Theology and the Four Princes

THEOLOGY AND THE FOUR PRINCIPLES OF BIOETHICS: A ROMAN CATHOLIC VIEW by John Finnis and Anthony Fisher, O.P.

in Raanan Gillon (ed.), "Principles of Health Care Ethics" (Chichester: John Wiley & Sons, 1993), 31-44.

I

'The four principles of bioethics' have their rational basis and truth only within the wider set of moral principles. Outside that context, they demarcate a rather legalistic ethic while also, paradoxically, providing labels for rationalising almost any practice.

Morality's principles (including 'the four') can be recognised by anyone following reason's guidance, undeflected by distracting emotion, prejudice or convention. They are matter for moral philosophy. But reason's full implications, and morality's practical applications, are well understood only when full account is taken of the human situation. And our human predicament and opportunities include some realities adequately and reliably revealed only by the life and teachings of Jesus Christ, through the Church's scriptures and tradition. All moral principles are thus matters also for doctrine, faith, and theology. They are guides to a life which befits human nature, responds to the divine calling, and prepares people for eternal life in God's family. They educate conscience, shape virtues, and make possible wise decisions in particular cases.

What is it reasonable to do? What choices 'make sense', are 'good', 'fair', 'right'? Moral philosophy begins its answer with two basic features of human persons. We are responsible, i.e. can deliberate rationally and make free choices [1], [2], [3]; and nothing short of a happiness and flourishing in which we might share can give our choices rationally sufficient point [4].

. When tempted, e.g. to fabricate or steal some experimental results, we see through excuses like 'only following orders' or 'my upbringing' or 'I'm slave to my passions'. In judging oneself or others culpable, or in thinking 'if only I'd...', one recognizes one's freedom to choose and to choose rationally. Inherited characteristics, upbringing, present restrictions and pressures, all can influence but none need eliminate the demand to choose, to adopt one proposal for action (or inaction) in preference to others. (self-rule) is less a principle than a fact.

Free choosing is self-making and self-telling [5]: choices shape and express one's life and moral identity ('character'). Choices last: they continue affecting who one is, at least until one makes some contrary choice. Some big choices commit one to a certain relationship; but each of my morally significant choices actualizes and limits me, and orients me (and everyone to whom my choice tacitly speaks as an 'example') towards similar future choices. Each such choice thus has implications far deeper and wider than the external behaviour and states of affairs which were its direct object and outcome [6]. Morality takes account of all this.

. No-one finds real happiness in sheer pleasurable experience, independent of worthwhile accomplishment. Happiness (including its joys) is personal completeness or harmonious wholeness, something achievable only along with and through other people. An human fulfilment, answering to all of one's reasonable desires, would be the happiness and flourishing of all human persons and their communities [7], [8]. Authentic morality is not social convention, nor a law supported by threats and prizes, nor a key to egoistic self-fulfilment. It articulates what is involved in being rationally interested (without sub-rational restrictions or deflections) in integral human fulfilment [9].

. Morality's guidelines for making one's choices fully reasonable all make more specific the most general and foundational moral principle: that one should will those and only those possibilities whose willing is compatible with integral human fulfilment [9].

The various aspects of this fulfilment provide the real all human actions: these are such basic human goods as life and health, knowledge, skills, friendship, practical reasonableness, and religion [10]. None of these basic human goods is a mere means to any of the others; all are equally fundamental and intrinsically good [11], [12]. Fully realised and actualised in all human lives, they would constitute integral human fulfilment, total human happiness. What sorts of choices are incompatible with that?

Various sorts. Choices shaped by egoism or partiality are not open to human fulfilment. So one basic moral principle is the Golden Rule: 'In everything, do to others as you would have them do to you' (Matthew 7.12). This is central to . Moral philosophers speak of 'universalizability'. Common speech talks of fairness. In the Old Testament, it was formulated along with : 'And what you hate, do not do to anyone' (Tobit 4.15). Jesus extended the Old Testament formulation so as to link it also with : 'You shall love your neighbor as yourself' (see Matthew 7.12 and 22.40).

Still, there are principles of non-maleficence distinct from the Golden Rule. Blood feuds, for example, need not be unfair, but are immoral. For, acting on hostile feelings towards oneself or others cannot be in line with a will to integral human fulfilment. Respect for the dignity of persons -- treating them always as ends in themselves and never as mere means -- involves more than treating them fairly.

Positive feelings, too, can motivate one to do evil -- to destroy, damage or impede an instantiation of some basic human good. Such choices are often defended as the greater good, or lesser evil. But, though many comparisons of values and disvalues are possible, any comparison which hopes to guide moral judgment by an overall 'weighing' of the goods and evils at stake in morally significant options is always made by feelings, not rational commensuration. Such 'calculations' can only be rationalisations. Choices to 'do evil', in the sense just defined, willy nilly play favourites among instantiations of basic human goods, just as in violating the Golden Rule one plays favourites among persons. No such choice is compatible with a will towards integral human fulfilment. Moral philosophy thus clarifies and justifies the common sayings: 'The end does not justify such means', 'Never treat anyone as a mere means', 'Do not do evil that good may come'.

Moral philosophy articulates other strategic moral principles, and identifies the virtues or character-traits which facilitate a life in line with all these guidelines for a conscientious openness to integral human fulfilment. But here we turn, instead, to note some implications of the additional data made available to conscience by revelation.

. In these wider and deeper perspectives, integral human fulfilment is no mere 'ideal of reason' for the critique of a will distorted (rather than supported) by feelings. Instead it is a reality which, by virtue of God's promise and grace, can begin in this life and extend into the completed kingdom and family of God [13]. In restating Christian hope, the Second Vatican Council indicated the intrinsic relationship between every morally good act, done in God's friendship, and the life of heaven. Even when defeated by events in this world, good works and dispositions are 'material' which God has promised to raise up into a city which will last for ever [14], [15].

Thus the most fundamental moral principle of openness to integral human fulfilment becomes: 'Love the Lord your God, and your neighbour as yourself' (cf. Leviticus 19.18; Deuteronomy 6.5; Matthew 19.19, etc.), and 'Seek first the Kingdom' (Matthew 6.33). Morality identifies not arbitrary laws and rewards, but sets us on the way to the ultimate happiness of communion with God's Trinitarian self, through living lives worthy of children of God the Father, of siblings and members of Christ the Son, and of temples of the Holy Spirit (Mt 12.50; Jn 1.12; 1 Cor 6.19; Eph 2.21; 4.1; Phil 2.15, etc.). Human nature's unity and dignity, and the permanence of the principles (the moral 'natural law' as clarified and supplemented by the revealed 'divine law') articulating conditions for its integral fulfilment, are guaranteed by Christ's sharing that nature with every human person, past, present and future, and by his having come once-for-all as teacher and saviour[16].

Moral teachings, like other matters of faith, can be definitively and thus by divine assistance infallibly taught. This authoritative distillation of the tradition can be by explicit definitions by a Pope or a general Council, as in the Council of Trent's teaching against polygamy and divorce. Or it can be by the concurrence, at some point in time, of the bishops, agreeing in teaching something as a moral truth to be definitively held [17], as in the teaching against adultery, abortion and indeed any direct killing of the innocent. Such teachings, like others authoritatively proposed by the Church's magisterium, either restate or consistently unfold implications of Christ's very firm moral teaching e.g. against divorce and remarriage, and his reassertion of the morality of the Ten Commandments (see Matthew 19:18-20)[18]. Thus they trace the implications of a free commitment to a way worthy of our earthly-heavenly calling, and befitting a human nature shared and redeemed by Jesus.

. Care for the sick, the weak, the suffering and the sinful was a principal focus of Jesus' life. A healing ministry taking many communal forms -- monastic pharmacies, hospitals, nursing homes, hospices and nurses' training run by religious orders, lay faithful committed to healthcare as their vocation, sacramental and other pastoral care for the sick, reflection on medical ethics -- fulfils the vocation to be a servant of humankind and mediator of God's healing power: true beneficence.

But pain and death will not be eliminated in this life. Suffering must be faced head-on, against the pervasive temptation to demand an immediate technological 'fix' for every discomfort, and to marginalize those who suffer so that the rest can withdraw undisturbed. Faith recalls the profounder possibilities for good occasioned by illness and pain: for the sufferer, re-evaluation, conversion, growth in virtue, setting things right with God and other persons; for onlookers, compassion and selfless behaviour [19]. The crucified God gives new significance to these redemptive qualities of suffering; contemplation of the cross and uniting oneself with Christ's passion make possible greater endurance, assist in our redemption (see e.g. Romans 8.17-18), and overcome temptations to a false beneficence and delusive mercy.

The Resurrection, too, has implications for bioethics. It recalls the eternal destiny of the moral agent who has only one life in which to choose for or against God; it discourages a therapeutic obstinacy born of secular despair of an afterlife; it demands that we respect the person's dignity to the end, and give special pastoral as well as medical care to the dying; and it requires that we honour even the symbol of that dignity, the corpse: their mortal remains.

II

Moral principles tend to lose their meaning and their rational warrant when they are announced (as by Beauchamp and Childress [20]) as if plucked out of the air, a 'moral code' akin to civil law or club rules to be strictly applied, compromised or 'balanced'. A bioethics with such oracular 'foundations' overlooks the true basis for a rational (and thus, too, a Christian) ethics [21], [22], [23] as set out in Part I. Such a bioethic is legalistic and fails, we think, to meet the contemporary challenges to morality in healthcare.

These challenges include:

-- using the prevalence of bioethical controversy to 'validate' denials of moral responsibility or a relativised or privatised morality ('what's right for me might not be right for you', 'I don't want to impose my moral beliefs on people', 'I can do whatever I please as long as I don't hurt anyone else'...). Slavery and genocide, even when 'controversial' or vigorously defended, were not thereby made right.

-- appeals to conscience as self-validating. To violate one's conscience by choosing options one believes wrong is indeed immoral, even when one is actually mistaken in judging them wrong [24], [25]. But it is also immoral to leave one's conscience uneducated, settling serious moral questions by mere preferences or private 'intuitions'. For conscience is simply one's ability to know moral truth, recognize objective moral standards, and bring them to bear in practical judgments about particular options -- an ability dependent for its proper use (as is every other intellectual capacity) on willingness to learn, attention to relevant data, self-discipline, and the help of a morally decent culture.

-- dreams of a 'value-free', 'objective', 'scientific' bioethic, as opposed to 'moralizing', 'judgmental', 'religious' or 'interfering' bioethics. Supposedly 'objective' principles like 'scientific progress should be allowed to continue unencumbered' are as value-laden as other ethical approaches. To call one's preferred ethic 'value-free' or one's principles of deliberation 'scientific' simply prepares one to shirk justifying them and to pursue uncritically whatever one's feelings or environment happen to favour.

-- subjection to the 'technological imperative': that whatever we can do, we inevitably will, and should or must. The illogicality of deeming all technological advances justified and good is not well disguised by tagging opponents 'backward' or 'fearful'.

-- consequentialist misconceptions of beneficence and denials of true non-maleficence. Claims that any means can be justified by a sufficiently good end are unreasonable, as we show in sections III and IV below. They also contradict the Western medical-ethical tradition (with its absolutes such as 'never kill, or exploit, your patients'), the political-legal tradition of inalienable and inviolable human rights, and the moral of most Christian churches (with their constant teaching against doing evil for the sake of good -- cf. Romans 3.8 -- and against every direct killing of the innocent)[26].

Take fertilization as one example (among many!) of all these conflicting ethical voices. 'Value-free' technological imperativists might say: this technology is available, its application is 'inevitable', so go ahead. Relativists: it's for the individual couple or their doctors or their society to decide. Legalists: the Law of Beneficence requires it (or: this holy book forbids it). Consequentialists: though not the best way to have a child, it is the only way for some, and on balance is good (or: it will lead to Brave New World and on balance is bad).

A better approach [27], [28] recognizes that not all ways of supplying good desires are truly open to integral human fulfilment; some ethical principles cannot rationally be compromised. More specifically, human life must not be intentionally destroyed or damaged, even in its earliest stage. And the radical equality of parents and child is wrongly contradicted when the child is brought into being precisely as a product of mastery over materials. Nor can there be any genuinely rational 'balancing up' of IVF's bad effects (such as the disjunction of the life-giving and love-giving dimensions of marital intercourse, the enslavement and destruction of many embryos, the dangers to the women and children, etc.) with the good ones (giving a childless couple a child, new scientific knowledge, income and kudos for the scientist): for these values and disvalues are all so basically different. There remain also the self-making aspects of such choices. Acting as master of the destiny of tiny human beings, choosing to manipulate or kill some for whatever purposes, disintegrating human sexuality and parenting, all will mould us as certain kind of people and sway our future attitudes and choices in many, perhaps all, our activities. The Catholic moral judgment against all laboratory reproduction of human beings [29] is, then, considered and definite; it is not a 'law' or a 'ban' but a rational judgment about moral truth, drawing on an understanding of the human realities which is enriched by revelation.

Still, while it thus draws on a wider and deeper context of principle, it can also be taken as a conclusion about what, in this matter, truly is beneficent and just, and what is maleficent and unjust because imposing, in the name of parental or scientific autonomy, new forms of human domination and subjection. So, against this background, we offer a few further observations on 'the four principles'.

III

Healthcare's traditional vocation (object and responsibility) has been: Promote the good health of your patients and cure (or prevent) their illnesses. Though serving other basic benefits too -- knowledge, skill, community between patient and professional, practical reasonableness...-- healthcare has as its primary rationale the basic human good of life. 'Life' here includes health, the well-integrated, harmonious functioning of a living being of an organic, sentient and rational nature.

Healthcare often calls for 'calculation', to find the most efficient cure, palliation, management... the best proportion of likely therapeutic benefits to burdens. In relation to each available therapy one considers various factors; some are objective though partly indeterminable (prognosis, likely and possible side-effects, costs...); some are subjective (the patient's fears, ability to cope with pain, own assessment of benefits and burdens...).

This kind of assessment need involve no 'end justifies the means' ethic (consequentialism). The best-known consequentialism, 'utilitarianism', exists in many incompatible forms, but all assert something like: choose what seems most likely to maximize good and minimize bad effects. Lately, some Catholic bioethicists have proposed various hybrids of consequentialism with classical Christian morality. 'Situation ethics', for instance, counsels choosing whatever, in the particular 'situation', seems most humane or loving or in line with 'faith instinct'[30]. 'Proportionalism' (in its main forms) bids us seek the option promising to maximize the balance of 'premoral' goods (such as lives, health, contentment) over premoral evils (such as deaths, sickness, sadness) [31], [32], [33], [34].

Such approaches have been refuted at length elsewhere [35], [36], [37], [38], [39]. They all fallaciously assume that because some rational comparisons of value are possible, therefore it is possible, at least in principle, to make a determinate rational comparison of the goods and bads anticipated in options. Extrapolating rashly from what is (at least logically) possible in a technical, cost-benefit problem with a single definite goal, they all gratuitously suppose a similar logical possibility in moral deliberations, which involve an open horizon, many different benefits and harms, and one's whole stance towards integral human fulfilment.

True beneficence, then, will not be so narrowly focussed on 'foreseeable consequences' that it overrides questions of means and intentions (which have implications and consequences that only divine providence can adequately foresee, master and dispose).

IV

('first of all, do no harm') was a classic first principle of medical (and other) ethics. As the Hippocratic Oath puts it: 'I will use treatment to help the sick to the best of my ability and judgment, but I will never use it to injure or wrong them'. But what is harm, what is wrong?

In section I, we sketched the rational basis for such traditional formulae as: 'The end does not justify the means', 'Never treat anyone as a mere means', 'Do not do evil that good may come'. It is always wrong to choose to destroy, damage or impede an instance of a basic human good for the sake of some ulterior end. That good provides a reason against such a choice, and because that good cannot rationally be 'outweighed', that choice will be not merely against reason but against .)

In healthcare practice, three forms of maleficence are common: (i) lying, (ii) killing and (iii) mutilation.

(i) In , one expresses outwardly, and tries to get others to accept, something at odds with one's inner self. One thus divides one's inner and outer self, contrary to one's own self-integration and authenticity, and impedes or attacks the real community that truthful communication would foster, even when deception seems very desirable. So, though telling the whole truth (or even telling anything at all) is quite often destructive or heartless, lying is always wrong.

(ii) . Someone who brings about death, intending to do so as an end or as a means (and whether by action or deliberate omission), is said to kill 'directly'. (Causing death only as a side-effect, however predictable, is 'indirect' killing.) The always violates the principle of maleficence and is always wrong [40] [41]. (Some but not all indirect killings, too, violate the principles of justice and non-maleficence.) Whether in abortion, eugenic prenatal testing and selection, embryo experimentation and non-therapeutic genetic engineering, infanticide of the handicapped, assisted suicide or euthanasia, direct killing always demeans both victim and perpetrator, invites further 'therapeutic' killing, and violates the divine trust given us in human life.

'Quality of life' decisions to deal with certain persons on the basis that they are 'better off dead', because their life 'is of no benefit' or has no (or a negative) value are notoriously arbitrary and elastic. They also, and inevitably, violate either the principle of non-maleficence, or a principle of justice (or both). Even the very reduced and deficient life of the irreversibly comatose is an instance of a basic human good; it is the very existence of a unique person, who can still be harmed, e.g. by being subjected to indignities. A decision to discontinue feeding and hydrating may be either direct killing (as a means to relieve others of burdens created by the patient's continued existence) or, if motivated solely by desire to avoid the burdens of , an abandonment which could be just only in circumstances of emergency or poverty rarely if ever found in modern Western society [42], [43].

Of course there may be good reasons for withholding or withdrawing some treatments. Their continued use may be futile, i.e. of no therapeutic value. Or they may impose a burden (such as pain, indignity, risk, cost etc.) which those concerned feel is out of proportion to the benefit gained. Here the healthcare worker does not indulge in arbitrary 'quality of life' decision-making, but rather makes a (sometimes difficult) therapeutic judgment about the helpfulness or not of the proposed medical treatment in dealing with the patient's illness. On this basis some treatments will be medically indicated and morally required ('ordinary'); others will be optional ('extraordinary'); and still others will be contra- indicated (and immoral) [44], [45], [46].

(iii) . Respect for persons and the good of life includes respect for their physical, psychological and spiritual integrity. Non- maleficence forbids mutilation, even when consented to (e.g. to facilitate begging, preserve choristers' voices, or prevent conception). For example, sterilization chosen in order to prevent conception is, at best, a bad means to a good ulterior end, an act of well-motivated but morally confused maleficence. For in no way does sterility as such truly benefit anyone; it only facilitates sexual intercourse -- a distinct act in and through which some benefit is expected -- by excluding conception. Even when well- motivated, every choice directly to impair a function involves an intention to damage a basic human good, and is always wrong.

But it can be morally good and even obligatory to remove a part of the body when this removal, of itself, protects or promotes health, and one does not intend the detriment to function as a means to any end, but only accepts it as a side effect. For example, an infected limb or nonvital organ may rightly be amputated or excised when that is necessary to prevent the infection from doing great harm to the whole body. Even a healthy part may be removed if doing so has natural consequences which are necessary for the health of the whole body and cannot be effected in another, less detrimental way.

Donating parts of one's remains after death damages no human good, and can rightly be done to benefit another or others -- provided, of course, that death is properly established and there is proper respect for grieving relatives and staff. Donating blood typically involves no harm and very little risk, is permitted by the principles of non-maleficence and can be recommended or even required by the principles of beneficence. The live donation of an organ (e.g. a cornea), when the benefit to another will be secured only and precisely by detracting from the functioning of the donor (e.g. the donor's depth vision), is a bad means to a good end, and always wrong. But the live donation of an organ (e.g. a kidney) can be right, when it involves only some risk of future detriment to function; for here the potential loss of function is not part of one's chosen means but only an accepted side effect.

These distinctions are often explained by Catholic moralists by reference to a 'principle of totality': mutilation is morally permissible when necessary for the good of the whole body [47], [48]. But that principle is no more than the application, in a particular context, of the quite general considerations which determine when there is and is not a choosing of evil for the sake of good. Catholic moralists, during the last 200 years or so, often discussed those considerations under the heading of the 'principle of double effect'. But that principle [49], [50] (which is misrepresented in many works, e.g. [51]), is reducible, on analysis, to two propositions: (i) neither as an end nor as a means may one choose to destroy, damage or impede any instance of a basic human good; (ii) a result of a choice is not a chosen means merely because it is foreseen as a probable or certain result but because it is part of the proposal which one shaped in deliberation and adopted in that choice. The analysis of chosen actions, to establish what one is and is not really intending, can be difficult and delicate. It affords much opportunity for rationalisation and self-deception. But it is eminently a matter for rational reflection and discussion. It is also a matter on which, for salient conclusions about the morality of some specific types of choice, one can look to the Church's authoritative wisdom.

V

Ideals of autonomy today contain much that is unacceptable. They often involve or promote a dream of absolute self-sufficiency, independent of God, community, reason and reality. Social authority is seen as a necessary evil for limiting social conflict, but ideally one should be free to do as one pleases, adopting one's own lifestyle and conception of fulfilment. 'Privacy' and 'my right to my body', in the context of such ideas, veil a hardening of hearts against human beings for whose very existence one is responsible. Conscience is considered a private internal voice with authority to judge without too much regard for reality, truth and wisdom. The ideal of autonomy woven of these strands, though widely felt to be self-evident, is but the distorted shadow of a truth clarified by revelation: every human person has the dignity of one redeemed by Christ, and none is properly the slave or instrument of another's purposes. So the greatest of Catholic moralists have made the cornerstone of their ethics this proposition: mature human persons, having free will, image God principally by being rational masters of their own acts [52], [53].

Properly understood, then, the principle of autonomy is an acknowledgement of both the radical equality of all human beings, and the inalienable responsibility of all who can choose to make their choices open to integral human fulfilment.

We have mentioned one way in which that radical equality is denied (in IVF). Here is another: well-intentioned lying. Those who lie to their patients manipulate them. Very often they overconfidently judge what they cannot know: that the one they try to deceive cannot deal with reality, cannot make good use of the freedom that only truth can give, and will not suspect or even detect the deception, with a consequent loss of trust. By their impact on freedom and fostering of mistrust, supposedly helpful lies often do great, although unintentional, harm.

As to each individual's inalienable responsibility: the primary duty of health care is one's responsibility to look after oneself, physically, psychologically and spiritually -- to treat one's health as one of the 'talents' entrusted by God to one's stewardship. In seeking and consenting to the needful help of others, one cannot repudiate one's personal responsibility or grant them authority to do more than one can responsibly ask. Interventions by healthcare professionals which do not respect the proper directions of a patient fail to respect the patient as (like all human beings) the healthcare worker's radical equal.

We shall not here repeat the still generally sound norms of the healthcare professions concerning respect for patients, informed consent, nurturing of trust, confidentiality of records, and so forth. Instead we express a fear. Unhinged from its true ethical context, the principle of autonomy (often reduced to the right to 'privacy' or 'to choose') soon may become the principal formula for rationalising the extermination of many sick and handicapped persons, young and old. For if non-maleficence is re- interpreted so as to allow assisted suicide and voluntary euthanasia in the name of autonomous 'self'-liberation from a burdensome life, it doubtless will soon be held that those who (and in many cases did or could) give their consent to it should not thereby be deprived of their equal 'privacy right' to liberation from burdensome life. The 'right' will be exercised 'on their behalf' by someone who will choose for them the death which, it will thus be presumed, they would have (or should have) chosen had they been capable of choice. A false 'principle of autonomy' could thus be the constitutional and ethical vehicle for the profound injustice of a 'beneficent' maleficence, ridding the community of many lives deemed 'not worth living' ().

VI

There are two senses of 'justice' [54]. As fairness, justice is a principle distinguishable from beneficence and non-maleficence. As respect for all the rights of others, justice is a principle which includes beneficence, non-maleficence and true autonomy. Here, then, we add only a few points.

Concern for the common good -- 'love of neighbour', or 'solidarity' -- requires fellow-feeling, genuine self-giving, joint effort with others to promote the flourishing of all, encouragement and support for the efforts of others. Healthcare certainly requires joint effort and deliberate coordination, at various levels of institutions, communities and governments. But true autonomy requires that larger communities should assist smaller ones, not absorb them -- this is the principle of 'subsidiarity' -- just as smaller ones should help individuals to help themselves. Governments should assist with resources, coordination and encouragement, but not take charge of all the functions of smaller groups where (given suitable freedom and assistance) those smaller groups could direct and perform these functions [55], [56].

Justice supports neither centralized control of all aspects of healthcare (a violation of subsidiarity), nor leaving healthcare, a fundamental right [57], to the whim of 'market forces' (which violates solidarity). As we have the right to expect the help of others, so we have the reciprocal duty to help others in need of healthcare, whether through our taxes, insurance payments, or provision of personal care. A system of healthcare violates the Golden Rule (I must presume) if I would think that system unfair were I (or someone I loved) in the weakest position in the community. The world's material resources are given to all humankind, for the needs of all, and so while private property is often a requirement of justice, the needs of others establish duties on the part of those who have more than they need towards those who have less than they need -- in healthcare as in other basic human needs [58], [59], [60].

Special care for the (materially and/or spiritually) poor, underprivileged, powerless and desperate is something the Church considers itself called upon to give ('the preferential option for the poor') [61]. Among the various just regimes of healthcare distribution which are possible in a community [62], the Christian will prefer ones which give special care to the most needy and defenceless.

Mercy calls us to go beyond (without violating) the principles of justice and non-maleficence in healing every form of evil [63]. Is 'mercy killing' (euthanasia) the truly compassionate way to treat those in severe pain or incurable illness or coma? Or to distribute finite health resources? Compassion means wanting the best for the other, having empathy with them in their suffering, and seeking positively to assist by acts of mercy in keeping with their dignity. Far from contributing to 'death with dignity', support for euthanasia promotes a culture which whispers to the old and infirm 'Your condition is intolerably undignified. You would be better off dead. We would be too, if you were dead. You may even have a duty to acquiesce in being killed.' Thus false views of mercy and justice can conspire to institute a 'beneficent' maleficence, injustice, and the ultimate negation of autonomy [64].

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3 Finnis, John. Fundamentals of Ethics. Oxford: Clarendon Press, 1983; 137

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20 Beauchamp, Tom L., and James F. Childress. Principles of Biomedical Ethics. 3rd ed. New York: OUP, 1989

21 Hauerwas, Stanley. Vision and Virtue. South Bend: Fides, 1974

22 Hauerwas, Stanley, et al. Truthfulness and Tragedy. Notre Dame IN: University of Notre Dame Press, 1981

23 MacIntyre, Alasdair. After Virtue: a study in moral theory. 2nd ed. London: Duckworth, 1985

24 Thomas Aquinas. Summa Theologiae. 1a.[2]ae question 19 articles 5-6

25 Grisez, reference (13); 73-96

26 Grisez, Germain. Abortion: the Myths, the Realities, and the Arguments. New York: Corpus Books, 1970; 155-184

26 Fisher, Anthony, O.P. IVF: The Critical Issues. Melbourne: Collins Dove, 1989

28 Catholic Bishops' Joint Committee on Bioethical Issues. In Vitro Fertilisation and Public Policy. Abingdon, Oxford: Catholic Media Office and Joint Committee on Bioethical Issues, 1983

28 Congregation for the Doctrine of the Faith. Donum Vitae. Instruction on Respect for Human Life in its Origin and on the Dignity of Procreation (22.2.87). London: Catholic Truth Society, 1987

30 Rahner, Karl, S.J. Theological Investigations. Volume 9. New York: Crossroad Press, 1976; 243

31 Hoose, Bernard. Proportionalism: The American Debate and Its European Roots. Washington DC: Georgetown University Press, 1987

32 McCormick, Richard. Ambiguity in Moral Choice. Milwaukee: Marquette University Press, 1973.

33 McCormick, Richard A. Health and Medicine in the Catholic Tradition. New York: Crossroad, 1985.

34 McCormick, Richard A., and Paul Ramsey (eds.). Doing Evil to Achieve Good. Chicago: Loyola University Press, 1978.

35 Finnis, Boyle and Grisez, reference (7); 238-272

36 Finnis, reference (3); 80-135

37 Grisez, Germain. Against Consequentialism. American Journal of Jurisprudence 1978; 23:21-72

38 Kiely, Bartholomew, S.J. The Impracticability of Proportionalism. Gregorianum 1985; 66:655-686

39 Finnis, reference (16); 13-24, 93-101

40 Finnis, Boyle and Grisez, reference (7); 297-319

41 Pius XII, Pope. Address to the St. Luke Union of Italian Physicians (12.11.1944). Discorsi e Radio-messaggi 1944; 6:191; quoted in Congregation for the Doctrine of the Faith. Declaration on Procured Abortion (18.11.74). In: Flannery, reference (45); 452.

42 Grisez, Germain. Should nutrition and hydration be provided to permanently unconscious and other mentally disabled persons? Linacre Quarterly 1990; 57:30-43

43 May, William E. Feeding and hydrating the permanently unconscious and other vulnerable persons. Issues in Law and Medicine 1987; 3:203-17

44 Sacred Congregation for the Doctrine of the Faith. Jura et Bona (Declaration on Euthanasia), 5.5.80. In

Flannery, Austin, O.P. (ed.). Vatican II. Volume II: More Postconciliar Documents. Northport, New York: Costello Publishing, 1982; 510-18

45 Linacre Centre. Euthanasia and Clinical Practice: Trends, Principles and Alternatives. London: Linacre Centre for the Study of the Ethics of Health Care, 1982

46 Pollard, Brian. Euthanasia: Should We Kill the Dying? Sydney: Mount Press, 1989

47 Ashley and O'Rourke, reference (19); 36-43, 194-196

48 Gallagher, John, C.S.B. The Principle of Totality: Man's Stewardship of His Body. In: McCarthy, Donald G., Moral Theology Today: Certitudes and Doubts. St. Louis, Missouri: Pope John Center, 1984; 217-242

49 May, William E. Double Effect, Principle of. In: Reich, Warren, ed. Encyclopedia of Bioethics. New York: Macmillan, 1978

50 Boyle, Joseph M. Toward Understanding the Principle of Double Effect. Ethics 1980; 90:527-538

51 Beauchamp and Childress, reference (20); 127-134

52 Thomas Aquinas. Summa Theologiae. 1a[2]ae. Prologue

53 Grisez, reference (13); 41-72

54 Finnis, reference (10); 161-197

55 Finnis, reference (10); 146, 159, 194

56 John Paul II, Pope. Centesimus annus. Encyclical on the Hundredth Anniversary of Rerum Novarum, 1.5.91. Middlegreen: St Paul Publications, 1991; paragraph 41

57 John Paul II, Pope. Laborem exercens. Encyclical on Human Work, 14.9.81. London: Catholic Truth Society, 1981; paragraph 19.5

58 Vatican II, reference (14); paragraph 69

59 John Paul II, reference (15); paragraph 42

60 John Paul II, reference (56); paragraph 31

61 John Paul II, reference (56); paragraph 57

62 Ashley and O'Rourke, reference (19); 112-144

63 Grisez, reference (13); 644-646

64 Grisez, Germain and Joseph M. Boyle. Life and Death with Liberty and Justice: A Contribution to the Euthanasia Debate. Notre Dame and London: University of Notre Dame Press, 1979

ABSTRACT

Morality identifies the basic reasons for human choices, and articulates principles for making those choices compatible with openness to integral human fulfilment. Many ethical approaches and many sorts of choices are incompatible with this. Faith guided by church teaching offers further and surer education for conscience, and deeper understanding of the healthcare worker's vocation.

The 'four principles' have their grounding and proper meaning only within such a fully developed ethic. Beneficence requires the promotion of the life and good health of patients; non-maleficence forbids harming them, or compromising any instance of a basic human good in deceptive moral calculations and quality of life judgments. Autonomy directs respect for human dignity and responsibility; it does not justify individualism independent of God and community, or exterminative medicine. Justice and mercy enjoin solidarity, subsidiarity, fair resource allocation, and special care for the poor and helpless.

This Catholic approach is shown to have implications for abortion, IVF, sterilization, euthanasia, withdrawal of treatment, and honesty in medical communication.

'THE FOUR PRINCIPLES' -- A CATHOLIC VIEW

John (M.) Finnis LL.B. (Adelaide), D.Phil. (Oxon.), M.A. (Oxon.), F.B.A. Professor of Law and Legal Philosophy, Oxford University; Fellow and Tutor, University College, Oxford University College, Oxford, U.K.

Anthony (C.) Fisher, O.P. B.A. (Sydney), LL.B. (Sydney), B.Theol.(Melbourne), D.Phil. Candidate (Oxon) Blackfriars, Oxford, U.K. Address: Blackfriars, St. Giles, Oxford, OX1 3LY