on Human Life and Abortion: by the Permanent Committee of the
Spanish Episcopal Commission (February 15, 1983) in the face of State ini-
tiatives endorsing the proposal to lift the penalties on abortion to the Spanish
Parliament.
c) The Legalization of Abortion: A document of the 38th Plenary Session of the
SEC (July 25, 1983), prior to the parliamentary debate on the proposed Law
67
Licitude of the So-Called "INDIRECT" ABORTION
After having considered the illicitness of all methods of
directly-induced abortion (therapeutic abortion, eugenic abor-
tion for social or psychological reasons, etc.), we shall now
discuss briefly those cases in which abortion is not directly
sought. This abortion follows an intervention intended to treat
a gynecologic pathology, independent of the pregnancy. We-
refer to the so-called INDIRECT ABORTION. It may occur
following hysterectomy performed in a pregnant woman
suffering from uterine cancer, or following an intervention in
cases of ectopic pregnancy.
In such cases we have to resort to a principle of great moral
value which recognizes acts with two-fold effects in order to
give an adequate moral solution. This is the principle of double
effect; it was discussed in Part I.
When therapeutic abortion is induced for the purpose of
avoiding a pregnancy deemed risky for the mother, the act
is illicit. It is considered direct homicide, because the medical
procedure would have a single immediate effect (therefore, only
one end) that is-to destroy an innocent life, one with the right
to live-no matter how difficult that destruction might be. The
subsequent end to which the abortion was ordained was to
save the liberated mother (and because she was freed) from
the fetus. But the primary action would have not accomplished
anything more than to save the life of the pregnant woman,
using death as a means. Now, to kill the innocent is always
intrinsically evil, because no one has the right to do so.
on Abortion. The document exhorts that the right to life cannot be renounced
in favor of a presumptive common good mainly because abortion undermines
the foundation of the social order.
d) Lifting of the Penalties on Abortion: by the Permanent Commission of the European
Economic Community (EEC) (May 10, 1985).
e) Moral and Christian Attitude towards the Law on Abortion Gune 24, 1985). Once
the Law on Abortion is approved in Spain, all are earnestly asked to manifest
their passive resistance to an unjust law. Concretely, medical personnel should
invoke objection of conscience. Moreover, catholics should initiate activities
that uphold the "respect for life." The document also reminds that it is the
responsibility of the citizenry to apply pressure, through the exercise of their
civic rights, so as to obtain a change in legislation. PRO-LIFE Movements
are growing in number each day.
f) Criteria in Favor of Life, Not Death: A document of the Episcopal Committee
for the Defense of Life published during the Anniversan; of the Partial Approval
of Abortion. "Ecclesia," October 4, 1986, pp. 1354-57.
68
a) ']
E
t
b) ~
I
I
Whi
::-:cture
~ a k i n
:a on iE
_- consE
esions
:the al
.:.e eml
Admini
Fetus a
Inn
eed f,
5
n
te
;t
d
!5
l
ir
Is
:e
a/
On the contrary, it is licit to submit a pregnant woman
to an emergency medical or surgical intervention in order to
cure a specific and serious disease (Proportionate Cause), e.g.,
to remove a malignant tumor, (The action in itself is good),
foreseeing that abortion might be induced by this intervention
(the undesirable effect), in the absence of other effective treatment
less risky for the . fetus and whenever necessary, prior to the
viability of the fetus. Likewise, this applies in the case of ectopic
pregnancy. In this pregnancy, gestation develops outside the
uterus, either in the fallopian tube, uterine cervix, ovaries or
within the abdominal cavity.
The most common type of ectopic pregnancy is the implan-
tation of the fetus in the fallopian tube. This is a pathological
situation because the normal sequence of implantation of a
fertilized ovum occurs in a place that is neither anatomically
nor histologically prepared for this invasion. The fallopian tube
is not fit to accept and permit the development of the embryo
and the placenta; therefore, it undergoes erosion of the mus-
culature, leading to rupture. Two probable consequences are:
a) Tubal abortion at 6-12 weeks of fetal development. The
embryo is expelled from the terminal fimbriae of the
tube. It is deposited within the abdominal cavity; there
it dies.
b) Tubal rupture. The invasive elements of the placenta
perforate the wall of the tube, causing the latter to
rupture.
Whichever is the case, acute abdomen dominates the clinical
picture which necessitates emergency operation. Morally
speaking, in these cases it is assumed that the zone of implan-
tation is the tube. Because the tube is unfit to receive the fetus,
it consequently develops pathologic traumatic lesions. These
lesions threaten the life of the mother and therefore the zone
of the affected lesion is excised although it contains the embryo;
the embryo is also eliminated.
Administering Baptism to the Aborted
Fetus and Premature Newborn
In nursing practice, particularly in the maternity clinic the
need for emergency Baptism occasionally arises. This is
69
especially true for aborted fetus, whether defective or not, and
above all, for newborns who face imminent danger of death-
the premature babies. However, this is less frequent today than
in the past because of the enormous progress in perinatology.
Since Baptism
14
is necessary for salvation (cfr. Jn 3:5), it is
understood that, in the face of more or less proximate danger
of infant death, one is obliged to baptize the child as soon as
possible. It is a matter of "obligation," affirmed Pius XII, "that
rests primarily on the parents, but in case of emergency when
there is no time to lose and no priest is available," the Pope
was addressing a group of midwives, "a sublime duty of charity
of conferring Baptism is your mission. Do not neglect to perform
this service of charity and to exercise that active apostolate of
your profession. May the words of Jesus bring comfort and
encourage you: 'Blessed are the merciful, for they shall obtain
mercy.' (Mt 5:7) Is there any mercy greater and more beautiful
than to save the soul of an infant, who just passed the threshold
of life and is ready to cross the threshold of death, that opens
to a glorious and beatifying eternity?" (Allocution, October 8,
1953).
This emergency Baptism ought to be administered by the
hospital chaplain, a physician, a nurse, etc. As generally it is
the nurse the one who is more in immediate contact with the
mother who delivers and with the newborn, it is she who ought
to intervene in these emergency cases. For this, no special
formation is needed precisely on account of the importance
of the subject. It will suffice to pour water over the child's
head and pronounce th-ese words: "I baptize you in the name
of the Father and of the Son and of the Holy Spirit," while
at the same time having the intention of doing what the Church
does.
In relation to the aborted fetus, the Code of Canon Law
says: "Aborted fetuses, if they are alive, are to be baptized,
insofar as this is possible" (Can. 871).
14
Cfr. Part II, Chapter 13 of this book.
70
3
Mec
safegua
among
'f almc
-, there
And is
able to
_ ecessa1
existenc
-:dll dis
ain.
The NCJ
All
- as co
:crious,
:- profo
_ ent c
Pain
C:!.sease.
pea
=- "an
.simulu
e fr
Mec
:;:_easun
1)
2)
Pair
- not .
e
s
e
lt
al
:e
. S
e
e
ch
i.W
eel,
3 Respect for the Suffering Patient
Medicine is perpetually battling against disease and death,
safeguarding health and life. Grappling with disease signifies
among other things, wrestling against pain. This last always
or almost always accompanies disease. The task of medicine
is, therefore, to alleviate pain and suffering. But, is it sufficient?
And is pain inevitable? Is there any sense in suffering? To be
able to respond to these questions, in the first place, it is
necessary to grasp the nature and meaning of suffering in human
existence. We also will consider fatigue and illness. Lastly, we
will discuss special problems related to the struggle against
pain.
The Nature and Meaning of Pain
All men experience pain; no one can escape from it. Pain
is as common, as unavoidable and as familiar-as it is mys-
terious, above all, as regards its significance. It begins with life.
It profoundly influences the latter's development, and subse-
quent conformation. It concludes only with death .
Pain is the most frequent and most bothersome sign of a
disease. Witrout pdin, without suffering, there would be neither
sick people nor physicians. Physiologically, pain may be defined
as "an unpleasant sensation produced by the action of a
stimulus, noxious in character" (MacByrde). These stimuli may
come from the outside or originate from within the organism.
Medical manuals refer to pain as "a localized corporal dis-
pleasure." Two types of pain are distinguished:
1) somatic pain (originates from the skin, muscle, tendons
and joints).
2) visceral pain (originates from the autonomic n<:rvous
system supplying the visceral organs).
Pain is not always defensive. Besides, the painful sensation
is not always proportionate to the gravity of illness. Fatal
diseases like leukemia can lead to death without much suf-
fering. Some, however, like trigerminal neuralgia, consist mainly
in pain. Vital organs, of the first order (e.g., the brain) can be
manipulated intraoperatively without causing pain. However,
less vital organs hardly tolerate minimal noxious stimuli. At
times, pain is physiological rather than pathological, e.g., labor
pains.
All these show the complexity of pain. Consequently, pain
is relevant to psychology, philosophy and theology, aside from
physiology. On the other hand, it is useful to distinguish pain
from suffering, although the terms are frequently used as
synonyms. In our discussion, we shall use them interchange-
ably, while knowing their conceptual difference:
PAIN pertains to the somatic, organic order. It constitutes
a sign, indicative that harmony in the physiological order is
getting disturbed. Thus, it is interpreted as the protest of the
organism.
SUFFERING, though begins often as physical pain, possesses
other characteristics. It is more internal, more psychological.
It is related to other factors (personality, capacity to take life's
difficulties, physical vigor and spiritual energy of the individ-
ual). It is accompanied by a host of emotional experiences like
anguish, sadness, pessimism, and so on. Likewise, it can help
to know the positive aspects of human life: maturing of the
personality, sociability, openness to transcendence, and so forth.
1
Leaving aside the technical aspects (anatomy and physi-
ology of pain) we shall proceed to consider its significance.
The meaning of pain. To discover and give the precise meaning
of pain is one of the problems that preoccupy humanity. "Each
day more people propose or pledge to penetrate anew the more
fundamental questions; what is the meaning of suffering, of
evil, of death-that these subsist until now, inspite of all the
progress achieved?" (Gaudium et Spes, no. 18).
The Council itself replies: "The enigma of suffering and death
is illumined by Christ. Outside the Gospel, these are wrapped
in absolute obscurity" (ibid). Only with the light of faith can
one comprehend the meaning of suffering. "Faith in Christ-
said John Paul II-does not eliminate suffering, but fai th
enlightens, elevates, purifies, ennobles and validates it for all
1
Cfr. E. Rojas, Una teoria de Ia felicidad (A theory on happiness). Dossat, Madrid
1986, pp. 283-304, conceptual differences are discussed.
72
eternity" (Allocution, March 24, 1979). Otherwise, bereft of faith,
in the face of suffering, man gets disconcerted , protests, rebels
or at most resigns, but is never happy. "When divine foun-
dation is lacking and the hope of eternal life is dwindling, human
dignity is gravely wounded (which happens quite frequently
today). The perplexities of life and death, of guilt, and pain
continue unresolved, causing man to despair" (Gaudium et Spes,
no. 21).
One thing is clear. Man, born to be happy, becomes
disconcerted by the reality of suffering, an inseparable com-
panion along the road of life. "Suffering," says John Paul II,
"is a dreadful fact of reality, sometimes awful and shattering.
Physical, moral and spiritual suffering afflict humanity all the
time. We are indebted to science, technology, medicine, social
and civic institutions which endeavor by all means to elimi-
nate, if not, alleviate suffering. But it is the latter that seems
to end up always the winner. And the defeat weighs on afflicted
and impotent man.
To some, extent, it seems that a greater social progress goes
hand in hand with moral backsliding, bringing in its wake,
other forms of suffering, fears and anxieties. Indeed, suffering
is a baffling mystery."
2
In this regard, we recall the Apostolic letter Salvifici Doloris
3
of John Paul II (February 11, 1984). Here, the Pope incisively
and intensively confronts the problem of human suffering. He
points out that the mystery of suffering becomes clear in the
light of faith. This is because in the eyes of God suffering has
a meaning, an explanation. "In order to discover the true answer
to the 'WHY' of suffering, we need to turn our gaze to the
revelation of divine love, ultimate source of meaning of all that
exists. Love is also the richest source of meaning of suffering,
a never ending mystery" (no. 13). As Blessed Escriva reaffirms:
"Suffering enters into the plans of God. It is a fact, at times
incomprehensible" (Christ is Passing By, no. 168).
Suffering is fully understood only in the light of the Cross
of Christ. He suffered willingly in order to redeem mankind.
He teaches that suffering when freely accepted is a gift from
2
Allocution, March 24, 1979. In: H. Garcia Seage and Benito Melero, Juan Paulo
II a los Enfermos Gohn Paul II addresses a group of Sick people), Eunsa, Pamplona
1980, p. 28.
3
"0n Suffering," Papal audience, June 4, 1986.
73
God. Therefore, it is not proper to consider suffering as a natural
misfortune, let alone a punishment. Thence, whenever possible,
suffering ought to be avoided. However, experience shows that
frequently, one cannot avoid either physical or moral suffering.
When that happens, no other solution remains except that of
generously accepting it, viewing it with a Christian outlook,
as a means of uniting oneself with Christ's suffering, a means
of purification and penance. In a word, one should see it as
something positive. This is true, however, only if the individual
accepts it. The patient who rebels against pain suffers uselessly
to the point of desperation. In turn, when he accepts it
wholeheartedly, though he may not understand why, he finds
peace. Christian life produces this paradox: suffering and at
the same time being happy.
As hospital chaplain, I have experienced this on several
occasions in many patients. I vividly recall a certain patient
whose biography has circulated worldwide.
4
Fatigue
There are moments in life when one feels exhausted or worn
out. And it is not so much physical exhaustion. Physical ex-
haustion has less import. I refer to the more subtle, less
differentiated, mental exhaustion which may evolve into true
nervous breakdown, or overexhaustion. It is not solely physical
fatigue, muscular in origin, consequent to a more or less
prolonged and intense professional activity. One readily recovers
from this with simple rest (sleep, calisthenics, etc.). It is rather
a kind of fatigue which accumulates gradually, a product of
the interplay of several factors: wanting of deserved rest,
environmental conflicts, routine, failure (whether real or
apparent) involving family life or professional work, meaning-
lessness in one's existence when it is not lived with a constant
supernatural outlook, earthly existence felt as an agony,
dominated by incertitude and risks and the constant need to
make decisions not only abou direction in life (choice of
profession or civil status) bu also about the trifles of daily
living. This is the well-_ o enon of physical exhaus-
-Ma.. V. - jrer .. #. Y ~ ~ =-
inC., 1988.
u d ~
e f1
=--.--:-ays
Hov
ditic
so
:::is an
yom
SJ. L. ~
_adrid 1'
6J.B.
tion peculiar to the medical profession, an outcome of affection
inanition (feeling) towards one's profession.
Occasionally, fatigue offers the most basic explanation to
an apparent crisis that affects an individual in the course of
his life. For example, why does a loving, thoughtful husband,
suddenly becomes intransigent or irritated with whatever the
wife does t8 please him? Why does a loving and caring mother,
who usually participates in the children's play, one fine day,
scold her children bitterly without any reason? Why does a
nurse popularly known for her amiable and delicate manner
with patients, one day become irritable and answer rudely?
Certainly, the problem is co!llplex for some; for many, however,
the explanation is simple: fatigue, exhaustion. What happens
is that these individuals are simply tired.
5
a) Causes
If we synthesize the immediate causes behind this situation,
we can distinguish various factors. One factor-viewed collec-
tively-includes the accelerated feverish pace of modern living,
ambitions and professional goals, reversal of sleep patterns due
to work shifts, social relation customs, etc., excessive acoustic
stimuli (noise) and light considered as forms of psychological
bombardment. Other causes are of an individual nature-
internal conflicts, absent-mindedness, familial problems or
professional difficulties, chronic insomnia, interior haste that
produces an exhausting psychological stress.
Judging from medical consultations, these factors are far
more frequent today-needless to say-because people are
always in a hurry. Lately, there has been a significant rise in
the incidence of neurosis, depression and stress concomitant
with fatigue which is easily confused with the latter and masks
it.6
However, tiredness, as such, exists in reality, akin to the
condition of being human. Along with it are infirmity, pain
and so forth. All these accompany man in his earthly journey.
It is an echo of the divine oracle: "You will eat by the sweat
of your brow" (Gen 3:15).
5
J.L. Soria, Cuestiones de Medicina Pastoral (Questions in Pastoral Medicine). Rialp,
Madrid 1973, pp. 236-237.
6
J.B. Torello, Psicologia Abierta (Open Psychology). Madrid 1973, p. 108.
75
In principle, i -- :- - -....eed abnormal. Some saints also
experienced fatigue. - - eresa derwent this situation herself.
She gives an interestinu a ount as she describes herself as a
woman with extraorciinar: >iuor. Inspite of this, she felt tired
and severely exhaus eeL occurs on certain awful days, not
many, three, four o ;:. e-':-.-_ apparently all the good things,
fervor, and >.isio ' a ~ Ge:1i o. me, even from my memory.
Although I \.\"anted , : _' ow what good thing I have
had. Everything seems ha\e been a dream or at least, I cannot
remember anythin _ Bodily ailments gang up on me. My mind
is disturbed. I canna think of any thing about God, nor do
I know by what law I lh-e. If I read, I cannot comprehend,
I seem to be aboundina ,,;th faults, without any liking for virtue.
The great strength that I usually have has been reduced to this:
that at the slightest temptation and gossip of the world, I cannot
resist. They tell me, instead, that I am good for nothing, I am
sad, I seem to have deceived everybody who had confidence
in me. I would like to hide so that no one could see me. I
do not prefer solitude for virtue to cowardice. I feel like quar-
reling with anyone who might disagree with me" (First Account
of Conscience, 1560, nos. 29-30).
b) Symptoms
We have listed down systematically a series of manifes-
tations which could uncover a state of "FATIGUE." They are
both somatic and psychic. (Obviously it is not necessary for
all these to be present in order that the clinical picture may
appear very black, almost bordering on the pathological.)
hypersensitivity to heat, cold, strong odors, and noises
(specially shrieking, high-pitched voices).
headaches, muscular incoordination.
presence of fraud, pessimistic ideas, almost obsessive,
in relation to oneself or others ("they do not esteem
me," "they do not understand me," "they do not mind
me").
insomnia, light or superficial sleep.
exaggerated critical spirit.
persistent, unexplainable sadness and bad humor. Eve-
rything hurts and causes anger. Everything appears
76
Th
Do
_.:utd
:!::aV e.
_.:._s for
It i
:::us, I
-- . all.
::ualiti
:::OW
.s.. oulc
.: eiri
::es" (
As
50-Call
cor
~ e fo
r
I
s
> _,
n
d
rs
black. Annoyance with the neighbor's being in high
spirits.
rude, exploring and hurting answers; merciless irony
The nearest person appear distant, indifferent, like
strangers, while their company becomes unbearable.
longing for solitude, tendency to self-centeredness, or
to tears.
experimentation with novelties, including ways that
separate from God.
lack of attention, disinterest for the things that enthused
in the past; evasion of reality.
c) Remedies
The first remedy would be to recognize the need for rest.
Don't be like that famous singer, who replied when asked:
"And you, Sir, when do you rest?" -"Never! I will rest in the
grave. For that, I have all eternity. We are not here as tourists.
As for me, I will sing all the days of my life."
It is necessary to be humble and accept our limitations. And
thus, we need rest. The need for rest is a fact acknowledged
by all. Vatic an II states: "All workers should develop their
qualities and personality, precisely in work itself. Moreover,
after spending their time and energy responsibly in the task,
they have the right to relaxation and rest periods. This will
allow them family life, cultural, social and religious life. They
should be given the chance to develop their aptitudes, if ever
their professional work does not provide sufficient possibili-
ties" (Gaudium et Spes, no. 67).
As preventive measures, it is very helpful to practice the
so-called rules of ordinary rest. These vary, ranging from general
or common rules to specific or particular ones. They include
the following:
Sleep the sufficient number of hours. The matter is quite
important. Certainly, one may have to skip hours of
sleep occasionally without thinking that in doing this,
one is playing the hero. But it is better not to abuse
oneself. I remember what a friend told me: "Sleep debts
are likened to a game: they are always paid for." Another
said: "When you have been sleeping only five hours
77
for the a:.
loved."
. - -
think that you are- not
with an a . ;: =-- --=::--
When - - - = ,...._--=,<:D
the ph ca.;_ _ erson, then one has to
apply extrao. - "'-:- -== --- - e days of quiet, if possible
in the countr; acc..:::- :__ : ":. n< and environment; a longer
schedule o= :._ee::: :: amusing and light reading
(children' -= _ :- . e.!.S, etc.). Finally, follow the
:o,_.;;:=-""'-:..... --= scr:iYa: "Physically exhausted.
_ For this, have interior life.
don't worry anymore. Soon
- fe and you will improve if
you are fai ' =-.1... .:... _ _ ::._ :ate" (no. 706) . A forewarning
while - ::125 maj or decision which you
might regret lau:r : _ :::-"' ::esc o: your life. Remember that you
lack objecmit: in therefore, be prudent
so as to a\oid ec:: ;and not destroy all the great
things you ha\e all your life.
Illness
illness comes ' :re frequently than fatigue in the
course of our liYes. ._ car ha\e many complex consequences.
In the natural or er, es is linked to the biological nature
of man. HoweYer, fait.. tea es that, at one point in time, prior
to original sin, ctisea_c::.e did no exisl Neither did pain, or fatigue ...
These privileges were los with original sin. From that

-OI
t
e
; .
e
)r
moment on, disease has come to accompany constantly earthly
existence. At times, this has been dramatic.
When man contracts disease, perhaps for the first time, he
experiences physical pain. This latter is unpleasant and annoy-
ing. Nevertheless, if he knows how to accept it, it purifies.
Other times, what worries him more is the interruption of
his activity, with the pain being slight or even altogether gone.
The sudden change from health to sickness, above all, with
one who has been in full use of his physical and mental
faculties- plus the suffering, the inability to continue the normal
pace of life-can all influence adversely. It can provoke a
depressive reaction, a desperate rebellion. Occasionally, it may
even lead to a profound spiritual crisis. But it can also be a
first step towards a spiritual renewal that can be very fruitful.
This is what one ought to do to help bring about this.
Torello affirms that "It is necessary to possess a sound
spiritual orientation and a certain maturity in virtues to be able
to obtain from illness its positive fruits. In itself, illness is merely
a trial, a difficult test. In the Imitation of Christ, one reads:
'Sickness has improved but a few men' (Book I, Chapter 23).
This truth applies also from the point of view of psychoso-
matic diseases because the altered soma can provoke passions,
even authentic interior temptations. But all these trials are
directed towards the good, the created good for those who suffer.
God permits them for our own benefit, although, we may not
grasp their meaning absolutely."
7
This is the goal: to transform illness into an offering, a self-
giving to God. Needless to say, one has to employ all human
means to overcome the illness. However, when this is not done,
the sick individual has to remember that he is not useless ...
that his life has a certain meaning. Pope Pius XII reminded
patients: "You suffer to see yourselves inactive, idle, useless,
a seeming burden to your companions. And you live a
devastated and sterile life. Nevertheless, is it not true that
sickness, when accepted serenely, refines the spirit, resuscitates
in the soul noble ideals, curing its moral wounds, giving way
to generous resolutions?" (Allocution, November 21, 1949).
It is especially when his illness is prolonged or the prog-
nosis is uncertain or even fatal that the patient must reject the
7j".B. Torello, Medicina y Pecado: Rea/idad del pecado (Medicine and Evil: The Reality
of Sin). Rialp, Madrid 1962, p. 306.
79
temptation to think that his life is no longer of any value. Illness
and suffering, in this way, puts to the test his faith. That is
why, illness destroys some and rectifies others. Some take it
calmly because they put all their trust in the Lord. Others plunge
into the night of despair as soon as they get to know that their
destiny is irremediable. As Pius II reaffirmed, "it is not very
difficult for someone unprepared to open himself to the
liberating truth, renounce completely all useless rebellion and
enter into the redemptive world where suffering is viewed as
an expiation for sin, a participation in the power of Christ,
and his salvific power" (Alloc. November 11, 1955).
On these occasions, it quite important not to lose sight of
the deep christian meaning which illness has. It is true that
when illness comes, like aging, the individual rejects the idea
of the breakdown of his own body. It is quite hard to accept
physical decadence and the limitations that come with ailments
or with aging. On account of his spiritual nature, the human
being adapts badly to decay. However, one is confronted with
an irreversible process which has to be accepted and made use
of. I remember the editorial of a medical journal which dealt
with the problem: the so-called "RETIREE SYNDROME." This
disease affects the man who retires from his professional work
in which he used to be engaged intensely. Overnight he becomes
jobless, without his appointment with "tomorrow" (such was
the title of the editorial).
It is strange that these individuals become sick people with
a vague symptomatology. It is even more strange that the
remedies that are usually prescribed turn out to be ineffective.
From the psychological point of view, Rof Carballo explains
this crisis as the realization that life has lost its meaning, or
better, its purpose. From that moment on the retiree ceases to
be somebody. He is no longer important to others, he ceases
to be taken note of. Well and good. Perhaps, psychologically
man needs to get signals from the others to feel good, in order
to carry out his work well. For example, the writer needs to
be told that his writings enthuse, the doctor, that his patients
need him. But the truth of the matter, however, is that we are
dealing with a deeper problem.
In fact all men, (this includes the sick, the aged, the one
who is a failure), have their appointment with "tomorrow."
But it is a "tomorrow" that is not centered on success nor on
public recognition of one's personal merits. Rather, it consists,
80
- "
1
st
A
re:
Fr
~ f
~ ~ i s i
:.-:.algt
n
:;:.. ia
_:.e bi1
::_:ildrl
)
e
II
n
;,
above all, in God's positive judgment of him. And God dwells
not so much on the results of our actions but on the love we
put into them. In this regard, a life with few achievements to
boast of, shorn of possibilities, can be pleasing to God as well.
Borrowing the terminology of another psychologist, the homo
patiens, the man who suffers and who knows why he suffers,
and who knows how to suffer finds fulfillment in failure as
well. In contrast, the homo sapiens, the intelligent man, moves
between the two extremes: failure and success. This latter can
sink into despair despite all the successes achieved.
8
Therefore, the key to the problem is to adjust, to accept
one's life situation and try to find meaning in it. For a man
of faith, it is obvious that such meaning is always there even
in the most humanly desolate situation. For this reason, in the
face of pain, sickness, fatigue, old age, and so forth, the only
proper attitude possible is that of loving acceptance.
Obstetric Analgesia
Anesthesia is the absence of sensitivity of all or a part of
the organism. It is caused either by disease or by artificial means.
What is of interest here is artificially produced anesthesia. This
kind of anesthesia serves to suppress pain during operations,
producing a loss of consciousness (sleep) or sensibility in the
whole organism (general anesthesia) or in a part of it (local
or regional anesthesia).
From the ethical point of view, anesthesia does not pose
any problem. Not only is it perfectly licit; it is even morally
advisable. The difficulties are encountered during obstetric
analgesia. These we shall discuss shortly.
Painless Delivery (Childbirth)
The woman's suffering during delivery has become pro-
verbial, as we read in both profane and sacred scripture. Recall
the biblical punishment: "In sorrow shalt thou bring forth thy
children" (Gen 3:16).
8
Cfr. V. Frankl, Sacerdozio e sensa della vita. (Priesthood and the Meaning of Life).
Milan 1970, pp. 38 ff. The same ideas are found in another book of his, El hombre
doliente (The Suffering Man) . Herder, Barcelona 1987.
81
Modern obstetrics has made considerable progress in its
endeavor to alleviate, if not completely eradicate these suffer-
ings. One can already say that it is achieving it today. At present,
there are two ways of achieving this. These techniques are
ordinarily combined.
a) Natural spontaneous delivery. Today, it is also called psy-
choprophylaxis. It consists in adequately educating the
pregnant woman, helping her understand the physiol-
ogy of labor and evaluate adequately its different emo-
tional components. It is combined with the exercises of
relaxation, of muscular self-control and coordination,
together with respiratory exercises. These are adapted
to the various phases of delivery. Thus, the patient
participates actively in her delivery with little or no pain
at all.
b) Anesthesia and analgesia during delivery. It consists in
utilizing modern pharmacological substances which
reduce or eliminate the labor pains. These drugs have
minimal risks when used properly.
In the past, total anesthesia or hypnosis was given.
Today, epidural anesthesia is used in a highly effective
way.
From the ethical viewpoint, let us analyze and refute some
of the arguments against painless childbirth:
a) The potential risk of obstetric anesthesia. As mentioned,
although there are some risks, today these have become
minimal. Besides, if done in a well-equipped medical
center with prior tests of the mother for anesthetic
contraindications, and careful choice of anesthetic
technique, the risks are ftrrther reduced. The same thing
can be said for the baby. The anesthetic must not affect
him.
b) Is there any contradiction between the passage of Genesis
3:16 and painless child birth? The answer is no. It is
only an apparent contradiction. Pius XII teaches: "Eve
was punished. But God did not prohibit her nor any
other women from using the appropriate means to make
child birth easier and less painful. These words hold
true in the wider sense, as expressed by the Creator:
82

G
j
A
rr
d
II
p
h
d
0
D
I
f
c
The
::... r in
-: en t:
pli<
-=...nt. I1
...:e Ch
=ons f,
a)
b)
As
one h
ropo:
prema
quate
"Maternity will bring much suffering for the woman"
(Address, January 1956). Adam received the same
punishment: "because of you, cursed be all the earth ... "
God did not want to forbid man from investigating and
utilizing all the wealth of the earth.
c) Anesthesia during delivery. Does it affect adversely the
mother-baby relationship? This, perhaps, is the greatest
difficulty. For this reason, psychoprophylaxis has been
more successful becanse it helps the woman deliver
painlessly but consciously her baby. Remember,
however, that the emotional mother-child relationship
does not necessarily become more intense on account
of the mother's experiencing less pain. Nevertheless, the
mother's not seeing her baby delivered is a difficulty.
Psychoprophylaxis obviates this since it helps the mother
face childbirth more calmly and actively and consciously
collaborate in the process. Likewise, all this is effectively
accomplished under epidural anesthesia.
Induction of Labor
The above phrase signifies premature artificial labor, i.e.,
labor induced by pharmacological means prior to term but only
when the fetus is viable. Ordinarily, this is done to avoid the
complications of pregnancy or those which can arise if it reaches
term. In relation to this a consultation was made in 1898 with
the Church Hierarchy. The reply stated the following condi-
tions for the INDUCTION OF LABOR:
a) when a just cause exists; and
b) whenever labor is induced in the appropriate moment
and with appropriate means that best guarantee the life
and health of both mother and child.
As regards the specific evaluation of these circumstances,
one has to take into account the accompanying risks, the
proportion between those risks and the reasons that call for
premature artificial child birth and available assistance: ade-
quate incubator, trained personnel and so forth.
83
4 Drugs
In Medicine, the so-called DRUGS are those substances used
for treating, alleviating or preventing diseases in man. These
substances are, therefore, intended to suppress or mitigate
disease. In this sense, the term "drug" is synonymous to
"medicine. "
However, strictly speaking, drugs are those substances used
(by auto-administration) for motives other than that of legiti-
mate ones. They also produce some physiological or psycho-
logical changes in the human organism.
These drugs generate a physical or psychic state of sub-
jective pleasure. They progressively lead to a habitual use of
them and a subsequent need for higher doses each time. Thus,
they eventually make the user addicted or dependent.
From the ethical standpoint, we will analyze two aspects:
first, the therapeutic use of some drugs and second, the non-
therapeutic use. The first does not pose any problems. The
second, however, undoubtedly constitutes one of the biggest
problems in present-day society.
The Therapeutic Use of Drugs
If the principle that ought to guide medical actuation is
the relief of pain and mitigation or treatment of the consequences
of physical or mental disturbance, then the licitude of using
such substances (including "drugs") for therapeutic purposes
is clear. This is so even when their use can lead to temporary
loss of consciousness. This, therefore, justifies the use of
analgesics, anesthetics, and drugs to cure insomnia, and psy-
chotropic drugs, etc.
With regard to the use of these drugs in hopeless cases,
there is nothing objectionable in helping a patient die pain-
lessly. However, in doing this, one must not directly seek to
shorten life (as happens in euthanasia), even though the use
of analgesics may eventually lead to that. This happens on
account o: mxi: with its administra-
tion. Howe>-e:, - -_ - '!..' Lrii::o::-..5 a..-e necessary:
a) that o:-..e :-.z: ::::.z-..ci m suppress pain as a principle
a.'ld a: a.... ;:::-..r s::::-.:J:,- diminishes or removes it
in a :-ease:-..::.=.: -
b) that :l-.e co :10 impede the person from
prepa:i::.g :-..==.sc:.: :c: ceath \vith lucid mental faculties,
and ro;;-. fui5J:t7:g :-.is duties to God, his family and
socier;.
Non-Therapeutic l:se
Disregarding the .forensic uses (so-called truth serum), and
the erroneously-labelled light" stimulants (coffee, tobacco,
alcohol, etc.) \\e wiL. deal exclusively with "drugs" (described
as "hard" or "soft") which cause habitual use or "drug-
addiction."
The topic is quite relevant because of the widespread use
of drugs in various sectors of modem society including the
very young. It is a sign of alarming moral degradation and
loss of coherent meaning of life. Above all, it is an occasion
for physical or psychiatric harm for many people. Frequently,
the harm is irreparable. For this reason, we will discuss this
topic extensively.
All agree that "hard" drugs cause grave harm. On the other
hand, at present, some still question the dangers of habitual
usage of "soft" drugs. We will, therefore, discuss in detail the
latter.
Included among the well-known "soft" drugs are marijuana,
hashish, amphetamines, certain analgesics and tranquilizers.
Despite the name "soft," which seems to indicate innocu-
ousness, in reality, these drugs have the opposite effect. More
recent investigations ha\e concluded that soft drugs are
dangerous. John Paul II, in this regard, said that these drugs
have been erroneously described as "light" (Homily, August
9, 1980).
For example, it is important to emphasize that while only
physiological effects were pre,iously attributed to marijuana,
newer investigations shov . its serious psychological effect, above
all, during the most delicate period of adolescent crises. Among
86
All
;.'lt t
.:..s."-Usl
-=.= pu
- ciist
,..::dicti
a)
'C!
the major effects described are: apathy, depression, obsessions,
fixed ideas, and in extreme cases, even suicidal attempts. Drs.
H. Kolansky and Wt. Moore
1
opine that the teen-ager who
smokes marijuana is playing the chemical Russian roulette, and
those who smoke it because of psychological problems are taking
a "dynamite."
While it is true that obligatory sequence from soft drugs
to hard drugs does not exist, from the physical viewpoint, soft
drugs do create psychological dependence. This dependence
in turn facilitates initiation with hard drugs. Many drug addicts
affirm this.
The close relation between delinquency and drugs must also
be taken into account; all studies undertaken on this topic
concludes this. Although the relation is not absolute, it can be
concluded that narcotic drugs significantly act on the brain of
the individual. Thus, they modify his will and make him more
inclined to anti-social behavior.
Effects of "Soft" Drugs
All "soft" drugs produce more or less the same effects. The
slight differences presented by the various types (marijuana,
hashish, amphetamines, etc.) will be described together. For
the purpose of an ethical evaluation, however, it is necessary
to distinguish between their sporadic use, habitual use and
addiction:
a) sporadic use: :::efers to the occasional use or administra-
tion of drugs in a single dose. In these cases, the "normal"
dose is employed. It usually does not lead to a pre-
disposition nor to the need to take the drugs continu-
ously. Moreover, the effects are self-contained. We are
referring to cases, somewhat hypothetical, of normal per-
sons. Now it is quite known that drug use is commonly
provoked by personality conflicts and difficulties and
moral problems. It is quite difficult for a balanced person,
who has found his place under the sun, and with good
morals to fall into the desire of trying what he knows
can lead easily to serious consequences.
' Cfr. Report of "Journal of the American Medical Association," 1971.
87
In any case, it would help to know the effects of
the drug- in "normal" (not high) doses, and after a single
dose and when not abused. They are the following:
Mood: immediate sensation of well-being (eupho-
ria), facility for verbal expression, qualitative
changes in sensation and perception. As soon as
the euphoric state elapses, psychic depression,
dysphoria and fatigue ensues.
Capacity for work: increased output in persons
who, in taking them find themselves without
fatigue; inhibition or excitation of certain psy-
chomotor skills; enhanced concentration, less
fatigue and less insomnia.
Sexual drive: initially enhanced sexual arousal in
external sensual acts, especially in women,
followed later by a feeling of numbness, apathy
and frigidity. In the male, large doses can cause
impotence. Augmented fantasy.
Hearing capacity: reduced acuity.
Cardiovascular system: tachycardia, hypertension,
peripheral vasoconstriction.
Brain circulation: vasoconstriction of cerebral ar-
teries.
It is important to remember in relation to its ethical
evaluation that although the sporadic use of soft drugs
does not cause tolerance and is easily controllable, it
can, however, produce side-effects like apathy, psychic
depression, inability to concentrate, tendency to lewd
actuations not only due to the aphrodisiac effects of some
of them but also because of the "clouding" of conscience
that they produce. Not infrequently, the patient suffers
from an underlying mild depression or anxiety or despair
crisis. The subject cannot cope with frustrations in life
and resorts to "soft" drugs under the pretext of "toning
up."
b) habitual use: means continued or uninterrupted intake
of drugs. However, it is difficult to determine precisely
at what moment one crosses the threshold from spo-
radic use to drug abuse. Several interrelated factors are
also considered, e.g., the individual's personality, quan-
88
c)
q
d
2"
ad.olesce
;:onvinci
~ not!
::agic, d
some pe
August
l ar-

ngs
I:: it
clUe
ewd
erne
ence
:::ers
S>air
life
rung
:;ake
::.sely
spa-
s are

tity of drugs ingested, periodicity of intake, composition
of the drug, (clandestine marketing and frequent fraud,
etc.- account for the difficulties in determining the
composition of the substance).
As the body "gets used" to the drug (tolerance), it
is necessary to administer the drug each time at pro-
gressively higher doses and at shorter intervals to get
the desired effect. Therefore, the subject becomes less
and less master of himself, the drug becomes more and
more "tyrannical," as he approaches intoxication. Fre-
quently, these individuals end up resorting to "hard"
drugs.
Habitual intake has the following effects:
on the emotional state: lessening of tolerance to
euphoria, increasing dysphoria, irritability, emo-
tional depression, mistrust, phobia, apathy;
abrupt change towards paranoid psychosis.
on the intellectual output: lessened output; loss of
memory; lessened concentration.
on the state of watchfulness: reduced feeling of tired-
ness during periods of sleep deprivation.
on the sexual drive: in men, gradual reduction of
sexual excitability; tendency to impotence; in
women, hyperexcitability or frigidity, as the case
may be.
The continued use of drugs eventually causes the
breakdown of the personality structure. The "sensations,"
created by the drugs enslave the intellect and annihilate
its capacity for ideals or values. Thus, the cycle is closed.
If drug abuse is related to conflicts and personality dis-
orders/ the habitual use ends up seriously changing an
initially weakened personality.
c) addiction: state or situation produced by drug abuse. At
this level, it is usually the "hard" drugs which have
2
Psychologists and sociologists say that the primary cause which pushes
adolescents and adults to the deleterious experience of drugs is the lack of clear and
convincing motivations in life. In fact, bereft of reference points and values, convinced
that nothing makes sense, they conclude that life is not worth living. Besides the
tragic, desolate feeling of being an unknown vagabond in this absurd universe urges
some people to search for exasperated and desperate flights." John Paul II, Homily,
August 9, 1980.
89
been resorted to. After knowing the effects, one can
conclude about the grave repercussions of drug abuse.
Death is not ruled out. Likewise, it is important to
remember that alcohol, barbiturates and other drugs can
add more strength to those effects.
According to the World Health Organization (WHO),
true addiction is characterized by the following:
1) uncontrollable desire to consume drugs uninter-
ruptedly, obtaining them by whatever means.
2) tendency to augment dosage (phenomenon of
tolerance).
3) psychological dependence; in some cases, also
physical.
The different phenomena that comprise addiction
include:
paranoid psychosis: auditory and visual hallucina-
tions; paranoid delirium without confusion;
anxiety; aggressiveness; impulsiveness; homicidal
acts.
stereotyped conduct: repetitive compulsive acts;
neglect of the body, indigestion of one type of
food, cleaning of objects.
choreic syndromes: muscular hypotonicity of
extremities, involuntary movements of the face,
hands and head (rotation, flexion and extension).
excitation syndrome: a clinical picture of psycho-
motor excitation, wi th increased blood pressure,
tachycardia, hyperthermia, pupillary dilatation,
pale and cold skin. Evolution to lethal stage due
to shock or circulatory collapse.
dysautonomic syndrome: great anxiety, motor
tachycardia, pale complexion, nausea and
vomiting, generalized convulsions, coma and
card.ioYascular shock.
cerebrovtL"C.l!ar accidents: cerebral hemorrage,
intense headaches, hemiparesis and hernipares-
thesia.
antisoaal ar..d ...-.a:adfusted behavior: at the level of
the nenous system, the habitual use of drugs
n
~
0
n
),
r-
;.
iO
m
a-
n;
rai
ts;
of
of
re,
n).
JO-
re,
~ :
r
:
d
I
blocks the relation of human acts with their
consequences. What was previously a source of
motivation is turned into indifference. Nothing
stimulates the appetite; nothing satisfies it. A
picture of apathy and boredom ensues. The
antisocial and maladjusted conduct persists
inspite of cessation of drug intake.
The Ethical Evaluation of Drugs
In the first place, when making an ethical judgment, it is
important to remember that although these drugs are grouped
under the same name, each one acts in a peculiar way. Likewise,
within a specific subgroup, one has to take into account the
dosage. For example, the concentration of 9-delta-tetrahydro-
cannabinal, active ingredient of marijuana, varies from 0.5%
up to 20% in different consumer countries. Besides, the mode
of administration, past experience, emotional state of the subject,
and the environment all play some role. All these factors
obviously influence at the moment of evaluation. Finally, it is
important to note whether the drug is consumed sporadically
or habitually.
In summary, one may conclude the following:
1) In a few cases, more in the abstract than in real life,
the sporadic use of "soft" drugs may be considered licit.
2) It also may constitute merely a slight transgression, that
is, in the case of a mature person who takes soft drugs
occasionally, out of curiosity or for some other reason.
3) In general, however, the use of soft drugs ought to be
considered ethically illicit, considering the above-
mentioned effects. The use of drugs is an attempt against
one's own life, i.e., psychological or physical health. Also,
the drug addict easily becomes a drug pusher who does
harm to others. Drug use facilitates the acquisition of
vices and the commission of crimes. In the case of the
latter aggravating circumstances are added: age (the ado-
lescent and the young are involved), reasons for use
(escapism, training for an anti-social life, etc.), environ-
ment in which it is propagated, and the risk of
imprisonment for drug trafficking.
91
4) Inspite of the attempts to legalize the matter, the u_;;c
of soft and a fortiori of hard drugs ought to be co:r
sidered ethically reproachful. In the better cases, ::
signifies merely self-gratification, in the worst, th=
destruction of the person. Simply consider the difficul-
ties, ... and the economic burden caused by the rehabili-
tation of drug addicts.
_1


f01
s=rge
X
--:hE
--nt
s:.:C. 1
n
.r.d E
_-=.est
.

A

.::eath
:n del
:o loa

:...'leir
does
apply
aU, tl
LE
;:onte
t.se

it
be
::ll-
!!1-
5 Duties Toward the Dying Patient
Medicine is at the service of life. It is a struggle to conserve
health, alleviate suffering and as far as possible prolong life.
Today, the human life span is higher compared to that of three
or four decades ago, thanks to medical progress: antibiotics,
surgery, etc.*
Notwithstanding these achievements, man continues the
journey towards his final destiny. He reaches a point when
neither physician nor medicine can do more for him: "It is sheer
madness of a man to cling to his life when God wills that he die ... "
said the poet.
1
The moribund patient needs an extremely delicate atten-
tion. In this regard, the nurses play a vital role. Likewise, the
patient has the right to be informed about the gravity of his
illness (See Chapter 11), especially about the use of ordinary
and extraordinary therapeutic means to support his life. The
question of euthanasia is very important.
The Terminal Patient
Although the average life span and quality of life has
significantly improved, a point is reached sooner or later when
death is the final outcome, despite the efforts of medical science
to delay it. It is frequent in these moments for medical personnel
to look for means in order to help these patients in the terminal
stage. It is as if they had nothing else to do, when actually
their mission is to help patients have a good death. This task
does not consist in a passive attitude. Medical personnel must
apply appropriate measures to relieve pain and anxiety; above
all, they must provide moral support.
Let us now consider "Terminal Illness" in its proper scientific
context, before discussing the duties to the moribund patient.
*In Spain, life expectancy for males is 70 years; for females, 76.
1
J. Manrique, Cop/as a Ia muerte de su padre (Verses on the death of his father).
a) "Terminal Disease
, __ _
-- ..i..i
("Incurable DiseLse
Terminal illness IS co:-.s:..:c:-ed. as the final phase of many
progressive chrome cEseases T -:.en all available treatment has
been exhausted cu"'td t:-.e rita: :e.-el of irreversibility has been
reached.
Among the hie.., frequently course to the termi-
nal stage in the hospital are the following:
cancer
degenerative diseases of the central nervous system
(CNS)
liver cirrhosis
chronic obstructive pulmonary disease (COPD)
arteriosclerosis (arterial hypertension, ischemic heart dis-
ease, diabetes mellitus and senility).
Medical abstention is never justified in any of these
conditions. Strict diagnostic-prognostic criteria must be met
before judging a clinical condition as "terminal syndrome."
Likewise specific therapeutic indications are to be given. The
criteria include:
2
1) Progressive evolution of the underlying disease: All forms
of conventional treatment have been employed. New
strategies, including experimental modalities have been
tried. The response is unfavorable, or the side-effects
are intolerable for the patient.
2) Life expectancy of less than one month: Actuarial tables,
clinical experiences and natural history of the under-
lying disease are the bases for prognostication. It has
been observed that 90% of terminal patients die within
a month.
3) Emaciated state: Because of debility, poor hygiene, and
other factors, the patient cannot sustain himself nor
perform any activity like reading or conversation. His
basic organic functions deteriorate progressively. They
corresponds to the 40th percentile of the Scale of
KARNOFSKY.
2
Brugarolas et a!. Sindrome terminal de Ia enfermedad: criterios y actitudes. Revista
de Ia Universidad de Navarra. April-June 1988, pp. 11-118.
94
4
s:
6)
.I
:<e
~
es,
er-
~ s
.md
:lOr
His
[ey
r of
f=-vista
4) Single or multiple-organ failure: When there is gross loss
of function or abnormal laboratory findings, organ failure
should be suspected: dyspnea and cyanosis (respiratory
failure); elevated serum BUN-CREATININE and edema
(renal failure); jaundice and ascites (liver failure), and
brain failure as seen by the functional loss. In the case
of terminal sickness on account of cancer organ insuf-
ficiency depends on the predominant place of the
metastasis, the most severe ones being the liver, the lungs
and the brain.
5) Failure of conventional therapy: Terminal illness is diag-
nosed only after having tried all forms of available
treatment. The evaluation of this condition is reserved
for the specialists. They can certify that indeed all
adequate means have been employed with nil results.
Therefore, treatment has failed.
6) Absence of other active treatment: The patient and his family
suspect what is later confirmed by the physician: that
the illness has become incurable and irreversible-a
prelude to the end.
7) Final irreversible complication: An error in diagnosis or
prognosis may occasionally be discovered. The terminal
illness may linger for some time until an irreversible
complication suddenly supervenes. This then leads
inevitably to death.
The criteria for irreversibility include specifically the
following complications:
sepsis
acute respiratory failure
malignant hypertension
severe oliguria
pulmonary embolism
metabolic coma
hemorrhagic shock
acute abdomen.
Surgery is contraindicated at the terminal stage. As-
sisted ventilation, renal dialysis and related maneuvers
are considered impractical, futile, and even risky when
the illness is already "irreversible." The physician should
explain clearly to the relatives about the serious con-
95
clition of the patient and the futility and contraindica-
tion of therapy. Then he leaves the following orders in
the patient's chart: "NO CARDIORESPIRATORY
RESUSCITATION OR OTHER MEASURES."
b) Attitudes Toward Terminal Patients
In the majority of cases, the patient's role in managing his
illness is restricted due to the poor general state he is in and
the deterioration of his mental faculties. The responsibility, con-
sequently, falls primarily on the medical team and the nurses.
They count on the family, or even, if possible the patient himself.
The actual concept of "terminal syndrome" of a disease is
oriented to three important areas of actions. Their concrete
objectives are:
1) Communication. Information to patient and relatives.
Respect for their will. Assessment. Emotional aspects.
2) Treatments and specific attention. Life support. Feed-
ing, hygiene.
3) Organization in order to continue giving care. Foresee-
ing help.
A detailed discussion is given below.
1) Rapport, Respect and Counsel
One must show the terminally ill patient that all his
limitations and needs are understood. He must be shown that
medical team intends to collaborate "limitlessly." For example,
the physician should explain matters clearly and simply,
dialogue with the patient and his family in order to ensure
their consent. He must offer 24-hour professional assistance.
He should always tell the truth, tactfully and without wound-
ing; never should he lie to the patient. He must bring calm,
allaying whatever fears the patient or his relatives may have.
He should visit the patient more frequently (doctors, at least
twice daily, and nurses, more often). He should not allow the
patient to nurture sentiments of neglect and uselessness. Above
all, he must respect his privacy and if possible, place him in
an individual room.
96

..:.t::::::ta'
p::en
.._.. j
z:::rasu
.....:ess
2)
Th
;orms

sil
:::utse
::. sug:
::anqt

Kubler Ross enumerates three distinct psychological stages
in the evolution of a serious illness towards its final outcome-
death:
Stage 1 - rebellion and negation
Stage 2 - frustration and negotiation
Stage 3 - depression and acceptance
These three stages evolve together and sometimes occur
simultaneously. Frustration, depression, and fear can predomi-
nate the clinical picture. It may also be possible that great hope
is present and is habitually maintained up to the end. Then
it gives way to the acceptance of death as something beyond
remedy.
3
The physician, as well as the nurse should try to under-
stand the patient through hints that reveal the latter' s emo-
tional state. With that knowledge, they should then act in con-
sequence. The terminally ill patient must be consoled and
encouraged to make use of his illness spiritually, inasmuch as
he may not understand well the reasons for his suffering. Quality
patient care which is personalized and holistic is attainable only
in so far as each member of the medical team, physician and
nurses, take their individual formation seriously. Only in the
measure that one has taken up this whole context of suffering,
illness and death, the possibility of getting sick, suffering and
dying himself, will it be possible to offer these concepts to the
suffering and the needy.
2) Symptomatic and Supportive Forms of Treatment
The alternatives are narrowed down to the symptomatic
forms of treatment inasmuch as the definitive forms hitherto
applied have not been effective. Medical literature has reported
the signs and symptoms frequently observed in the terminal
phase: anxiety, pain, dyspnea, coughing, hiccups and so forth.
It suggests specific measures like administering analgesics and
tranquilizers, prescribing antibiotics, giving blood transfusions,
giving oxygen, and placing indwelling or straight catheter.
3
Kubler Ross, "Sobre Ia muerte y los muribundos" (About Death and Dying), Grijalbo,
Barcelona 1974.
97
"To improve the quality of life" is the immediate goal of
these supportive and symptomatic treatment. The specific
objectives are:
to prolong the rest periods of the patient and his family;
to increase communication and physical activity of the
patient; and
to relieve the patient' s feeling of guilt and powerless-
ness.
A therapeutic regimen is carefully planned by a trained
physician and nurse specialist to include the following:
a) Effective control of pain: Pain is the common symptom
of terminal illness, particularly cancer (70% of cases).
Today, pain clinic's offer a wide range of modalities,
including drugs, to control all types and degrees of pain.
b) Management of anxiety and depression: Neuroleptics
are indicated to help control fear and anxiety, combat
depression, and cure insomnia. They also strengthen the
effect of analgesics.
c) Twenty-four hour watch by the medical team and
nursing staff.
d) Multi-disciplinary approach to different problems.
3) Total Quality Care
1\eedless to say. the patient deserves continued medical
attention, whether a: nome or in the hospital.
The patient be allo.,ed. to stay at home for human
reasons. These a:e :.;.e company of his loved ones, a conducive
atmosphere, a....-..d the c.-...a..oce ro combine special attention without
being bound ... e a....""td limitations of the hospital.
=-arv ci=es this situation causes in the sick
person and :.."'1 b.:.s :a....-:il: a...LXIety and suffering. It may even
cause ieeli::::- 3esices !S not always possible to treat
at home the cm=._:-::.::ad.o:-.s :...:.....ar ca..'"\ arise in the course of his
illness. is why ci-..ec:lC::g-i.Tl in special hospitals, center for
chroruCC.::: centers, anti-TB and Cancer
centers Centers, AIDS center, etc. is rec-
omrner.cieci..
But co:- ..:....2eci i;- t.".;e hospital where the patient
has bee:i. still be advisable. There are
- - .
- ...-
--
1
?
(
(
of
iic
ily;
t.he
!SS-
ed
l>m
~ .
res,
ain.
:ics
U,at
the
and
sick
=ven
;::eat
-his
for
cer
are
advantages to this. For instance, the patient may have checked-
in in different stages of the illness; he knows the medical team
and relates to it with affection and trust.
In many hospitals, attitudes towards the terminal patient
are negative. Arguments brought forward can be lack of trained
personnel, lack of usefulness from the therapeutic point of view,
financial problems, etc. But one has to give these sick people
a hospital bed, rendering them all the necessary attention and
treatment.
"In few areas of medicine does a vocational and profes-
sional richness exist such as in this, where the highest value
of human cooperation and consolation are interwoven, together
with the suffering and the struggle for life (this is etymologi-
cally what is meant by agony). The physician or the nurse can
perform an absolutely gratifying professional work in these
cases."
4
Disthanasia or Employing
"Disproportionate" Means for Therapy
Today certain dilemmas are paradoxically created as result
of technological progress.
Is there a limit to the use of therapeutic modalities in a
patient?
Is it licit to utilize highly-expensive, complex treatment which
offers little chance of success?
Is one obliged in every case to exhaust all available means
to prolong the life at all cost?
Should one prolong life through artificial means?
(Remember the Karen Anne Quinlan case in the U.S.)
The ambiguous expression, "the right to die with dignity" is
questionable as it can have different meanings. It can mean the
right to procure death (euthanasia) for oneself or for others.
For others it signifies the "right to have a humane death."
We cannot permit death to be converted to a mechanical
event by the abuse of technology. The terminal patient is exposed
to these dangers. These points have been raised. Abusive medical
technology has subjected many patients to the so-called
"therapeutic obstinacy."
4
A. Brugarolas, o.c., p. 118.
99
The physician (or the relatives or the patient himself) may
not wish to accept that the end has come. Instead of searching
for new therapeutic modalities, the proper attitude would be
to allow the patient "to die peacefully."
Although the physician should find solutions, he is not
obliged to use all forms of available treatment indiscriminately,
in the opinion of the experts. These are the so-called "extraor-
dinary" means to sustain life. Nevertheless, such valid opinions
could appear vague today due to ambiguous terminology and
therapy advance. Thus, it is better to use the terms "PROPOR-
TIONATE" and "DISPROPORTIONATE" MEANS. When
evaluating the means one has to take into account the thera-
peutic modality, degree of difficulty, the accompanying risks, costs,
practicality of application as against expected results considering the
patient's condition, physical and moral stamina.
5
Having made these considerations, there will be enough
data to decide on a treatment to prolong life or alleviate pain
using the proportionate medical means. To reject other
"disproportionate" means (not exempt from risks, too expen-
sive, etc.) is not equivalent to suicide. "Rather, it signifies the
acceptance of our condition as human, or the desire to avoid
putting into practice a medical technique disproportionate to
the expected outcome, or the will not to impose excessively
onerous experiences on the famil y or the collectivity."
6
After studying the matter, the German Bishops propose the
following: "If, after deliberating over all the circumstances, the
patient, his relatives and the physician decide to renounce the
use of extraordinary means and medicines, they cannot be
accused of arrogating an unlawful right to dispose of life."
The Bishops, however, also teach that "When a grave
disease is curable, one is obliged to use all available means.
It is the duty of the State to facilitate the acquisition of
equipment and medicine for the patients in need, including
the highly expensive ones. The use of extraordinary means
must be limited only when the expected result is the artificial
delay of death."
7
The problem can be summarized as follows:
5
Congregation for the Doctrine of the Faith, Declaration on Euthanasia, May 5,
1980.
6Jbid. IV. Congregation for the Doctrine of the Faith.
7
Cfr. L'Osservatore Romano, September 23, 1978.
100
e)
\\
del
a) The purpose of medicine and consequently, the phy-
sician's duty is to protect health, cure diseases, alleviate
pain, comfort the suffering always with due respect for
the freedom and dignity of the person.
b) In the absence of alternative therapy, it is licit to resort
to "new modalities" that "avant-garde" Medicine can
offer, including experimental and risky ones, with the
patient's consent. This attitude of the patient can even
be an example of generosity for the benefit of humanity.
c) However, as per agreement between the patient, rela-
tives and competent physicians, it is licit to interrupt
the application of these new modalities when the results
are disappointing.
d) It is always licit to conform to ordinary therapeutic
means. Thus, no one is obliged to utilize risky and ex-
pensive therapy. These are the so-called "DISPROPOR-
TIONATE MEANS." Pope Paul VI affirmed in 1970 that
the duty to defend life does not oblige the physician
to use all available means offered by a tirelessly creative
science.
e) In the face of the imminent death, it is licit to renounce
treatment that would merely obtain a precarious and pitiful
extension of existence.
f) IT IS NEVER LICIT TO SUSPEND THE ORDINARY
MEANS in patients even if the prognosis may be fatal.
Some hospital personnel have adopted the wrong
attitude of denying all life support for incurable patients
when biological death is inevitable.
We conclude by citing some paragraphs of the commentary
of Vatican Radio towards the start of 1973 on the ambiguous
declaration of National Association of Hospitals of the United
States concerning the "right to die with dignity."
"By vocation the physician is the irreconcilable enemy of
death. Neither incurable illness nor intolerable suffering can
ever dispense the physician from defending life, to which he
has committed himself. Science is human only for as long as
it defends, protects and saves life at every moment. But it is
not so when it renounces to keep alive the last flame of life.
For those who believe in the infinite value and eternal destiny of
human life, even the last moments of agony that precede the
death of every person, adult or child, rich or poor, at home
101
or in the -
x;.:::.-:c-.:.
being p:n!._._
The .... _--..-.- .
mentalir:-, -- -
as su ore:::-.e 2'ril. ..
Euthanasia
- in the street or in a
- - ; - crr-..hy of assistance, and of
.s:il::!:=.:..e r.ri love.
a..-:- ::-.0::1ent, by direct interven-
-s an egoistic, materialistic
-- - C.:u::.:::e and a vision of suffering
''Eu:::'12...-..:.ci;: the Greek eu (good) and tha-
natos . -. e=:...... - ,:=-aJ : signifies good death, a pleasant,
gentle .i.:: _: awiU: suffering. Euthanasia may be
defined as a:. aGio:: n: o:mss1on, that by its very nature, or
in the btenriar., cat!SCS death, for the purpose of eliminating
whatever pa.L.1.
The \\ord ,,as used for the first time by F. Bacon in 1623.
He affirmed me task of the physician is to bring back
health, to mitigate suffering and pain not so much in that this
mitigation can lead to a cure, but that it may also serve to
procure a peaceful and easy death (euthanasia)," (Historia Vitae
et Mortis). The word is used today to signify that procedure
which facilitates death and liberates from all types of pain,
provoking the death of the hopeless patient and suppressing
"useless" human lives.
People in ancient times did not usually have scruples to
eliminate in any way those individuals considered useless to
society. Plato, for example, wrote: "Discipline and jurisprudence
shall be established by the state; this will be limited to caring
for healthy citizens (in body and soul). The unhealthy are left
to die" (Republic, III). A laudable exception is found in the
Hippocratic Oath (450 A.C.): "I will give poison to no one,
when asked; nor will I take the initiative of suggesting such
act."
But the ethical question on euthanasia was not presented
until after the arrival of Christianity. During this period, there
was a moral renewal following the divine law "Thou shall not
kill" (Ex 20:23, Mt 5:21).
102
_)
3)
5)
1
i
b) Different Kinds of Euthanasia
In order to understand this topic adequately it is important
to know the terminology employed by various authors. The
terminology is quite confusing and needs clarification. The
different types of euthanasia are as follows:
1) SUICIDAL EUTHANASIA. It is so-called when the
subject himself (alone or with the help of the others)
resorts to lethal means to interrupt or suppress his life.
Therefore, it is done with the subject's consent.
2) HOMICIDAL EUTHANASIA (2 forms):
Compassionate Euthanasia (pious homicide) is performed
to liberate a person from a terrible disease, agonizing
senility, etc. Today this type of euthanasia is presented
as the most "reasonable" compared to other types.
"Death without suffering" for hopeless patients, saving
them any "useless," "unnecessary" suffering.
Social or Eugenic Euthanasia seeks to eliminate "lives
devoid of vital value" or to "purify the race," etc.
3) ORTOTHANASIA. Etymologically, the word ortothana-
sia means normal death. The subject is left to die by
omitting any medical assistance. But for some authors,
this terminology has other meanings (just death, death
in its due time) which are considered ethical.
4) POSITIVE OR NEGATIVE EUTHANASIA. Positive
euthanasia provokes death through adequate interven-
tion (equivalent to suicidal and homicidal euthanasia).
On the other hand, negative euthanasia, is the result
of omitting necessary medical support, i.e., ortothana-
sia.
5) ACTIVE (DIRECT) EUTHANASIA & NEGATIVE (IN-
DIRECT) EUTHANASIA. There is a growing tendency
today to impose the terminology, "active or direct eu-
thanasia" to mean euthanasia, properly speaking (to
procure death in order to eliminate pain). "Negative or
indirect euthanasia," which is not and should not to be
termed euthanasia seeks to alleviate a patient of his
sufferings with the accompanying risk of shortening his
life. We will discuss this later.
103
6) PAINLESS DEATH is not, properly speaking, euthana-
sia. Drugs are administered to modify or suppress pain
and not to provoke death. (Painless death is inappro-
priately termed as euthanasia lenitiva). Neither can we
call euthanasia the acceleration of death when it is due
to drug therapy which shortens life but is not intended
for this end.
c) Moral Evaluation
Euthanasia, in the strict sense, is gravely illicit because it
implies homicide. Therefore, no reason (like commiseration,
humanitarianism or apparent piety) can justify the act of sup-
pressing life. Man is not the absolute owner of his life.
The fundamental principle of natural law and christian
morality, over and above medical science and human endea-
vors, is the absolute respect for human life. "Anything that goes
against life itself, e.g. homicide, genocide, abortion, euthana-
sia ... etc. is evil and undermines human civilization, degrades
those who practice it mtJre than those who suffer from it. It
is a grave offence against the honor of the Creator" (Gaudium
et Spes, no. 27).
1) Suicidal euthanasia is just another form of suicide; it is
equally immoral.
2) Ortothanasia is professional negligence through neglect
of attention and the necessary measures for the patient.
From the legal standpoint, it is culpable homicide.
3) Eugenic euthanasia (for political, economic, racial motives,
etc.) is universally condemned today. "To kill directly
by mandate of public authority those who have not
committed any capital crime, but are considered useless
to the nation due to physical defects or psychiatric
problems is contrary to the natural law and divine
positive law" (Pius XII, Aloe. July 2, 1940). This was
written about 50 years ago when Europe trembled with
barbaric acts of Adolf Hitler. Among them was that of
eliminating the life of the old, considered useless to the
nation. Hitler's concept of "utility" is well-known.
The promoters of euthanasia assure that this bar-
baric act will not happen again because we are now
104
l
:i
it
l,
) -
n
:1.-
~ s
~ s
It
m
is
~ s
:ly
tot
~ s
ric
ne
as
ith
of
:he
ar-
ow
dealing with a voluntary, freely-solicited death. But
experts affirm that the senile rarely ask to die, except
in cases of psychopathic suicides. Instead the relatives
are the ones who; tired of attending to them, desire to
end their suffering.
In this respect, will approval of the law not endan-
ger many lives, leaving in the hands of the unscrupu-
lous a means, which in time will remind us of Hitler?
The right to life is a fundamental human right. If an
individual in the future were to be compelled by the
social environment to abandon his life, human freedom
would be greatly chiselled away. Besides, let us not forget
that if some states have legislated regarding the incep-
tion of human life, will they not feel tempted also to
dispose of life which has reached its final stage?
4) Compassionate Euthanasia
Euthanasia out of compassion is illicit. Some,
however, have tried to justify and even legalize it.
Regardless of sentiments or economic motives, its moral
character remains the same.
Human life deserves absolute respect. Thus, eutha-
nasia is always illicit. Compassion does not change the
morality because what remains at issue is the direct
suppression of human life. It is homicide. Besides, to
consider some "compassionate" arguments is to open
the floodgates to sinister opportunities: compassion may
be utilized to justify the elimination of the feeble and
abnormal people. It would lead to the terrible pressure
by reason of public interest (with more or less basis).
It may also invite the aged people to "freely" or spon-
taneously seek euthanasia.
Another social consequence of legalizing euthana-
sia is the patient's loss of trust in the physician. He can
consider him as his future assassin. Homicide by eu-
thanasia could be easily committed in order to hasten
taking possession of an inheritance. Let us add the risks
of errors in diagnosis that could lead to euthanasia, e.g.,
persons being considered "incurable" when they are in
fact curable. The scientific and humanitarian endeavor
in taking care of the insane would disappear. Not only
105
hospitals but also welfare institutes, homes for the aged,
etc. would lose their physionomy and become sinister
establishments, dedicated to professionally and scien-
tifically planned assassination.
8
But the heart of the matter remains this: leaving it
up to the physician to decide what is suffering and what
is death. The goal of Medicine is to impede death and
alleviate suffering through science and technology. The
brutal solution to eliminate life is contrary to the very essence
of a medical act.
From the christian point of view, it is a grave sin. It
directly deprives a man of a time of his life which could
be decisive for his eternal salvation.
Catholic morality condemns emphatically euthana-
sia. In 1949, Pius XII denounced "the false compassion
that seeks to justify euthanasia and deprives man of
meritorious, purifying suffering, not by means of a
charitable and laudable alleviation, but by means of
death itself, something conceived only for mortal, non-
intellectual animals (brutes)" (Alloc. November 11, 1949).
The words of the Pope underline the value of suffering
and pain, as was mentioned, which are intended to
purify.
"To live is to suffer and to survive is to find the
meaning of suffering" said Victor Frankl. For a man of
faith, suffering has meaning. While it is licit to alleviate
pain in the patients and the dying, it is never licit to
suppress their life so as not to make them suffer.
Suffering is, in the end, the last chance of identifying
oneself with Jesus Christ before commencing the beatific
vision in heaven.
In a 1970 discourse, Paul VI recalled the same doctrine on
the illicitude of euthanasia: Euthanasia, with the patient's consent
is suicide; without it, homicide. Later, he affirmed: "It is a
temptation to attempt against human life with the false pretext
of procuring a soft and quiet death in order not to see life
continue desperately or in awful agony. But what is morally
an object of crime cannot, under any pretext, be legalized. "
9
8J.L. Soria, Euthat!tlsia, Gran Encyclopedia Rialp, Madrid 1972, p. 579.
9
Paul VI, Alloc. to the International Federation of Catholic Medical Association,
1970.
106
u
J
b
.::c:rJ
- 0
t
l
t
e
'f
'9
n,
We are reminded by a recent document of the Church
regarding euthanasia and problems medical progress present
in relation to the prolongation of life (what we have termed
DISTHANASIA). The document deals strongly with euthana-
sia. "Nothing or no one can authorize the death of an innocent
life whether fetus or embryo, whether child or adult, old,
incurable or agonizing.
Besides, no one can request this homicidal gesture for
himself. Nor can those to whose responsibility others are
confided, consent to it explicitly nor implicitly. No authority
may legitimately impose or permit it."
10
Other arguments
favoring euthanasia to save the patient from useless suffering
are not valid. Physicians agree unanimously.
In this connection, one has to try to alleviate all the "useless"
suffering in a terminal patient. Fortunately, modern pharma-
copoeia offers an arsenal of potent analgesics and other
modalities for relieving pain and anxiety. Hence, it is absurd
to justify euthanasia in order to relieve suffering. Dr. Wilke,
President of the National Committee for the "Right to Life"
in the US states sarcastically: "If they cannot alleviate your pain,
please don't ask for euthanasia. Go to another physician because
the present one is incompetent" (Spanish Newspaper "Ya," June
3, 1988).
Vital Testament
In September 1989, The Episcopal Conference of a Euro-
pean country* released to the public a report entitled "Accom-
panying the Moribund Patient and Legislation on Euthanasia."
In it it affirms that the problem of euthanasia affects another
grave problem from the point of view of health personnel: the
need for an integral attention to the terminal patients, their
relatives and those that assist and care for them. In fact, the
statement continues, by saying that "everybody is aware of the
inhuman manner of dying today: patients, especially in big
hospitals, with medical attention but left in solitude, without
the support of human warmth and supernatural outlook of those
who can and should remain close, by surrounding the patient
(like parents and children, doctors and nurses)."
10
Congregation for the Doctrine of the Faith. "Declaration Regarding Euthanasia,"
June 5, 1980, published in June 27, 1980.
"Spain.
107
The document s.:.gsesc : concrete actions on how to
humanize the ac: The,- are:
- - .
dramatize :25.5 .:-.e of death;
arouse t.l'e .... o: C.elping the moribund and their
family m.err.::e-s;
inform about alternative solutions to
euthanasla :.alliati:e medicine, pain clinics, etc.;
get the co.:c-ma:ic:t of the Religious Help services of
the hos?::a! c:n....-...stian medical personnel in order
to pro'.1de a goc:xl death to the admitted patients, etc.
A i..1.1hatiYe of the report is the proposal for
a "VITAl This is distinct from the Living Will
of the pa.rtisa.ns o: euthanasia. It was promoted by a Boston
lawyer, lecis :ru..-wer. It spread in the USA in the 70s.
This Chrisna..1 'Yital Testament" is inspired by the Dec-
laration abou! Euthanasia by the Congregation for the Doctrine
of the Faith m 1980 and the Note about Euthanasia by the
Episcopal Commission for the Doctrine of the Faith of the said
European country, Spain, of June 15, 1986 (cfr. Ecclesia 2265-
66 [1986] pp. 620-623).
The testament is addressed to the family, the physician, the
priest and the notary. It affirms that "earthly life is a gift and
a blessing from God, but it is not a supreme and absolute value
and that death is a path to God, to eternal life. He that subscribes
to it p leads that:
he be not subjected to active euthanasia
neither disproportionate or extraordinary treatment be
applied to him should the situation becomes critical o::
irreversible;
he be administered adequate treatment in order m
alleviate his sufferings.
We do not know how much use or acceptance this docurne:--
has among Catholics. However, it is a very positive
to approach the problem of pain, sufferinE and death from =
christian perspective. It only lacks an explicit reference to fr _
administration of the sacraments to the terminal patie:--
particularly the Anointing of the Sick. Undoubtedly, howe,-e:
it constitutes an adequate means of evangelization, in
to promote the "good death" among christians.
108
a
tO
of
er
1c.
for
iill
:on
leC-
ine
the
.aid
~ 6 5
the
and
lue"
ibes
1t be
al or
~ r to
ment
iative
om a
:o the
ttient,
ever,
order
6 Bodily Integrity
Biologically speaking, life is the result of the harmonious
functioning of a series of organs. However, it can happen that
at a certain moment a diseased organ may threaten the entire
human body. The problem then arises at to whether or not
the organ should be extirpated or eliminated. In morals, this
is termed as "mutilation." May one proceed to the suppression
of this organ? The answer is yes, whenever necessary by virtue
of the "Principle of Totality."
Principle of Totality
This principle is the basis for mutilation. It is as follows:
"The parts of a physical whole, inasmuch as they are parts,
are ordained to the good of the whole. The reason is because
this good is that which gives fundamental meaning and raison
d'etre to the whole." Applied to the human body, it means that
if some part or function becomes a threat to the whole body,
e.g., an infected appendix, a nonfunctioning kidney, etc. the
suppression of its function is within the right moral order.
1
This principle justifies a series of surgical interventions done
in daily clinical practice. Specific operations do not in them-
selves present moral problems if surgical ablation involves a
diseased organ, e.g., the appendix, gallbladder, kidneys, lungs,
etc. The difficulties are encountered in cases of plastic surgery,
organ transplants and above all, sterilization.
Plastic Surgery
It is not easy to ethically qualify the case of "unnecessary"
surgery. "Unnecessary" surgery, is one in which there is no
'A. Alcala Galve, Medicina y moral en los diswrsos de Pio XII (Medicine and Morals
in the Discourses of Pius XII) Taurus, Madrid 1959, pp. 109 ff.
real medical indication. It is carried out instead for other motives.
Now, if the motives are reasonable, there is no objection.
However, if performed for twisted motives, for example, tc
evade military service, to disguise the face of a criminal, etc.
then it becomes unethical. Plastic or aesthetic surgery is licit under
the following conditions:
that the intention is good;
that the patient is not exposed to grave medical risks
and finally,
that the motives are reasonably proportionate to the
extraordinary means employed.
2
Therefore, aesthetic surgery as it is now performed is
definitely licit under the following conditions.
to improve bodily appearance following injury caused
by accidents, congenital deformities, etc; and
when the external features could be a psychological
social, or economic handicap with repercussions in the
individual's adaptation to society.
Nevertheless, the risks of these interventions and the
expected outcome should be proportionate.
Today this does not present any ethical dilemma if the
previous criteria are followed. Pius XII inspired the surgeons
with his speech, encouraging them in their task of improving
the harmony, order, and beauty of the human body. He made
an analogy between the task of a plastic surgeon and the divine
action of Creation. God formed the first human body out o:
the slime of the earth, and infused life into it. This analog::
stresses that their work can alleviate those who suffer frorr.
deformities.
Organ Transplants and Donation
A transplant may be defined as the transfer of an orgar
or a major or minor portion of a tissue from one part of the
body to another, or from one organism to another.
2
Pius Xll, Italian National Congress of Plastic Surgery. October 4, 1958, in A. Alcalz
Galve, o.c., pp. 229240.
110
.e
; ,
: )
Elh
-)
es.
n.
to
the
The development and progress of the technique of trans-
plantation belongs to the 20th century Medicine.
3
In clinical practice, besides blood transfusion, the following
have become ordinary: corneal transplant, bone transplant, skin
grafting, cardiac valve transplant, and other transplants. The
first successful kidney transplant between monozygotic twins
was performed in 1954. Since then thousands have survived
all over the world because of kidney transplants. Many other
transplants have been performed: heart transplants (Barnard,
1967), transplants of the liver, pancreas, lungs, and so forth.
Except for kidney transplants, organ transplantation is at its
inception. Nevertheless, many interesting experiences with
different transplants have already been gathered.
a) Terminology
Transplants may be classified into:
1) autotransplants (autografts or autoplastic grafts): The donor
and the recipient is the same individual. The transfer
is of one part to another part of his body, like a portion
of skin or bone; and
2) heterologous transplants: The donor and the recipient are
two different individuals. In some cases the donor is
an animal; more frequently, it is another human being.
The latter is also termed as "homotransplant" (homograft
or homoplastic graft or homologous transplant). Within the
subtype of human-to-human organ transplant, there are
two possibilities-either from a living individual or from
a cadaver.
b) Ethical Evaluation
After studying the different types of transplants, we can
make the following conclusions:
1) Autotransplants are ordinarily considered as licit (for
the same reason as ordinary surgery). Heterotransplants
involving animal donors are also considered licit.
3
J.A. Cienfuegos and F. Pardo, Nuevas Perspectivas del trasplante de organos (New
Perspectives in Organ Transplantation). Tribuna Medica, June 1989, pp. 7894.
111
2) Likewise, a transplant of organs obtained from cadavers
is licit whenever performed according to civil laws (the
law on transplants is already in force in some coun-
tries). "Natural law prohibits that a human cadaver be
treated merely like a commodity or like an animal" (Pius
XII, Alloc. May 14, 1956).
If there is no law on transplants, then the donor's
consent must be obtained prior to his death; otherwise,
the relatives must give authorization.
Certitude of death is an important ethical question
to be considered in transplants. The success of trans-
plants depends primarily on the promptness in dispos-
ing of organs for transplants. It, however, must be certain
that the donor is dead before extracting the organs (some
organs and tissues can survive vegetatively postmortem).
In the next chapter, we will discuss the diagnosis of
death.
3) Homologous transplant between two living individuals
became the subject of many arguments among moralists
recently. Some rejected this as a form of mutilation. How-
ever, these transplants are justified today by the so-called
Principle of Finality: "A healthy man may voluntarily
donate any part of his body not essential to his life,
without contradicting nature, for the benefit of his sick
neighbor. Done out of generosity, (which is frequently
the case), his gesture is not only justified; it is meri-
torious. Organ donation is fostered among Christians
today as a way of imitating Jesus Christ, "who gave
his life for the salvation of others" Oohn 3:14) (Episcopal
Commission of Spain, October 25, 1984).
Above all, this refers to the most common type of trans-
plant involving cadaver donors. With advanced medical tech-
nology, i.e., mechanical ventilators and other modem equip-
ment, the extraction of organs- kidneys, eyes, heart, bones, etc.
- from cadavers has been quite successful. Public sentiment
is increasingly in favor of postmortem organ donation.
Nevertheless, we must consider this with reservations, i.e.,
personal freedom must be respected and organ donation must
not be imposed as an obligation.
The donation of organs-manifested or accepted by the family
of the deceased, is a positive gesture because of the nobility
112
,
.=om
-Sth
B
-..:me
==otb
:ose
a:"d I
Sli:fe.J
- -.edc
If
- 0 l
Or
:n,
--::-on
e
.s
's
e,
m
15-
>S-
lln
me
n).
of
tals
l.Sts
ow-
fled
rrily
life,
sick
!:'ltly
and dignity of its motives. Pope John Paul II lauded this initiative
and its finality in his speech to the Association of Blood Donors
and Organ Donors of Italy:
"This praiseworthy gesture which transcends earthly desires
and human outlook, moved by the generosity of the heart, is
a manifestation of human and Christian solidarity-love for
one's neighbor-that constitutes the motive that inspires coming
from the Gospel message and that has been defined rightly
as the new commandment (Cfr. John 13:34).
Blood donation and organ donation will always have a
human and religious dimension. This gesture towards our needy
brothers becomes an offering to the Lord, by identifying with
those who suffer from sickness, or injury from traffic accidents
and occupational hazards. Let this offering be made to the
suffering Christ, Who gave himself totally during his Passion,
shedding his blood for the salvation of men.
If you add a supernatural intention to your humanitarian
gesture, in itself noble, it will be transformed into a splendid
testimony of Christian faith with all its merits" (John Paul II,
Alloc. August 2, 1984).
Nevertheless, certain conditions regulate transplants between
two living individuals. These conditions seem totally reason-
able. The following criteria are required for licitude:
On the Part of the Donor:
a) that the organ is strictly not essential to life.
b) that the donation is voluntary, not demanded, nor
obliged, nor coerced, even from relatives; that it is
done for honorable purposes; and
c) that the donor understands clearly the risks involved.
On the Part of the Recipient:
That the transplant is truly necessary for his health.
On the Part of the Operation:
a) that the operation has a reasonable chance of success;
and
b) that the benefits for the recipient and the risks for
the donor are proportionate.
The question on economic compensation for blood trans-
fusion or organ donation is often presented. Pius XII resolved
113
the issue by saying: "It is meritorious for the donor to refuse
any compensation; but, it is not necessarily a fault to accept
it" (Speech, May 11, 1965).
On the other hand, civil legislation* affirms: "No one in
any way can demand, offer or give material or economic com-
pensation for organs or anatomical parts" (Art. 2, Law on Trans-
plants, October 17, 1979).
c) Criteria on Donation
There have been a lot of arguments in the past as regards
organ donation. Not every one who dies can be a donor. The
medical criteria for patients suitable for organ donation has
to be rigidly followed once the diagnosis of death is certain.
For example, it is absolutely contraindicated to extract organs
for donation in cases of:
1) sepsis or proven bacteierrUa,
2) prolonged shock.
Specific criteria are further i.'ldicated for probable donors
of kidneys, the most frequencly Lransplanted organs. The
requirements include:
age 12 months to 50 rea:-s old.
no existing process (except for
brain tumors cii.:.'-:.e:C systemic angiopathies
(arteriosclerosis , or infectious diseases,
serum-positire AIDS, collagenous
diseases.
Other ethical !JIO::,.e:;:-.,: :..... -'0_. 5 u-ansplants:
1) determinano:1 o: =x.a"i death of the donor,
before proceeC.ir; t::! ex:::a.Gmn of organs.
2) legal nature of .:i-.e :-o has the authority or
power oye:- wb ::z.:: -ea:...:e !tS use for therapeutic,
scientific pt:.. pf:-
rn Spain.
De
c.ec.
?rc
des
:no:
scie
for
seql
imp
A co
it fa
]
butJ
Stant
of f1
simt:
and
ofth
immt
v
tanec
cente
and'
the o
Tl
be del
scienc
su j.
Lord, fc
earthly c
ofChris1
6J. 1
Tiempo,
se
"?t
in
m-
:s-
rds
h.e
1as
tin.
IDS
LOIS
The
for
hies
J.Ses,
LOUS
mar,
y or
utic,
f the
if the
sked
dent.
This is because before carrying out this type of intervention
they have to be totally sure that the donor is "irrefutably" dead.
At the same time he encouraged them to pursue research in
order to determine the "exact" moment of death" (Cfr. Ecclesia,
January 6-13, 1990).
Determination of Death
Philosophy and theology teach that death, "the mystery of
death" (Gaudium et Spes, no. 16) is a transition from the
provisional to the definitive state of the human being.
5
They
describe what death is, however, they do not mention its exact
moment.
Theology accepts the definition of death according to medical
science: the arrest of respiratory and cardiac functions (e.g.,
for the administration of the last sacraments). With the sub-
sequent development of diagnostic techniques, science has
improved and enhanced the definition and diagnosis of death.
Accordingly, Theology adheres to its definition inasmuch as
it falls on the physician to determine the moment of death.
Evidently, the decision is not based on subjective criteria
but rather on strict verifiable standard criteria. From the medical
standpoint, death is defined as the total and irreversible cessation
of functions involving the whole organism. This does not
simultaneously affect all component cells and tissues. Some cells
and tissues remain viable for a variable period after the death
of the organism. Neurons are the most sensitive cells, they die
immediately after cardiac arrest.
We can conclude today that death does not occur instan-
taneously. It begins at the cellular level, it initially affects higher
centers incapable of activation when deprived of circulation
and ventilation. The "moment" of death would precisely be
the outer limit, the point of no return.
The task of establishing a definitive criteria of death cannot
be delegated by the physician as it is a task proper to the medical
science. "
6
5
"Although the sadness of death gives way to the bright promise of immortality.
Lord, for your faithful people, life is changed, not ended. When the body of our
earthly dwelling lies in death we gain an everlasting dwelling place in heaven," (Preface
of Christian Death I) Cfr. Sobre Ia Muerte. Gran Enciclopedia Rialp, Madrid, Vol. XXVI).
6
J. Tejeira, El final en Ia vida humana (The final moment of human life). Nuestro
Tiempo, Pamplona, pp. 205-206 m(197), pp. 81-91.
115
Various ::=.26cal organizations and neuro-
logical , :.mportant matter. The Superior
...... October 13, 1968) issued the
most im:: ""':'":-e diagnosis of definitive and
=>
on the total abolition of the
.........:;,.___..... :::::::::-:::::::::s-:3, a=:.:: disappearance of all encepha-
i:'eriod of time."
o: February 22, 1980 (later to
;=:":...rti .... ,...l of Organs and Transplants"),
__ organs are transplanted.
c.:- o:Uv be extracted from a dead
... -
of cerebral death. This is based
:"rrence of signs during a period
c..-rl :>ersistence of six hours, there-
coma until the following obser-
:-esponse with absolute loss of
- - -2.""" _;c abo\'e signs are not sufficient during
:--&: mduced artificially or following
;::;:-;i>: depressants.
s.r::c - this legislative norm as simplistic
:r.:: i_:-'='25C' fr_ .M.a=-w.cez-Lage comments: "Death or the
- G.ilE5 i"O: admit of adjectives." Therefore, it is
like "brain death," "clinical
-=-;-..:.2 _::::rases which erroneously imply grades
: :::&=:- :)eath is a unique, unequivocal event. "The
........ o death must be total, absolute, and
- 5aao: or circumstance surrounding the dead
?e:sori - 2 or beliefs of the family or an eventual
r"'""' u-......, .... -.,.-- Eor transplant."
7
..... ....,.. - ........ ._::: ... ..:. .
M.a. i>..;gntstico de muerte: Criterios Neurologicos (Diagnosis of Death:
C;-.2;".a). A:l official document of the Spanish Society of Neurology
apprmce d=g 5;:.'": Xational Congress, September 12, 1982).
116
The
1)
2) I
c;
r
c
F
v
c
u
0
ti
3 Ir
lE
h
o;
n<
tit
bi
ar
Si1
de

to
' },
~
!ad
:.ed
iod
!:e-
:er-
of
::1nia
:lee-
cing
ing
!is tic
: the
it is
nical
:a des
"The
and
dead
rntual
f. Death:
rrology,
The following principles are derived from these discussions:
1) The diagnosis of death demands an exact and objective
knowledge of the nature of the illness or the accident
which caused the cerebral failure. If this cannot be
obtained, one must abstain from pronouncing a judg-
ment of possible death. Moreover, the following con-
2)
3)
ditions must be definitely ruled out as these can mimic
death:
intoxication with drugs or other pharmacological
substances;
hypothermia;
endocrinological or metabolic disorders;
severe cardiogenic shock; and
with children weighing less than 30 kg, precautions
have to be more strict.
8
In the great majority of cases, death, the so-called habitual
death, usually occurs with the irreversible cessation of
respiration and circulation.
This functional failure is diagnosed by an adequate
clinical examination. It is rarely necessary to utilize
paraclinical tools, e.g., electroencephalogram. The irre-
versible nature of the patient's condition is observed
clinically for several minutes. In cases of unwitnessed,
unexpected or sudden deaths, with or without intention
of resuscitation, observation demands longer periods of
time.
In a few cases, (1% of cases in countries with the highest
level of medical assistance) death, the so-called excep-
tional death results from the irreversible cessation of brain
or encephalic function.
Cerebral failure is diagnosed through clinical exami-
nation; this demonstrates the absence of all cerebral func-
tions. Paraclinical examinations provide data like cere-
bral electrical silence by EEG or circulatory failure by
angiography. An angiography will confirm the diagno-
sis.
The irreversible character of total cerebral failure is
deduced from the primary cause of death, with exclu-
8
/dem. , Seminarios de Etica en Enfermeria. Eunsa, Pamplona 1987, p. 166.
117
sion of possible recovery, and persistent clinical obser-
vation.9
Nature of the Cadaver
Once death takes place the legal nature of the cadaver is
questioned in view of its possible utilization. The cadaver is
no longer a subject of rights in the strict sense of the word
(Cfr. Pius XII, Alloc. May 14, 1956). However, this does not
mean that there are no specific ethical obligations towards it.
The cadaver constitutes the "remains" of the person. The
person has ceased to live. Nevertheless, he persists temporarily
in his "mortal remains." Therefore, the cadaver merits respect
and consideration.
Christian doctrine teaches that it is not simply a "thing"
(experts may argue if it is a "thing" in the legal or vulgar sense;
this, however, is not our concern here). Neither can we treat
or use the cadaver according to whim. "The human body is
the dwelling place of the spiritual, immortal soul, essential ele-
ment of the human person, which shares in its dignity. Some
dignity remains in the cadaver" (Pius XII, Alloc. May 14, 1956).
For this reason, the cadaver ought to be respected.
However, this does not impede autopsy or organ extraction
for transplants and different anatomopathological studies.
Besides, the utilization of the cadaver in this manner is a
manifestation of solidarity, as we have said.
Medicine utilizes cadavers for its therapeutic and research
needs. In this regard, there are no objections. Portions of the
cadaver (e.g., cornea or heart) have been transplanted with
success, thus prolonging and improving the life of seriously
ill patients. Therefore, organ donation is a laudable gesture that
should promoted. It however, should be stressed that the donor
or in his incapacity, the relatives, should be free to decide,
whether or not, to donate an organ.
Therefore, a law which imposes cadaver donation violates
freedom. This is because it presumes that the cadaver is not
a subject of rights, and is at the mercy of the State. This attitude
reflects a secularized society. We can cite as an example-the
Spanish Law on Transplants. This law establishes all citizens as
donors, except upon their expressed rejection (Cfr. Art. 5.3).*
9
/dem., Diagnostico de muerte, o.c., pp. 987-988.
*A similar law has been passed in Singapore.
118
Fn
COl
Th
exF
sor
OpJ
dor
anc
5pe
Ste1
(
am
ci:.a1
;:::tC
s
--=-gi
~ l i E
.::::ai
.:...:fe.J
!r
a)
c)
:c
~
=>
.s
is
d
)t
_t.
le
ly
ct
711
:>
;e;
at
is
le-
ne
6) .
on
es.
, a

the
i th
.sly
hat
nor
.de,

not
ude
-the
s as
.3).*
From this point of view, the "letter of rejection" can be
considered as a document of defense against an aggression.
The ideal thing would be a "letter of donation," an evident
expression of freedom of disposition of an individual over
something which properly belongs to him- his body .
In any case, one has to take to his conscience this great
opportunity for living solidarity with others through the
donation of organs from one's body after death. It can save
and improve significantly the life of another human being. The
speech of John Paul II, already cited, can enlighten Christians.
Sterilization
Sterilization may be defined as any medical or surgical
intervention which renders a patient, female or male, incapable
of reproduction, organically or functionally, temporarily or
permanently.
a) Types
Sterilization may be classified according to the different
techniques employed. These include both surgical and non-sur-
gical methods. The former cause organic sterilization; the latter,
functional sterilization.
Sterilization in medicine employs both surgical and non-
surgical or functional methods. The surgical methods were the
earliest employed. They involve the suppression of the repro-
ductive organs (male or female) by operating on any of their
different parts.
In the female the surgical method employed includes:
a) ophorectomy, or extirpation of the ovary, which manu-
factures germinal cells;
b) salpinguectomy, ligation or extirpation of the fallopian
tubes; and
c) hysterectomy, or removal of the uterus.
Following a similar order in the male, the following tech-
niques are employed:
a) castration, or extirpation of the testicles;
b) vasectomy, or ligation or extirpation of the vas defer-
ens; and
c) emasculation, or suppression of the male genital appa-
ratus.
119
Some of these interventions are brutal and obsolete.
Nevertheless, tubal ligation and vasectomy are still popular
today. They are considered select methods for "birth control"
in developed countries. These techniques have minimal trau-
matic effect. They do not affect the sexual appetite even after
suppression of the reproductive capacity.
The non-surgical methods involve a blockade of the matu-
ration process of the ovum using pharmacologic agents-
anovulatory drugs. These drugs inhibit ovulation. Thus, they
cause temporary or permanent sterility in women. These are
also called functional methods. They will be discussed later
in detail.
Roentgen or X-rays can also cause sterility; their effects,
however, are less certain.
From the legal viewpoint, another classification is used. The
motives for sterilization rather than the method are considered.
Accordingly, sterilization is classified into:
1) Eugenic Sterilization: performed to avoid the birth of a
defective or diseased offspring. Some countries have
legalized it. The Law on Eugenic Sterilization was first
approved in 1907 in Indiana State, United States. Those
who suffer from epilepsy, presenile dementia, manic-
depressive psychosis become candidates for this type
of sterilization. We shall see the illicitness of eugenic
sterilization later.
2) Therapeutic Sterilization: the consequence of extirpating
a pathologic reproductive organ, which endangers the
life of the patient. This is exemplified by the extirpation
of a cancerous uterus.
3) Contraceptive Sterilization: whether organic or functional,
it consists in suppressing ovulation in the female, thus
rendering her sterile. We will discuss this further when
we discuss contraceptives. We will see the reasons for
its moral illicitness.
b) Ethical Evaluation
Before analyzing the different ethical problems related with
sterilization, it is important to distinguish between direct and
indirect sterilization.
120
-s
y
e
r
:;,
i.
a
re
st
se
c-
Je
tic
ng
he
on
al,
lUS
len
for
rith
md
1) Indirect or Therapeutic Sterilization is that which is not
sought in itself. It is the result of a therapeutic inter-
vention on a diseased organ, demanded by the health
. or life of the person. The intervention is not directed
towards sterilization, but sterility results from the
extensive extirpation of pathologic tissues.
2)
The morality of these interventions is based on the
Principle of Totality. Inasmuch as reproductive organs are
like other organs, i.e., integral parts, they must serve
the total good. For example, the extirpation of a part
of or the whole genital apparatus affected by cancer.
In this regard, Church doctrine clearly states: "The
Church does not judge in any way as illicit the use of
therapeutic means, necessary to treat diseases of the
organism, inspite of the fact that it may be followed
by an impediment to procreation, even if foreseen in
such a way that this impediment, for whatever motive
is not directly sought for" (Humanae Vitae, no. 15).
Direct Sterilization by its very nature has one sole im-
mediate effect: to make procreation impossible. This
includes the so-called "preventive sterilization" (erro-
neously termed as "therapeutic"). According to its
proponents, pregnancy can aggravate some diseases.
Thus the risk of getting pregnant is removed by ster-
ilization. For example, a woman with cardiopathy would
be a candidate for sterilization.
Direct sterilization is unethical, despite the good in-
tention-prevention of a future disease arising from
pregnancy. Besides, today Obstetrics has progressed so
much that these serious problems (high-risk pregnan-
cies) are adequately managed in modern hospitals.
Church doctrine regarding sterilization is quite clear:
"The Magisterium of the Church also taught many times
that direct sterilization must be condemned, whether
it is temporary or permanent, whether it involves the
man or the woman" (Gaudium et Spes, no. 14).
10
When consulted whether this practice is licit if done
in Catholic hospitals, the Congregation for the Doctrine
10
Cfr. Paul VI, Enc. Humanae Vitae, no. 12. John Paul II, Gen. Audience, September
9, 1984.
121
oi .: .; :::...:. a:-s ... ered: direct sterilization which is
perma:-..e:::: :.s absolutely prohibited.U
In partiaLal', the so--12alled preventive sterilization
is absolutely prohibited regardless of any upright sub-
jective intention of the physician aiming at cure or
prevention of a disease, foreseen or feared as a con-
sequence of pregnancy. This is true of physical or
psychological diseases (dr. Ibid.).
Direct sterilization is an attempt against the dignity
of the human person. It harms the integrity and the very
essence of matrimony by voluntarily and artificially
separating the unitive and procreative aspects of the
conjugal act.
John Paul II (Gen. Audience, August 22, 1984) explains
clearly: " According to the criteria of this truth," (the Pope
was referring to the language of the body in all the truth
proper to it) the conjugal act signifies not only love,
but also potential fecundity. Therefore, the act can-not
be deprived of its complete and adequate meaning
through artificial interventions. It is illicit to separate
the unitive meaning and procreative meaning of the
conjugal act because one and the other pertains to the
intimate truth of the conjugal act. One is realized precisely
with the other, and in a certain sense, one is realized
through the other. Therefore, the conjugal act, deprived
of its interior truth, upon being deprived artificially of
its procreative capacity, also ceases to be an act of love."
Sterilization breaks the "communion of persons"-
separates artificially the two aspects of the conjugal act-
reducing it to mere corporeal union. This betrays the
interior truth of the person, the true language of the
body, and the dignity of personal communion. Thus it
is a fallacy of that true gift of self, which is mutual. The
same ethical evaluation is given to eugenic sterilization.
It is ethically inadmissible, particularly if contrary to
the will of the patient (a grave attempt against personal
freedom), although apparently requested voluntarily.
The right of every human being to freely dispose
of his generative faculties and of his members is prior
11
Cfr. Document regarding Sterilization in Catholic Hospitals, 1976. "Ecclesia," no.
1.821, January 15, 1977.
122
tu
se
in
St.
rc
0
It
it
IV
cins
:ope
th
r.s"-
act-
:: the
...: the
us it
L The
ation.
cy to
-sonal
arily.
.spose
prior
::a," no.
and superior to the power of the State over the indi-
vidual on account of the demands of social life. Nev-
ertheless, since the individual is neither the absolute
master of his life nor of the integrity of his members,
he can only licitly dispose of his body and its members
whenever it is necessary to safeguard his life or conserve
his failing health.
Let us recall the teaching of the Pope Pius XII (1950):
"The public authorities do not have power whatsoever
over the bodily parts of their subjects. Therefore, the
State cannot directly injure their bodily integrity either
for eugenic or any other motives."
3) Post-Caesarean Sterilization
Some authors argue whether it is licit to ligate the fallopian
tube of a woman who has undergone successive caesarean
sections. They say that if the incision is on the same location
in the uterus, the uterine scar might spontaneously rupture in
subsequent pregnancies. Hence, some obstetricians ligate
routinely and indiscriminately post-caesarean to avoid the risk.
This abusive practice is being questioned by modern
Obstetrics. The President of the American College of Obstetrics
and Gynecology (1984) affirmed that the old aphorism-"once
a caesarean, always a caesarean" - is obsolete. "The anxieties
over maternal and fetal morbidity as a consequence of uterine
rupture during induced labor is not based on real figures" (L.
Klein, "Caesarean Birth and Trial of Labor." The Female Patient,
1984, 9:106)_12
From the ethical standpoint, this attitude is not justifiable.
It is a form of direct sterilization to prevent conception. Hence
it could affect the woman's health .
What could be done in these cases?
In the first place, note that there have been cases of
9 or more consecutive caesarean operations which have
delivered live babies without maternal nor fetal
complications. Therefore, it cannot be affirmed that a
woman who has had 3 or 4 caesareans will present grave
12
Cfr. Roy M. Pitkin, Clinics in Obstetric and Gynecology. Vol. 4/1985. Inter-americana,
Madrid 1986, pp. 925936.
123
problems. One has to evaluate in each case whether or
not a real pathologic situation exists.
In those cases wherein the obstetrician judges that after
successive caesarean operations the uterus has become
pathological due to scars or adhesions and therefore,
may rupture with a subsequent pregnancy, he would
have to advice the woman to resort to licit methods
of avoiding conception.
An alternative solution would be to perform elective hys-
terectomy if the uterus is indeed pathological (due to scars,
adhesions, danger of rupture, etc.). This would then be a case
of indirect sterilization whereby a diseased organ is removed.
In summary, we conclude that it is licit to perform only
indirect sterilization, i.e., that which results from therapeutic
means used to cure a diseased organism. This can be done
either by surgical intervention, extirpation of a pathologic organ
(ovary, uterus, testicles, etc.) or through pharmacologic agents
which secondarily produce sterility. The other methods, namely
eugenic sterilization, preventive or punitive sterilization, are
all morally illicit.
124
7
Mt
~ 1 a t i t
~
co:1cei
~ ~ a1
Daren!
-ility,
~ a
Th
a)
b)
c)
7 Sexuality: At the Service
of the Person
Modern man lives under the powerful influence of "sexual
inflation." This last upholds abnormal behavior as an ideal of
freedom. With this panorama, we are obliged to review basic
concepts on the nature and end of sexuality. Thereafter, we
can analyze some relevant ethical problems like responsible
parenthood, licit and illicit means of exercising this responsi-
bility, genetic counselling, etc.
Sexuality in Human Beings
The word "sexuality" has various connotations:
a) In the first place, sexuality is the totality of character-
istics proper to each sex of the human species and all
animals and plants that reproduce through the union
of specific but different cells: one masculine and the other
feminine.
b) Sometimes sexuality is understood-today, even among
higher beings- as a specific aspect, i.e., the attraction
towards individuals of the opposite sex. This impulse
is clearly instinctive in animals. In man, however, taking
into account his rationality and influence of the will on
his behavior, it adopts other modalities. Therefore, it
is better to refrain from using the phrase "sexual instinct"
when referring to human sexuality. The words "ten-
dency" or "impulse" are preferred since "instinct"
denotes involuntariness, spontaneity or apprenticeship,
all of which is improper of man.
c) A third connotation, widely accepted, identifies sexu-
ality with genitality, i.e., one of its elements. Genitality
is directly related to the mode of propagation of the
species. In other words, sexuality, a sum total of various
characteristics, is reduced to the level of the phenom-
ena and mechanisms involving the genital organs and
their physiology.
In a similar restricted but opposite sense, sexuality
is understood by some as the sum total of genetic,
anatomical, hormonal, physiological, and psychological
constituents of a man or a woman, as the case may be,
abstracted from what is specifically genital.
Both ways of understanding sexuality result from
prejudices of the rational will, the distinction being
merely speculative. This is because in reality one cannot
completely separate sexuality from genitality. However,
this distinction is useful because it permits the study
of many related problems.
The study of sexuality can be approached from different
perspectives. These are the biological, psychological, philosophi-
cal and theological perspectives. In order to it fully,
however, a holistic outlook is needed. One must analyze the
different elements which comprise it and integrate them into
the whole person.
The isolated consideration of sexuality, a common occurrence,
can endanger and disrupt the unity of the whole person. It
will exaggerate its role in human existence. Man is a sexual
individual. However, it does not mean that he hardly has
anything else.
The absolutization of what is partial, in the phrase of R. Allers,
was the error of Freud. This was reflected in Freud's Psycho-
analytical Theory. This theory influenced the majority of the
present theories on sex.
By way of introduction to the topic, let us consider Catholic
theological teaching. It will serve as a guideline.
First, remember that, confronted with some baseless accu-
sations, Catholic doctrine has always taught the natural good-
ness of the human body, specifically sex. It teaches that sex
has its proper place of exercise within marriage. Both are the
work of Divine Providence. The latter has willed this manner
of perpetuation for the human race.
Therefore, sexuality is not purely biological nor exclusively
natural. "In fact, the biological, psychological and spiritual
characteristics which make a person male or female find their
126
on
an
int
exc
"w
are
GE
-r
:Jll(
- a
_: e
.
-
5
i
L
::>
_,
,,..
_ ,
origin in sexuality. Therefore/ sexuality considerably influences
an individual's progress towards maturity and incorporation
into society."
1
In fact, no aspect in man's life can ever be considered
exclusively natural or biological. Any manifestation of life reveals
11
What man is," a complex being in which matter and spirit
are united. "Man, created according to God's image and likeness
Gen 1:26-27), is not just flesh and blood. The sexual instinct
is not all that he has; man also possesses in a pre-eminent way
:mderstanding, choice, freedom. Because of these faculties he
- and will always be superior to the rest of creation. He has
::mlStery over his physical, psychological and affective appe-
=L5."2
At any level of human nature, in any area of human
ence, in any manifestation of life, matter and spirit are
-ays present. Certainly, there is something biological in sex.
- :owever, transcends the biological (like anything human) .
.: .:::tan sexuality is an expression of the desire for union which
-' - the yearning to prolong oneself beyond one's own life.
:=:ore, the profound human desire for paternity is integrated
::-u.man sexuality.
-
0
not strange that man has always experienced sex as
sacred, as something that puts him in front of a
- - _--the mystery of life and of its propagation. If sexuality
,.:erstood outside the context of the spiritual nature of man,
,:_ up inhuman. And what is inhuman is infra natural,
.z-,--=_- ring lower than what is simply animal.
:en sexuality is isolated from spirituality, one sees the
::-erson as "a sexual object," instead of as "a beloved
3!!!:5:!:-... - n A purely carnal union deprived of the spirit humili-
reduces persons to the condition of "things" that have
. ..,. only for as long as they satisfy or give pleasure. In
....z._ language this has been always called "lust."
3
- important to remind those who consider sex as the
expression of love between two persons that in the
.:::::Up between man and woman, "sexual submission can
=ation for the Doctrine of the Faith, Declaration Persona humana, on certain

0
sexual ethics. December 29, 1975, no. 1, St. Paul's Publications.
-: Encyclical Sacerdotalis caelibatus, June 24, 1967. Encyclical letter on priestly
....z:-.:ia Hoz, La escalada de erotismo (The height of erotism). Palabra, Madrid
--w.
127
be love transferred to the corporeal sphere. It however, is
always a 'proof' of love, although often it is demanded
such."
4
Sexuality is definitely a biological vehicle of self-giving. Lon:
however, being human, commits all dimensions, including tlu:
affective and spiritual dimension of the person. Torello con-
tinues: "Love is not directed towards the psychological oy
physical attributes of the beloved, but toward the exclusive,
unique being of the person loved."
5
The Purpose of Sex: Unitive and Procreative Aspects
"Is there any meaning in sexuality?" Biology shows that in
living beings, sexuality is radically oriented towards procrea-
tion. In fact, for many centuries, sexuality in the human species
was understood in this perspective, while the gratifying aspect
intimately united to this radical end remained incognito.
Nevertheless, let us attempt to reassess this fact today. Many
propose the dilemma: "Should sex continue being radically
oriented towards procreation or be transformed to a kind of
pleasure that man or woman can procure devoid of this radical
orientation?" In other words, Should the unitive and procrea-
tive aspects integrating human sexuality remain always united
or be dissociated from without and voluntarily? We think that
this is the key to the solution of the problem that we have
presented. Either we continue to accept that sex, by its very
nature is ordained to procreation, or we deprive it voluntarily
of its finality.
About 50 years have already elapsed since Wilheim Reich,
the principal pro-Marxist proponent of sexual revolution
theories, heralded the rupture of the two elements by saying
that "To understand sexual desire as oriented towards pro-
creation is a means of repression employed by conservative
sexology." This statement, at most divested, but at times not
even of its demagogic charge, is becoming ordinary in many
sectors of the contemporary world. Today men and above all,
women (because they are more affected) clamor for the right
to dissociate sexual behavior from the procreative finality of
sex. It is enough to cite two examples which reflect this attitude.
4
J.B. Torello, Psicologia Abierta (Overt Psychology). Rialp, Madrid 1972, p. 94.
5
/bid.
128
a:l
a:l
d
a:
li
c
f
f
A leader of the feminist movement in France wrote: "For many
years the woman's love life and sexual life were completely
absorbed in maternity, intricately mixed with fertility ... Only
quite recently, fertility and sexuality cease to coincide. For the
first time since the world came into being, woman- owner of
her fecundity, called to live longer, to be more free and apt for
sexual life-discovers the demands of her corporeal fulfillment."
In a more dispassionate manner that resembles scientific
formulation, the same idea is expounded in many sexologist
studies. Sexology is a new discipline which emerged to counter-
sign such theories. This it did by erecting Statistics as moral
norm. A German gynecologist, writing for a journal of medical
sexology, began his article: "As a consequence of the devel-
opment of highly effective methods of contraception, planned
paternity and maternity as primary value concepts in society
become realizable each time. The dissociation of sexual behav-
ior from the reproductive process is thereby achieved. This leads
to the liberation of woman (and, man) from unwanted preg-
nancies."
These presumptions consider sex as the source of pleasure
essential for the development and maturation of the person.
It is not oriented, though, towards the creation of a new life.
Consequently, sex is ordinary and normal. Therefore, indiscrimi-
nate satisfaction of the carnal appetite, without any condition
or ordination, is licit and good.
The Bishops of a European country* forewarn against the
devaluation of sex that predominates the culture of contempo-
'"ary society: "Sexologists try to justify the dissociation of sex
and love, of love and fidelity to the conjugal partner, of sexuality
and procreation ( ... ) thereby they pretend to reduce the sexual
dimension of man and woman to mere satisfaction of pleasure
and dominion, isolated and irresponsible" ("La Verdad os hara
:ibres," The truth will make you free, November 20, 1990, no. 19).
Whenever confronted with this situation, the Church de-
:e.t1ds the natural moral doctrine which is based on Divine Law.
ill 1975 a document was published by the Magisterium in
defense of the dignity of the human person. It reiterated
?'ffmanent doctrine about some problems on sexual ethics,
r emarital relations, homosexuality and masturbation."
6
"Spain.
6
Declaration Persona humana, o.c.
129
Pope John Paul II (Apostolic Exhortation "Familiaris con-
sortia," 1981) explains the mission of the christian family in
the world. Among other things, His Holiness reminds the world
that the christian doctrine on sexuality is "a value and function
of the entire humanity, both men and women created unto the
image of God."
7
It is important to remind others that sex is good, that the
acts by which the spouses are united in an intimate and chaste
manner are noble and dignified, and that when exercised in
a truly human way, they signify and foster reciprocal self-giving
with which they enrich each other mutually in a climate of
joyous gratitude.
8
But with the same firm conviction, it is also important to
remember that the sexual or marriage act (because marriage
is the unique place for the exercise of sexuality) is subordi-
nated to that great law of procreation. The sexual act by which
God has disposed the transmission of life has one finality,
procreation. From procreation, one cannot deprive oneself vol-
untarily if he desires to respect its proper laws. This has always
been the sentiment of the Church. In his Encyclical "Casti con-
nubii" Pius XI teaches: "No motive, even grave ones, can make
an act that is intrinsically against nature become honorable and
in conformity with the same nature: the conjugal act is directed
by its very nature towards the generation of offsprings. Those
who disregard this end during the exercise of marriage, dis-
regard its very essence and perform a lascivious and intrin-
sically evil act."
Other documents of the Church Magisterium confirm this
teaching. It is a known fact that the Encyclical "Humanae vitae"
of Paul VI was not written simply to settle a disputed question
(whether or not it is licit to use contraceptives). It expounded
directly on the meaning of human sexuality, the basis for the
Pope's rejection of the methods of contraception: "The Church,
nevertheless, in urging men to the observance of the precept
of the natural law, which it interprets by its constant doctrine,
teaches as absolutely required that in any use whatsoever of
marriage, there must not be impairment of its natural capacity
to procreate human life. This particular doctrine, often ex-
pounded by the Magisterium of the Church, is based on the
'John Paul II, Apost. Exhort. Familiaris consortia, no. 32, St. Paul's Publications.
8
Gaudium et Spes, no. 49.
130
ir
0"
aJ
ac
d.
d
th
l1E
ar
re
5U
n
tal
[
_;e
- E
inseparable connection, established by God, which man on his
own initiative may not break, between the unitive significance
and the procreative significance, both inherent to the marriage
act. The reason is that the marriage act, because of its fun-
damental structure, while it unites husband and wife in the
closest intimacy, also brings into operation laws written into
the actual nature of man and of woman for the generation of
new life. And if each of these essential qualities, the unitive
and the procreative, is preserved, the use of marriage fully
retains its sense of true mutual love and its ordination to the
supreme responsibility of parenthood to which man is called."
9
The same doctrine has been repeated in the Apostolic Exhor-
tation "Familiaris consortia" of John Paul II and the Instruction
"Donum Vitae" of the Congregation of the Doctrine of the Faith.
10
Therefore, it is wrong to separate the two aspects of sexuality.
This is precisely what the advocates of birth control are trying
to achieve. They don't see the divine origin of sexuality, the
key to the understanding of sexuality. They thereby separate
these aspects into two different realities, disconnected from each
other: on one hand, the offspring, a possibility of marriage,
external to it, something extrinsic which God established and
which the Church regulates; on the other hand, sex, instinct,
love, as natural intimate realities, by themselves proper to man.
Thus, children would be imposed as a burden, imposing against
the enjoyment of these goods. Therefore, the use of sex, the
exercise of love becomes an intangible and unlimited right...
With this attitude, it is understandable that in order to avoid
children, the couple initially resort to an effective contraceptive
method. If this fails, ... they find no difficulty in resorting to
abortion although in principle they judge it as repugnant. In
fact, confronted with the complications and contraindications
to the anovulatory pills, they are unconsciously clamoring for
abortion, which is undoubtedly the most effective means of
achieving their goal.
9
Paul VI, Enc. "Humanae vitae," no. 11-12. Regarding the inseparability that the
Church teaches, one may also refer to F. Gil Hellin, "Aspectos unitivo y procreativo
del ser del matrimonio y Ia vida conjugal" (Unitive and procreative aspects of the marriage
act and conjugal life). In: "Persona, verita e Morale" (Proceedings of the International
Congress of Moral Theology, Rome April 7-12, 1986) Cita Nuova Editrice, Roma 1987,
pp. 149-176.
10
Cfr. Chapter VIII of this book on: Artificial Fertilization which analyses this
document. February 22, 1987.
131
The increasing use of the intrauterine device (IUD) is along
this line. Paradoxically, the recent practice of 'in vitro' fertili-
zation (IVF) reflects this 'dissociation' phenomenon. According
to an English author's jovial remark: "We are passing from a
sex without children' to 'children without sex'." This is because
IVF offers the technical possibility of total separation between
the begetting of children and the sexual relation between a man
and a woman. In both cases of contraception and 'in vitro'
fertilization, however, the ethical evaluation is similar."
Contraception intentionally deprives the conjugal act of its
openness to procreation and realizes in this way a voluntary
disposition of the two ends of matrimony. Artificial homolo-
gous fertilization, attempting a procreation which is not the
fruit of a specific conjugal union, objectively achieves an analo-
gous separation between the goods and the significance of mat-
rimony."11
Therefore, love and sex must not be isolated from the
begetting of children; all form part of the divine plan. This
plan does not present fissures nor indices of correction. There
is no opposition between what is human or natural on one
hand and what is divine, on the other hand, inasmuch as God
is the Author of human nature.
Marriage between man and woman, the family, love, the
sex differences: all constitute various aspects of one and the
same divine plan. The use of the generative faculty in disregard
of its natural-and divine-ordination towards procreation (man
considers himself master of his sexuality, something which
pertains to him and is not a gift from God) excludes him from the
divine plan, the realization of which created the different sexes.
We can see clearly with all these explanations to what extent
a sound sex education is necessary.
12
Having in mind all the
aforementioned elements, such education projects over the other
educative aspects, because "sexuality is an enrichment of the
whole person-body, emotions and soul-and manifests its in-
timate meaning upon leading the person towards the gift o:
self on account of love."
13
11
Congregation for the Doctrine of the Faith. Instruction Donum vitae, Februa;: _
22, 1987, p. 4.
12
Cfr. Congregation for Catholic Education. Orientaciones educativas sober e/
humano (Educational orientation about human love). Guidelines for sex educa
November 1, 1983.
'
3
Familiaris consortia, no. 37.
132
In synthesis the essential elements of human sexuality are:
a) The sexual instinct or tendency is innate (inborn); theo-
logical (ordained towards an end-procreation); tran-
scends psychologically (ordained towards another person
away from self); does not need intelligence but is
regulated by the latter.
b) Man is sexual. This however, does not mean that he
has no other quality besides being sexual. Though always
present, sexuality is not everything (just as white light
includes the color blue, but is not only blue). The error
of S. Freud aside from his technico-mechanistic views,
etc. was "pansexualism."
14
c) Sex is an objective reality in accord with God's plan
for man; therefore, it is good in itself. However, sex must
be subjected to moral norms just as anything worth-
while remains within the just limits of the spirit. Thus
sex life ought to be regulated morally according to
Natural Law. The first principle of the sexual life is:
marriage is the only natural way willed by God wherein
sexual life may be exercised morally.
d) Sexuality is the biological vehicle for self-giving between
man and woman. However, human love involves eve-
rything-all the dimensions of "being," including the
affective and spiritual. Sexuality ought to be at the service
of the person. Today the tendency is to dissociate love
from sex. In other words, "love" is used as a simple
requisite to practice sex.
e) The sexual instinct is ordained essentially to the propa-
gation of the species, to the transmission of life.
Therefore, the unitive and procreative aspects of sexual
love must not be separated.
Responsible Parenthood
The concept of responsible parenthood, a noble but frequently
perverted concept appears for the first time in the Constitution
14
The Freudian concept of man is that of a man controlled primarily by his instincts,
such that his essence consists in satisfying them. Among these the sexual instinct
stand out: cfr. M. A. Monge, Psicoanalisis como unidad. Palabra, 108-109 (1974), pp.
285-289; V.E. Frankl, La idea psicologia del hombre. Rialp, Madrid 1965.
133
The increasing use of the intrauterine device (IUD) is along
this line. Paradoxically, the recent practice of 'in vitro' fertili-
zation (IVF) reflects this 'dissociation' phenomenon. According
to an English author's jovial remark: "We are passing from a
sex without children' to 'children without sex'." This is because
IVF offers the technical possibility of total separation between
the begetting of children and the sexual relation between a man
and a woman. In both cases of contraception and 'in vitro'
fertilization, however, the ethical evaluation is similar."
Contraception intentionally deprives the conjugal act of its
openness to procreation and realizes in this way a voluntary
disposition of the two ends of matrimony. Artificial homolo-
gous fertilization, attempting a procreation which is not the
fruit of a specific conjugal union, objectively achieves an analo-
gous separation between the goods and the significance of mat-
rimony."11
Therefore, love and sex must not be isolated from the
begetting of children; all form part of the divine plan. This
plan does not present fissures nor indices of correction. There
is no opposition between what is human or natural on one
hand and what is divine, on the other hand, inasmuch as God
is the Author of human nature.
Marriage between man and woman, the family, love, the
sex differences: all constitute various aspects of one and the
same divine plan. The use of the generative faculty in disregard
of its natural-and divine--ordination towards procreation (man
considers himself master of his sexuality, something which
pertains to him and is not a gift from God) excludes him from the
divine plan, the realization of which created the different sexes.
We can see clearly with all these explanations to what extent
a sound sex education is necessary.
12
Having in mind all the
aforementioned elements, such education projects over the other
educative aspects, because "sexuality is an enrichment of the
whole person-body, emotions and soul-and manifests its in-
timate meaning upon leading the person towards the gift of
self on account of love."
13
11
Congregation for the Doctrine of the Faith. Instruction Donum vitae, February
22, 1987, p. 4.
12
Cfr. Congregation for Catholic Education. Orientaciones educativas sober el amor
humano (Educational orientation about human love). Guidelines for sex education.
November 1, 1983.
13
Familiaris consortia, no. 37.
132
R
pE
sue
ta
In synthesis the essential elements of human sexuality are:
a) The sexual instinct or tendency is innate (inborn); theo-
logical (ordained towards an end- procreation); tran-
scends psychologically (ordained towards another person
away from self); does not need intelligence but is
regulated by the latter.
b) Man is sexual. This however, does not mean that he
has no other quality besides being sexual. Though always
present, sexuality is not everything (just as white light
includes the color blue, but is not only blue). The error
of S. Freud aside from his technico-mechanistic views,
etc. was "pansexualism."
14
c) Sex is an objective reality in accord with God's plan
for man; therefore, it is good in itself. However, sex must
be subjected to moral norms just as anything worth-
while remains within the just limits of the spirit. Thus
sex life ought to be regulated morally according to
Natural Law. The first principle of the sexual life is:
marriage is the only natural way willed by God wherein
sexual life may be exercised morally.
d) Sexuality is the biological vehicle for self-giving between
man and woman. However, human love involves eve-
rything- all the dimensions of "being," including the
affective and spiritual. Sexuality ought to be at the service
of the person. Today the tendency is to dissociate love
from sex. In other words, "love" is used as a simple
requisite to practice sex.
e) The sexual instinct is ordained essentially to the propa-
gation of the species, to the transmission of life.
Therefore, the unitive and procreative aspects of sexual
love must not be separated.
Responsible Parenthood
The concept of responsible parenthood, a noble but frequently
perverted concept appears for the first time in the Constitution
14
The Freudian concept of man is that of a man controlled primarily by his instincts,
such that his essence consists in satisfying them. Among these the sexual instinct
stand out: cfr. M. A. Monge, Psicoanalisis como unidad. Palabra, 108-109 (1974), pp.
285-289; V.E. Frankl, La idea psicologia del hombre. Rialp, Madrid 1965.
133
Gaudium et Spes, no. 50 of Vatican II. It is Paul VI, however,
in Humanae vitae who explains its meaning in depth.
According to Humanae vitae:
a) The meaning of "responsible parenthood" is primarily
influenced by the level of knowledge of the biological
processes involved in reproduction (no. 10).
When John Paul II "encourages couples to live human
sexuality according to God's plan" he particularly refers
to the knowledge of the "body and its fertility cycle"
(Familiaris consortia, no. 33). He stresses the need to exert
all efforts to make this knowledge accessible to all
couples through clear, timely and serious instruction
imparted by other married couples, physicians and
experts (ibid.) . Therefore, it is important for spouses
(according to their respective capacities) to know the
mechanism of the female cycle.
Nevertheless, knowledge of these mechanisms must
not lead them to interfere with the cycle. It ought to
move them to respect these natural pr-ocesses because
they are not dealing simply with natural biological laws
but of "biological laws which involve the person"
(Humanae vitae, no. 10). That couples acquire knowledge
on the transmission of life and utilize it to act as
"arbiters" of the divine plan by "manipulating" human
sexuality, is a different matter altogether, forewarns John
Paul II (Familiaris consortia, no. 32).
b) "If, on other hand, we examine the innate drives and
emotions of man, responsible parenthood expresses the
dominion which reason and will must exert over them"
(Humanae vitae, no. 10). Everything directly related with
the transmission of life participates in the creative power
of God; consequently, it should be treated with respect
and responsibility.
Pope John Paul II stresses that knowledge of bio-
logical mechanisms "must lead to education in sell-
control": hence, the absolute necessity of the virtue :
chastity and of permanent education in this virtue.
Needless to say, irresponsibility in this aspect GC
have grave consequences. When this sense of res
for the sexual act is replaced by the egoistic, superfi =
134
t
Cl
~
search for pleasure, the moral life of the individual and
marriage end catastrophically.
c) "If we consider the relevant physical, economic, psy-
chological and social conditions, responsible parenthood
is exercised by those who prudently and generously
decide to have a large family or by those who, for serious
reasons and with due respect for the moral law, choose
not to have children for the time being or even for an
indeterminate period (Humanae Vitae, no. 10).
As regards the decision to limit the number of children,
two important problems are presented:
1) the existence of a serious motive for avoiding the birth
of another child; and
2) respect for the moral law while searching for the most
adequate means of avoiding the birth.
As regards the first problem, it is important to remember
Church teaching, i.e., that there should be a serious, well-
founded motive for the spouses to decide to limit births. This
is because "the characteristic sign of a christian couple is their
generous openness to accept from God children as gift of love"
(John Paul II, Homily, Limerick, Ireland, October 1, 1979, L'Os-
servatore Romano).
Regarding the second question, only periodic continence
or-in exceptional cases- absolute continence may be employed.
However, true responsible parenthood may be exercised in
another manner, by generously deciding to have a big family
with many children. John Paul II reiterates: "Helped by grace
of the sacrament and guided by the teachings of the Church,
parents will remind themselves that to deny the children some
comfort and material advantage is less evil than to deprive
them of brothers and sisters who help develop their humanity
and enable them to experience the beauty of life in all its phases
and variety" (Homily in Capitol Hall, Washington, October 7,
1979, L'Osservatore Romano). Likewise, Vatican II teaches sol-
emnly that "among married couples( ... ) special mention should
be made of those who, after well-thought out mutual agree-
ment, magnanimously accept a large number of children in order
to educate them with dignity" (Gaudium et Spes, no. 50).
The couple who conscientiously, upon knowing that they
are called to participate in the creative power of God (cfr.
135
Familiaris consortia, no. 28), assume the decision of raising a
big family, will also realize that they are giving their children
not only life, but also all the fruits of a moral, spiritual and
supernatural life which father and mother are asked to give
to their children and through them to the church and to the
world (ibid.).
Therefore, the Church, aware that her teaching may not
always agree with the opinion of the majority, repeatedly
re]Ilinds couples to defend life. She asks them to fulfil their
duty of unmasking many false reasons which create the
"contraceptive mentality." She further warns christians that they
cannot adopt this mentality.
However, this does not mean that we should have the
attitude of "natalism" at all costs, as if the "number" of children,
in itself, were the unmistakable sign of authentic christian
matrimonial life. Blessed Escriva teaches that, "the number is
not, in itself, the decisive factor. The fact of having few or many
children does not, on its own, make a family more or less
christian. What matters is the integrity and honesty of married
life" (Conversations with Msgr. Escriva, no. 94 Sinag-tala Pub-
lishers, Inc.).
An unmistakable sign of uprightness in married life is
docility to the criteria given by the Church as guidance for
christian spouses. These criteria are basically permanent and
unchanging. In the Church teaching of this century, it is
contained in Pius XI's Casti Connubii and in the successive
documents, all the way to Vatican II and Paul VI's Humanae
vitae, until the Apostolic Exhortation Familiaris consortia.
Regulation of Birth
The sexual act, properly exercised within marriage onl -.
is ordained primarily to the propagation of life. "Marriage an -
married love are, by nature, ordained to the procreation an
education of children" (Gaudium et Spes, no. 50). But it is knm -:-
that not all acts are fertile because there are fertile and inferti.:c
periods within the female sexual cycle. Magisterium therefo_
teaches: "In their primary mission of transmitting human li:=
the spouses by 'mutual consent and joint effort,' will strive
form correct judgments' ... which involves a consideratio
their own good, and the good of their children already
136
or yet to come, an ability to read the signs of the times and
of their own situation in both material and spiritual levels, and
finally, consider the good of the family, of society and of the
Church" (ibid.) .
The so-called problem of "regulation of birth" or "birth
control" is thereby presented. According to christian moral
teaching, there are illicit and licit methods (Cfr. Humanae vitae,
nos. 14 &15). The artificial methods are illicit while the natural
methods are considered licit.
15
a) Illicit methods: from the moral viewpoint, abortion and
sterilization have been openly and repeatedly con-
demned by the Magisterium. "Any act performed before,
during or after sexual intercourse which is intended to
prevent procreation- whether as an end or as a means"
is likewise immoral (Humanae vitae, no. 14).
All contraceptive methods which interfere with the
normal development of the conjugal union, whether
mechanicat physical or chemical or directed in any way
or at any moment against procreation are classified under
illicit methods. We will study these methods later.
b) Licit methods: regarding the regulation of birth, Humanae
vitae states that "if there are reasonable motives for
spacing births, arising from the physical or psychologi-
cal condition of the husband or wife, or external circum-
stances, the Church teaches that married couples may
take advantage of the natural cycles of the reproductive
system and use their marriage precisely those times that
are infertile, and in this way control birth, a way which
does not in the least offend the moral principles which
we have just explained (no. 16).
15
Cardinal Karol Wojtila explained very clearly that the word "method," cannot
be applied in the same sense in all cases. Whenever the natural method is accepted,
it is usually considered from the same viewpoint as the artificial methods, i.e., with
a utilitarian concept... i.e., from a utilitarian viewpoint. When the natural method is
considered in this sense, it becomes one more method which assures "maximum"
pleasure, with the unique difference that pleasure is achieved by means other than
artificial ones. Therein lies the fundamentaLerror. Therefore, the new method called
natural is not morally good, unless it is correctly interpreted and applied (Love and
Responsibility, p. 273). In this connection, the use of contraceptives and the practice
of periodic continence is clearly differentiated in Familiaris consortia: in the first case
the spouses become "arbiters" while in the latter case they become "ministers" of
God's design (cfr. no. 32).
137
1. Periodic Continence
Research studies by Ogino and Knaus on the periodic fertility
of the female have established the basis for the so-called "Ogino-
Knaus Method." This method has been recently improved by
recording basal temperature and observing changes in cervical
mucus elasticity (Billings Method). It has been known for many
years that the female. is fertile only a few days in the cycle,
i.e., immediately before and after ovulation. This is the basis
for periodic continence, a method introduced by Ogino (1932)
and Knaus (1933) .
If we consider the normal menstrual cycle as 28 days
(although it can vary from one female to another) and ovulation
to take place around day 14- taking into account the limited
viability of the spermatocytes and the ovum- it can be deduced
that fertilization cannot occur before day 11 nor after day 16.
This means that the woman is maximally -fertile for 5 or
6 days each month. Consequently, she will avoid another birth
by abstaining from sexual relations during these days. Some
books on morals and of course, medical books usually present
complex tables. These tables predict the day of ovulation based
on the duration of the menstrual cycle. They also indicate the
days of abstention.
In theory it seems easy; in actual practice it is complicated
(with a high failure rate). There are two reasons for this:
1) it is difficult to ascertain the exact day of ovulation (it
is only established a posteriori), and .
2) "spontaneous" or "reflex" ovulations occasionally occur.
Thus the key to the problem is to know the exact date of
ovulation. Two methods have been devised to enhance the
effectivity of periodic continence: the basal temperature method
and the Billings method.
1) Temperature Method. It is based on the presumption that
the lowest point of registry before the elevation of basal
temperature coincides with ovulation. The woman who
has a daily record of her temperature can detect when
her ovulation occurs.
16
16
Cfr. Geller, La temperatura, guia de Ia mujer (The temperature, a woman' s guide).
Rialp, Madrid 1971.
138
2) Billings Method. This method is based on the observation
that vaginal mucus becomes humid, and secretions of
the uterine cervix more watery during the periovulatory
period. When cervical mucus changes from sticky to
viscous forming filaments, it is a sign of fertility. When
it becomes sticky again, probably the days of ovulation
have passed.
17
2) Ethical Evaluation
Therefore, periodic continence is the only licit method of
avoiding conception while performing sexual union because
it conforms with human nature and the dignity of the person
(absolute continence is possible but this usually does not present
moral problems).
However, the fact that the method is licit does not always
mean that it is moral to use it. Periodic continence cannot be
practiced according to whim. As mentioned, it is a personal
decision of both spouses, who ought to judge the gravity of
the circumstances and have serious reasons.
18
Whenever it refers to periodic continence, Church Magis-
terium has always emphasized the need for sufficiently serious
concrete motives, insurmountable difficulties, etc.
It is quite understandable that these grave motives should
be proportionate to what they impede: the transmission of life,
a very serious matter. Besides, love and conjugal union, by
their very nature, are oriented towards procreation (Cfr. Vatican
17
J. Billings, Regulacion natural de Ia natalidad (Natural Birth Control) . Sal Terra,
Santander 1975.
18
John Paul II has explained this matter on various occasions. "Limiting the conjugal
union within infertile periods can be abused if, without a just cause, the spouses
want to avoid procreation, reducing procreation below the level morally justified for
his family. It is important to establish this just level taking into account not only
the good of their own family, state of health and capacity of the couple, but also
the good of their society, and of the Church and the entire humanity" (Alloc. May
5, 1984).
The phrase "responsible parenthood" is presented in the encyclical "Humanae
vitae" as a concept of high ethical value. This phrase cannot be used exclusively in
the unilateral sense, that is, limitation of the number of offspring, much Jess the exclusion
of offspring. Responsible parenthood, moreover, in the sense in which we use the
phrase, retains a further and deeper significance of paramount importance which refers
to the objective moral order to which a right conscience is the true interpreter. (Humanae
vitae, no. 10); Cfr. L' Osservatore Romano, September 6, 1984, p. 4).
139
Council II, Gaudium et Spes, no. 50; John Paul II, Familiaris con-
sortia, no. 26).
19
The fact that many couples have serious motives cannot
undermine this criteria in such a way that any subjective motive
becomes valid.
Artificial Contraceptive Techniques
The artificial methods for birth control have been classified
in several ways:
a) according to the mechanism of action (antigametes,
contraceptives, antiimplants, chemical or mechanical
methods ... )
b) according to the effectivity (maximal, minimal, etc.).
The following is a brief description of the methods more
commonly used, together with their ethical evaluation.
a) Sterilization
1) Tubal sterilization (salpinguectomy) consists in the
ligation or electrocoagulation of both Fallopian tubes.
It is a highly effective contraceptive method. It is usually
irreversible, although there are already techniques of
recanalization.
2) Vasectomy in males consist in bilateral ligation of the
vas deferens which impedes the passage of the sper-
matocytes.
These methods are illicit. See Chapter VI, steriliza-
tion.
b) Intrauterine Device (IUD)
These devices, of inert material (polyethylene) and tale:-::
different forms, are introduced into the uterine cavity. :--
act by producing a mechanical effect or local irritation. Alth _
the exact mechanism of contraception is not known, it
19
Cfr. J.L. Soria, Paternidad Responsable (Responsible Parenthood). Ri alp
1971, pp. 51-52.
140
F
=
to produce inflammation of the uterine mucosa which impedes
the implantation of the ovum. Likewise, it alters the mechanism
of transport of the spermatocytes. Therefore, it has anti-
implantation and abortive effects. The IUD is morally rejected
like any abortifacient.
c) Physical barriers and chemical methods
A series of physical and chemical barriers impedes the
passage of spermatocytes. Among the more popularly used are:
gel or preservative
vaginal diaphragm
vaginal spermicides, creams, gels, ovules, aerosols, foams
All these contraceptive methods impede fertilization. From
the moral viewpoint, these are illicit as they separate the two
aspects of matrimony, i.e., unitive and procreative aspects (Cfr.
Humanae vitae, no. 14).
Coitus interruptus (withdrawal) and the vaginal douche are
also methods employed for contraception. These are consid-
ered morally illicit.
d) Contraceptive hormones
Hormones have been considered for many years as the most
effective contraceptives. These preparations contain two types
of female sex hormones in variable proportions. The hormones
interact to impede ovulation.
Their mechanism of action is explained by Botella Llusia
et al:
20
the progesterone contraceptive is comparable to a security
measure composed of a series of security devices with alternate
functions in case some elements fail. Thus, artificial sterilization
in the female is achieved.
20
Cfr. J. Botella Llusia, Comunicacion en Ia XX Asemblea Medica Mundial. Madrid
1967; J. Jimenez Vargas and G. Garda Lopez, Aborto y anticonceptivos (Abortion and
contraceptive pills) . 3rd Ed. Eunsa, Pamplona 1980, pp. 91 ff.
141
ORAL CONTRACEPTIVES
HYPOTHALAMUS
HYPOPHYSIS (1)
OVARY (2)
FALLOPIAN TUBES (3)
ENDOMETRIUM (4)
CERVICAL MUCUS (5)
The schematic diagram shows the effects of contraceptive
hormones on the different organs.
(1) (2) The effect of contraceptive hormones on the hypo-
thalamus and the ovary is the inhibition of ovulation (contra-
ceptive effect).
(3) Hormones also affect the motility of the Fallopian tubes
advancing or delaying the moment of arrival of the zygote to
the uterus, depending on the chemical composition of the
contraceptive. Either way, implantation does not occur because
the embryo arrives before the time of settling down and dies.
(4) The endometrium undergoes changes which impede im-
plantation of the zygote (abortive effect).
(5) The cervical mucus becomes highly viscous and forms
a plug. The plug then impedes the entry of spermatocytes into
the uterine cavity (contraceptive effect).
As affirmed by its advocates, the "pill" is quite an effective
contraceptive. The high success rate in preventing pregnancy
is explained by its multiple mechanisms of action:
a) inhibits ovulation
b) prevents fertilization (union of sperm and ovum)
c) impedes implantation of zygote in the uterine wall
(a) and (b) are contraceptive effects, while (c) is abortive.
Only one effect may be seen. More frequently the effects are
superimposed and complementary (depending on the type of
preparation, composition and dosage). If the contraceptive
mechanism fails, the anti-implantation mechanism is activated.
Finally, it is important to know that the newer preparations
do not inhibit ovulation, a sign of normal function. It is the
abortive effect which is increasingly being utilized.
142
1
r
s
r
t:
F
b
p
Sl
aJ
ri
cc
OI
dt
H,
rc
an
sic
=
Therapeutic Use of "Pills"
Some contraceptive pills have been used for therapeutic
purposes. Many arguments have arisen regarding this practice.
Nevertheless, from the ethical viewpoint, there is no objection
to a therapeutic use of pills in gynecological disorders. "The
Church in no way regards as unlawful therapeutic means
considered necessary to cure organic diseases, even though they
also have a contraceptive effect, and this is foreseen-provided
that this contraceptive effect is not directly intended for any
motive whatsoever" (Humanae vitae, no. 15). Therefore, it is the
role of Medicine to study the different syndromes (causes of
sterility, metrorrhagias, dysmenorrheas, endometriosis, painful
menstruation, etc.) in which the use of progesterones is
therapeutically indicated. However, it is not justified to use
pills to prevent conception when pregnancy is considered a
burden, a danger to the mother's health. For example, some
physicians proceed without hesitation to use progestogens in
such circumstances (female with cardiopathy, tuberculosis,
anemia, etc.) as a means of contraception in order to avoid
risks. This is unethical. The use of progestogen pills for a
contraceptive purpose is always illicit.
What is considered licit is the therapeutic use of pills in
organic diseases even though secondary sterility may be pro-
duced.
There is no doubt as regards the therapeutic use of pills.
However, the therapeutic application in each case is still doubtful
from the moral standpoint. It is a matter that both physicians
and ethicists must study further. For example, the use of pills
to regulate an irregular menstrual cycle. If the latter is con-
sidered pathological, the use of pills to regulate it is justified.
Thereafter, one can resort to practice periodic continence.
Physicians and ethicists, however, doubt the efficacy of pills
during the lactation period when there is a transient physi-
ologic female sterility. This is because lactation inhibits ovu-
lation. Some prescribe pills to assure "ovarian rest" during this
period, as there have been quite a number of cases which show
that lactation did not inhibit ovulation. In practice the use of
anovulatory pills during this period does not have a firm basis.
Whether or not precocious ovulation during lactation is a
pathologk event is not yet certain according to physiologists
of pregnancy and puerperium. Based on the data provided by
143
the physician, the ethicists will judge the conformity or non-
conformity with the moral law of such cases.
A more complicated aspect is the use of pills as a means
of protecting the woman from pregnancy in rape cases (proposed
many years ago in mission countries in war) . Sometimes it is
presumed that the administration of the pill "a posteriori" to
a rape victim assures an immediate pharmacologic interven-
tion with an inhibitory and not a multiple effect.
In summary, we can make the following conclusions
regarding the use of progestogens in medical practice:
a) It is licit to prescribe these drugs to treat gynecologic
disorders. The contraceptive effect is permitted as a
secondary effect.
b) It is not licit to use these drugs for contraceptive
purposes, i.e., to avoid a pregnancy which can aggra-
vate a medical condition, like grave cardiopathy, tuber-
culosis, physical exhaustion, etc.).
c) Recently, physicians and ethicists have discussed the use
of contraceptive hormones by citing concrete cases which
can present dilemmas like consideration of the menstrual
cycle, lactation, climacteric period, a woman's honor,
etc. Nevertheless, the matter can only be resolved when
each one studies the problem according to his compe-
tence, while respecting the competence of others and
remaining attentive to the teachings of Church Magis-
terium. Finally, it is important to remember that more
and more experts (physicians, biologists, pharmacists,
etc.) question the therapeutic use of progestogens
available commercially. Evidently, these pills are manu-
factured and bought for contraceptive purposes (its
composition, dosage, mode of use, etc.). These persons
want to avoid conception at all costs even by means
of abortion. It is well-known that abortion is one of the
mechanisms of action of the hormonal pills (Cfr. J.
Jimenez Vargas, A que se llama aborto? Eunsa, Pamplona
1982).
144
t<
fE
lS
te
e'
A
8 Artificial Fertilization
Fertilization is the biological process by which two repro-
ductive cells (the ovum or "female gamete" and the sperma-
tocyte or "male gamete") unite and form a new life. This new
life is that of the "zygote." This usually takes place under
normal conditions in the outer third of the Fallopian tube. The
zygote immediately undergoes mitotic divisions while travel-
ling towards the uterine cavity. It is then implanted there and
completes its development during nine months until birth.
Sometimes, the woman remains sterile because fertilization
does not take place. This may be due to either an obstruction
of the Fallopian tube (tubal occlusion) or other causes. In an
attempt to restore female fertility, scientists have tried- by some
form of manipulation- to introduce the male sperm or the
fertilized ovum into the female genital apparatus.
Two methods have been devised to enable infertile couples
to have an offspring: artificial insemination (AI) and "in vitro"
fertilization (IVF) followed by embryo transfer (ET). The latter
is termed IVFT or simply IVF. We will describe the charac-
teristics of each method; afterwards we will give their ethical
evaluation.
Artificial Insemination
This reproductive technique has been widely employed in
veterinary medicine. The male germ cells (spermatocytes) are
artificially introduced by means of instruments into the female
genital tract to fertilize the female germ cell (ovum). Therefore,
direct action of the male in the reproductive process is absent.
The use of AI is highly restricted because of its grave ethical
implications.
Insemination may be intrauterine, endocervical and, more
commonly, exocervical. Fresh or frozen semen may be used.
After insemination, the reproductive process continues its
normal course.
There are two types of AI:
a) homologous artificial insemination (HAl): from the hus-
band.
b) heterologous artificial insemination (DAI): from a donor
other than the husband.
Ethical Evaluation
Artificial insemination presents many ethical problems; we
will discuss them together with IVF. AI involves manipulat-
ive, artificial techniques which threaten to convert procreation
(a human act) into a mere technique devoid of interpersonal
relations. Let us recall that the offspring is the fruit of an act
of love of the parents, the conjugal act. This act is the only
dignified way of engendering. The child is the fruit of the
conjugal union. In this act, the organic function concurs with
sensible emotions and is nurtured by spiritual, disinterested
love.
1
John Paul II teaches that man originates from an act of
procreation which is not exclusively biological. It is also spiritual.
This is because the parents are united by the "bond of mat-
rimony."2
Conjugal union does not take place in artificial insemina-
tion. The biological process is separated from the personal
relations of the spouses. Therefore, both homologous and heter-
ologous artificial insemination are morally illicit.
Nevertheless, Church Magisterium does not object to the
so-called "improper" artificial insemination. This last is limited
to certain techniques ( dilatation of the uterine cervix, collection
of the semen found in the vaginal recess and its ulterior
reintroduction into the uterus) so that sexual union can result
in pregnancy. "If medical techniques facilitate the conjugal act
or helps it to attain its natural objectives it can be morall_-
accepted. On the contrary, however, when the technique
introduced substitutes for the conjugal act, it is morally illicit."=
'Pius XII, Alloc. May 19, 1957.
2
John Paul II, Address to Participants of the XXV General Assembly of the v.
Medical Association, October 29, 1983.
3
Instruction, Donum vitae, February 22, 1987, no. 6, Part II.
146
(
t
t
c
fi
1I
L
o:
In Vitro Fertilization
In vitro fertilization consists in putting spermatocytes in
contact with oocytes inside a test tube. It is an attempt to simulate
in a culture medium what occurs naturally in the Fallopian
tube.
The oocytes are obtained from the mother or a donor by
puncture of the ovary; the sperms, ordinarily, by masturbation.
Once fertilization takes place inside the test tube with
consequent fusion of the pronuclei, division begins. The fer-
tilized ova (zygotes) already in the embryonic stage are then
transferred to the uterus; there they continue their normal
development.
Well-known and heralded by the press at that time, the
first case of IVF was performed by Drs. Edward and Steptoe
in England in 1978, with the birth of the first test tube baby,
Louise B r o ~ n Thereafter, IVF has been employed in many parts
of the world.
In the Third World Congress on IVF (May 1984, Helsinki)
the following data were presented: 7,733 women received at
least one embryo in their uterus; 1,160 (15%) of these women
became pregnant but only 590 babies were born.
4
Note that inspite of employing highly-refined technology
the success rate of IVF is quite low. The following results were
obtained during the different phases of the IVF:
in the capture of oocytes: 98%
in the fertilization: 60%
m the embryo transfer: 20-22%
Therefore, the final result is only about 20%, i.e., for every
5 married couples who resort to IVF, only one obtain an
offspring.
The World Congress on IVF of May 1987 (Virginia, USA)
was attended by renowned specialists on IVF from all over
the world.
5
The following data of great importance was cited:
Only 9 out of 100 women who underwent IVF, obtained the
desired baby.
4
Cfr. M. Plachot, J. Mandelbaum, La fecondation in vitro: 5 ans, bientot !'age de
raison. "Anales de Genetique," 27 (1984) 129.
5
J. Cohen eta!. Pregnancy outcomes after "in vitro" fertilization. "Annals of the
New York Academy of Science." Vol. 541, New York 1988, pp. 1-6.
147
Studies presented at the Congress showed that the preg-
nancies subsequent to IVF were oftentimes complicated. Based
on the report of Dr. Jean Cohen out of 2,342 cases reported
from all parts of the world, the rate of spontaneous abortion
following IVF is 26.2%-higher than what occurs in a natural
pregnancy. Ectopic pregnancy occurred in 5.25%, while multiple
pregnancies (twin or triplet) occurred in about 19.3% following
IVF. Caesarean operation was performed in 46% of single
pregnancies and 72% of multiple pregnancies. The risk of
premature delivery and fetal hypotrophy is 3 times higher than
that of normal pregnancy. According to Dr. Gilbert Sarrot, the
peculiar psychologic state- of nervous tension- which is
frequently observed among the members of the medical team
which performs the IVF and the woman- seems to have a strong
influence on the final outcome of the IVF.
Other Aspects
The first thing that comes to mind when one talks of IVF
is homologous AI. This utilizes the husband's semen and the
wife's ovum. The "zygote" produced is implanted in the uterus
of the wife.
Other methods of artificial insemination are:
fertilization of the ova of the wife with the sperm of
an anonymous donor.
fertilization of the ova of the wife with the sperm of
the husband but the "embryo" produced is transferred
to the uterus of another woman ("surrogate" mother
or mother "for hire").
fertilization of the ovum of a donor by the sperm of
the husband and the "embryo" is transferred to the
uterus of the wife.
fertilization of the ovum of a female donor with the
sperm of a male donor and the "embryo" is transferred
into the uterus of the wife.
The possibilities and interchanges may be multiplied leadinu
to varied situations including aberrant ones: "post mortem
insemination of a single women who want a child "withou-
father," etc. It can be said in jest that a test tube baby car
148
i
t
r
a
E
o1
have up to 5 parents: the mother and the father who paid the
donors; the donors of the gametes (who are the genital parents),
and the "surrogate" mother who received the embryo and in-
cubated it until it is delivered.
One to 4 embryos are transferred to the uterus because the
probability of pregnancy is 7%, 21%, and 28% when 1, 2, or
3 embryos are transferred, respectively. The transfer of more
than 4 embryos increases the risk of multiple pregnancy;
therefore, it is not advised.
A large number of embryos must be produced in order
to proceed with IVF. "What happens to the embryos that are
not transferred to the uterus?" Some embryos are discarded,
others conserved, frozen to be transferred to the same patient
in another session or to another patient with the consent of
the donor couple. The embryos are also utilized in scientific
research. In any case IVF involves manipulation of human beings
as we will analyze later.
Ethical Evaluation
The first ethical problem as regards IVF is the "legal status
of the human embryo." Is it a human being in the embryonic
stage or is it considered a "thing"? The answer to this question
is decisive because IVF involves the loss of embryos during
the different phases of the procedure. Besides, the excess
embryos are discarded while others are utilized for research.
The question was taken up in the discussion of abortion.
The answer is quite clear: the embryo is already a human being
because life begins at fertilization. From that moment there is
already human life, a life full of value like any other human
being. Therefore, the manipulation of an embryo or leaving
an embryo to die violates a fundamental right.
Some obviate this serious problem by saying that the embryo
is not a human being but a pre-human until it has reached
a certain phase of development or until nidation has taken place.
For example, the Warnocke report (commissioned by the
Secretary of State for Social Services of the British Government)
set the maximum limit of 14 days for all types of manipulation
of the embryo. According to it before this time the embryo
is not yet a human being. But, THE HUMAN EMBRYO IS
TOTALLY HUMAN FROM ITS CONCEPTION. There is no
149
phase in the embryonic development that is not human: the
DNA of the germ cell is the same DNA at 14 days, years, until
the individual dies (if he is allowed to be born). Dr. Edwards
himself defines the embryo in the pre-nidation phase- as "a
microscopic being in a very precocious state of development"
(A Matter of Life, London 1981, p. 101).
The Congregation for the Doctrine of the Faith has pub-
lished the "Instruction on Respect for Human Life in its Origin
and on the Dignity of Procreation" (entitled Donum vitae) dated
February 22, 1987. This document replies to certain questions
of the day. Part I no. 1 of this instruction affirms: "Human
life must be absolutely respected-as a person-and protected
from the moment of conception. The fruit of human generation
from the fi:vst moment of its existence, that is to say from the
moment the zygote is formed, demands the unconditional
respect that is morally due to the human being in his bodily
and spiritual totality." This signifies that the human rights must
be respected from the moment of conception. The first right
of all the inviolable human rights is the "right to life."
As regards questions on the beginning of life, the individ-
ual nature of the human embryo or the moment of infusion
of the soul into the body, the document explains: "Certainly,
no experimental datum can be in itself sufficient to bring us
to the recognition of a spiritual soul; nevertheless, the conclu-
sions of science regarding the human embryo provide a valuable
indication for discerning by the use of reason a personal presence
at the moment of the first appearance of a human life: how
could a human individual not be a human person?" (no. 1).
This is the most solid argument against IVF. Despite
fact that this technique may resolve the problem and bring jo_
to infertile couples it cannot be ignored that this is obtainec
at the cost of sacrificing many human lives-through aborti
IVF is morally illicit.
Heterologous "in vitro" fertilization which utilizes do::-
sperms or ova or hire surrogate mothers is clearly imm -
It presupposes anonymous paternity (equivalent to bioloc-
adultery). Moreover, heterologous IVF carries the d n g ~
consanguinity or incest and other problems (legal,
psychological) which needs further study.
Other ethical problems concerning IVF include the -
of obtaining semen. Ordinarily it is by masturbation w
morally illicit. Likewise, IVF promotes erroneous thi:
150
0
people are taught to think that they have a "right to a child"
as if it were a necessity to own a child at all costs.
7
Yet no
one properly has the right to possess another person.
Lastly, there is another grave reason, not the less important,
that applies to all IVF cases (both homologous and heterolo-
gous) and to cases of artificial insemination. It is the rupture
of the unitive from the procreative aspect of the sexual act. Here,
the doubt that can be sown is the following: is it morally licit
to give rise to a new person with an act distinct from the conjugal
act? The answer is no. Only an act of love in which all the
person of the spouses is implied is worthy of giving rise to
a new human person.
Therefore, every person-including the fetus-ought to be
loved as he is and for his own sake. IVF creates a relation
of "production of an object" between the scientist and the test
tube baby. A person cannot be the mere product of human
experimentation. He is the result of a personal act of love.
8
This perhaps is the most difficult question to understand
in our time. IVF is offered to some infertile couples as the only
means of having their desired offspring. And they ask if, in
their case, the totality of their conjugal life would not be sufficient
to assure the dignity proper to human procreation. Good
intentions, however, are not enough. "The process of IVF and
ET must be judged in itself and cannot borrow its definitive
moral quality from the totality of the conjugal life of which
it becomes part nor from the conjugal acts which may precede
or follow it" (Donum vitae, II, no. 5).
The key to this problem is by understanding the nature
of marriage and the intimate connection between the two
aspects, the unitive and the procreative.
9
Thus: "The moral relevance of the link between the meanings
of the conjugal act and between the goods of marriage, as well
as the unity of the human being and the dignity of his origin
7
The omnipotent power attributed to science makes our frustrations unbearable.
The woman's desire is converted into an obsession: "a child at any time, howsoever
one desires it and at any price one desires it. If I do not want any child, no way.
What can we say about the incoherence of our society which spends enormous energies
in conceiving a test tube baby while annually it immolates about 200,000 human beings
through abortion (statistics in France) and considers both practices as a sign of progress?"
(Commission for the Family, Episcopal Conference of France) Vida y muerte, par encargo
(Life and death, by order), November 1984. "La Documentacion Catholique," 81, pp.
1126-1130, 1984).
8
C. Cafarra, L'Osservatore Romano; July 4, 1984.
9
See Chapter VII.
151
demand that the procreation of a human person be brought
about as the fruit of the conjugal act specific to the love between
spouses" (Donum vitae II, no. 4).
In the last few years, various bishops conferences (in
England, Canada, Australia, France, etc.) have made negative
pronouncements on IVF. The Congregation for the Doctrine
of the Faith has already published the Instruction Donum vitae
(February 22, 1987). We have cited this document several times.
The text begins with an introduction. This presents the fun-
damental principles (i.e., science and technology ought to be
at the service of the person, biomedical experiments must be
guided by anthropology, etc.). Then three parts follow:
A. Part I: It deals with respect for the human embryo. Then
it draws the following conclusions:
1) Therapeutic interventions on the human embryo are licit-
" as long as they respect the life and integrity of the
embryo and do not involve disproportionate risks for
it but are directed towards its healing" (no. 3).
2) "Unless there is moral certainty of not causing harm
to the life or integrity of the unborn child and the mother,
and on the condition that the parents have given their
free and informed consent to the procedure" (no. 4)-
only then can we consider licit any type of research and
experimentation on embryo and human fetuses.
3) "Corpses of human embryos as fetuses, whether deliber-
ately aborted or not, must be respected like mortal
remains of any other human being" (no. 4). Therefore,
these cannot be mutilated or autopsied without the
consent of the parents. Much less can they be object
of commercial trafficking.
4) The document stresses "the special gravity of the
voluntary destruction of human embryos obtained in
vitro for the sole purpose of research" (no. 5).
5) It also rejects other forms of biological or genetic manipu-
lation of human embryos against the dignity of the
human being proper to the embryo and that transgress
the right of the person to be conceived and born in and
of marriage. Examples are attempts or plans for fertili-
zation between human and animal gametes and the
gestation of human embryos in the uterus of animals
152
5
or the hypothesis or project of constructing artificial
uteruses for the human embryo ... "twin fission" (to
provoke the duplication of the zygote), cloning or
partenogenesis (no. 6).
6) The freezing of embryos, even when carried out in order
to keep alive an embryo--cryopreservation- "constitutes
an offence against the respect due to human beings by
exposing them to the grave risks of health or harm to
their physical integrity" (no. 6).
7) Likewise, certain attempts to influence chromosomic and
genetic inheritance that are not therapeutic but are aimed
at choosing the sex or other qualities "are contrary to
the personal dignity of the human being, to his or her
integrity and to his or her identity" (no. 6) .
B. Part II of the document answers the moral questions raised
by artificial procreation. These questions are artificial insemi-
nation, "in vitro" fertilization, surrogate motherhood, etc.
C. Part III gives orientation on the relations between Civil
and Moral Law in this field. An appeal to responsibility is made
to the public authorities in this matter. This is because, in
defending personal rights, the self-discipline that can come from
researchers does not suffice. If the legislators neglect their duty
of vigilance, "eugenics" and other types of discrimination of
human beings can easily be legalized. When ethical reserva-
tions concerning these practices are disregarded, humanity is
exposed to grave risks. "The possibilities offered by these
techniques are more and more segregated from the initial
'questionable' goal- to solve sterility problems and make genetic
selection. They lead to the manipulation of the ovaries and
sperms of donors, ovary culture, octogenesis, interspecies
fertilization, etc., to a situation in which reproduction is
converted into one more of those 'techniques,' completely
separated from the family and left 'to the responsibility of the
learned.' One would have arrived at the greatest folly of history:
a society that 'edits' children, without father or mother... and
when the word LOVE has no meaning."
10
10
A.C. Marcuello, Primer Curso de Etica en Enfe rmeria. "Escuela Universidad de
Enfermeria," Navarra, Pamplona 1985, p. 52.
153