i? REFERENCE MANUAL for MEDICAL ETHICS / by Charles J. McFadden, O.S.A.,Ph.D Faculty of Villanova College Villanova, Pa. DAVIS COMPANY r* ,Γ Nihil Obstat: Robert E. Regan, O.S.A., S.T.D. Imprimi Potest: Mortimer A. Sullivan, O.S.A Prior Provincialis April 1, 1949 Nihil Obstat: Joseph A. Quigley, J.C.D Censor Librorum Imprimatur: Dennis Card. Dougherty Archiepiscopus Philadelphiensis April 8, 1949 < COPYRIGHT. SEPTEMBER 1949 BY P. A. DAVIS COMPANY Copyright, Great Britain. All Rights Reserved 49.9 PRINTED IN THE UNITED STATES OF AMERICA 1 * · PREFACE This Reference Manual contains the solutions to the “Prob­ lems for Discussion’’ which are found at the end of each chapter of the author’s text on Medical Ethics. The demand for a Manual to accompany the text has come from all quarters. So constant and so pressing have these requests been that there can be no doubt that both teachers and students have felt a definite need for such a work. It is to be hoped that this aid which is now offered to them does not fall short of their needs or expectations. In the solutions presented, the author has made an extensive effort to give more than a mere answer to the problems. Hence, while the analyses of the problems do not profess to be exhaus­ tive treatments of these cases, an attempt has been made to include a wealth of pertinent material which it is hoped will be most enlightening to the student and most helpful to the teacher. Furthermore, it is to be acknowledged that the proposed solutions are not always beyond question. Many of the prob­ lems are rather difficult, and some of them certainly admit of a legitimate difference of opinion. The author hopes that this Manual will contribute in some way towards developing in our doctors and nurses a profound respect for the Moral Law and a right conscience to guide them in its observance. Charles J. McFadden, O.S.A., Ph.D. •A-S; CONTENTS CHAPTER PAGE L The Nature and Value of Ethics............................... 1 II. The Foundations of Morality..................................... 4 III. The Nature of Christian Marriage........................... 9 IV. Contraception................................................................ 13 V. The Safe Period Method............................................. 18 The Christian Philosophy of Suffering.................... 21 VII. Direct Abortion............................................................. 27 VIII. Therapeutic Abortion................................................. 32 IX. Indirect Abortion......................................................... 37 X. Ectopic Gestation.......................................................... 40 XL The Sacrament of Baptism......................................... 42 XII. Sterilization.................................................................... 48 XIII. Assistance at Immoral Operations............................. 55 XIV. Property Rights............................................................ 65 VI. XV. Truthfulness and Professional Secrecy..................... XVI. The Last Sacraments................................................... INDEX ...................................................................................... « · Vll 68 77 83 I 1 CHAPTER I THE NATURE AND VALUE OF ETHICS It would be very unwise for a girl to enter the nursing profession simply to earn a livelihood by it. It is doubtful that a girl could go through nursing school with only such motiva­ tion. A love of the sick and a desire to help fellowman must be at the root of a career in nursing. Without these high ideals, a nurse’s work will not only fall far below standards but it will always be characterized by a reluctant fulfillment of the bare minimum demanded of her. There will be no spirit of self­ sacrifice that will urge her on to the achievement of the high ideals of her noble profession. A Christian love of the sick and a real desire to help them should certainly be the paramount reason for any girl entering the nursing profession. Only such motivation provides the soundest assurance of being happy and successful in this pro­ fession. Occasionally a girl does enter nursing school without proper motivation; few such girls survive the nursing school course, and the few that do survive are neither happy nor effi­ cient in their work. 2. There are, of course, several factors which account for so many books on Nursing Ethics restricting their content to the field of mere etiquette. The principal reason, however, is the fact that outside the Catholic Church, morality is an untouch­ able sphere. Each person has his own moral code or rejects all moral codes. Each person recognizes no one—not even his or her own church—as having the authority to dictate on moral matters. Practically speaking, it would be impossible to find a text which would handle the moral aspects of a nurse’s actions and yet be acceptable to the heterogeneous group which makes up the nursing class in the average secular hospital. The easiest solution to this problem is to produce texts which avoid the treatment of moral problems and confine themselves to the mere etiquette of the profession. ·■? J»· J _ Reference Manual for Medical Ethics 3. Reason is a valuable source of moral knowledge. It is> however, subject to error. Revealed truth, as presented by thé infallible teaching of Christ's Church, is the best source of such knowledge. Reason often senes to make revealed truth better under­ stood and more acceptable to many men. Revelation always senes as a guide and check on the accuracy of man’s reasoning. The infallible teaching of Christ’s Church always has its basis in Revelation as found in Sacred Scripture or Tradition. Reason can provide man with some moral truths which are not formally and explicitly found in revelation. Thus, one will not find a formal and explicit statement on the morality of arti­ ficial insemination or the sterilization of mental defectives in Revelation. Moral teaching which implicitly treats these mat­ ters is, of course, to be found in Revelation. Revelation provides man with many moral truths that are not clearly, easily and readily discoverable by reason. The uni­ formity of moral belief within the Church and the complete lack of agreement among those outside the Church is evidence of this fact. The unity and indissolubility of marriage are ob­ vious examples of this type of truth. 4. It is not accurate to refer to Ethics as a course in religion. Strictly speaking, ethics is a branch of philosophy and its ap­ proach to morality is a purely rational one. Religion, on the other hand, is based primarily upon revelation; it relies upon the teaching of Christ’s Infallible Church on the moral and dogmatic truths contained in Sacred Scripture and Tradition. In the text on Medical Ethics—as explained in the first chap­ ter—there is no intention to restrict the treatment of the various topics in the book to the purely ethical and natural level. The approach in the text is primarily, but by no means exclusively, a rational one. The moral ideals of the nurse should certainly be molded on the revealed word of God and the teachings of Christ’s Church, as well as on the dictates of reason. Both reason and revelation are, therefore, utilized throughout /Med­ ical Ethics. 5. A hospital’s reputation is the estimation in which it is held in the mind of the community. Many qualities enter into flic Nature and Value of Ethics 3 any good reputation—whether it be of an individual person or an institution. Moral standards and ethical ideals, however, constitute the very foundation of any reputation. If these qual­ ities be lacking there can be no worthwhile reputation. 6. When the ethical standards of the medical and nursing professions are high, the physical welfare of the community is in the best possible hands. Self-sacrifice will characterize the service of the professions to the community; and the commun­ ity, deeply respecting the high standards of the doctors and nurses who serve them, will have the utmost faith and confi­ dence in them. 7. Moral laws and moral ideals are not synonymous. There is always a distinction made between what is of command and what is of counsel. Moral laics indicate courses of action that bind under pain of sin. Moral ideals indicate courses of action which, though not compulsory, are truly noble. Too often stu­ dents finish an ethics course with only a knowledge of moral law—knowledge of how far they can go without actually com­ mitting sin. Such is certainly not the objective of a Christian life. The nurse must, of course, be thoroughly familiar with moral law as it pertains to her profession. But her life should reflect more a constant striving to achieve ideals, rather than a mere conformity to the minimum demands of law. CHAPTER II THE FOUNDATIONS OF MORALITY 1. A sound principle of morality is that “one may never act on a doubtful conscience.” The nurse in this case is definitely in a state of doubt concerning the sterility of the instruments. It would be a sinful act for her to turn in such instruments and, in addition, she would be morally responsible for any harm which might befall a patient—should it later develop that the instruments were unsterilized and produced an infection. Technically, the harmful effects of her act would be classified as indirectly willed. In this case the nurse is morally obliged either to make cer­ tain that the instruments have been sterilized, sterilize them herself, or secure a set which is sterilized. 2. Over and above the deceit involved in charting the med­ icine as given, the nurse is morally responsible for any harmful effects which may result from the deception. Such harm would be the indirectly willed effect of her deliberate concealment. A failure on the part of the patient to show expected improve­ ment from the use of the present drug could deceive the doctor, and the latter might be led to change from a perfectly good to a less effective drug. An admission by a nurse that she has fallen asleep on duty may bring a reprimand but it will also create an admiration for her honesty. A willingness to be sub­ jected to a reprimand or receive some punishment rather than have a patient suffer any possible harm is a highly valuable trait in the character of a nurse. 3. A nurse must be sensible enough to appreciate that her medical education, and probably her medical experience, has been very slight in comparison to that of a doctor. She should realize that there is a lot of truth in the saying that “a little knowledge is a dangerous thing.’’ It would be amusing, if it were not so serious, to encounter the nurse who couples her elementary studies with a little practical experience, and im- The Foundations of Morality 5 mediately feels capable of passing judgment on the diagnosis, treatment and skill of a medical specialist. In the light of these facts, the nurse must ordinarily regard the action of a doctor as presumptively correct and faithfully carry out his orders. In extraordinary instances, it could happen that the simplic­ ity of the matter and years of experience would combine to convince a nurse that she could not, in conscience, obey the order of the doctor. It is never permissible, of course, to act contrary to one’s certain conscience. Hence she would be com­ pelled to use all of the tact and diplomacy at her command to inform her superior or the doctor himself that she could not, in conscience, carry out the order. She would not, incidentally, be justified in secretly lessening the quantity of the dose and allow­ ing the doctor to believe that his orders had been executed. 4. As in the previous case, the nurse must assume that the doctor is carrying out his duties with due knowledge and care. Is is not within the sphere of a nurse’s rights to decide when a medication shall be discontinued. In all ordinary cases, there­ fore, the nurse should continue the medication until she is able to contact the doctor. In extraordinary instances, an experienced nurse may know that the medication involved is rarely continued over a longer period and that prolonged use is frequently dangerous. In view of her experience and the possibility that the doctor has for­ gotten to discontinue the medication, it is suggested that she contact another doctor, preferably a friend and associate of the physician in charge, explain the problem to him, and follow his advice. 5. Very little can be said to minimize the gravity of such negligence. Any young woman who is old enough and intelli­ gent enough to be in the nursing profession must realize that her duties revolve around the gravest of matters. She must understand that all instructions given to her on the care of a patient are the product of someone’s professional training, ex­ perience and serious consideration. Technically, the nurse in this case has indirectly willed the death of the patient. She has directly willed some act of negligence (such as absenting her­ self from the patient’s room or allowing the patient forbidden 6 Reference Manual for Medical Ethics freedom). Due consideration of this action and a proper respect for the instructions given should indicate to her that some serious harm could result from such neglect of duty. The nurse involved is guilty of a grave sin of negligence which has resulted in the death of a patient whom she was obliged to protect. 6. In tribute to the nursing profession, the author must hon­ estly say that he does not believe constant contact with suffer­ ing and death hardens a nurse’s conscience to the point that she minimizes the importance of actions which may produce injury or deadi to her patient. In some very few instances such laxity may be detected, but these cases are so rare that they are negligible. When a patient is not seriously ill, it is true that many nurses regard their duties too lightly. But whenever a patient is critically ill, nurses appreciate the importance and gravity of their work and make every sacrifice to live up to the ideals of their noble profession. 7. Almost everything that was said in the answer to the first, second and fifth questions, applies in this case. A nurse who would deliberately hand a contaminated instrument to a sur­ geon, rather than risk his wrath, is a moral coward and a dis­ honor to her profession; she is indirectly willing whatever harm befalls the patient and is morally responsible for it. 8. One of the most valuable lessons a nurse can learn is that serious thought and sound scientific principles underlie hospi­ tal regulations. Centuries of medical experience and countless thousands of unwittingly sacrificed lives lie behind the regula­ tions which govern our modem hospitals. Respect for this herit­ age is the mark of a true nurse. A nurse who would deliber­ ately curtail the prescribed sterilization time would be indi­ rectly willing whatever harmful effects follow from her action. 9. Unfortunately, it is very easy to enumerate many matters in which nurses tend to develop a lax conscience: Inaccuracy in charting, carelessness in handling instruments, improper dis­ position of waste material, failure to check pulse and respira­ tion for full time, removing thermometers too soon, cutting short the time required for sterilizing instruments, neglecting to check charts for medications, not putting up crib sides on .· : I > •‘Tr V rhe Foundations of Morality beds which require them, failure to observe strict isolation techniques, failure to check exact dosage of a medicine to be given, giving medication before time to hurry off duty or delay­ ing medication beyond prescribed time. 10. One does not encounter many nurses who have scrupu­ lous consciences. Occasionally, however, certain nurses mani­ fest some traits which might be classified under this heading. Thus, some nurses who are truly diligent in their work con­ stantly worry about many things, viz: whether or not they have given the wrong medication or the wrong amount of a medica­ tion, whether the death of a patient is possibly their fault, or whether a doctor has made a mistake in a medication he has ordered. 11. Most of the matters mentioned in the answer to the ninth question can develop into habits of carelessness which may result in injury to patients. If the nurse is able—in the light of her training and after due consideration of her action—to foresee that harmful effects will even probably result from these habits, such harmful effects are indirectly willed by her and she is morally responsible for them. If the nurse is able, in the course of the repeated acts which build up the bad habit, to foresee that it will eventually become so deeply imbedded in her character that she will perform harmful actions without advertence—and if she does not make reasonably diligent efforts to overcome this habit—the harmful effects, when later produced without advertence, are virtually voluntary and she is morally responsible for them. 12. There should be a whole-hearted cooperation between the State and the Medical and Nursing Associations. The State exists to secure the complete temporal welfare of its citizens, whereas the Medical profession has for its objective the health of society. The State should make such laws as are needed to protect legally, the existence, proper interests and efficient operation of the Medical Associations. On their part, the Medi­ cal and Nursing Associations will frequently find it possible to render invaluable aid to the State in the formulation and enforcement of laws vital to the welfare of society. 8 Reference Manual for M ed i ca 1 E t h i es Natural Law should be the basis of laws and regulations of human origin. Civil Law, for example, should take the basic principles supplied by Natural Law and apply these principles to the specific conditions of a given time and place. In fact, any Civil Law that runs counter to Natural Law is invalid and has no binding force. CHAPTER III THE NATURE OF CHRISTIAN MARRIAGE 1. The birth of a child is an invaluable asset in bringing husband and wife closer together. The child is truly their child —something of each has gone into this new person. Their love for each other becomes deeper and stronger as they realize that here is a little family unit that is all their own. They recog­ nize that they must now work shoulder to shoulder to solve the problems, assume the responsibilities, and overcome the hard­ ships which their little society must face. But, they now also begin to share together the countless joys which are found only within the family unit. 2. The statistics on divorce in the United States certainly present an unfortunate picture. In direct answer to the ques­ tion asked in this problem, it is a fact that approximately threefifths of the divorces in our country are between childless couples. Some additional statistics on divorce are also enlightening: whereas about seven percent of marriages ended in divorce within five years in 1941, the proportion reached seventeen percent in 1946. Under present conditions a greater propor­ tion of marriages are dissolved by decree within five years than had been dissolved within the first fourteen years of married life in any year of our history prior to 1941. While the divorce rate between 1941 and 1946 increased 130 percent among those married less than five years, the rate rose 55 percent among those married five to nine years, and 33 percent among those married ten to fourteen years. 3. While it is true that the procreation and rearing of chil­ dren is the primary purpose of marriage, one must not forget that there are legitimate secondary purposes of marriage. It is regrettable that there are some persons who, though capable of natural marital relationship, are—because of accident or disease—physically incapable of having children. In these cases, 9 ; ·· ; 10 .u '1 Reference Manual for Medical Ethics sterility is present, but not impotence. It is therefore morally permissible for these persons to marry in order that they may attain the various secondary benefits of marriage. 4. After teaching thousands of Catholic college young men and women over a period of years, it is the opinion of the author that, as a general rule, the physical basis of marriage is not over-emphasized by these young people. The factors involved in die spiritual basis of marriage—as explained in the textusually provide the primary motivation for their marriages. The same statements, unfortunately, cannot be made of most “teen-age" marriages nor of those of most young people who lack a sound moral and religious education. 5. Marriage is contracted “by proxy” when one of the parties to the contract is not present at the marriage ceremony but is represented at the ceremony by a person who is delegated by him to express his consent for him. Just as other contracts may be made “by proxy” so may one enter marriage in this man­ ner. As in the case of the witnesses, any person who knows what he is doing is able to act as a proxy. I The Church has stipulated that the proxy must have received, , in writing, a special authorization to contract marriage with a specified person. This authorization must be signed by the principal, and by either the pastor or the bishop (Ordinary) of the place where the authorization is issued, or by a priest dele- I gated by either the pastor or the bishop (Ordinary), or by at i least two witnesses (Canon 1089, #1). 1 If the principal does not know how to write, this impossi­ bility—under pain of nullity of the contract—must be men­ tioned, and the signature of a supplementary witness be added (Canon 1089, #2) . 1 If, before the proxy agent has contracted marriage in the name of the principal, the latter revokes his mandate or lapses into insanity, the marriage is invalid (Canon 1089, #4) . Marriage by proxy is obviously an unusual way of entering the contract and the Church demands that there be a just reason for it before proper ecclesiastical permission is granted. There are many instances in which marriage by proxy pro­ vides a satisfactory solution to a difficult moral, legal and medi- The Nature of Christian Marriage cal problem. Thus, two persons who intend to marry but who are separated by vast distances and unable to come together for a ceremony may find marriage by proxy of inestimable value. It serves frequently as a means of having a child born in law­ ful wedlock who would otherwise be born illegitimate. It has served as a means of gaining admission to a country as the spouse of one of the citizens of that nation. It has also enabled persons to share in wills and estates when it was suddenly learned that the terms of the latter have specified marriage by a certain age or date. However, inasmuch as marriage by proxy is not recognized by civil law in many states, a couple would have to have such a marriage performed in a state which per­ mits such marriages. Only in this way would the marriage be legal and the civil effects of marriage guaranteed for the couple. 6. The primary purpose of marriage is the procreation and rearing of children. It can, therefore, reasonably be presumed that the prospective husband’s desire to marry is at least par­ tially motivated by the hope of raising a family. It would, there­ fore, be a grave injustice for the young woman to conceal delib­ erately from him the fact that she could never bear children. One might also add that, even humanly speaking, it would be a very foolish and imprudent concealment; if she tells him the truth, it is extremely unlikely that it will affect his intention of marrying her; if she conceals the truth, and he discovers at a later date that she deliberately hid the facts from him, it may create a serious crisis in the marriage. 7. This text of the New Testament does not authorize divorce and remarriage in the case of marital infidelity. It must be noted that the clause “except it be for fornication” is joined only to the “putting away” and not to the “remarrying”; and the Catholic Church admits that mere separation by the innocent party is permissible in the case of marital unfaithful­ ness. (For a fuller explanation consult the pamphlet on Matri­ mony by Father Connell which is referred to in the text). 8. Any Catholic who attempts marriage before a civil magis­ trate is, of course, not married at all. This question therefore asks for a comparison between the marriages of Catholics in the Church with those of non-Catholics before a civil magistrate. •V ... *·■ Sæ.;ÿ «. ji'i· · - ï ’ ·* 12 Reference Manual for Medical Ethics Is it easier for Catholics who have been married in the Church to live up to the moral ideals of their state in life than it is for non-Catholics who have been married before a civil magistrate? The objective of this question is to point out that the more grace possessed by a couple the easier it will be for them to live up to the moral ideals of their state of life. There are many sources of grace for a married couple but the Sacrament of Matrimony is certainly one of the most fruitful. All other factors being equal, the couple who receives the Sacrament of Matrimony is better fortified spiritually to live up to the moral ideals of marital life. The important point, therefore, is not so much where or before whom a marriage is contracted as it is of the possible sacramental character of the marriage. The student is referred to the text for the conditions under which the mar­ riages of Catholics and baptized non-Catholics are sacramental. Divorce followed by remarriage is a violation of the unity of marriage as well as of its indissolubility. Since divorce does not sever the bond of marriage, remarriage with a third person is a clear violation of the unity of marriage. 10. The welfare of any society hinges upon its respect for Natural Law. In fact, powerful nations have collapsed because of their widespread disregard of Natural Law. It is the duty of the State to adapt the basic principles of Natural Law to the specific conditions prevailing in its area. The success of the State in achieving the very purpose of its existence—the temporal | welfare of its citizens—will hinge upon its success in formulating! and enforcing laws which are derived from Natural Law. When either the “donor’’ (the man) or the woman, or both, are married, artificial insemination is adultery: it is, therefore, a violation of the unity of marriage; it is destructive of the dig­ nity of Matrimony and of Christian womanhood; it obliterates the Natural Law relationships which should exist between a father and his child; and, for all of these reasons, it is seriously harmful to the moral fibre of society. It should be clear that it is the duty of the State to make artificial insemination an act punishable by law. .·»·· ·»· ' v?.. ·- V ■ ■- CHAPTER IV CONTRACEPTION 1. It is the duty of the State to provide an environment in which man can earn a living and support a family. The State frequently fails in this duty due to bad politics and graft; at other times, even well-intentioned state authority finds it most difficult to solve the economic problems which it must face. The State has a positive duty to take such steps as are needed to secure the temporal welfare of its members. Unemployment insurance, the social security program and legislation assuring a proper relationship between the owning and working classes, are some of the more recent helpful steps taken by our Government to provide its citizens with the economic necessities of life. There can be a legitimate difference of opinion on the advis­ ability of the Government giving a direct “bonus” to a family for each child bom. Some foreign nations have given a bonus to a family for each child—to encourage large families. In some nations, the State places much higher tax rates on unmarried persons—to encourage marriage. In Spain, effective July 1, 1949, each man and woman of the working class who is under the Na­ tion’s social security program will receive at marriage, a gift of $230.00 from the Government (on Spain’s wage scale, this sum would be equivalent to six months’ salary for most workers) ; if both bride and bridegroom meet the qualifications the award will be doubled; the gift is “to help the laboring classes to found new homes and numerous families.” In Spain, the State also contributes the equivalent of about forty cents a day to the support of each child (in families having more than two chil­ dren) until the age of fourteen years; special rationing privi­ leges and notably reduced train fares also prevail for large families. 2. The best recommendations of a medical nature which would help to combat the medical argument for contraception are hinted at in the text: adequate medical care before mar13 ; H· 14 Reference Manual for Medical Ethics riage which would discover at an early stage, and remedy many of those physical conditions, such as heart conditions, high blood pressure and tuberculosis, which may later create serious complications of pregnancy. Adequate prenatal care made avail­ able to die prospective modiers of the nation, and an educational program which would indelibly stamp on the minds of all women a realization of the value of early prenatal care and an appreciation of how such care can prevent the arising of com­ plications of pregnancy that might otherwise prove most seri­ ous at a later date. 3. The eugenic argument for contraception is usually pro­ posed by those who are admittedly materialistic in their phil­ osophy of life. It is possible, of course, for someone who believes in the spirituality and immortality of man’s soul to be interested in a physically superior type of race. Historically, however, those who have been the most ardent advocates of contraception and sterilization for eugenic purposes—such as the founders and leaders of the Nazi Movement in Germany—have been acknowl­ edged materialists and atheists. Anyone with a true philosophy of life appreciates the value of health; but he does not allow his interest in the achievement of such temporal and physical goods to distort his scale of values. Nothing is so important for man as the attainment of his final end—union with God. 4. The so-called "moral” argument for contraception is not an argument in its own right. Actually, it is an argument which is built upon the economic or medical argument, or sometimes upon both of them. It is called the "moral” argument simply because it contends that some good in the moral order, such as the strengthening or preservation of the marriage bond, will result from the practice of contraception. Careful analysis will usually reveal that the proponent of the argument feels that the birth of a child will endanger the marriage because of exist­ ing economic or medical factors. The "moral” argument is | usually, therefore, more of a derivative of the other arguments [ than an argument in its own right. i 5. "The end does not justify the means.” This basic ethical | principle portrays the thought that we cannot evaluate the I Contraception 15 morality of an act simply in terms of the material and temporal benefits that may be derived from it. The fact that much good may result will never justify the commission of an act that is immoral in its nature. 6. A stable moral code could not possibly exist if one were to reject the principle that “the end does not justify the means.” There are very few acts—if any—which would not at some time or other produce some worthwhile good. The very same act would, therefore, be moral in one instance and immoral in the next. The morality of the act would change as often as the effects of the act changed. Lying, murder (euthanasia and direct abortion), sterilization of mental defectives, contraception, divorce and a host of other crimes would immediately be classi­ fied as morally good in all those instances in which they produced physical, material and temporal benefits. 7. As explained in the reference cited in the text, it can hap­ pen only very rarely that a married person who is a Catholic, can be in good faith regarding the sinfulness of contraception,— in view of the fact that instructions on this point are so fre­ quently given in sermons, books, and pamphlets. At most, in­ culpable ignorance on this matter could occur in the case of a poorly instructed and lax Catholic. 8. There is a lot of truth in the statement that the medical profession is placed under pressure to provide a solution to problems created by economic distress. This is particularly true during a period of economic depression. At such times many married couples lack the material necessities of life; it is fre­ quently very difficult for them to support a normal-size family and next to impossible to raise a large family. With husband and wife living together under the stress of such conditions, it is not long before the medical profession is asked to supply a means of avoiding conception in marital relationship. It is regrettable, indeed, to encounter a State which fails in its duty to provide man with an environment in which he can earn a living for himself and his family. But it is even more regrettable to find the medical profession entering the picture by developing and distributing contraceptives. By such actions, the medical pro­ fession lowers itself in dignity; it steps out of its own proper V . i-5 ç ;.‘ 41 ο "I •1*' * -- S Ii I r» 16 Reference Manual for Medical Ethics sphere; it acts immorally and it provides the State with an excuse for not fulfilling its duties towards its citizens. 9. This statement evidences a complete lack of knowledge of the reason for the immorality of contraception. As explained in the text, the immorality of contraception is to be found in the unnaturalness of the act—it involves a grave abuse of a natu­ ral faculty. It is perfectly true that contraception does not destroy human life and hence is not wrong for that reason. The very sound moral principles that do underlie the serious im­ morality of the act are adequately portrayed in “Medical Ethics.” 10. It has often been said that “an ounce of prevention is worth a pound of cure” and that the best way to solve some problems is to avoid creating them. The Church repeatedly warns its children that there are serious risks involved in mixed marriages. Such marriages frequently create problems for which there is no wholly satisfactory solution. Despite the age-old wisdom of Holy Mother Church, some of Her members reject Her counsel in this matter—and live to reap the sorrows that flow from their action. The woman in the case mentioned in the text is a perfect example of a problem resulting from a mixed marriage. She ignored the counsel of her Church and bound herself to a man who rejects its moral laws and ideals. Contraception being im­ moral, the woman has left herself just three alternatives: her first moral obligation is to call upon whatever love her husband has for her, asking him to live in total sexual abstinence, so that she may live in peace of conscience; if such total and com­ plete restraint would constitute a grave hardship to either party, possibly involving, for example, the danger of extra-marital relationships by the husband or a serious threat to the per­ manence of the marriage and the home, her obligation is then to consult a specialist so that he may guide her in the selection of the probable safe period in her marital life; finally, if the husband is unwilling to confine marital relationships to the probable safe period, and if there is a real danger of such evils resulting as were mentioned immediately above, she may con­ tinue normal marital relations—hoping that, if she does become U λ. Contraception 17 pregnant, the medical opinion on its probable risk for her will prove, as is often the case, to have been exaggerated. 11. The nurse can discover the attitude of her own State on contraception by consulting the text. Actually there are only two States—Massachusetts and Connecticut—which prevent the medical profession from engaging in the distribution of contra­ ceptives and instructions on their use. (The advocates of con­ traception strive tirelessly to overthrow die laws in these two States; in the November 1948 elections, for example, an attempt to discard the Massachusetts law had to be rejected by the voters of the State.) Unfortunately, it is a fact that the laws on contraception, are not rigidly enforced in any state. In most instances the lack of enforcement is due to a sheer negligence and disinterest on the part of the State; in some instances, it is due to the fact that a law of this type is extremely difficult to enforce—the profits on die sale of contraceptives are high and “under-the-counter sales” of this type to willing customers are hard to detect. seldom do much good. Unrelenting protests by large and active groups frequently achieve much good in matters of this type. CHAPTER V THE SAFE PERIOD METHOD I. Two comments may be made on the statement “I’ve tried the safe period and it is not reliable, so I must use contracep­ tion”: First, most of the “failures” of the safe period method seem to be attributable to an improper understanding of it and care­ lessness in its application. It is readily admitted that the safe period method is not an infallible guide to infertility. But it is equally true that a sound knowledge and a careful application of data on menstrual cycles and basal body temperatures can usually determine the fertile and infertile periods in a woman’s life. Second, even if the safe period method could not be applied successfully by a certain person, it would be both bad logic and bad ethics to contend that one would therefore be justified in engaging in contraception. As has been explained in the text, contraception is immoral and is never permissible. There are sometimes justifiable reasons for not having children, but one may never engage in an immoral act to attain this or any other end. Periodic or habitual abstinence from marital rela­ tions is the only permissible means of avoiding conception. 2. “I cannot see any difference between contraception and the safe period method; both represent steps to avert preg­ nancy.” Once again, we are concerned with a statement that lacks all logic. Imagine the reaction to a comparable statement such as this: “I cannot see any difference between ‘stealing money’ and ‘working for money,’ because both represent steps to avert poverty!” The morality of an act is based on the nature of the act itself, not on the effects of the act. It is true that we may look to the effects of an act to determine its gravity or slight­ ness—but we must first examine the nature of the act to estab­ lish its basic moral goodness or moral badness. As explained in 18 • 4 ·* Z·' * •7/ÿWF b - .,4 . ; J r· << Period Method 19 the text, contraception is an unnatural act, while the proper use of the Safe Period Method involves an exercise of marital rights in a perfectly natural manner. 3. It docs not appear likely that widespread knowledge of the safe period method would result in an increase in immor­ ality among unmarried persons. Unmarried persons who act immorally are hardly going to subject themselves to the trouble involved in working out the safe period—especially since there is no absolute guarantee of sterility even after it is worked out. Such persons will simply act in an immoral manner with or without the use of contraceptives. 4. It does seem reasonable to assume that widespread knowl­ edge of the safe period method would make many married couples more sensual minded and both encourage and provide an escape from the normal duty of parenthood. It is a fact that the effects of original sin are still in our nature; there are inclinations towards selfishness, laziness, and sensuality. Such being the case, it would seem likely that many married persons who would not stoop to immorality in their marital relation­ ships would frequently use the Safe Period Method to avoid the hardships and sacrifices involved in bearing and rearing children. Many couples who would not stain their marital lives with the unnatural vice of contraception would be in­ clined to use the Safe Period Method to partake of the privi­ leges of marriage without ever shouldering its obligations. 5. The advocates of any theory or movement are usually over-enthusiastic about their cause. As the popular saying goes, “the wish is father to the thought.” It does seem that most “failures” of the safe period method are attributable to insufficient data, lack of sound knowledge of the principles involved, and carelessness in application; but it is also true that some informed and careful couples have little or no suc­ cess with the safe period method. The Safe Period Method is a valuable help to many couples, but the advocate of the method who regards it as infallible is overly enthusiastic. Similarly, the proponents of contraception are usually preju­ diced against the safe period method—they seem to see in it a rival to their own movement. A i’œ' · * - ♦** CHAPTER VI i THE CHRISTIAN PHILOSOPHY OF SUFFERING 1. It is true that each case is an individual one. For this reason it will be most helpful to know as much as possible about the personality and background of the patient. In gen­ eral, however, the nurse should endeavor to develop in the patient a Christian attitude towards suffering. She should point out that suffering is of the essence of human life—that it is inescapable in some measure for all—that it is wise and brave to accept it and to utilize it—that it is foolish and cowardly to revolt against it. She should remind the patient of the many blessings which God has bestowed upon him throughout life. She should point out the fact that countless others—with resignation and dignity—have suffered more in­ tensely and for much longer periods of time. Above all, the nurse should teach the patient that a proper resignation and offering up of his sufferings can serve to atone for the moral offenses of his past life—certainly this achievement will make a life of suffering worth living. Finally, the patient must also be made to appreciate the fact that he now has a social responsibility, that he has a splendid opportunity to help others who are afflicted with suffering, for—if he bears his suffering with resignation and fortitude, with dignity and spiri­ tual profit, other sufferers will be inspired to follow his noble example. Surely, this achievement, too, will make life worth 2. The Catholic philosophy of suffering is treated at length in the sixth chapter of “Medical Ethics,” in the Foreword to the text, and more briefly, in the above response to the first problem. In contrast, the materialist’s outlook on suffering is com­ pletely pessimistic. For him there is no God, and the universe is simply a mass of powerful, blind, inexorable, and often cruel, forces. When man can control these forces he regards him21 c .. -* · « f |< 22 I «MJ ■ Reference Manual for Medical Ethics self as happy and fortunate. When he cannot control them and finds himself subjected to disease, suffering, and death, he lapses into some pitiable mental attitude. Frantic despair often grips the materialist when suffering becomes intense or death inevitable; others attack, with a blind and bitter hatred the forces which are beyond their control; still others—true to their false philosophy to die end—accept suffering and death in a cold spirit of materialistic resignation. Whatever be his precise personal reaction, die materialist can see neither hope nor spiritual value in suffering and in death. For him, man must, along with the plants and the brute animals of this world—pass from life into utter nothingness. 3. The attitude of the Christian Scientist contrasts sharply with that of the materialist. The Christian Scientist believes in “healing by faith alone.” This absolute confidence in God to overcome sickness, disease, and injuries traceable to accidents, by the prayer of faith is the outstanding feature of Christian Science. This faith of the Christian Scientist necessarily in­ volves a complete rejection of any aid which could be offered by medical science. (In fact, the children of Christian Science parents have often been injured on city streets and been brought to city hospitals—the parents of such children have frequently rushed to the hospital and forbade the hospital to minister to their children. In each instance the hospital has given the needed medical care; and, in the court cases that have followed, the action of the hospital has been upheld.) The materialistic philosophy of pain and suffering represents one extreme—no belief in God and a belief in human intelli­ gence as the only force which can, to some extent, assuage the pain due to sickness, disease and accident. The Christian Scientist’s philosophy of pain and suffering represents the opposite extreme—a belief in God and a convic­ tion that faith in Him is the only remedy for life’s ills. The Catholic philosophy of pain and suffering possesses the moderation which each of the other extremes lack—a belief in God and in His complete power over all nature, and, on the other hand, a proper respect for man's science, its potentialities and the benefits that can be derived from it. f· The Christian Philosophy of Suffering · ■ « 23 4. Among several factors that account for confessed mercy­ killers being acquitted, two factors, in particular, stand out. First, it is regrettable but true that there are a great many people in our nation who firmly believe in euthanasia. It is reasonable to expect that some of these persons will be found on many juries trying cases of this type. Second, there is probably no type of case in which a clever lawyer can more easily play upon the sympathies and emotions of a jury than in a case of mercy-killing. After an hour of such oratory many juries are in tears at the thought of the years of intense suffering the patient had endured and are convinced that the one who took the life has done a brave and charitable deed. 5. A properly developed presentation of the points em­ phasized in the answer to the first problem in this chapter will provide the best answer to the mental attitude of the patient referred to in this fifth problem. 6. Two statements on this matter are quite pertinent; first, it is wrong to deprive a dying person of consciousness who has not yet had the opportunity of making his peace with God and receiving the Last Sacraments; second, when reasonably pos­ sible, it is more fitting that a person be conscious when dying and willingly offer up his final sufferings to the Saviour who died in agony to redeem him. Having made the above restrictions, it may be conceded that, if the patient has been spiritually prepared for death and the intensity of pain very great, a drug may be given which will render the patient unconscious. We insist, of course, that the drug must not in any way directly hasten the death of the patient but merely render him insensible to his sufferings. 7. The happiness of any person who must face a life of suffering depends completely upon his philosophy of life. Without a proper philosophy of suffering, a sick, diseased or crippled person is without hope; his pain has neither value nor purpose. There is certainly nothing in this picture that would make happiness possible for such a person. In contrast, there is both purpose and value in the suffering of a person imbued with a true philosophy of life. The example of Christ on the Cross and the realization that such suffering έ . / 24 F I ’.x i ilOf % 2 . Reference Manual for Medical Ethics can atone for die moral offenses of one’s life are factors that can certainly enable a person to enjoy happiness though living in pain. 8. The influence of the mind on the body can never be denied. Everyone recognizes that “the will to live” is an invalu­ able asset in the recovery of any seriously ill person. It is equally true that a proper attitude toward the suffering that is part of any sickness will foster recovery. The mind that is constantly worrying, complaining, rebelling and despairing over suffering will necessarily have a bad influence on the physical condition of die patient. On the contrary, the healthy mental attitude found in the person with a sound outlook on suffering cannot help but contribute to his physical well­ being and possible recovery. 9. The answer to this personal question rests, of course, with each nurse. It is hoped, however, that frequent contact with suffering and death will have taught the nurse a great deal. She must have encountered those who rebelled and despaired in these ordeals—and felt sorry for them. She must have encoun- i tered those who bore up bravely under intense suffering and . imminent death—and felt inspired by their example. If good ' and bad example teach valuable lessons—and they certainly j should—no one should know better than a nurse, when that · inevitable time comes, the best way to face suffering and death. 10. Since a nurse may not administer drugs on her own | authority, it is presumed that the suggested administration of · morphine in this case has been authorized by a doctor. With ; that initial reflection it must be stated that several additional . comments are quite appropriate on this case: First, those who are familiar with institutions are well aware I of the fact that they are sometimes “understaffed.” Experi- I ence shows that if the existing staff adopts short-cut methods to handle the work of the institution those in authority will I delay for a long time before they supply an adequate staff; in I contrast, if some essential work is not completed because the staff insists upon doing a conscientious job on all the matters I it can handle, the authorities are soon forced to supply suffi- I cient personnel. I On the individual level, Civil law holds a doctor responsible | [ The Christian Philosophy of Suffering 25 for any lack of care owed to his patient—and it will not take as an excuse the fact that he had so many patients that he lacked time to care properly for each one. Civil law insists that lie may not take on more patients than he can adequately handle. The same principle should apply in this case: the sanitarium is at fault if it admits more patients than it is cap­ able of handling and the under-sized staff will not only do many patients serious injustice but will also delay the remedying of the situation by adopting improper, “short-cut” methods to handle the excessive work of the institution. Second, even if a nurse cannot be constantly with the patient referred to in this problem, it would seem possible to prevent his suicide by a prudent restriction of his liberty to use articles or even, if need be, to move about. Finally, it must be emphasized that one may never admin­ ister a drug that will hasten the death of a person. Our obliga­ tion is to take at least ordinary measures to conserve life, not to hasten or destroy it. The matter presented in the text on euthanasia applies to any such administration of drugs. 11. In this problem, we assume that death is certain and inevitable within an hour or so, as is stated in the case, and also that the patient has made his peace with God and received the Last Sacraments. Under such conditions, there is no moral obligation to give a stimulating drug that will merely prolong life in intense pain for so brief a period. Such a step should be construed, under the above conditions as an extraordinary means of preserving life; and, as is explained in the following problem, no one is obliged to sub­ mit to such grave hardship in order to fulfill a duty, that is, to take such a step to prolong life for such a brief period. Appropriate words of warning, however, are in order: one must not be too ready to believe that death is certain and inevitable; and, if a dying person has not yet received the Last Sacraments, every effort should be made to keep him alive until he has had the opportunity to do so. 12. Involved in this problem is the principle that we are obliged to adopt all ordinary means to preserve health and life, while we are not obliged to take extraordinary means to achieve these ends. Whether or not a given step should be B· I· I · 26 » ’’■* I '1’ C' ftr Reference Manual for Medical Ethics classified as ordinary or extraordinary is dependent upon many factors: the level of science of the day, the economic status o{ a person, and the degree of hardship it will impose upon a per­ son, are some of the many points that must be considered. In the case under consideration, it appears evident that the mere placing of a child in a heating bassinet is an ordinary means of preserving infant life. The nurse is, therefore, per­ fectly right in standing her ground. The doctor is wrong in requesting the nurse to deprive the infant of an ordinary means of conserving life. 13. In this case, as in the previous one, the solution hinge upon the moral principle that we must adopt ordinary means of preserving life but need not take extraordinary measures. In this problem, the step suggested would clearly constitute an extraordinary method of maintaining life and is, therefore, not morally binding. Several thoughts will clarify this fact: First, in any such case, success in the operation would be 2 phenomenal achievement; the skill and technique involved would far surpass that possessed by any surgeon the patient could likely contact—in fact, some measure of success in this operation has been limited to Doctor Ladd of Harvard Uni­ versity and to a few younger surgeons who have followed hit leadership. Secondly, even if a capable surgeon could be had, it is extremely difficult to get another esophagus to serve as a transplant. Thirdly, any infant that would have congenital atresia might also have other congenital defects which would make it extremely unlikely that life could be preserved. Finally, if the life of such an infant can be preserved, the ordinary measure would be to perform a gastrostomy—the sur­ gical creation of a gastric fistula through the abdominal wall. This latter operation is within the skill of a good surgeon; it is quite commonly performed in cases of carcinoma of the esophagus; it will almost always be successful in providing a means of introducing food directly into the stomach. Gas­ trostomy would therefore appear to be an ordinary and proper method of attempting to save the life of the infant referred to in the text. 14. This question requires no comment in this Manual. ■'·' ·■· ■ 'rhS*-τ*·ί · i1* i I.-5t . iy. CHAPTER VII DIRECT ABORTION 1. The question states that the woman has been guilty of direct abortion (criminal or therapeutic), that is, with due knowledge and freedom she has directly intended and effec­ tively produced the expulsion of the living, inviable fetus. This woman has committed a grave sin of murder and incurred excommunication reserved to the bishop of the diocese. The woman must confess her sin—with proper sorrow and a will­ ingness to do penance—to a duly authorized priest within the Sacrament of Penance. After determining that the excommuni­ tion has been incurred, the priest will take the appropriate steps to have it absolved. 2. The question in the text remarks that “a nurse casually discusses methods of committing abortion with two women friends.” Very quickly, one must retort that such information should not provide the basis of casual conversations. A nurse must understand that much of the knowledge she possesses and many of the experiences she encounters are not fit topics for conversation. Human nature being what it is, idle conversa­ tions along such lines will frequently provide temptations and occasions of sins for her listeners. In the case at hand—since the nurse had no idea that either of the women would use the information to bring about abor­ tion—she is not morally responsible, as an accessory or partici­ pant, in the crime of abortion. The evil of abortion would have to be willed, directly or indirectly, before it would be morally imputable to her. Since the nurse could not have foreseen, at least as a probability, that the women might use the information to procure abortion, she cannot be regarded as guilty of this crime. She is, however, morally at fault for the carelessness of her speech. She should appreciate the fact that her thoughtless conversation has cost a life; and she should certainly learn a lesson from this experience, namely, that she should never needlessly give out information that may be 27 it . '?ss ·. >.-■ 1 *7 AMS? - < ? » 28 Reference Manual for Medical Ethics abused by others. Naturally, there will be times when she must divulge information that others may possibly abuse. But she must be particularly careful not to discuss such matten merely for the sake of conversation, gossip, or simply to satiate the morbid curiosity of others. 3. As explained in the text under the treatment of hydram­ nion, it is not morally permissible to procure abortion simply because the membranes have ruptured before viability. The critical point in the discussion is not whether the membranes have ruptured but whether the fetus is still alive. If the evidence is sufficiently strong that it constitutes moral certitude that the fetus has died after the rupture of the membranes, it can be removed. But there are many cases on record in which the fetus survives the rupture of the membranes—hence die mere rupture of the membranes is not in itself sufficient justi­ fication for removing the fetus from the uterus. 4. The first sensible reaction on the part of this woman would have been to seek a prompt treatment of the venereal disease with which she was afflicted. If she had followed this course of action, her child might well have been born in a healthy and normal condition. However, taking the case as it is presented and considering it objectively, the woman has committed a grave sin and incurs excommunication. Her attitude towards the unborn child, who may possibly be born in a deformed or diseased condition, is identical with that of any advocate of mercy-killing. In all of these cases, the person is deliberately destroying a life which belongs to the Creator. The unjustifiability of such an attitude and the grave immoral­ ity which it involves are portrayed in detail in the chapter on The Christian Philosophy of Suffering. 5. The attitude of this woman is wholly unreasonable and her action unquestionably immoral. It is difficult, indeed, to believe that she could possibly be in good faith. The fact that her two previous children were bom dead is no proof whatever that this child will be still-bom. Furthermore, even if it were certain that the child would ultimately be bom dead, it is absolutely no justification whatever for deliberately destroying the life of a living child. • *1 Direct Abortion I 6. As stated in the case, “the woman does not desire a child, I engages in strenuous athletics with the realization that abor­ tion may result but would not think of directly taking the life of die unborn child.” In passing, one might say that—though it is hard to grasp completely this woman’s mental attitude—she does come very close to directly willing the destruction of the life of the un­ born child. (And if it were clear that she did directly will and effectively produce abortion, she would not only commit grave sin but also incur excommunication.) In the absence of sufficient evidence that she has directly willed a destruction of fetal life, her act should be evaluated in the light of the principles learned under the heading of the Indirectly Voluntary Act or the Twofold Effect Principle. The woman could, should, and actually does foresee that the abortion may result from the act (the strenuous athletics) in which she deliberately engages. The grave evil of abortion is therefore indirectly willed by her and is morally imputable to her. Furthermore, if the student would like to evaluate the action under the Twofold Effect Principle, the complete breakdown of the third and fourth conditions will indicate the complete unjustifiability and immorality of her action. Without desiring to minimize in any way the carefulness which is demanded of the expectant mother, it should, how­ ever, be stated that ordinarly abortion is not easily produced either by violent physical exercise or by the taking of drugs. This thought is pertinent not only to the answer of this ques­ tion in the current chapter but also to the third question in the chapter on Therapeutic Abortion and the second, third, and sixth questions in the chapter on Indirect Abortion. A statement from a “Report on Abortion” presented to the Brit­ ish Ministry of Health in 1937 is worthy of quotation: "Despite the widespread use of these drugs and prepara­ tions, it is only in a small proportion of cases that they appear to be successful. There is evidence to show that abortion may be produced by drugs which ordmardy have no abortifacient action, if they are taken m quantities to be severely toxic, causing a dangerous illness. There is on t. ? ; ίί< Ι>Γ «T. » ■ ·' '■* T. Z· k ·*Γ »■ ·’’ V*.J *··Δν*ϊ.>' t* •4r 4 •.'•y -S- À -λ* 30 Reference Manual for Medical Ethics record a large number of authenticated cases of this type, many of which have terminated fatally. It appeared to be generally agreed also by medical witnesses who submitted evidence on this point that there is a limited class of women whose condition of health disposes them to abor­ tion, and who may abort as a result of taking certain drugs in moderate quantities. Little precise evidence was sub­ mitted on this matter, and it may be that in some of these cases abortion would occur spontaneously, even if no at­ tempt was made to induce it. There is no evidence that a drug or other preparation taken orally in non-toxic quan­ tities can cause the abortion of a woman in normal health, and it is undoubtedly a fact that as a general rule they do not fulfil the expectations in which they have been taken. It is possible that a virtue which is largely fictitious has been ascribed to diem on the evidence of women who have taken them in the mistaken belief that they were pregnant.” <1 f - ! •* f» Λ ■ 'λ Λ· · I I The thoughts expressed in the above passage reflect rather accurately the attitude of most specialists in the field of obstet­ rics. 7. Some of the more common causes of the high number of criminal abortions are as follows: the hidden nature of the crime, whether performed by a “doctor” or by the person her­ self; police graft which often covers up the offences of known professional abortionists; and, a refusal on the part of families involved to testify in public court on a matter that will bring only further disgrace to them. Among the more needed remedies for this situation are these: the practice of religion and the development of moral character in our citizens; a careful screening of those who are charged with the enforcement of these laws in our communi­ ties; and quick and severe penalties for anyone apprehended in the commission of this crime. 8. The nurse should certainly take some effective measure to lead this patient into the adoption of a moral life. Each case, however, will differ. The nurse must approach the prob­ lem with tact and diplomacy. Severe reproach may serve only to render the patient obstinate. Prayer will prove invaluable. ’JRj) ' ίβ ii·'1 J&j ... ··&( • ÈKU-r · · Direct Abortion 31 The spirituality of the nurse’ s ideals and character as reflected in her actions will mean much. The friendliness of the I nurse for the patient will open the door for instruction and guidance. Frequently the nurse’s first and best approach will be to create in the patient a desire to return to the general practice of religion. 9. The actions of this woman are the product of either crass ignorance or bad faith. The judgment as to whether or not the fetus is living belongs to a medical specialist, not to this woman. Since there is a reasonable probability that the fetus may still be alive, the woman’s act is gravely immoral: she is deliberately doing an act that she should realize is probably destroying an innocent life. 10. Many factors account for the psychological fact that many persons will destroy the life of an unborn child who would shudder at the thought of murdering an innocent mem­ ber of their own family. Some of the factors are these: a failure to appreciate the fact that the living fetus is truly a person and endowed with a spiritual soul; the fact that they have never known and loved this unborn child; the fact that even our civil law and some Christian Churches condone therapeutic abortion; and, finally, the fact that persons who commit abor­ tion are frequently under the stress of violent emotions involv­ ing fear of loss of life or loss of reputation. & i «> • · * < / ; CHAPTER VIII THERAPEUTIC ABORTION * Λ; : r-i λ 1. Therapeutic abortion is always immoral and, as explained in the text, can never be justified or permitted. On the other hand, premature delivery is allowable whenever it is in die best interests of mother and child. The precise conditions under which premature induction of labor may be carried out are explained in the chapter on Indirect Abortion. It is suffi­ cient to say here that a small pelvis and numerous other physi­ cal conditions frequently make cesarean section or premature delivery both morally permissible and medically necessary. 2. Pernicious anemia rarely, if ever, complicates pregnancy. Hence, it does not even bring about a demand for therapeutic abortion. There is, however, another primary anemia—macro­ cytic anemia—wffiich sometimes complicates pregnancy. Thera­ peutic abortion is, of course, immoral and can never be adopted as the solution of such problems. As is implied in the text, liver and blood transfusions and vitamins are of inesti­ mable value in handling difficult cases of this type. 3. Any such form of activity or employment would have to be evaluated in terms of the twofold effect principle. In most cases of this type, the first three conditions are readily verified. The solution to the case will hinge upon the verification of the fourth condition. The following pertinent questions must be answered. How great is the danger of abortion? Does the woman actually need to work? Is so, is employment of this type the only form of work available? Is she willing to leave this position as soon as work of another type becomes avail­ able? Has a good doctor actually told her that this work may result in abortion? Did she ever engage in this type of work before while she was pregnant? If so, what effect did it have on her? (Consult the sixth answer in the previous chapter.) The answers to the above questions will determine the solu­ tion of the particular case. In general, if the woman need not 32 V I Therapeutic Abortion 33 work or can procure other employment she may not take a 1 position which carries with it a probability of abortion. On the other hand, if the woman must work to gain a livelihood— 1 no other employment being available and is willing to take ' another type of job as soon as it becomes available—she may take a position which involves some risk of abortion. It must be emphasized, however, that she must adopt all possible pre­ cautions and leave this type of work as soon as possible. 4. When the uterus of a pregnant woman is subjected to prolonged irradiation (roentgen rays or radium) the almost inevitable effect is that the child will be born a microcéphalie idiot. No doctor would knowingly subject a pregnant woman to such irradiation—but there have been instances wherein an incorrect diagnosis (mistaking pregnancy for uterine fibroids) resulted in such irradiation being given to a patient. 5. The expectant mother must realize that a life is in her care. Common sense will tell her that she must restrict both the type and intensity of her recreational and social life. As her condition becomes more advanced, her carefulness must proportionately increase. If her health is poor or if she has had difficulty during previous pregnancies, she must be willing to adopt special precautions. In all cases, the expert guidance of a capable doctor should be scrupulously followed. In these matters—above almost all others—“an ounce of prevention is worth a pound of cure.’’ To disregard this counsel may endan­ ger both her own life and that of her child. 6. \7arious requirements are set up by civil law for the pro­ curing of therapeutic abortion. In some places, the law de­ mands that the doctor consult with one or more reputable members of his profession and receive their confirmation that the step is necessary to save the mother’s life. Where such consultation is not demanded, medical text books still urge doctors to take this step as a means of protecting themselves against a possible later charge of serious assault or criminal abortion. For therapeutic abortion, Civil law also requires the consent of the patient or her husband, or both, or of the woman’s guardian. Frequently, a clear-cut line does not exist between therapeuI t 4 ·■ · ■ 3! * π ♦ ·· 1 Ί i h Reference Manual for Medical Ethics tic and criminal abortion. Since the sole distinction between therapeutic and criminal abortion is the supposed physical need of the mother for it, one can readily understand that many border-line cases will arise. Furthermore, in those cases in which a child is not desired, unscrupulous doctors do not hesitate to magnify the import of some existing condition and then perform what is really a criminal abortion under the guise of its being a therapeutic abortion. As is explained in the chapter on Direct Abortion, there is no essential moral difference between therapeutic and criminal abortion. Both are forms of direct abortion; they do not differ in the nature of the act performed—but only in the special motive that prompts the performance of the act. Since direct abortion is gravely immoral in its nature (murder) —and since "the end (special motive) never justifies the means” (an act immoral in its nature) —neither therapeutic nor criminal abor­ tion can ever be justified. 7. It is not true that "Catholic Ethics”—if we may use the term—places a preference on the life of the child over the life of the mother. This misconception is very prevalent and prob­ ably arises from our refusal to allow a direct and intended destruction of fetal life in cases in which it is contended that a cessation of pregnancy is required to safeguard the life of the mother. Actually, the life of mother and that of the unborn child are held in equal regard by our Ethics: one may never do any act that is directly aimed at the destruction of either life; one may do a morally indifferent act that may in­ directly result in the loss of either life—provided the four con­ ditions of the twofold effect principle are verified. One must, of course, make every effort to save the lives of both mother and fetus. 8. A fourfold answer to this objection is given in the chap­ on Direct Abortion. To repeat the answer here in a condensed form is unnecessary and would serve only to weaken or obscure it. Consult the text in the above-mentioned chapter. 9. In the response to the sixth problem in this chapter, atten­ tion was called to the fact that the State’s action of authorizing doctors to determine when therapeutic abortions are necessary ·£·1 ΛΛ * 4* * Γ II ■»· Therapeutic Abortion 35 does occasionally produce an excuse to perform a criminal abortion. When the doctor is unscrupulous and the woman does not desire a child, one may expect the worst-if there is any conceivable way, real or imaginative, in which the preg­ nancy can be construed as constituting a danger to the physi­ cal well-being of the woman, the abortion will probably be per­ forated. It will be recorded as “therapeutic”; actually it is a criminal abortion. 10. As previously mentioned, a nurse must be most circum­ spect in her speech. Much of the knowledge that she possesses can be put to immoral uses and the careless divulging of this information in casual conversations may frequently constitute an occasion of sin for her listeners. In the case suggested for consideration, it is mentioned that the nurse has reason to sus­ pect that the woman questioning her about ways of inducing abortion desires the information so that she may utilize it in her own personal life. Hence, there is a clear-cut obligation on the part of the nurse to withhold such information. In some in­ stances, the nurse may be best able to deter the woman from her contemplated sin by letting her know that her criminal intent is suspected. In other instances, the response to her may be all the more effective if the woman has no idea that anyone suspects her intentions. The nurse should judge which of these courses of action would appear most effective in the par­ ticular case and then give the woman a good graphic portrayal of the dangers of interfering with nature in this matter: the lost maternal lives, the possible resulting sterility (often so deeply regretted at a later date), the multilations received that frequently constitute a permanent barrier to health, the shame and disgrace if apprehended by Civil law, the excommunica­ tion by her Church, and the unhappiness of living with a con­ science that daily calls us a murderer. These points should be developed by the nurse with fervor and conviction—conscious that a life may depend upon her efforts. After such a talk the woman will probably go away thinking what a fool she might have been. 11 It is a fact that the medical profession devotes its full time and tireless energy to the conservation of human life. It î I ’*,··>.· y TJ· ·'>*■ •’»1* M-* *4 r 36 - · r? , »4 r·, · n 9 k*. • - ♦ ' It J Reference Manual for Medical Ethics pursues this objective so relentlessly and with so much sacrifice involved that a distorted sense of values is a frequent result. For many in the profession, die preservation of a human life is the greatest good imaginable; for others, it is the only really great good. In a true scale of values, life is surely a great good. It is probably the greatest good in the physical and temporal order. But there is a higher order than the physical and temporal, namely, the spiritual. No value in the temporal order begins to compare with those in the higher order—because the latter are directly concerned with the achievement of man’s final destiny. To preserve a physical and temporal good at the sacrifice of a higher spiritual good is, therefore, the highest folly. Hence, one could not possibly agree with the statement that “a doctor has the professional obligation to save human life by all possible means.” We must retort, ‘‘not if the ‘pos­ sible means’ are immoral means.” Doctors, like all other men, are bound to the observance of Natural and Divine Law. 12. The axiom “Necessity knows no law” is a trite little say­ ing that may have some general validity in certain fields. Its general application to the sphere of morality is utterly impos­ sible. To adopt such an attitude would be equivalent to setting up expediency as the basis of morality. If the expediency of the moment were to determine the morality of an act, there could not possibly be any uniform moral code. (For a further devel­ opment of these thoughts, consult the answers to the first and second problems on the chapter devoted to Ectopic Gestation.) Therapeutic abortion, as explained in the text, is always an im­ moral act—and no expediency will ever justify it, because "the end will never justify the means.” 13. The Church’s penalty of excommunication extends to all who directly intend and effectively produce—whether by phys­ ical or moral cooperation—the expulsion of a living, inviable fetus. As is emphasized repeatedly in the text, there is no essen­ tial moral difference between therapeutic and criminal abor­ tion. The penalty of excommunication extends, therefore, to those who commit either form of direct abortion. ·;· 1 viaVXi·· W; 5 TŒ ··>· » CHAPTER IX INDIRECT ABORTION !<■ ?· s 1. This question was originally proposed in the ]uly, 1935 issue oE The American Ecclesiastical Review. In that instance, the author sanctioned the use of the drug (ergot} under the application of the twofold effect principle. Since that time, however, notable advances have been made in the treatment of threatened abortion accompanied by hemorrhage. The best presentation of these advances is to be found in the American Journal of Obstetrics and Gynecology (issue of November, 1948, pp. 821-834) . In this article, the use of the drug diethyl­ stilbestrol is shown to produce extremely satisfactory results in handling cases of this type. In two hundred and nineteen cases of threatened abortion, accompanied by hemorrhage be­ tween the sixth and twenty-first week of pregnancy, the fol­ lowing results were achieved through the use of diethylstilbes­ trol: there were no maternal deaths; seventy-eight percent of the fetuses were carried to viability (28 weeks') ; and seventytwo percent of the deliveries resulted in babies who were liv­ ing and well. In the light of these advances, the following reflections are I pertinent: first, it would be both bad morals and bad obstetrics to administer ergot today in cases of threatened abortion acI companied by hemorrhage; second, the use of diethylstilbestrol, I accompanied by rest in bed and an ice pack on the abdomen, is usually the proper treatment; third, the hemorrhage will rarely be fatal; in fact, after a certain amount of bleeding, the blood pressure will usually drop and the hemorrhage cease; finally, the prognosis for both mother and child is excellent under the use of the above drug. 2. This problem presents a typical double effect case. The first three conditions of the twofold effect principle are rather easily verified. The solution of the case, however, hinges upon the verification of the fourth condition: is the need for engag37 ? t. ' « ·■ .·; .··■ I 38 ■· ■ -•..i.-·.: I ' 1 ?’ >·-» If » f i » .· * *’ * h <« Î3 Μ i 1 $·. Reference Manual for Medical Ethics ing in this type of livelihood sufficiently great to justify the risk of an abortion resulting? If this position is the only means available of gaining a livelihood, it would appear morally per­ missible for the woman to run the risk involved in her work. If the woman can possibly secure another position or delay taking any work until a later favorable date, she is morally obliged to do so. (Consult the sixth answer in the chapter on Direct Abortion.) 3. It is evident that this young woman has shown more in­ terest in athletics than in the life of her unborn child. She is morally guilty of grave negligence for needlessly engaging in such strenuous activities during pregnancy. She realized that they constituted a serious danger to her child; and, while she did hope that no harm would befall her child and did take some precautions to prevent such an effect, she still acted rashly and failed to consult a doctor on such questionable activities. It appears equally clear, however, that the woman did not will to commit the crime of abortion and, therefore, does not incur the penalty of excommunication. (Consult the sixth answer in the chapter on Direct Abortion.) 4. Strong emphasis is to be placed on the moral principle that premature delivery is justified only when the physical health and welfare of mother and child necessitate the step. In normal pregnancy, each added week of gestation makes the child stronger and better able to face the hazards of birth and infancy. Those persons who have recourse to the premature delivery of a child for their own selfish reasons merit only our most severe reproach. The Hollywood stars who so frequently have premature deliveries “to preserve their figures”; the pa­ tients who request a hastened delivery for the sake of conven­ ience; and the occasional doctor who somehow manages to clear up all of his pending maternity cases before a scheduled vacation trip—all of these persons are trifling with innocent life and de­ serve only stem condemnation. 5. The solution to this case should be based upon the answers given to the third and fourth problems of the second chapter. There is no need to repeat those points under this problem. 6. The taking of strong purgatives for reasons of health by a ο Indirect Abortion 39 woman during the course of pregnancy must be evaluated in the light of the twofold effect principle. The first three conditions will most likely be verified in the ordinary case. In general, how­ ever, it would appear that the fourth condition will not be verified: usually, there will be no sufficient reason for using drugs that involve a risk of producing abortion. (Consult the answer to the sixth question in the chapter on Direct A bortion.) Vf Tuf if· CHAPTER X ECTOPIC GESTATION ’· 1. The thoughts expressed in this problem are an expression of Relativism in morals. In every error, it is said, there is a grain of truth. So it is with Relativism. Changing cultures and different forms of education frequently do affect a person’s knowledge and appreciation of moral law. But moral law re­ mains unchanged (universal, immutable, and absolute) throughout all ages—regardless of man’s knowledge or ignor­ ance of it. 2. The absolute unchangeability of moral law rests upon the immutability of God as the Divine Lawmaker—upon the indis­ putable fact that human nature, though varying greatly in acci­ dental characteristics in different nations and ages, always re­ mains essentially the same—and, lastly, upon the fact that the final destiny of all men is one and the same for all. A detailed refutation of the error of Relativism in morals (problem No. I above) and a detailed presentation of the true basis of morality (problem No. 2) will be found in most stand­ ard works on ethics by Catholic authors. 3. There has been no change in the moral principles gov­ erning cases of ectopic pregnancy during the past twenty or more years. The moralists of all ages would unhesitatingly assert that it is morally wrong to excise a healthy Fallopian tube; all would also readily agree that it is morally permissible to excise a diseased Fallopian tube. The only change that has occurred has been a change in the opinion of authorities in Moral Theology on which moral principle applies to the case of the excision of the pregnant Fallopian tube. In former years, they regarded the Fallopian tube—in early pregnancy—as healthy; the embryo and tube were looked upon as normal in condition, and the pregnancy was simply regarded as develop­ ing in an unusual place. In contrast, contemporary authorities in Moral Theology, influenced by convincing evidence pro40 Ectopic Gestation 41 duced by modern medical science, maintain that—from almost the very beginning of tubal pregnancy—the Fallopian tube is in a pathological condition. The changed attitude of moralists towards tubal pregnancy does not, therefore, represent any alteration in moral prindples-it is simply an application of traditional ethical prin­ ciples to the condition existing in tubal pregnancy as it is under­ ΤΙΊ by modern medical science. stood 4. In discussing an ectopic pregnancy case within her experi­ ence, it is suggested that the nurse emphasize the following points: How early in pregnancy was the condition discovered? Was it discovered in the course of an abdominal operation? Was the case accurately diagnosed before the condition became serious? If the ectopic gestation was in the Fallopian tube, was the operation delayed until the rupture of the tube was im­ minent? How quickly was the embryo baptized? CHAPTER XI THE SACRAMENT OF BAPTISM li MV ·. ·. : - τη μι. Im 1. The value of baptism is thoroughly understood by any Christian nurse, and every reasonable effort should certainly I be made to secure this great good. As has been explained in the I text, baptism can be bestowed only after rupturing the mem· I branes. The doctor’s request that the membranes not be rup- I tured is an unreasonable one and should not be complied with I by the nurse. Time is very important in cases of this type, so I the nurse should not delay the baptism to engage in a debate I with the doctor. Instead, she should promptly break open the I membranes, perform the baptism as directed in the text, and I then explain her action to the doctor. I 2. The nurse should tactfully inform the minister that, as a Catholic, she may not serve as a god-mother at a non-Catholic baptism. The minister will be able to procure a sponsor from among the non-Catholic nurses, doctors, attendants or visitors in the hospital. The Catholic nurse may express her willingness to serve as a messenger for him in procuring such a person, but she should not take it upon herself to select and to procure the sponsor. 3. There is no good to be achieved by “baptizing” a fetus, even conditionally, when it is evident that the fetus has been dead for several weeks. In fact, it would be wrong for the nurse to attempt such a “baptism.” To do so would be an abuse of the sacrament. 4. The obligations of a godmother arise from valid emer­ gency baptism, as well as from valid solemn baptism. 5. As indicated in the text, the baptismal waters must flow immediately upon the fetus. The nurse cannot, therefore, be content with merely “baptizing” the blood clots. Furthermore, there should be no great difficulty in discovering whether or not the fetus is present in a discharged clot of blood. After all, at two months the embryo is 2.5 to 3 cm. in length; the 42 The Sacrament of Baptism 43 head is large in proportion to the rest of the body and the nose, eyes and mouth are already distinguishable. A little less haste and a little more care in observation should solve the difficulty involved. 6. If there is any probability of validly administering intra­ uterine baptism in this case, without subjecting the mother to serious risk (either from the uterine baptism or from the delay involved in attempting it) —this step should be taken before the craniotomy. Whether the intra-uterine baptism is at­ tempted or not, the fetus should be conditionally baptized im­ mediately upon its delivery. 7. The mother’s “desire” of baptism for her unborn infant does not constitute baptism of desire. This type of baptism is present only when a person himself—prevented by circum­ stances from receiving baptism of water—unites an act of per­ fect love or perfect sorrow with an explicit or implicit desire for the sacrament of baptism. 8. The action of this nurse is unjustifiable. By baptism one becomes a member of a society, the Church of Christ, and, therefore, subject to its authority and laws. It is not permissi­ ble to make a person a member of a society without at least his or her reasonably presumed consent. Neither is it permissible to make a person a member of a society when every normal expectation is that he or she will never respect the authority and laws of that society or fulfill the duties incumbent upon its members. 9. Since a hospital nursery is supervised, the infant has in all likelihood been dead only a short time. Conditional bap­ tism should be bestowed upon the baby. 10. In the early days of the Church, there were numerous instances of persons deliberately delaying baptism until adult years were reached. The Church condemned this practice as an abuse, steadily insisted upon early baptism, and finally overcame the practice of postponing the reception of the sacra­ ment. The danger involved in delaying baptism should be clear· many persons suddenly die in infancy and childhoodthese persons would pass from this life into the uncertain future of those who die without baptism. Furthermore, since one i· Fl U * IV 44 Hit J Reference Manual for Medical Ethics must receive baptism before receiving any other sacrament, persons who are unbaptized are unable to utilize any of the sacraments instituted by Christ for the spiritual perfection of man. 11. The child is a Catholic. The desire of the parents and the reasonably presumed desire of their infant is to become a member of the Catholic Church. The Methodist nurse, more­ over, uses the matter and form of baptism recognized as valid by the Church and intends to make the child a member of Christ’s true church. A few additional thoughts along these lines should help to clarify this answer: It is understood, of course, that baptism is the juridical act which was specified by Christ as the means of incorporation into His Church. For this reason, every valid baptism by its very nature makes the person baptized a member of the Cath­ olic Church. There is, however, another meaning which is frequently at­ tached to the phrase "baptized in the Catholic Church.” Thus, when canon No. 1098 says that all who are "baptized in the Catholic Church” are bound by the canonical form of marriage, it is evident that it does not simply mean all persons who have been validly baptized. It means all who are validly baptized with the positive intention of aggregation to the Catholic Church. In the ordinary case, there is no difficulty as to whose "pos­ itive intention” constitutes the basis of incorporation into the Church. Thus, when Catholic parents send their child to a Catholic priest to be baptized, or ask a nurse or doctor to bap­ tize it in danger of death, it is clearly “baptized in the Catholic Church” in the meaning of canon No. 1098. Similarly, an adult pagan who wishes to become a Catholic and requests a Catholic priest to baptize him is "baptized in the Catholic Church.” On the other hand, when Protestant parents send their own child to a Protestant minister for baptism, with the intention of mak­ ing him a member of their sect, the child is certainly not "bap­ tized in the Catholic Church” in the meaning of the abovementioned canon. The same conclusion applies with equal The Sacrament of Baptism 45 clarity to the adult pagan who, wishing to become a member of a Protestant sect, requests baptism from a Protestant minister. Other eases arc not so readily solved. Such is the case of a child of Catholic parents who is baptized in danger of death by a non-Catholic minister, because there is no one else avail­ able who knows the form of baptism. Such is the case of a child of Protestant parents who is baptized by a Catholic nurse with the intention of making him a Catholic. The solution of diffi­ cult cases of these types cannot be reached by the mere recol­ lection of the principle that a person is said to be “baptized in the Catholic Church” when there is present the positive inten­ tion of incorporating the person in the Catholic Church. There is the obvious and definite need of determining whose inten­ tion is to be considered—the parent’s, the minister’s, or the subject’s-and, in the case of a conflict of intentions, whose intention is to prevail. In these difficult cases, the following principles will prove to be of value: I (a) In the case of the baptism of an adult, the person’s own intention is the only one to be considered. If such a person, in receiving baptism, wishes to become a Catholic, he is “bap­ tized in the Catholic Church.” This is true even though the sacrament was validly conferred upon him by a non-Catholic minister (possibly because the person was in danger of death and no priest was available). It remains true even though the intention of the non-Catholic minister was to incorporate die person into his own Protestant sect. It must be stated, how­ ever, that, when there is no positive evidence to the contrary, an adult is ordinarily presumed to desire incorporation into die denomination to which the minister belongs of whom he requested baptism. (&) In the case of a person who is baptized before attaining the use of reason, the intention of his parents or guardians is normally the determining factor. According to law, the child is dependent on his parents or guardians. Hence, since the child does not have the use of reason and is not capable of having an intention of his own, that intentton is so to speak, supplied for him by his parents or guardians. This principle 46 • *7 Hl R. Reference Manual for Medical Ethics would hold true even if a child was actually baptized, possibly in danger of death, by a person of a denomination other than that into which his parents wished him to be incorporated. Thus, a child of Catholic parents, who wish their child to be made a member of the Catholic Church, might be baptized in an emergency or for some other reason by a non-Catholic min­ ister. This child would be “baptized in the Catholic Church,” even though it might be the intention of the minister to make the child a member of his own denomination. Similarly, a child of Protestant parents, who desire their child to be bap­ tized in their own religious group and who, not being in danger of death, is baptized by a Catholic nurse, is not “baptized in the Catholic Church.” This is true even though it may have been the intention of the nurse to make the child a member of the Catholic Church. So long as parental authority remains vested in the parents and the child is not in danger of death, the intention of the parents is the determining factor. (c) We have said above that normally the intention of the parents is the determining factor. In unusual instances, the intention of the minister, and not the parents, prevails. In general, we might say that this is true in all cases in which it is lawful for a minister to baptize a child without the consent of at least one parent. This situation would be verified when­ ever it appears likely that the child will die before coming to the use of reason, even though the parents are unwilling to have it baptized, or whenever there are no persons, whether parents or guardians, who can effectively exercise parental authority over the child. The Catholic rearing of the child must, of course, be safeguarded in all such cases. In all of these unusual instances, the child is said to be “baptized in the Catholic Church” if it was the intention of the minister to in­ corporate him into the Catholic Church. 12. The state of grace on the part of the one administering either solemn or emergency baptism is not required for the validity of the Sacrament. However, a person should endeavor to attain the state of grace before baptizing, because it is a sin —at least a venial sin—to administer, even as an unconsecrated minister, a Sacrament while in the state of mortal sin. The Sacrament of Baptism 47 13. According to Canon Law, the normal infant should be baptized "as soon as possible” after birth. Various directives of the Church suggest that baptism be conferred “within eight days after birth.” In the United States, the infant is usually brought to the Church for baptism on the first or second Sun­ day after mother and baby return home from the hospital. To delay baptism for a month after the birth of the child, with­ out serious reason, would appear to be gravely sinful. 14. It is the desire of the Church that baptism not be de­ layed beyond one month after the birth of the baby. Hence, if circumstances prevent solemn baptism within that time, the Church wishes the child to receive private baptism. (It can later be brought to the Church for the “supplying of the cere­ monies”) . Similarly, if a priest is not available within the month, the Church desires a lay person to administer the bap­ tism, rather than tolerate further delay. 15. Medical science does not seem to offer any estimate, even approximate, on the length of time that life may be present, in an embryo or fetus after abortion and apparent death. In the absence of any evidence on this point, it would therefore appear proper to bestow conditional baptism upon the aborted fetus-unless positive indications of death were present in the form of putrefaction. If life is clearly present, baptism is, of course, given in the absolute rather than in the conditional form. i ft ■’ •I* I ’·♦ . ’ r. ‘.‘.’.’A»* CHAPTER XII STERILIZATION 8 /2 ··<. ·< · · ' ** » I I V i ri­ ll r I I·* 1. Right reason and the decree of the Church (cited in the text) condemn any deliberate production of either temporary or permanent sterility for purely eugenic purposes. In the problem under discussion, the proposed sterilization is purely eugenic. In no sense can it be construed as thera­ peutic, because it is not a remedy for the tuberculosis with which the patient is afflicted. The deliberate production of sterility, whether temporary or permanent—not as a remedy or treatment for any condition present in the person’s body but only as a means of avoiding a pregnancy which might be hazardous—is wholly immoral. It must be condemned with the same degree of firmness that one would prohibit die temporary practice of contraception until such time as pregnancy no longer involved a risk to a woman’s health or life. 2. The same moral principle—the supreme dominion of the Creator over a creature—is involved in both sterilization and abortion. There is, however, no parallel between the morality of therapeutic sterilization and therapeutic abortion. In the former instance, the health and life of only one person is involved. This person is charged with the moral obligation of doing all that he reasonably can to maintain his health and life. At times, this duty can be discharged only by sacrificing a part of his body in the interest of preserving the whole. In such cases there can be no grounds for any moral objection to therapeutic sterilization. In the case of therapeutic abortion, however, the inviolable rights of two persons are involved. The mere fact that the continuance of the pregnancy will involve a definite risk to the health of the mother (or even her certain death) cannot justify the deliberate and intended destruction of the life of her innocent unborn child. 48 Sterilization The above principles governing the morality of therapeutic sterilization and therapeutic abortion—briefly presented here ait treated in detail in the text. 3. When the State calls upon a citizen to “sacrifice" his life for his country, it does not take the life of its citizen—it merely forces him to undergo various degrees of risk in the defense of his country; The State has both the moral right and duty to defend itself against unjust aggression—and this obligation necessarily falls upon the citizens who compose the State. In the fulfillment of this task, every reasonable precaution muse be taken to safeguard the soldier in the dangers which he must face in the defense of his nation. In contrast, a person is not an unjust aggressor against the nation merely because he is mentally defective. The State possesses no right whatever to mutilate the body of one of its innocent citizens. In the words of the Encyclical on Christian Marriage: “Public Magistrates have no direct power over the bodies of their subjects; therefore, where no crime has taken place and there is no cause present for grave punish­ ment, they can never directly harm, or tamper with the integ­ rity of the body, either for the reasons of eugenics or for any other reason.” 4. Disagreement between ethics and medical science is oc­ casionally the result of a misunderstanding of each odier’s ter­ minology. So it is in this case. The phrase “potentially infected” would mean to the phil­ osopher that no infection is currently present but that there is merely a capacity for it or some likelihood of it arising from presently existing conditions. The phrase “potentially infected” is used by medical science to indicate, for example, the condition that exists within the pregnant woman after there has been a rupture of the mem­ branes. Infection will result after the rupture of the mem­ branes—different schools of medical thought varying on their estimate as to the precise number of hours that will elapse before infection actually sets in. Once that period of hours has elapsed, medical science refers to the woman as “poten· tially infected.” (From the moralist’s point of view the woman ■ ^-· j·- · isai ■■■■■ - -few 50 F Reference Manual for Medical Ethics Sterilization Even in these instances, however, a punishment more fitting is at least probably infected with an infection serious enough than sterilization could always be found. (The text adequately to endanger her life.) demonstrates that, in practice, punitive sterilization is rarely, The medical scientist holds that Cesarean section accom­ panied by removal of the uterus is indicated in these infected if ever, a moral form of punishment.) 6. It is perfectly true that the State frequently subjects its cases, in rupture of the uterus, in the presence of multiple or citizens to vaccinations in the interest of society. It is also single large fibromyomata, and in abruptio placentae where true that these vaccinations may produce fevers, temporary the uterine muscle is infused with blood under the serosal illness and permanent scars. But there is no comparison what­ surface. ever between vaccination and sterilization. The latter act With this background to the case, the following observations mutilates the body, that is, it permanently destroys the opera­ are pertinent: First, the best method of accomplishing a Cesarean section tion of one of man’s natural powers. It robs the human in probably or certainly infected cases is to perform either the body of essential integrity—rendering it permanently incapable Waters or Latzko operation: both of these operations are rela­ of playing a vital rôle that is normal and natural for man. tively new (Dr. Edward Waters’ original presentation of his Vaccination has no such effect. It does not injure the body technique is to be found in the American Journal of Obstetrics in any of its natural functions. It does not lessen in any con­ and Gynecology for March, 1940 and June, 1945. The Latzko ceivable sense the integrity of the body. In fact, it is a step that operation has been presented in a new light and with fine suc­ not only safeguards the health of society but also of the individ­ cess within the past decade by Dr. Jas. Norton of the Jersey ual who is vaccinated. City Medical Center.) Both the Waters and Latzko operations Obvious as these facts are, it is to our undying shame that are quite difficult; relatively few obstetricians are skilled in the Supreme Court of the United States did not grasp them. them, while many are not even familiar with them. Both Thus, in 1927, Justice Holmes rendered his decision: operations allow the uterus to remain. For these reasons, they “We have seen more than once that the public welfare receive our highest approval and all obstetricians are urged to may call upon the best citizens for their lives. It would familiarize themselves with them. be strange if it could not call upon those who already sap When the woman is probably or certainly infected—and the the strength of the State for these lesser sacrifices, often not doctor unfamiliar with or incapable of performing the Waters felt to be such by those concerned, in order to prevent our or Latzko operation—it is morally permissible to perform the being swamped with incompetence. It is better for all the Porro operation (which will involve removal of the uterus). world if, instead of waiting to execute degenerate offspring 5. The Encyclical on Christian Marriage does more or less for crime, or to let them starve for their imbecility, society can prevent those who are manifestly unfit from leave open the morality of punitive sterilization. In its con­ continuing their kind. The principle that sustains comdemnation of those civil officials who inflict sterilization on I pulsory vaccination is broad enough to cover cutting the their subjects, the Encyclical expressly states that it is referring Fallopian tubes.” to instances “where no crime has been committed.” I We need only repeat the words of the Encyclical: Public It does appear accurate to state that—at least in theory—puni­ tive sterilization could sometimes be moral. Certainly there masistrates have no direct power over the bodies of their are instances in which it would be in proportion to the crime subjects; therefore, where no crime has taken place and there committed and at the same time serve a retributive purpose. is no cause present for grave punishment, they can never di- - H* J ·** MM’· tv ·. Reference Manual for Medical Ethics 4. f to >91 V·**· Sterilization Sute and that men are begotten not for the eartli and for time, rectly harm, or tamper with the integrity of the body, either but for Heaven and eternity. for reasons of eugenics or any other reason.” 8. There is no necessary connection between conditions re­ 7. The condemnation by the Church of eugenic sterilization quiring the removal of the tubes and nephrectomy. In one brief does not necessarily imply its approval of marriages between sentence, die mere fact that nephrectomy must be performed the mentally unfit, as well as their having children. provides no justification whatever for a removal of the tubes. The Church opposes sterilization of mentally defective 9. The Encyclical on Christian Marriage does not forbid at­ persons because such a procedure is simply an immoral solu­ tempts to dissuade certain mentally defective persons from tion to a pressing social problem. The reasons for the immor­ marrying. In fact, the Encyclical itself states that “often these ality of eugenic sterilization arc adequately presented in the individuals are to be dissuaded from entering matrimony.” text. The Church, therefore, positively suggests that it is often wise The Church actually adopts a very charitable and reserved to do all that we reasonably can to deter such persons from attitude towards the marriage of those who are mentally handi­ marrying. This is especially true when it is very clear that the capped. Naturally enough, marriage is impossible for those persons involved will find it most difficult to earn a livelihood, who, because of insanity or severe mental deficiency, do not maintain a home, solve the problems of domestic life, and have the rational knowledge and freedom of choice demanded properly rear their children. by Natural Law for the valid making of this contract. The Church, however, strongly condemns the materialistic eugen10. The segregation of mentally defective persons meets with icist who is over-zealous about physical and mental perfection the Church’s approval when such a step is in the best interests and who endeavors, by arbitrary tests and standards, to achieve of the individual and society. There are many mentally defec­ his ends. In the words of the Encyclical: ‘‘There are some who, tive persons who must be kept in institutions: in the case of oversol ici tous for the cause of eugenics, not only give salutary severely handicapped persons, confinement in an institution counsel for more certainly procuring the strength and health is to the best advantage of both the mentally defective person of the future child—which, indeed, is not contrary to right and society; the patient receives the supervision and medical reason—but put eugenics before aims of a higher order, and by treatment demanded by his condition, and innocent members public authority wish to prevent from marrying all those of society are protected from any harm which such a person whom, even though naturally fit for marriage, they consider, might—through lack of sound judgment, not malice—inflict according to the norms and conjectures of their investigations, upon them. would, through hereditary transmission, bring forth defective It should be evident that there is no fitting comparison be­ offspring. And more, they wish to legislate to deprive these of tween confinement and eugenic sterilization. Confinement is that natural faculty by medical action despite their unwilling­ necessitated by the very nature of mental deficiency, and it is ness; and this they do not propose as an infliction of grave punish­ in the interest of the patient as much as it is in the interest of ment under the authority of the State for a crime committed, society. Eugenic sterilization, on the other hand, has no neces­ nor to prevent future crimes by guilty persons, but against sary connection with mental deficiency; it is not a natural, but every right and good they wish the Civil authority to arrogate a purely arbitrary step in the handling of such persons, and, to itself a power over a faculty which it never had and can never since mental deficiency does not by its very nature necessitate legitimately possess. Those who act in this way are at fault in sterilization, the latter procedure becomes immoral-a needless losing sight of the fact that the family is more sacred than the invasion of the integrity of the body-and, in consequence, docs SS 54 Reference Manual for Medical Ethics not necessarily confer any benefit on either the patient or society. II. If only the Fallopian tubes need be removed in a specific case to restore the health of a woman, it does not appear morally permissible to remove die uterus. In past years—and probably in most places today—the uterus would be removed. The general attitude of the surgeons was that the removal of the tubes would result in the sterilityof the woman—so they might as well remove the other internal organs connected with reproduction (ovaries and uterus). The practice of the better surgeons today is towards con­ servatism on this score. The experienced specialist will state that once a woman is deprived of all her internal sexual organs it often has a bad effect on her. The harmful effects, it is true, involve more or less intangible, but none the less real goodssuch as a change in her physiognomy and in her mental attitude towards marital relationship. For these reasons, we feel that if the woman's present condition does not necessitate the removal of the uterus—and if there is no reasonable probability that her health will later necessitate the removal of the organ—it should i not be needlessly removed. A somewhat more lenient attitude might be taken in cases of women who are over forty years of age. In these instances, the organ either already has or will shortly cease to function. Hence no appreciable loss—physical or psychological—will result from its removal. The indiscrim­ inate removal, however, even in these latter cases, is not ap­ proved. If the excision would involve the real likelihood of conferring some benefit upon the woman—such as the elimina­ tion of a definite danger of a cystic condition arising in die organ—the removal would be morally permissible. In response to the question: what effect would the removal of the uterus have on menstruation and on the ovaries—the answer is that it would necessarily bring about a cessation of menstruation and would have no definitely established effect upon the ovaries. CHAPTER XIH I ASSISTANCE AT IMMORAL OPERATIONS 1. Co-operation, in the moral usage of the term, is present when "any real or physical help is given to another in the com­ mission of a sinful act.” This co-operation is said to be formal "when the one who is aiding the principal agent freely agrees with the latter’s sinful intentions and freely chooses to help in the performance of the immoral act.” In contrast, co-operation is said to be material “when unwilling aid is given to another in the commission of an immoral act; that is, the one co-operating neither agrees with the sinful intentions of the principal agent nor desires the sinful effect to take place, but does actually render some aid because of some personal benefit that will be derived or because of some loss that will thereby be averted.” Formai co-operation is immoral because the aid rendered is in the form of an act which is prompted by a sinful motive. Material co-operation is wrong because there is no proportionate reason for rendering the aid, even reluctantly, to the one who is actually committing the immoral deed. Cooperation, in the moral usage of the word, is present when a person does not perform, wholly or partially, the im­ moral deed itself but simply renders some aid to the one who actually performs the deed. To some extent at least, the use of the traditional term ‘‘co-operation in an immoral act” creates confusion and misunderstanding. The author would much prefer to use the expression “assistance in the performance of an immoral act.” Careful analysis will reveal that the nurse who operates an X-ray machine to effect an immoral sterilization is not render­ ing co-operation in the moral sense of the term. In the case cited, the nurse is the principal agent in the immoral act. She is obviously the only person who is the physical cause of the effect and she certainly cannot be regarded in any lesser light than 'as a "co-principal” with her superior who orders the sterilization. 55 2 Λ a r· 1 Hi ·*« Jt i h •4 1Λ r “ I » * * S· λ/' \ * 1 56 . .HI. I · J> r Reference Manual for Medical Ethics Assistance at Immoral Operations 57 The mere fact that the nurse “reluctantly” operates the X-ray Some persons will ask: is it not permissible to render such machine does not alter the situation. The act which she docs coopération in the case of non-Catholic women patients, since is in itself evil—and one cannot divorce one’s intention from these people do not consider contraception wrong and their sin the nature of such an act. In more technical language, the is merely a material one? The answer is that co-operation in object of the act (finis operis) is bad, while the end of the act in intrinsically evil act is forbidden, even when the sin of the (finis operantis) may possibly be good or indifferent. Her principal agent is merely material because of his or her good fundamental and primary motivation of will is the choice to faith. At most it would follow from this circumstance that a do the evil act (finis operis) ; while the secondary motivation­ less weighty reason would be required to justify material co­ in view of her reluctance—is probably “the desire to retain her operation than in the case when the sin is presumably formal present position” (which possibly can be achieved only by on the part of the principal agent. But in the present problem, obeying this command of her superior). I on account of the proximity of the co-operation of the doctor In Ethics, one learns that an act derives its essential moral or nurse and the gravity of the sin involved, a very serious character from its object (finis operis) and that a good end reason, such as those mentioned above, would be required even (finis operantis) will at best lessen to some degree the moral when it can be prudently judged that the chief perpetrators guilt attached to the doing of an act which is immoral in its are invincibly ignorant of the sinfulness of their actions. very nature (finis operis). Other persons will object that if the Catholic doctor or In summary, this nurse is not a “co-operator —she is a prin­ nurse refuses to fulfill the person’s request, she will have tire cipal agent. The act which she does is in itself an immoral act and—regardless of the reasons for her reluctance—she is, in the i contraceptive device fitted by someone else—hence the refusal would have no practical value. In answer, it is to be said that final analysis, still choosing to perform it. In no sense whatever the fact that the woman would have someone else fulfill her can her action be justified or declared permissible. 2. A doctor or nurse who fits a woman with a contraceptive i request—i£ the Catholic doctor or nurse refuses—does not sub­ stantially alter the case. If such an argument were admitted, device co-operates towards the sins she is thereby enabled to all kinds of untenable conclusions could be drawn about the commit. The co-operation is material, not formal; but it is so proximate in the order of material co-operation that, consider­ cooperation of Catholics in abortion, sterilization, and count­ less other immoral acts. ing the heinous nature of the sin toward which it concurs and 3. It would be permissible for the hospital to accept this the disastrous effects of this sin on society, only a most grave woman and to cleanse out the uterus. As stated in the case, reason would justify the doctor or nurse in performing this the woman’s attempts at abortion have already destroyed the service. Thus, if a doctor were threatened with death or with life of the unborn child and seriously endangered her own. a long term in prison in the event of a refusal, he might be The immoral act of the woman is already completed and its allowed to accede to the woman’s request. But the mere fact disastrous effect—the destruction of an innocent life—already that a doctor’s practice would be considerably diminished if he a reality. Acceptance and treatment of die woman does not turned away all women who sought this type of co-operation imply any approval of the woman’s gravely sinful action it is would certainly not be a justifying reason. simply an attempt to save the seriously endangered life of the Similarly, the mere fact that a nurse would lose her present woman and thus to prevent her sinful act from taking an even position by a refusal and be forced to accept a lower paying job would not be sufficient reason to tolerate such close co­ It Vs permissible to allow a Jewish rabbi to perform a operation in so grave a sin. . . \ m aa Catholic We presume that refercircumcision cainuuL hospital. r • 'I *V*Z£rb** K - · · ·· ·· t 4^.14« Λ 58 * h v Γ* Reference Manual for Medical Ethics ence is here being made to the circumcision of a Jewish infant and that no Catholic nurse actively participates in this religious rite of the Jewish religion. 5. In the case cited, the Catholic hospital may not allow the Jewish rabbi to perform a circumcision on the baby. Regard­ less of the attitude of the mother, the fact remains that cir­ cumcision by a Jewish rabbi is a religious rite. The Catholic mother who would allow the circumcision of her child by a minister of another religion would be violating the commands of her Church and acting sinfully. No Catholic hospital may co-operate in this sinful act of the mother by placing its facil­ ities at her disposal for this purpose. 6. The senior nurse who contends that she has the right to order a junior nurse to falsify records on temperatures and pulse is either lacking in sincerity or thoroughly ignorant of the scope of her authority. No matter how vehemently this misguided senior nurse may insist upon her authority or her willingness to accept full responsibility for the falsifying of the records, the junior nurse must refuse with unbending firmness to have any part in the action. 7. The general principles which govern the solution to this problem have already been presented. (Refer to the solutions of problems #3 and #4 in the chapter on Foundations of Morality and problem #2 in the chapter on Truthfulness and Professional Secrecy. Some additional thoughts on this matter may be of value: It is true that there are cases in which the doctor, for a perfectly good reason, desires an unusually large or unusually strong dose of medicine to be given. In such cases he is ex­ pected-according to the ethics of the medical profession—to mention this fact to the nurse who is going to administer the drug and to warn her of possible danger symptoms for which she is to be on guard. In cases in which the doctor gives the above explanation and guidance, the nurse is free to carry out the order—unless she is very certain, because of her knowledge of chemistry or of the drug in question, that the order, if carried out, will al­ most certainly injure the patient. Assistance at Immoral Operations In all of these matters, however, the nurse must never forget the implications of the Somera case discussed in this chapter. Civil law regards the nurse as a person in her own right and insists that in certain instances her knowledge and training should be sufficient lor her to appreciate the harm that will result from the use of certain drugs. In such cases, the nurse may be charged with criminal negligence, even though she administered the drug at the explicit command of the doctor. When the nurse is convinced that the drug will certainly injure the patient she should explain to the doctor that she cannot, in conscience, carry out his order. If the doctor still wants the order carried out he is then obliged—according to the ethics of the medical profession—to carry out the procedure or administer the medication himself. Under no consideration may the nurse secretly administer a dose smaller than the one ordered or actually give no medication while leaving the doctor under the impression that his orders have been executed. In some hospitals and schools of nursing there is an excellent regulation to the effect that no nurse, whether student or graduate, should ever administer a medication which she her­ self has not prepared and for which she has not seen a written order. Except in cases of grave emergency, when it would en­ danger the patient’s life to delay, no doctor has the right to expect a nurse to give any medication unless he has signed the order for it. On the rare occasions when an emergency will not allow time for a xvritten order, the nurse should repeat the order in the doctor’s presence before administering die drug. This precaution will afford the doctor an opportunity to verify or correct his order and also act as a safeguard for both patient and nurse. 8. The nurse must appreciate that she is charged with the welfare of her patient. It is the duty of the doctor to specify the medication and treatment which the patient is to receive, and it is the duty of the nurse to make certain that these direc­ tives are faithfully observed. Ί he nurse would certainly not tolerate any ordinary person giving her patient unprescribed and uncharted drugs. Neither should she allow an unscrup­ ulous and unethical nurse who happens to be on the same case η ·. I . · ' ■ Reference Manual for Medical Ethics with her to endanger the health of her patient. Whatever steps are needed to stop the unprofessional actions of this nurse must be quickly and firmly adopted. 9. This case is governed by the same principles which were applied in the solution of the previous problem. There is a great likelihood that the situation present in this case is of a most serious nature. The nurse should therefore lose no time in reporting the matter to proper authorities and thus safe­ guard the health of her patient to the best of her ability. 10. Two thoughts merit immediate expression in reference to this problem. First, the nurse is charged with die care of the patient in the absence of the doctor and the latter depends upon her to inform him accurately and fully on all matters pertinent to the patient’s condition. This obligation of the nurse is one which she must ordinarily fulfill with the same diligence with which she keeps her charts and records of the patient. Second, it does not ordinarily fall within the province of the nurse to decide whether a patient’s violation of a doctor’s orders has resulted in any harm. This decision belongs to the doctor. One never desires to see ill-feeling arise between nurse and patient. Such a possibility is present in this case if the patient feels that he has not offended seriously and that the nurse has refused to conceal the fact from the doctor. This difficulty could easily be handled by the nurse informing the doctor of both the patient’s violation and of his request for her to keep silence on the matter. If the doctor decides that the disobedi­ ence to his orders has done no harm, the patient need never know that the doctor learned about the violation. There is no intention of magnifying trifles or encouraging a scrupulous attitude of mind on the part of the nurse. When­ ever common-sense indicates that the disobedience of the pa­ tient has been on some trivial score, that it has been on a single occasion, and that there is moral certitude that no harm could have resulted from the act, she need not tell the doctor. In such a case, no good will be achieved by telling the doctor; whereas, the granting of the patient’s request should make both for a good relationship between patient and nurse and a Assistance at Immoral Operations better observance of regulations in the future by the patient. 11. Scarlet fever is an extremely serious complication of pregnancy. In addition, modern medical science still has much to learn about this disease and the precise manner in which it is transmitted from one person to another. In view of these facts, no responsible doctor would ask any­ one who has just nursed a scarlet fever case to assist at a de­ livery. If such a request were made—even though the doctor foolishly states that he will assume full responsibility—the nurse should refuse to participate in the delivery. 12. This case differs from the seventh problem of this chap­ ter in one notable respect: this nurse is not being asked to per­ form the action which she believes will be seriously harmful to die patient—she is simply an interested bystander or possibly a nurse who is rendering some form of proximate or remote assistance to the doctor. Regardless of which of these rôles she is playing, she most certainly should not “watch a doctor making a mistake which may cause the death of the patient.” Doctors are not infallible; pressure of work, for example, may cause them to forget some vital piece of information about a patient. Whatever be the reason for the possible error of the doctor, the nurse should speak up quickly and tactfully before any harm is done. If the nurse has been correct in her judg­ ment, no one will be more grateful to her than the doctor. If it so happens that her fears were unfounded, the doctor will assure her that there is no cause for worry and will probably give her some valuable instruction on this particular type of case. 13. This problem is almost identical with the preceding one. If the nurse is convinced that her patient has a fracture which the doctor has not discovered—and has “hinted at it to no avail -she should certainly make known her convictions to the doc­ tor in a respectful and tactful manner. Once again: if the nurse proves to be correct, the doctor will be grateful; if she proves to be wrong, no harm is done and the nurse has the satisfaction of knowing’that she had the best interests of her patient at This case has been adequately solved in the treatment ·β 62 Reference Manual for Medical Ethics Assistance at Immoral Operations doctor is truly at fault and pays no attention to reasonable of the seventh problem of this chapter. (Additional helpful requests from the supervisor, the matter should be brought to thoughts may be had by consulting the references mentioned die attention of higher authority. In no case is there any need in the solution of the same problem.) for the offended nurse to approach the doctor on the matter, 15. Since this question mentions a danger of infection it and it would not ordinarily seem to be the best course of action cannot possibly be referring to an ordinary pelvic examination for her to follow. —in which there is no such danger. The question must there­ 17. Every nurse is familiar with the fact that it is illegal to fore refer to a vaginal examination, probably during the last practice medicine without a license. When a nurse does at ­ six weeks of pregnancy or during the course of labor. At such tempt to step over into the field of the doctor by diagnosing times there is a real danger of infection because it is impossible conditions and prescribing drugs or treatment she probably to so sterilize the vulva that some bacteria may not be carried acts in both an illegal and immoral manner. into the birth canal by the examining fingers. Most state laws have provisions whereby it is not considered In a vaginal examination of the above type, medical stand­ ards dictate that the patient should be as carefully prepared I practicing medicine to advise or to give the remedies commonly found in homes, such remedies being referred to in the laws as if it were to be a vaginal delivery, while the doctor should as domestic,” “household,” or “family” remedies. Precisely be scrubbed and equipped with sterile rubber gloves, as would I what remedies fall into this category vary with time and place be done for a major surgical procedure. but are rather accurately understood by most people. There A “doctor” who would refuse to take the above precautions is, therefore, no intention of saying that the nurse acts illegally is not worthy of the name—and no nurse should assist him in or immorally when she suggests an aspirin for an ordinary his rash venture. If one might conceive of an extremely un­ headache. likely situation in which the time consumed in making a The nurse, however, who relies upon her experience, obser­ proper preparation would constitute a delay that would risk vation of symptoms and treatments by doctors, as well as var ­ the woman’s life, one could justify the doctor’s action and the ious other helps, to diagnose a real illness and recommend what nurse’s co-operation with him. Under any other conditions we might call a professional remedy or treatment is practicing nothing can be said in defense of such ruthless action. medicine without a license. She is violating civil law, and 16. It is very unlikely that there is any malice underlying leaves herself open to prosecution for her act. She is violating the situation presented in this problem. Possibly the nurse is moral law by possibly endangering the health of the person by young and unaccustomed to nursing duties. Possibly years of a wrong diagnosis or harmful “remedy.” practice have hardened the doctor to many things which right­ In one brief sentence: if a nurse is asked by family or friends fully offend the sensibilities of other persons. Whatever be the to do anything that would constitute “ practicing medicine ” she cause of the problem, it would appear best for the nurse to' should refuse to grant the request. explain the matter to her supervisor. The latter will be able 18. The correct answer to this problem depends upon the to call upon her experience and good judgment for a proper precise rôle which the nurse is expected to play. The various solution of the difficulty: if over-sensitivity or scrupulosity on possibilities are as follows: the part of the nurse is the cause of the trouble, a friendly and First, under no consideration could she herself be permitted instructive talk with the nurse should take care of matters; if to perform these abortions on the patients. There is little like­ thoughtlessness, callousness, or even malice on the part of the lihood that she is expected to act in this manner, because such doctor is at the root of the problem, a few tactful words from an illegal practice of medicine. constitute Rewould action the supervisor should bring an end to the difficulty. If the 1 E ·- -·■ ηΎ- A WM? · c 64 H* AI \ »r*t h n hIv ‘ tin « AieV.· • · Λ ÎA# Reference Manual for Medical Ethics gardless of civil law, however, she would be committing grave sin by acting as the principal agent in the procuring of direct abortion. Second, under no consideration could she herself be per­ mitted to act as a co-principal with the doctor in procuring these abortions. (We would regard her as a “co-principal” when bodi she and the doctor “work together as a team” in the very act of abortion—when both she and the doctor are partial effi­ cient causes of the abortion.) As in the above instance, the very nature of the act done by the nurse is immoral and cannot be permitted for any reason. Third, under no consideration could the nurse freely agree with the doctor s sinful intention of procuring abortion and freely choose to help him by rendering any aid which would be outside the act of abortion itself but helpful to the doctor in effecting it. We refer to such acts as preparing the patient foi the doctor, handing him drugs or instruments, and caring for the patient during and after the abortion. Any instance in which the one who is aiding the principal agent freely agrees with the latter’s sinful intention and freely chooses to help in the performance of the sinful act constitutes formal co-operation and is always immoral for the reasons advanced in the text. Finally, the nurse could render such assistance as was de­ scribed immediately above (preparation of patient, handing of drugs or instruments, care of patient during and after opera­ tion) if there is a proportionate reason for so doing. In this case, the nurse is giving various types of proximate and remote material assistance in the immoral act of the doctor. As the case is stated, it appears clear that the nurse is justified in render­ ing such assistance for the duration of her contract. Refusal to fulfill her contract might well cost her, not only her present position, but also leave her open to civil court action, loss of standing in her life’s profession, and deprive her family of its means of support. It goes without saying that—during the re­ maining duration of the contract—she should make every rea­ sonable effort to be assigned to other work in this hospital and at the termination of the contract to seek employment in an acceptable institution. CHAPTER XIV PROPERTY RIGHTS 1. There is no moral wrong in borrowing something from its rightful owner when we have the expressed or reasonably presumed consent of that person, the intention to restore it, and the sincere expectation that it will be possible to return it at the specified time. In practice, however, even if all of these conditions are verified, the nurse should remember that not all things that are permissible are prudent. There is no intention, of course, of condemning all borrowing. Nothing is to be gained by “mak­ ing mountains out of molehills”—an excessive concern over trifles is certainly not a healthy frame of mind. In fact, we even read in Sacred Scripture: “Give to him that asketh of thee, and from him that would borrow of thee turn not away” (Matthew V, 42). Nurses have—and probably always will­ borrow small amounts of money and articles of wearing apparel from each other. Such borrowing probably avoids inconven­ iences, lessens expenses, and solidifies friendship as often as it does harm. Both “lending” and “borrowing” must, however, be prudent. It is for this reason that there is some truth in the recommendation of Polonius to his son (in Hamlet) : “Neither a borrower nor a lender be.” As the nurse grows older, she will learn that there is a world of wisdom packed in those few words. Imprudent borrowing and lending will bring only sorrow and regret. One of the best ways to lose friends is to lend them something and then try to get it back! Psychologically, no debt is harder to pay back than that of borrowed money. The nurse should therefore be charitable at all times, but a careful avoid­ ance of both habitual borrowing and lending, especially of notable amounts of money or of expensive articles, is a sound practice for any nurse. 2 This nurse has committed a venial sin of theft. The mere fact that the patient has an abundance of gifts and cannot eat 66 ·;■ fe •U. nit· i M* · Reference Manual for Medical Ethics the candy at the present time provides no justification whatever for the nurse’s action. There are no obvious grounds for pre­ suming the consent of the patient to this act. Actually, the patient may desire to keep his gifts for later use or may prefer to give them to his own family or friends. The nurse is bound under pain of venial sin to make restitution to her patient. 3. As explained in the text, whenever there is an original intention to take a large amount—by spacing small thefts over a period of time—a grave sin has been committed. Assuming that the total value of all the articles taken exceeds the absolute standard of theft, the nurse is bound under pain of mortal sin to make restitution. 4. When a nurse on private duty in a home makes a chart, she is ordinarily regarded as its legal owner. In the case stated, however, if the nurse makes the record requested and gives it to the doctor, it becomes his property. In no case is the record the property of the patient or his family. It might also be added that it is usually unwise to grant the patient or his family ac­ cess to the chart. Too often the items on the chart are confus­ ing to the ordinary person and capable of misinterpretation. 5. Charts and records may be very valuable as history in the event that the patient re-enters the hospital at a later date. If treated at home at a future time, the patient’s doctor may find it most helpful to consult the hospital records on the earlier condition. With respect to the treatment of relatives of the pa­ tient, not only charts and X-ray pictures, but also autopsy re­ ports may prove extremely valuable. Finally, the publication of charts and case histories—under the safeguards mentioned in the text—may prove beneficial to medical science and mankind. All of these considerations should impress upon the nurse the fact that she has a serious obligation to be thoroughly ac­ curate and reliable in her charts. The most insignificant chart may later prove to be of inestimable worth. 6. A nurse is not morally responsible for damage unless she has been the actual cause of the loss. Obviously, this nurse has not broken the materials. Neither is it clear that the damage in this case can be attributed to negligence on her part. Unless the nurse has made an agreement with the hospital to make Property Rights 67 ood all damage that occurs to anything placed in her care— regardless of whether malice, negligence, or circumstances com­ pletely beyond her control caused the damage—this nurse has no moral obligation to make restitution. ' S’ ! ·. · Truthfulness and Professional Secrecy ·· · ' 1 CHAPTER XV TRUTHFULNESS AND PROFESSIONAL SECRECY 1 »! wi· 1 « kw] 1. In many instances it is far better that the hopelessly in­ curable patient know of the certainty and imminence of death. This is especially true if the patient has not been living up to his moral and religious duties. It is a serious injustice to build up false hopes of recovery' in such a person—when it is known only too well that death is fast approaching and that—because of our promise of recovery'—the person is not utilizing to good spiritual advantage the little time that remains for him. In certain instances it may be in the best interests of the pa­ tient to withhold temporarily from him the truth of his con­ dition. One point, however, must be emphasized. The nurse should not take it upon her shoulders to decide whether or not the patient should be informed of the hopelessness of his condition. The patient’s doctor or spiritual adviser, preferably both, should make such an important decision. Those who are charged with the care of a patient of this type should request the aid of the doctor and priest as soon as the hopelessness of the patient’s condition becomes evident. The informing of the patient should rest in their hands. If the nurse should be questioned on the matter by the pa­ tient before the above decision is made, she should refer him to the doctor, use an ordinary evasive answer or respond with a mental reservation. 2. In answering the third and fourth problems of the second chapter, strong emphasis was placed on the fact that a nurse is not ordinarily qualified to pass judgment on the diagnosis and treatment of a patient by a doctor. The same principle applies here with equal force. The doctor involved has received the stamp of approval from the Medical School from which he graduated and the State in which he is practicing. Further­ more, there are undoubtedly countless patients who think most 68 69 highly of the man. The nurse is being wholly unjust if she casts any reflection, even implicitly, upon the skill of the doctor inquestion. The nurse should say little more to the questioner than some remark such as "To the best of my knowledge, many people think highly of him.’’ 3. At the outset it should be made clear that both the patient and his attending physician have a strict right to their own business and their own privacy, the first on grounds of pro­ fessional secrecy, the latter on grounds at least of professional etiquette. If the nurse can reasonably presume that patient and physician would not have any objection to her answering such a question, she might reply. Whether or not this would be a reasonable presumption would depend upon the nature of the case, the relationship of the doctors to each other and possibly other factors peculiar to the case in question. With certain cases and certain doctors, the nurse might clear up any doubts in her mind by asking the patient and his doctor what she should say if so questioned. 4. When a patient begins to ask the doctor a personal ques­ tion while the nurse is in the room, she should leave the room -if she can conveniently do so. On the other hand, the fact that the patient has not hesitated to ask the question in the presence of the nurse implies that he does not seriously object to her overhearing the conversation. Such being the case, if the nurse’s duties demand her continued presence in the room she should not hesitate to remain. 5. If a young doctor is confronted with an emergency case and asks a nurse what treatment an experienced doctor gave in a comparable case there is no reason for the nurse to with­ hold the information. In the first place, die welfare of the pa­ tient in this emergency case may hinge upon the young doctor obtaining this information. Secondly, diere is every reasonableexpectation that the experienced doctor would desire the young man to have any information diat would help him in the emergency. , . One word of caution may be suggested: the nurse should be verv certain that she knows the precise treatment that the experienced doctor used in the earlier case. If there is any un- 4 ’ 70 i Reference Manual for Medical Ethics certainty on her part, she should inform the young doctor of this fact. Inaccurate advice from her may do more harm than no information at all. 6. The warnings given to the nurse in the second problem apply with equal force in this case. Under no consideration should she make any statement that, even implicitly, reflects upon the ability of the doctor. The nurse should leave the matter entirely in the hands of the family of the patient. At the very' most, one might allow the nurse to tell the family that —if they thought it would make them feel more satisfied to call in some highly recommended doctor—it would at least do no harm to make a change. 7. It is always the presumption of State law that a woman’s husband is the father of her child. If the Civil law of a State should also require that the husband’s name be recorded on the birth certificate as the father of the child—even though it is common knowledge that some other man is the father—the nurse should not hesitate to insert the husband’s name on the papers. Under such circumstances the State law is simply de­ manding that the name of the husband be listed as the pre­ sumed father of the child. If the husband is not the father of the child, this fact should be established by court action. The nurse should not, therefore, feel that by signing the husband’s name on the birth certificate she is stating that he is the actual father of the child. In the Canon Law of the Church, there is also a strong pre­ sumption that the husband of the mother of a child is its father. It is, however, a presumption which can be rebutted by con­ vincing evidence to the contrary. Such would be the case if husband and wife agree that another man is the father of the child, and if their statements are backed up by the established fact that the husband was not even living in the same part of the world as the wife at any time during which the child could have been conceived (as, for example, a husband who was · abroad in military service for a long period of time). Hence, in the baptismal registration of a child, the presumption of law would ordinarily require the listing of the husband’s name on the record as the father of the child. However, when Truthfulness and Professional Secrecy 71 absolutely convincing evidence indicates that someone other (han the husband is the real father of the child, the husband’s name should not be placed on the baptismal record. If the hus­ band’s name were inserted in such clear-cut cases of illegitimacy, it would be extremely difficult to prove afterwards that the child was illegitimate and therefore per se ineligible for certain offices and orders in the Church. Furthermore, it would seem that public order demands that there be some legal sanction against acts which are so detrimental to public morality. (Canons 1115; 777, #2; 2357.) 8. λο apparent good will be accomplished by the nurse con­ firming the patient s belief that his doctor has neglected him. The neglect—as the old saying puts it—is “water over the dam.” The nurse should merely tell the patient that there is room for a wide divergence of opinion on what constitutes neglect of a patient—that he will have to judge for himself—that she wOuld not feel competent or justified to render an opinion on such a matter. 9. This problem does place the nurse in an extremely diffi­ cult position, particularly because she is a friend of the new mother. Certain points, however, deserve explicit mention: first, apparently both mother and baby are in good health after the delivery so no injury has been suffered by the absence of the specialist; second, the specialist has undoubtedly given the woman an excellent prenatal care over a period of months— hence, recompense is due to him and the final good result pri­ marily attributable to him; third, the failure of the specialist to arrive in time was apparently not due to any negligence on his part; fourth, there is no indication that the specialist will not make some allowance on his bill for his inability to deliver the baby. It would appear that the best course of action for the nurse would be: first, to explain to her friend that professional eti­ quette does not permit her to discuss the manner in which a doctor has handled his patient; second, she should suggest to her friend that, if she feels dissatisfied about anything, she I I i cnral to the doctor about it and feel confident that she Sh°U e five kind consideration from him; third, the nurse - Γ\ •Λ 72 Γ ’*** I » Ml· If * U- f'·'· *·^· Reference Manual for Medical Ethics could speak to the doctor and explain to him the problem that is disturbing his patient. The doctor can emphasize the four points mentioned above in talking to the patient and possibly make some allowance on his bill for his inability to deliver the baby. As this case is presented, sufficient grounds are not pres­ ent to exempt the nurse from the obligation of professional secrecy. 10. Once again, the author feels that it would be extremely imprudent for the nurse to allow herself to be placed “in the middle” on a matter of this nature. In this case, in particular, it is evident that the patient has no grounds for serious com­ plaint. Practically speaking, the surgeon whom the patient engaged performed the operation, that is, it was done “under his guidance, counsel, and watchful eye.” It is strictly true that the first surgeon and his assistant collaborated in the perform­ ance of the operation. The nurse should tell the patient that many operations necessitate the collaboration of surgeons and that both the surgeon and his assistant performed the operation on him. 11. The problem states that the mother is seriously ill. At the moment she is in no condition to receive the tragic news that her child has been born deformed or still-born. The nurse may use any evasive answer or mental reservation to put off the pressing questions of the woman. She may tell her, for example, that she will inquire about the condition of the child and will let her know as soon as possible. Meanwhile the nurse should promptly inform the woman’s doctor and spiritual counsellor of the woman’s pressing questions. Either the doc­ tor or the clergyman, or both, should then handle the problem as promptly and as tactfully as possible. 12. The solution to this case is identical with that of the second problem of the second chapter. Refer to that section for the proper analysis of this twelfth problem. 13. In the text it is explained that the term “profession” is used in various ways. In standard dictionaries, for example, a profession is often defined as “an occupation that properly involves a liberal education or its equivalent, and mental rather than manual labor.” A much stricter concept of a “profession ” Truthfulness and Professional Secrecy 73 however, must be used in referring to those fields of endeavor ihichare bound by “professional secrecy.” I he opening lines of die Principles of Medical Ethics of the American Medical Association furnish us with a satisfactory concept of “profes­ sion.” It states that “a profession has for its prime object the service it can render to humanity; reward or financial gain should be a subordinate consideration.” In the light of these considerations—though there is room for a difference of opinion on the matter—it does not appear to the author that the knowl­ edge acquired by dentists and undertakers falls under profes­ sional secrecy in the strict sense of the term. The mere fact that knowledge does not fall under profes­ sional secrecy does not mean that it is exempt from all bonds of secrecy. The natural secret and the general committed se­ cret bind both the dentist and the undertaker in a high percent­ age of their activities. 14. This problem calls for a brief comment on the statement I cannot see anything wrong in telling a ‘white’ lie.” This attitude is very prevalent, particularly in the medical pro­ fession. In fact, an interesting example of this attitude was given some recent publicity in the press. It appears that Hahnemann Medical School, in Philadelphia, was conducting a two day scientific program in commemoration of its Centen­ ary (1848-1948) . On the program, Dr. Michele Viglione, as­ sociate professor of medicine gave a talk, according to the Philadelphia Evening Bulletin, on “Little White Lies—an Aid in Medicine.” The press report on the advantages of “white lies continues: “Doctor at Hahnemann tells how to use them— it’s not good medicine in a great many cases for a doctor to tell the patient too much about what ails him—the best results, said Doctor Viglione, might be accomplished in treating the worrying type by administering a liberal dose of little white lies, at least until the patient is well on the road to recovery. Actually the moral stand on this matter depends almost en­ tirely on what is meant by a “white” lie. Most people tend to include evasive answers, non-committal answers and particularly, mental reservations under the heading of “white" lies. As ex­ plained in the text, there are many instances in which it is not fl 74 Reference Manual for Medical Ethics permissible or prudent to reveal the truth. In many of these cases mental reservation is not merely allowable but highly recommended. On the other hand, a real lie that is being called “white” simply because some good is achieved by it and no harm pro­ duced by it cannot be permitted. Once again, we must repeat two thoughts: first, a real lie is an unnatural act, because it in­ volves the abuse of one of man’s faculties; second, the end never justifies the means—hence the mere fact that good is achieved through an act does not justify its commission if it be wrong in its nature. 15. This problem is treated at length, in the text under “The Revelation of Professional Secrets." The general prin­ ciple governing such cases is that “a professional secret must be revealed whenever its retention would result in grave harm coming to an innocent third party." The necessary restrictions which must be applied, as well as the attitude of the American Medical Association on these matters, is adequately explained in the text. There is no need to repeat the explanation in this place. 16. The same principles which govern the solution of the previous problem apply in this case. In the words of the text “a professional secret must be revealed whenever its retention would result in grave harm coming to an innocent third party; reference is here made to instances in which the patient is not merely the occasion of harm to another but is, or is soon to be, the actual cause of harm to the innocent person.’’ The matter is treated in adequate detail in the text and one must remem­ ber, in particular, that the actual revelation of the professional secret must be resorted to only as a last alternative. A word of caution should be suggested: before the nurse takes any step she must possess certain knowledge that the man is wholly and permanently incapable of marital relationship (permanent impotency must not be confused with permanent sterility). If the facts of the case are as stated, the man should not be allowed—through his ignorance or malice—to abuse the dignity of Marriage and precious rights of an innocent person. 17. According to eminent moralists, a man is not morally Truthfulness and Professional Secrecy 75 obliged to surrender himself to the State if he has committed a crime with which an innocent person is charged or even judged guilty—provided he has done nothing which has brought about the arrest of the innocent person (i. e. he has not “framed” the innocent person in any way). Since the man is not morally obliged to give himself up to the State, it would appear clear that the nurse is not entitled to reveal his secret. Additional important points in the problem which must be kept in mind are: first, the man is merely the occasion, not the cause, of harm coming to an innocent person (consult the text for the importance of this fact) ; second, the man, according to the text, is not a dangerous criminal and does not constitute a future menace to society ’; third, the nurse is free to urge the man to give himself up—out of charity towards the innocent fellow citizen who is about to suffer for his crime. 18. A nurse must appreciate the fact that a good reputation is one of man s most valuable possessions. She should realize that she has no more right than anyone else to injure need­ lessly the good name of another. U hen—in the interests of health—a patient has to submit himself to treatment by the medical profession, he has every right to expect that any facts injurious to his good name will not be needlessly revealed to those who are not charged with his care or treatment. Many nurses carry gossip outside the hospital unit—to their friends and acquaintances. These nurses are a disgrace to their profession. Other nurses—who would not carry gossip into the com­ munity-make it a practice of revealing facts of this type to the other nurses. There is absolutely no justification for such gossip. All persons within the medical unit who, because of the care or treatment they must render a patient, discover facts in­ jurious to his reputation are bound by strict professional se­ crecy All others within the medical unit who are not charged in any way with the patient’s care or treatment have absolutely no right to a knowledge of facts detrimental to his good name. 4 76 W’ é* Reference Manual for Medical Ethics 19. The practice in Nursing Schools of having student nurses write up actual case histories for presentation to the members of the teaching faculty must be governed by definite principles. It is true that the patient must allow a revelation of those secrets which pertain to himself and which the medical unit will require in order to care properly for him. On the other hand, he certainly does not have to allow the hospital to take those facts and to utilize them in a way that would be to their advantage (the training of its nurses) but possibly to his detri­ ment (injury to his reputation). One cannot therefore approve the practice of writing up the case histories in the manner de­ scribed in this problem. Two legitimate methods of writing up case histories are available. First, as is done in most Nursing Schools, the real name of the patient is not placed on the case history—merely the initials are used. A second course of action is open when­ ever there is any reasonable possibility that even the initials might reveal the identity of the patient to the teaching faculty or whenever the teaching faculty might desire to check the accuracy of the nurse's presentation against the actual case or the official record of the case—the patient can be consulted by the nurse or his doctor, the matter explained to him, and his permission requested to use the data for the above purposes. Ordinarily it would be very easy to obtain the patient’s con­ sent; most patients would be flattered to think that they could be of some help. If the patient should refuse, the matter should be dropped. 20. The solution to this problem is presented in the text when it states “whenever Civil law unjustly demands the rev­ elation of a professional secret, the nurse is ordinarily obliged to refuse to make it; if, however, her refusal to make such rev­ elation would result in grave harm coming to herself, she is morally justified in revealing the secret except in those cases where the preservation of the secret would be gravely necessary for the common welfare.” CHAPTER XVI THE LAST SACRAMENTS 1. The attitude of the family in this case is an unreasonable one and should, therefore, be disregarded. When the nurse requests the priest to attend the patient, she might also tell him that she was ordered by the family not to take this step. On the basis of the general knowledge in the parish that the person is sick, the priest could then drop in to visit the patient, admin­ ister the Last Sacraments, not reveal to the family that the nurse sent for him, and possibly instruct the family on its duty to a person in danger of death. 2. There are times in life when it is not only a relief but also wise and necessary to allow someone else to shoulder an obligation. In this case the obligation of deciding whether or not the patient should be visited should rest with the parish priest, not with the nurse. The parish priest probably has a fairly good idea of the mental attitude toward religion within the household. The nurse should simply inform him of the opposition of the family, the attitude of the patient, and the fact that the patient is in danger of death. The burden of de­ ciding on what steps, if any, are to be taken would then rest with the priest. As in the previous case, the nurse could request the priest not to mention that he had learned of the patient’s condition from her, so that no unpleasantness might arise be­ tween her and the family. The priest’s supposedly casual visit could be based on the general knowledge in the community that the person was seriously ill and had formerly been a prac­ ticing Catholic. 3. Cases of this type are admittedly very difficult to handle. A high percentage of these patients are in danger of death in the moral sense and, therefore, are free from any obligation to fast prior to the reception of the Eucharist. The author believes that in cases such as these, the tube should be clamped off and the patient given a small piece of unconsecrated host 77 cP'· i/, 78 S' .·· • *·*· s ». ; /.· γ.- < u FFj ιΗι p Reference Manual for Medical Ethics —explaining, of course, to the patient that this is only an exper­ iment to determine whether or not he could retain a comparable piece of consecrated host. If the experiment proves successful, the tube should be clamped off and the patient be given the Eucharist. In these cases, there is ordinarily no difficulty in keep­ ing the tube shut off for fifteen minutes to an hour. Naturally, the tube could not be left on and the patient given the Euchar­ ist—the syphoning effect of the tube would bring the Eucharist up the tube as soon as It reached the stomach. If convenient, the tube should be shut off for half an hour but for no less than fifteen minutes. If the experiment shows that the patient cannot possibly re­ tain even a small piece of the host or if the tube cannot be clamped off, the Eucharist should not be subjected to certain profanation. 4. In almost all instances it will be possible for the nurse to leave the ward for the few minutes involved in the confession. Hence, if there is any likelihood of her overhearing the confes­ sion, this is the course of action which she should follow. If her duties make it impossible for her to leave the ward at this time, the priest and patient may choose to delay the confession until the nurse is free to leave or they may elect to continue despite her presence. Usually it will be possible to make the confession in a subdued voice which will not be understood by the nurse or by other patients in the room. If circumstances are such that the confession is overheard by the nurse or other patients, all must remember that they are bound, in the same manner as the priest to absolute secrecy. 5. 'The attitude of the doctor in this case would imply either that he is not a Catholic or, if he is, that he lacks an understand­ ing and appreciation of the necessity and value of Extreme Unction. In either case, it is not likely that the nurse will achieve very much by discussing the matter with him. In fact, if she does speak to the doctor about the reception of the Sacrament and, as is likely, fails to alter his stand, it will be more difficult for her to carry the matter further without incurring his displeasure. In contrast to the doctor, the family is devoutly Catholic and will be desirous of following the guidance of the Church once it is fhe Last Sacraments 79 made clear to them. The nurse should explain to the family that the Church desires Extreme Unction to be administered not only to a dying person but also to anyone who is as sick as this member of their family. She should explain also that it is the teaching of the Church that the Sacrament is often conducive to the physical recovery of the patient—something which they de­ sire very much. She should emphasize that delay in the matter is a serious injustice to the patient because it withholds from him the spiritual and possibly the physical benefits which would be derived from the reception of the Sacrament. 6. This case is concerned neither with a dying person nor with the reception of Holy Viaticum. It refers to a person who is undergoing a prolonged illness and wonders about the possi­ bility of receiving the Eucharist without fasting. As is stated in the text of this chapter, Church Law specifies that this dis­ pensation may be used only “upon the advice of the confessor.” The confessor whose advice must be followed may be any ap­ proved confessor, not necessarily the ordinary confessor of the patient. The duty of determining whether or not the conditions required by ecclesiastical law for the use of this dispensation are present rests wholly with the confessor. The duty of the nurse in cases such as these is to encourage the patient to talk the matter over with the confessor. She possesses no authority whatever to advise the patient to receive the Eucharist without observing the established law. 7. The law of the Church which forbids Christian burial to those who have committed suicide reflects its belief that it is possible for a man in the complete possession of his faculties to destroy his own life. Such an act is, of course, one of the gravest of all sins and the Church logically refuses Christian burial to such a person. On the other hand, the Church appreciates the fact that there are countless instances in which suicide is com­ mitted only because the person is not in the full possession of his faculties. Great personal losses, tragedies within the family, nervous breakdowns and comparable unfortunate occurrences can sometimes notably impair the knowledge and freedom which nrdinarilv provide the basis of a person s action. The Church Îsln ttoeTases, as in all others, a kind and understanding /.cvcir..rtt 80 ? I r t • V · U - ‘ Reference Manual for Medical Ethics Mother who gives Her children the benefit of every doubt. Whenever the person has led a good life and commits suicide under circumstances which imply that his mind was tempor­ arily unbalanced, the Church relaxes its law and bestows Chris­ tian burial upon him. These principles apply also to the ad­ ministration of Extreme Unction to an unconscious dying per­ son who has attempted suicide. It is true that at least an habitual intention to receive the sacrament is required but the benefit of every doubt is to be decided in favor of the person. Extreme Unction should be withheld only in the case of a person who had abandoned the Church and steadfastly refused the Sacra­ ments in life because of an expressed lack of faith in their efficacy, and who—we are certain—has maintained this attitude up to the very time of lapsing into unconsciousness. All others should be given at least a conditional administration of Extreme Unction. 8. Medical science has devoted years of research to the study of infection and the methods required to control its spread. The fruit of this research is reflected in the hospital regulations gov­ erning each and every disease. Unless there be very grave reasons necessitating an exemption, everyone who comes in contact with the patient should scrupulously observe these regulations. Doctor, nurse, and priest alike have a moral duty to protect their own health and to do nothing that will endanger the health of the many persons with whom they daily come into contact. A tactful word from the nurse to the visiting priest on the seriousness and contagious character of the patient’s disease should suffice. The nurse should then provide the priest with whatever is required by regulations in the way of gown, mask, or cleansing facilities for his hands. She should properly dispose of soiled cotton, and sterilize any article, such as the crucifix, which may have come in direct contact with the patient. 9. In normal cases every effort is made to surround the ad­ ministration of the sacraments with an environment that reflects their dignity and our respect for them. But we must remember that the sacraments were instituted by Christ for the benefit of man. Hence, in emergency cases the sacraments may be ad­ ministered at any place or any time to a person in danger of death. The Last Sacraments 81 10. The nurse should first explain to the patient that smok­ ing does not break his fast and, therefore, would not prevent him from going to Holy Communion. She should, however, explain to the patient that everything that is within the law is not, therefore, always most fitting and proper. If the patient can sacrifice this sense pleasure, without serious inconvenience, until some time has elapsed ajter his reception of the Eucharist, the nurse should encourage him to do so. In its stead, the pa­ tient should be instructed to turn his mind and heart to the Great Sacrament which he is about to receive. INDEX /Attitude of nurse to suffering and death, 6 of young people towards marriage, 10 Autopsy reports, value of, 66 Abortion, caused by strenuous athleucs, 28, 38 civil law on therapeutic, 33 criminal, reasons for prevalence of, 30 dangers of criminal, 35 danger of, from laborious work, 32 Baptism, conditional, 42 dangers involved in delaying, 43 direct, 27-31 discussion of means of procuring, how soon to be administered, 47 in early centuries, 43 27 •1111 excommunication and, 36 of aborted fetus, 47 indirect, 37-39 of Catholic by non-Catholic, 44-46 likelihood of, from use of drugs, of dead fetus, 42 29 of desire, 43 macrocytic anemia and, 32 of infant found dead, 43 nurse’s cooperation in, 63-64 of non-Catholic by Catholic, on pretext of child being defec­ 46 tive, 28 principles determining the Church on pretext of venereal disease, 28 to which it unites a person, pernicious anemia and, 32 44—46 rupture of amniotic membranes psychological attitude towards, 31 similarity between criminal and and, 42 therapeutic, 34 sacrament of, 42-47 therapeutic, 32-36 state of grace in minister of, 46 time of fetal death and, 47 uterine, 43 Bassinet, use of, 26 twofold effect principle and, 34 Abruptio placentae and cesarean Birth certificate, 70 control. See Contraception section, 50 Borrowing, moderation in, 65 Abstinence in marriage, 16, 18 Adultery by artificial insemination, Bonus from state for children, 13 Burial of suicide, 79 12 Administration of harmful drug, 5 Anemia, macrocytic, and abortion, Canon law on paternity, 71 32 Assistance at immoral operations, Carelessness causing injury to pa­ tient, 7 55-64 Case histories, 76 in abortion by nurse, 63-64 Artificial insemination as form of Catholic baptized by non-Catholic, 44-46 adultery, 12 nurse as god-mother at non-Cath­ Athletics as cause of abortion, 38 olic baptism, 42 Atresia, congenital, 26 83 84 Index Cesarean section, fibromyomata and, 50 infected cases and, 50 rupture of uterus and, 50 Charting, false, 4, 58 reliability in, 66 Charts, owner of, 66 value as case histories, 66 Children as unifying force of home, 9 Christian burial for suicide, 79 marriage as source of grace, 12 nature of, 9-12 philosophy of suffering, 21-26 Science and suffering, 22 Church approval of segregation of mentally unfit, 53 attitude toward marriage of men­ tally unfit, 52-53 sponsorship of safe period knowl­ edge, 20 teaching as source of knowledge on morality, 2 based on revelation, 2 Circumcision in Catholic hospital 57-58 Civil law demanding violation of se­ cret, 76 its attitude towards nurse, 59 on paternity, 70 on therapeutic abortion, 33 Community welfare, dependent on moral standards of medical profession, 3 Concealment of sterility, 11 Confession in ward, 78 Conditional baptism, 42 of aborted fetus, 47 Cooperation, definition of, 55 of state and medical profession, 7 Conscience, doubtful, 4 lax, examples of, 6 scrupulous, examples of, 7 Consciousness desirable at moment of death, 23, 25 V* â Contaminated instruments, use of, 6 Contraception, 13—17 and medical profession, 15 assisting patient in, 56-57 basis of its immorality, 16, 18 cooperation in, 56 eugenic argument for, 14 lax enforcement of laws on, 17 medical argument for, 13 moral argument for, 14 practised in good faith, 15 state laws on, 17 Contraceptives, doctor or nurse measuring for, or distributing, 56 Criminal abortion, dangers of, 35 reasons for prevalence of, 30 and therapeutic abortion, com­ parison of, 34 Criminal, secrecy concerning, 75 Curettage of uterus, 57 Damage, nurse’s responsibility for, 66 Danger of death, meaning of, 77 Death, nurse’s attitude towards, 6 patient to be informed of immi­ nent, 68 without Last Sacraments, 77 Delay of baptism in early centuries, 43 Delivery, payment for, 71 Dentist, secrecy of, 73 Diagnosis by nurse, 68 Diethylstilbestrol, use of, 37 Direct abortion, 27-31 Divorce and childless marriage, 9 and infidelity, 11 as violation of unity and indissolu­ bility of marriage, 12 statistics on, 9 Doctor, his obligation to inform nurse, 58 Index Doctor (Continued) his responsibility for negligence, 24-25 his title to knowledge about his patient, 60 Doubtful conscience, 4 Drugs, administered by nurse, 59 as cause of abortion, 29 nurse ordering discontinuation of, 5 nurse secretly lessening quantity of, 5 to be administered only on doc­ tor’s orders, 24 use of, when death is imminent, 23,25 85 Excommunication for abortion, 27, 28, 36 Expediency as basis of morality, 1415 Extreme Unction and suicide, 80 value of, 78 F Failures of safe period method, 18, 19 Fallopian tubes, excision of, 40, 54 False charting, 4, 58 Fibromyomata, cesarean section and, 50 Formal cooperation, definition of, 55 Foundations of morality, 4-8 E Ectopic gestation, 40-41 changed attitude towards, 40 Education, limited, of nurse, 4 Encyclical on eugenic sterilization, 49 on punitive sterilization, 50 End does not justify means, 14-15, 34 Ergot, use of, 37 Error, probable or possible, by doc­ tor, 61 Esophagus, artificial, 26 Ethics differs from religion, 2 nature of, 1 value of, 1 Eucharist, reception of, after smok­ ing, 81 reception of, with Levin tube, 77 reception of, without fasting, 79 Eugenic aims of Nazi movement, 14 argument for contraception, 14 sterilization by state, 49 contrasted with military draft by state, 49 immorality of, 48 in papal encyclical, 49 Euthanasia, reasons for acquittals in cases of, 23 Gastric fistula, 26 Gastrostomy, 26 God-parents, obligations of, 42 Gossip, harm coming from, 75 Grave theft, 66 Harmful drug, administration of, 5 Hospital regulations, respect for, 6, 80 Hydramnion, 28 Hysterectomy, 54 Ideals based on reason and revela­ tion, 2 differ from laws, 3 Ignorance of immorality of contra­ ception, 15 Illegal practice of medicine, 63 Immoral operations, assistance at, 55-64 Immorality of contraception, 16, 18 Impotency, marriage and, 9-10, 74 Indirect abortion, 37-39 Indirectly voluntary act, 4 abortion and, 29 by carelessness, 7 •*4J r:. Μ 86 Index Medical (Continued) examination, value of before mar­ riage, 13-14 Medications, recommendations for handling by nurse, 59 Medicine, illegal practice of, 63 Membranes, rupture of amniotic, 28 Mental attitude towards suffering as aid to recovery, 24 defectives, marriage and, 52 not unjust aggressors, 49 Mental reservation, 72 Mercy-killing, reasons for acquittal Jewish circumcision, in Catholic hos­ in cases of, 23 pital, 57-58 Minister of baptism, state of grace and, 44—46 Mixed marriage, moral dangers of, Last Sacraments, 77-81 16 Latzko operation, 50 Morality as basis of good reputation, Laws differ from ideals, 3 3 on contraception, 17 based on expediency, 14—15 Lax conscience, examples of, 6 foundations of, 4—8 Lending, moderation in, 65 Moral argument for contraception, Levin tube, reception of Eucharist 14 and, 77 laws differ from moral ideals, Lying by false charting, 4, 58 3 unchangeability of, 40 M principles, based on Church teach­ Macrocytic anemia, abortion and, 32 ing» 2 Marriage, attitude of young people known by reason, 2 towards, 10 known from Revelation, 2 impotency and, 9-10, 74 standards as aid to community mixed, dangers of, 16 welfare, 3 nature of Christian, 9-12 Morphine, use of, when death is im­ of Catholic before civil magistrate, minent, 23, 25 Motives for entering nursing profes­ of mentally unfit, 52 sion, I physical basis of, 10 proxy, 10—11 N purposes of, 9 Material cooperation, definition of, Natural Jaw as basis of all law, 8 55 as basis of social welfare, 12 Materialistic outlook on suffering, 21 Nazi eugenic movement, 14 Medical argument for contraception, Necessity knows no law, 36 13 Negligence in care of patient, 5, 24, care, adequate, and contracep­ tion, 13 of doctor, 71 Indirectly voluntary act (Continued) by false charting, 4 by negligence, 5 by use of unsterile instruments, 6 Infected cases, cesarean section and, 50 Infidelity, divorce and, 11 Instruments, unsterile, use of, 6 Irradiation, immoral, 55 of uterus during pregnancy, S3 Index Non-Catholic baptism, Catholic nurse at, 42 baptized by Catholic, 44-46 Nurse, her duty to assist doctor, 61 her duty to inform doctor about patient, 60 her responsibility in civil law, 59 troubled by doctor’s actions, 62 usurping role of doctor, 4 Nursing Ethics texts, absence of moral principles in, 1 profession, motives for entering, 1 Obedience to doctor’s orders bY nurse, 4, 5, 58 Operation, payment for, 72 Ordinary means to preserve health and life, 25-26 Ovulation, means of detecting, 20 Owner of charts and records, 66 87 Property rights, 65-67 Proxy marriage, 10—11 Psychological attitude towards abor­ tion, 31 Punitive sterilization, morality of, 50 Purgatives, use of, during pregnancy, 39 Purposes of marriage, 9-12 Reason and Revelation, both used in this text, 2 as aid to Revelation, 2 as basis of morality, 2 Reliability of safe period method, 18 Relativism in morals, 40 Religion, prejudice against, 77 Removal of uterus, 54 Reputation, based on moral ideals, 3 importance of hospital, 2 of doctor, 68, 70 value of good, 75 Respect for hospital regulations, 6 Responsibility for damage, 66 for under-staffed hospital, 25 Revelation as source of knowledge on morality, 2 Rupture of uterus, cesarean section and, 50 Paternity, presumption of, 70 Penance, sacrament of, 78 Pernicious anemia, abortion and, 32 Philosophy of suffering as aid to hap­ piness, 23 means of teaching, 21 s of Christian Scientist, 22 of materialist, 21 Sacraments, place of administration Porro operation, 50 of, 80 Safe period clinics, 20 Position of nurse in civil law, 59 method, 18—20 Preference of child over mother in compared with contraception, Catholic ethics, 34 18 Pregnancy, complicated by scarlet failures of, 18, 19 fever, 61 fostered by Church, 20 moderation of life during, 83 spread of knowdedge on, 19 use of purgatives during, 39 Scale of values, 36 Prejudice against religion, 77 Scarlet fever in pregnancy, 61 Premature delivery, 32, 38 Prescription of remedies by nurse , 63 Scrupulous conscience, examples of, Presumption of law, 70 Secrecy in case histories, 76 Profession, definitioni of,,72 Professional secrecy, 35, 68-/ Segregation of mental defectives, 53 Index 88 Separation, marital, because of in­ fidelity, 11 Sexual abstinence in marriage, 16 Sleeping on duty, 4 Smoking, reception of Eucharist and, 81 Social welfare, dependent on ob­ servance of natural law, 12 Spain’s aid to families, 13 State aid for families, 13 and medical profession, coopera­ tion between, 7 duty of, to family, 15 laws on contraception, 17 power and eugenic sterilization, 49 Statistics on divorce, 9 Sterility, deliberate concealment of, 11 marriage and, 9-10 Sterilization, 48-54 by irradiation, 55 immorality of, for eugenic pur­ poses. 48 punitive, 50 Suffering, means of teaching proper philosophy of, 21 Christian Scientist attitude to­ wards, 22 materialistic attitude towards, 21 nurse’s attitude towards, 6 philosophy of, 21-26 Suicide, Christian burial and, 79 Extreme Unction and, 80 Terminology, importance of. 49 Theft, slight, 66 grave, 66 Therapeutic abortion, 32-36 and criminal abortion compared, 34 and therapeutic sterilization com­ pared, 48 Truthfulness and professional se­ crecy, 68-76 Twofold-effect principle, 34, 37 U Under-staffing hospital, responsibil­ ity for, 25 Undertaker, secrecy of, 73 Unreliability of safe period method, 18 Unsterile instruments, guilt for use of, 4, 6 Uterine baptism, 43 Uterus, curettage of, 57 removal of, 54 Vaccination, compared with steril­ ization, 51 Vaginal examination, 62 X enereal disease as pretext for abor­ tion, 28 obligation to receive treatment for, 28 W Waters operation, 50 White lie, nature of, 73 X'ray machine operator, 55 x·· « Ü A