Dolentium Hominum N.46

DOLENTIUM HOMINUM No. 46 – Year XVI – No. 1, 2001 JOURNAL OF THE PONTIFICAL COUNCIL FOR HEALTH PASTORAL CARE

Proceedings of the XV International Conference

Organised by the Pontifical Council for Health Pastoral Care

Health Care and Society

November 16-17-18, 2000 New Synod Hall Vatican City gg

ARCHBISHOP JAVIER LOZANO, Editor-in-Chief CORRESPONDENTS MOST. REV.JOSÉ L. REDRADO, O.H., Executive Edi- tor REV. MATEO BAUTISTA, Argentina REV.FELICE RUFFINI, M.I., Associate Editor MONSIGNOR JAMES CASSIDY, U.S.A. REV.RUDE DELGADO, Spain REV.RAMON FERRERO, Mozambique REV.BENOIT GOUDOTE, Ivory Coast PROFESSOR SALVINO LEONE, Italy REV.JORGE PALENCIA, Mexico EDITORIAL BOARD REV. GEORGE PEREIRA, India MRS.AN VERLINDE, Belgium PROFESSOR ROBERT WALLEY, Canada REV. CIRO BENEDETTINI DR. LILIANA BOLIS SR.AURELIA CUADRON REV. GIOVANNI D’ERCOLE, F.D.P. DR. MAYA EL-HACHEM REV. GIANFRANCO GRIECO REV. BONIFACIO HONINGS, O.C.D. EDITORIAL STAFF MONSIGNOR JESÚS IRIGOYEN REV.JOSEPH JOBLIN DR. COLETTE CHALON REV.VITO MAGNO, R.C.I. DR. ANTONELLA FARINA DR. DINA NEROZZI-FRAJESE DR MATTHEW FFORDE DR. FRANCO PLACIDI REV.BERNARD GRASSER, M.I. REV.LUCIANO SANDRIN DR.GUILLERMO QWISTGAARD MONSIGNOR ITALO TADDEI

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Contents

6 Address of Homage to the Holy Father 29 IV: New Emerging Infectious Dis- H.E. Javier Lozano Barragán eases: The Globalized Public Health Crisis of the New Millennium 7 Address by the Holy Father Dr. Mary Healey-Sedutto

HEALTH CARE AND SOCIETY SECTION II THE ILLUMINATION OF THIS REALITY

34 thursday I: Theology and Medicine 16 november Rev. Dr. Angelo Brusco 42 II: Contemporary Questions 10 Introduction of Moral Theology H.E. Mons. Javier Lozano Barragán H.E. Willem J. Eijk

11 Medicine and Society H.Em. Card. Fiorenzo Angelini friday 17 november 13 Medicine Today in the Light of the Word of God H.Em. Card. Darío Castrillón Hoyos 51 III: Medicine and Cultural Change Prof. Diego Gracia Guillén SECTION I ACONFLICTING REALITY 58 IV: Light in Inter-Religious Dialogue 58 18 I: The Limits of Technology IV.1 Judaism and Health Care Prof. Alfons Hofstetter H.E. Mr. Yosef Lamdan 61 IV.2 A Light in the Inter-Religious 21 II: Dehumanization in Intramural Christian-Islam Dialogue: and Extramural Health Care, the Virtue of Compassion its Underlying Causes, Rev. Maurice Borrmans and Expectations for the Future 65 Prof. Joannes P.M. Lelkens IV.3 Hinduism Prof. Elena De Rossi Filibeck 69 24 III: The New Health Care Workers IV.4 Light in the Inter-Religious Dr. Orville B.R. Adams Dialogue: Buddhism gg

H.E. Ronarong Nopakun 95 Rev. Prof. Anthony Fisher SECTION III IV: The Teaching of the Future ACTION TO BE TAKEN Professionals of the World of Health and Health Care 73 Dr. Tomás Barrientos Fortes I: Pastoral Care in Medicine Today Rev. Mario Bizzotto saturday 18 80 november II: The Hospitals of the 20th Century: Ancient Charity and Modern Technology Rev. Michael D. Place 99 V: The Training of Chaplains 85 Rev. Rudesindo Delgado Pérez III: The New Frontiers

The illustrations in this edition are taken from the book: “Le copie dei mosaici antichi di Ravenna” published by Promo, Promozione Mosaico and the Municipality of Ravenna, Italy

6 HEALTH CARE AND SOCIETY

ADDRESS OF HOMAGE TO THE HOLY FATHER

Most Holy Father, Over recent days some of these new needs and requirements have been the subject of study: we in the context of the Great Jubilee we have gath- have considered the frontiers of medical technolo- ered together to celebrate our fifteenth internation- gy, the new places of care and treatment, the local al conference, which this year is held on the sub- areas, the new health care workers, the new sick, ject ‘health care and society’. In this Jubilee year the new emerging illnesses, the new meanings of we are experiencing the newness of Christ in our pastoral care in health, the new moral questions, lives so that the contemporary relevance of his inter-religious dialogue in these areas, and the message becomes the motor and the reason for be- training of health care workers, chaplains and vol- ing of our existence. This alive presence of Christ untary workers. has led us in this conference to address ourselves Most Holy Father: it is specifically in relation to to the pressing and topical subjects connected with these complex questions that we most have need of medicine and health in our society. your thought, so that you can enlighten us and Holy Father: in the constitution ‘Pastor Bonus’ guide us with the example of Christ, the divine you entrusted to this Pontifical Council for Health physician of bodies and souls. Pastoral Care all those who engage in service for We humbly ask Your Holiness for your authorita- the infirm so that the apostolate of compassion the tive words and we beseech the Apostolic Blessing. infirm await corresponds in ever an more effective H.E. JAVIER LOZANO BARRAGÁN, fashion to new needs and requirements (Apostolic President of the Pontifical Council for Health Pastoral Care, Constitution ‘Pastor Bonus’, 11. 151). the Holy See. gg

DOLENTIUM HOMINUM N. 46/1-2001 7

ADDRESS BY THE HOLY FATHER Medicine Must Serve Man’s Total Wellbeing

Venerable brothers in the Episcopate and the known because of social pressure and the power- Priesthood, ful impact of technology on individuals. There- Distinguished Ladies and Gentleman, fore, it is necessary to recover certain criteria of ethical and anthropological discernment, which 1. I am pleased with this meeting which allows make it possible to judge whether the decisions me to bring you my greetings on the occasion of taken by medicine and health care are really suit- the 15th international congress organized by the ed to the human being they must serve. Pontifical Council for Health Pastoral Care. I extend a particular greeting to the President of the 3. But prior to that, medicine must answer the Pontifical Council, Archbishop Javier Lozano question about the very essence of its mission. Barragán, whom I thank for the sentiments he has One wonders whether medical care finds its rai- expressed on behalf of everyone present. I ex- son d’être in preventing illness and, when possi- press my deep satisfaction to the organizers, as ble, in overcoming it, or whether one must accept well as to the distinguished scholars, scientists, every request for physical intervention because it researchers and experts who have wished to hon- is technically possible. The question becomes our this conference with their presence and pro- even broader if one considers the concept of fessional contribution. health itself. Today an idea of health restricted The days of the congress, which this year is dis- solely to physiological well-being and the absence cussing the important and complex theme of suffering is commonly recognized as insuffi- “Health Care and Society”, will help you to ex- cient. As I wrote in my Message for the World Day amine the new biomedical technologies and the of the Sick in this Jubilee Year, “health, based on difficult questions posed to the world of health an anthropology that respects the whole person, care by the profound social changes now taking far from being identified with the mere absence of place. Your meeting has encouraged a fruitful di- illness, strives to achieve a fuller harmony and alogue and a cultural and religious exchange be- healthy balance on the physical, psychological, tween qualified workers in the health society. spiritual and social level. In this perspective, the person himself is called to mobilize all his available energies to fulfil his own vocation and the Health cannot be limited good of others” (n. 13). This is a complex concept to physical well-being of health, which is more consonant with today’s sensibilities and is aware of the balance and har- 2. The theme of the congress highlights a reali- mony of the person as a whole: you do well to fo- ty of great importance and one in continual transi- cus your attention on this issue. tion, which should be carefully analyzed. In par- The question I asked above is important be- ticular, you have raised the problem of the rela- cause the profile of future health-care workers de- tionship between society and institutions on the pends on it, as does the style of the health centres one hand and those who manage the means of which one intends to establish and the very mod- health care, on the other. Profound changes are af- el of medicine which we want to guide us: medi- fecting the traditional structures of a society that cine at the service of the individual’s total well- is increasingly globalized and has difficulty in re- being, or, on the contrary, medicine marked by lating to the individual, while medicine is in- technical and organizational efficiency. You know volved in developing diagnostic and therapeutic that a medical science on the wrong track would methods which are ever more complex and effec- soon endanger not only the life of the individual, tive, but often available only to limited groups of but society itself. Medicine that aimed primarily people. Today the role of environmental causality at increasing its knowledge for the sake of its own in the genesis of certain diseases is also well technological efficiency would betray its original gg

8 HEALTH CARE AND SOCIETY ethos, opening the door to harmful developments. is asked of health-care workers. Experience Only by serving man’s total wellbeing can medi- teaches you that the sick person is asking for more cine contribute to his progress and happiness, and than a mere cure of the organic pathologies affect not become an instrument of manipulation and him. He expects support from the doctor in order death. to face the disquieting mystery of suffering and death. To give the sick and their relatives reasons 4. Distinguished biomedical scientists, in your for hope in the face of the pressing questions that activities you know well how to respect the beset them: this is your mission. The Church is methodological and hermeneutical laws proper to close to you and shares this impassioned service scientific research. You are convinced that they to life with you. are not an arbitrary burden, but an indispensable help that guarantees the reliability and communi- cability of the results obtained. May you always Christians are called to evangelize recognize with equal care the ethical norms at the world of health care whose centre lies the human being with his dignity as a person: respect for his right to be born, to 5. In a globalized society like today’s, with in- live and to die in a worthy manner is the basic im- creased technical potential but also new difficul- perative which must always inspire medical prac- ties, you have paid special attention during your tice. Do everything you can to sensitize the social congress to the new diseases of the 21st century. community, the national health-care systems and Nor have you failed to look at the conditions of their leaders, so that the considerable resources health care in certain regions of the world which directed to research and technical applications lack policies of support for primary care. In this will always have the total service of life as their regard, I have often had occasion to call on the re- goal. sponsibility of governments and international or- Yes, the centre of attention and care both of the ganizations. Unfortunately, despite praiseworthy health-care system and of society must always be efforts, in recent decades the inequalities among the person, considered in the concrete circum- peoples have seriously worsened. I appeal once stances of his family, work, social context and ge- again to those responsible for the destiny of na- ographical area. Reaching out to a sick person tions to do all they can to encourage suitable con- thus means reaching out to a person who is suf- ditions for solving such tragic situations of injus- fering, and not merely treating a sick body. This is tice and marginalization. why a commitment with the features of a vocation 6. Despite the shadows that still fall on many countries, Christians look with hope at the vast and varied world of health care. They know they are called to evangelize it with the vigour of their daily witness, in the certainty that the Spirit con- tinually renews the face of the earth, and that with his gifts he constantly spurs people of good will to open themselves to the call of love. Perhaps it will be necessary to take new paths to find suitable answers to the expectations of so many suffering people. I am confident that those who sincerely seek the total wellbeing of the person will not lack the necessary light from on high to undertake appropriate initiatives in this regard. Dear brothers and sisters, may Our Lady, Seat of Wisdom and Health of the Sick, invoked in Tradition as the New Eve, guide your way. You are committed to one of the noblest causes: the defence of life and the promotion of health. May the Lord sustain you in your quest and always grant you new zeal in your most noble service to your fellow men and women. With this hope, which becomes a prayer, I im- part my Blessing to you all. gg

Health Care and Society gg

10 HEALTH CARE AND SOCIETY

thursday 16 JAVIER LOZANO BARRAGÁN november Introduction

The Pontifical Council for Health their economic problems, to the the light that we can encounter Pastoral Care has already organised problems of committees of through inter-religious dialogue fourteen international conferences bioethics within hospitals, to the with Judaism, Islam, Hinduism, and on subjects of great contemporary new management of many hospitals Buddhism. relevance. Now, with the help of which belong or belonged to reli- Our conference will reach its God, we are about to begin this fif- gious orders and congregations, and practical conclusions by laying teenth international conference on to co-operation between hospitals stress upon pastoral care in contem- ‘health care and society’, that is to which are dependent on the public porary medicine, the situation of say on the subject of pastoral care in health system or those which are hospitals during our time, charity health in the present-day context of dependent on private non-Catholic and modern technology, new fron- the society in which we are living. systems. tiers, and the training of health care As an event within the framework It is our hope and wish that this workers, voluntary workers, and of the solemn reality of the Great Ju- international conference of ours chaplains. bilee, in this conference we will ad- will illuminate us deeply on the The quality of the speakers and dress ourselves to the inculturalisa- meaning of the world of health and chairmen is widely recognised tion of the Gospel within the con- health care in the light of the Word within the world context of health temporary context of health care. In of God, and that it directs and and health care. I would like to line with the basic process of incul- guides us in relation to the compli- thank each one of them for the kind- turalisation, we are face to face with cated moral problems which con- ness they displayed in accepting our two poles – the Gospel and health. temporary situations raise for us. invitation and for enlightening us From these two poles arises the We also hope and wish that to the with their learning and expertise in need for the Gospel to enter the very light provided to us by the Catholic the various fields which are touched heart of health and health care and Church we will add the clarification upon by our conference. to root itself in it, so that the world which will derive from dialogue I would also like to extend a very of health and health care becomes with the other religions, and that we special greeting to each and every transformed by the Gospel. This will reach practical conclusions in participant. You will take part in the pre-supposes a new evangelisation relation to the policies which various dialogues which will take of the world of health, that is to say should be followed in the various place and you will expound to us the transformation of health care in- fields of health care activity. your different points of view. As to Christian health care. This incul- With these perspectives, our con- you can see from the programme, turalisation of health and health care ference will open with a highly in- after a series of subjects which will constitutes authentic pastoral care in structive paper given by His Emi- be addressed by specialists a debate health. We must enter the funda- nence Cardinal Darío Castrillón will take place in which everyone mental values of the world of health Hoyos, Prefect of the Congregation will be able to participate. We hope and health care in order to transform for the Clergy, which will dwell up- and wish that the dialogues will be them and make them every time on contemporary medicine in the rich and interesting so that the mat- more in accord with the Gospel. light of the Word of God and then ters dealt with in the conference Our Ministry, which is rightly the enter into the realities of the world will be further clarified. Ministry of Health Pastoral Care, is of health and health care by touch- You are all welcome. We await interested in a direct and immediate ing upon the new frontiers of med- your fruitful co-operation. way in this subject, which specifies ical technology, the new places of It is an honour now for me to its character and provides it with its health care, the new workers of hand over to His Eminence Cardi- legitimacy. How can we inculturise health, the new kinds of patients, nal Fiorenzo Angelini, the Emeritus the Gospel in the world of health and emergency illnesses. After this, President of this Pontifical Council, and health care? continuing the illumination of reali- who will be so kind as to extend his During this conference without ty which we will receive from this greetings to those who are present. doubt suitable answers will be pro- paper, we will refer to the history of vided which respond to the contem- medicine, especially during epochs H.E. JAVIER LOZANO BARRAGÁN, porary globalisation of health and of cultural change, so as to then deal Archbishop-Bishop Emeritus of Zacatecas, health care, to the problems of bio- directly with the subjects of theolo- President of the Pontifical Council for genetics, to the problems of the new gy and medicine, the contemporary Health Pastoral Care, situation of Catholic hospitals, to questions of moral theology, and the Holy See gg

DOLENTIUM HOMINUM N. 46/1-2001 11

FIORENZO ANGELINI Medicine and Society

For those people who work in the every human being can grasp by the field are choices between civilisa- field of health care and health, to light of reason; thus it necessarily tion and anti-civilisation. speak about medicine and society concerns everyone’.2 Just as the advance of science and means above all else to speak about If the defence and the promotion technology is the fruit of constant medicine and civilisation, about of life are the field of civilisation in study and requires increasingly in- medicine and morality. which society calls upon medicine tense training, so also is it the for- The level of maturity of a society to operate, it follows from this that ward path of a society which wants depends on the civilisation which there is a very close connection be- to be of sufficient stature in relation inspires its laws and structures and tween civilisation and the ethical to the instruments which science guarantees that practice is consis- and moral vision of the human per- places at its disposal. tent with them. son, and thus between medicine and We must objectively recognise The Hippocratic oath itself has as society. that even in the case of the most its premise and assumption a moral Indeed, we are called upon to well trained and aware health care vision of human life – a vision of adopt a moral approach – towards workers the wish to be fully up to service to life, to the sacredness and the defence of unborn life and date in relation to knowledge of the inviolability of life, and to the qual- against abortion; towards responsi- increasingly advanced technical op- ity of life. ble motherhood and fatherhood and portunities which are offered by This is not a vision of life which against selfish population control; medicine tends to place in the shade is exclusive to Christians, or which towards the medicine of transplants a corresponding ethical and moral is under the banner or in the name and against genetic biology which grounding and training. of a religious faith. As the Holy Fa- threatens the roots of the individu- More than was the case in the ther John Paul II has stressed with ality of the human person; towards past, human reason must today be- great force and emphasis: ‘No sin- the safeguarding of the right to die come aware that it must not remain gle person or group has a monopoly in peace and against euthanasia; to- a prisoner of advances which, once on the defence and promotion of wards the humanisation of medi- they have been achieved, bring to life. These are everyone’s task and cine and against every bureaucratic the fore frightening possibilities responsibility’.1 Although it is true, and depersonalising form of medi- which only a broader vision – of a in fact, that ‘faith provides special cine; towards the right of everyone spiritual and transcendent charac- light and strength’ in relation to the without any exceptions to health, ter – can control in the right way.3 question of life, ‘in no way is that and this without any form of dis- It is specifically the rational value a concern only of believers. crimination. analysis of the imbalance, the state The value at stake is one which The choices of society in this of ill-being, and the illness which afflict modern man, the creator and at the same time the victim of technological progress, which brings out a new idea of health – an idea which is more complete and global. This postulates an anthropological diagnosis which reaches the spiritual patient, which discovers, that is to say, the roots of the malady, in addition to the mechanisms and the spectrum of his physical reality and his psyche. Medicine in its expressions in prevention, diagnosis, therapy and rehabilitation, works with rigour and methods that are not arbitrary in character. Society must be aware of this truth. There must, therefore, be a medi- gg

12 HEALTH CARE AND SOCIETY

Christ himself, fuses the human with the divine in the synthesis of love. ‘Man cannot live without love. He remains for himself an in- comprehensible being, his life is without meaning, if love is not revealed to him, if he does not encounter love, if he does not experience it and make it his own, if he does not participate in it strongly’.4 ‘Institutions are very important and indispensable. However, no institution can alone take the place of the human heart when one is dealing with encountering the suffering of another person’.5 Contemporary society, and this is especially the case in advanced countries, suffers from an insufficient interaction between profes- sionalism and sensitivity, between profession and vocation. Only from their mutual encounter can there mature that civilisation of service which is cine of the spirit, almost a form of able to give of its best but is also ex- clearly the safest parameter of a spiritual ascetics which helps to posed to extremely dangerous form of medicine which is of suf- prevent the spirit from falling into forms of being used and exploited. ficient stature to match the ad- the shadows of modern anxiety, or Today there is much talk about vances achieved by science and which helps to liberate it from those health policies directed towards up- technology. shadows if it has already fallen prey holding and ensuring the universal to them. human right to health and to quality His Eminence Cardinal In other words, in order to solve of life. FIORENZO ANGELINI, the dilemma, man, whether creator The lines along which every au- President Emeritus of the Pontifical or victim of technical progress, thentic and effective health care Council for Health Pastoral Care, must engage in a non-scientific policy can and must run are those of the Holy See. choice, a choice which is ethical the promotion and defence of life and spiritual, that is to say a choice welcomed as a gift of God. A so- in favour of civilisation. A rational ciety which sees the practice of choice, not an emotional choice. medicine in these terms is called Notes All this certainly does not in- upon to have a very positive appre- 1 JOHN PAUL II, encyclical letter, Evangelium volve an ambiguity in the meaning ciation of voluntary work, some- Vitae (25 March 1995), n. 91. of the term and concept of ‘health’ thing which is seen not as a 2 Ibid., n. 101. but means, rather, its necessary stand-in for the inadequacy of 3 C.J. PINTO DE OLIVEIRA, La Crisis della Scelta Morale nella SocietB Tecnica (Turin, completion. This is because a man structures and staff but as a stimulus 1978), pp. 65-66: ‘The problems raised or made cannot become healed if the therapy which enriches both. more acute by technological civilisation and, at does not reach the psyche and does The Christian response to this re- the same time, the questions of the men and women of our time converge to remind us of not heal that unitary nucleus which ality is to be found in the Gospels the dangers of the domination of a one-dimen- can only be expressed adequately where it is expressed not in philo- sional rationality. The scientific approach, the with the term spirit. sophical or theological terms but multiplicity of the branches and times of its research, the limits to knowledge and its commu- The health of the spirit is not on- through an image which is even nication, are all factors which throw new light ly a pre-condition of mental-physi- more exhaustive and complete in on the possibility and the universal and coher- cal health but an authentic libera- character, namely the image of the ent use of reason. Human reason presents itself today, with greater force than was once the tion of resources. It is thus an in- Good Samaritan. case, as a multi-dimensional capacity for strument for the real co-ordination The Good Samaritan, although knowledge and reveals its deep coherence only of the progress of science itself, placed in a historical period which at the price of reflection which is as necessary as it is difficult. From a directly ethical point of where everything is at the service of had no knowledge of the modern view... reason is endowed with multiple and a worthy quality of life. advances of medical science, is a correlative intentionality, as a capacity to deci- Every analysis of the socialisa- figure achieved by a mature civili- pher the world and man as an individual subject, as inter-subjective communication, as votion of medicine and the relation- sation because he bends down ‘with cation to development, that is to say, as rising ship between its practice and social love’ over the wounded man, who above, as transcendence’. structures must act on those premis- asks for the retrieval of his life. 4 JOHN PAUL II, encyclical letter Redemptor Hominis, n. 10. es, abandoning which medicine, in Expressing himself as love, the 5 JOHN PAUL II, encyclical letter Salvifici Do- all its expressions, is not only un- Good Samaritan, that is to say loris, n. 29. gg

DOLENTIUM HOMINUM N. 46/1-2001 13

DARÍO CASTRILLÓN HOYOS Medicine Today in the Light of the Word of God

1. Introduction made flesh and came to live born at Bethlehem and saw his first amongst us’.2 human face, certainly that of his In this Jubilee year the whole of Two thousand years ago an ovule Mother, with eyes which had re- the Church is celebrating the two was fertilised in a prodigious way cently opened. thousand years which have passed thanks to the supernatural action of Thus it was that Jesus Christ be- since the Incarnation of the Word of God. What a happy phrase is the fol- came the first born of every crea- God. This is a very meaningful his- lowing: ‘The Holy Spirit will come ture,5 the new Adam of the new cre- torical moment, when our minds upon thee, and the power of the ation. and our hearts are engaged in trying most High will overshadow thee. The Son of God redeemed cre- to penetrate the mystery of the Word Thus this holy offspring of yours ation with the most marvellous of made flesh, a truth of faith which, shall be known for the Son of God’!3 works – the human being. The re- however, is something which, with Thus it was that from this marvel- demption of man, indeed, began our poor human intelligence, seems lous union there sprung a zygote with the embryonic state. For this to us something which it is difficult which had its own chromosomal en- reason, the Catholic medical doctor to accept. Goethe, the multi-talented dowment. But in this zygote was the must have the following approach German man of letters, recognised Word of God. In him was placed the in order to understand his own mis- that ‘the supreme happiness of the salvation of men. sion – the Son of God was a zygote, rational being consists in exploring About seven days after this event an embryo, and a foetus, before the whole of that which can be in- there took place the nidation of the playing in the streets of Nazareth, vestigated and silently venerating blastocyte in the mucous of the en- before preaching on the shores of that which cannot be investigated’. dometrium and God was thus re- the Sea of Galilee, or before dying In the mystery of the Incarnation of duced to being a human embryo. crucified in the environs of Christ there come together the two However, this embryo was the Son Jerusalem. The Son of God com- elements of that which can be inves- of God and in him was placed the pletely, and without any reservation tigated and that which cannot be in- salvation of men. at all, took on the vocation of being vestigated – science and mystery. This alecithal egg developed a man. slowly and as the segmentation of the egg gradually developed, its dif- 2. Medicine in the Light ferentiations and the growth of the 3. Medicine and Creation of the Mystery first forms of tissue, organs and em- of the Incarnation bryonic apparatus began to appear. During the twentieth century sci- This new alecithal entity was the ence has achieved great advances. It We have to engage in violence Son of God, the Second Person of has been able to identify almost the against our minds in order to dis- the Trinity, and in him was placed whole of the human genetic code, it cover in the mystery of the develop- the salvation of men, of all men, of has broken the mystery of the ori- ment of a human embryo the Word each and every human being.4 gins of life, and has managed to of God which was made man. To- In the first month of pregnancy, penetrate deeply into the process of day, two thousand years after the when the foetus already measured conception. Despite this fact, it still birth of Christ, we find ourselves in from 0.8 to 1.5 centimetres in size, has some things to do: the study of the condition of being able to de- the heart of God began to beat with man as man, in all his profundity. scribe all the stages of the process of the strength of the heart of Mary and Not man as biology, nor man as psy- growth and development of an em- to use the umbilical cord to gain chology, but the human essence. bryo, but we go on turning to faith nourishment from his mother, the Man in his profundity: his ideals, his to understand that the God who Immaculate Virgin. The Word of must unconfessable fears, his moti- gives life, the Creator, the Lord of God totally depended upon a human vations, his questions and answers, all things, the Second Person of the being, yet at the same time he pos- his world of affections, his capacity Most Holy Trinity, the Word which sessed total genetic autonomy. to overcome things, and his disap- has the same nature as the Father,1 is However, nine months had to pass pointments, love and pain. One can present at all of the stages of the de- while the Word of God was in amni- say that science is outside the doors velopment and growth of the em- otic liquid, in the placenta which of the human spirit in the same way bryo. This and only this is the pro- protected him from the cold and the as it might be face to face with a for- found meaning of the phrase to be heat and provided him with nourish- eign field which cannot be penetrat- found in the Gospels: ‘the Word was ment and oxygen, before he was ed. There is, however, almost a be- gg

14 HEALTH CARE AND SOCIETY lief which is held by the scientist We often have the impression that pain. He wants to uproot it at any who draws near with honesty to the the human person is not perceived cost from his life, but he has also be- study of man, and that belief is that in the sick person and that only a bi- gun to realise that this is impossible. not everything ends with genetics, ological individual is seen. This is Hedonism has led us to search for with psychology, or with psychiatry. something which is explicable giv- perfect health, for eternal youth, and There is a spirit which goes beyond en the technological character of for the fullness of strength pro- biology, physics, chemistry, and medical care and treatment but it is longed for as much time as possible. mathematics, a spirit which attracts something which does not corre- And in this project, the appearance our attention, the same spirit, in- spond to the human nature of the of illness, of pain, and of desolation deed, which makes every act of re- sick person, a person who suffers, becomes something which is bitter, search possible. because ‘the sick person must feel something which is unacceptable. Man is a psychosomatic unity of that his illness is understood as an Where is this search for perfection soma and psyche. In the embryonic event of life, and understand recov- when the human being finds himself state there is a mystery and a special ery as an act which helps life, not as face to face with incurable illnesses dignity – that of the spiritual being. the mere repairing of the defect of a such as AIDS? Where is technology And this is something which medi- machine. But in turn, this is impos- when in our hands there is not to be cine cannot forget about. Today, sible without a specific ethical ap- found that pill which provides an when we see human beings used as proach, that is to say without pro- immediate remedy? Where is sci- laboratory matter or thrown away in found respect for life and without ence to be placed before the in- the form of frozen embryos; when matching sympathy for life. To lay evitable reality of death? Why has we see terminally-ill people isolated stress on all this is not sentimental- human genius not been able to dis- in wards equipped with the latest ism, but, on the contrary, belongs to tance the weight of the cross from discoveries of technology but with- the essence of the health care ap- the life of man? out the affection and the nearness of proach’.7 Human life is full of crosses their loved ones, a question comes Man must exercise his lordship which we cannot destroy, a thou- into our minds: is it not the case that over the creation which has God has sand crosses which touch us from science is forgetting about the deep- entrusted to him,8 but his lordship nearby or from a distance. There are est part of man and in fact merely over the creation begins with lord- many forms of human pain which disdaining what escapes its field of ship over himself. The medical doc- do not have their medical remedy. study? tor is certainly someone who lives In the face of this problem, what ap- The mystery of man us the mys- out this struggle with greater clarity, proach should we adopt? That of the tery of a being who is a citizen be- a struggle, that is to say, to dominate masochist who enjoys pain? No! We longing to two worlds. An animal? the creation in the realm of life and should adopt that of the human be- Yes! A biological being? Yes! But bring it to the service of man. With ing redeemed by Christ who sees in he is also endowed with an ungras- research or treatment he struggles to pain a path of love, the approach of pable and unfathomable spirit. A grasp in his innermost being the be- Christ in front of the cross. ‘Pain Son of God, a Brother of Jesus haviour of nature and to direct it to- and illness are a part of the mystery Christ. A being who is social by his wards the good of the human being, of man on earth. It is certainly the nature and needs the human pres- towards the maintenance of life. But case that it is right to fight against ence of his own kind in order not to he should not forget that he must do illness because health is a gift of feel that he is a stranger in his own this beginning with himself, with God. But it is also important to environment. An imperfect creature the molecules of his own being, know how to read the design of God who experiences pain, but at the with his own worries and cares, when suffering knocks at our door’.9 same time a creature redeemed by with his own fears and his own Jesus was not a masochist, but Christ. The intensive treatment wishes to love and to be loved, with loved the pain which he threw off.10 wards where so many patients his own life, and above all else with Here is the basis of the acceptance struggle between life and death his own spirit. The medical doctor of pain. Here we encounter his have been taken over by technology, sees in himself the man he cares for teaching: ‘if any man has a mind to which is welcome, but they have and treats, he experiences within come my way, let him renounce left out the comforting presence of himself what his patients experi- self, and take up his cross, and fol- families or the zealous spiritual sup- ence, and it is from here that there is low me’.11 To follow Christ we must port of a priest. Technology seems born a compassion and a very spe- renounce ourselves and take up that to have triumphed over the spiritual cial human nearness to the human cross. ‘Christians must imitate the aspects of man, when in fact what is being who suffers, with the person sufferings of Christ, and not try to needed is a complementary relation- who turns to him. achieve pleasure. One comforts a ship between the two. Technology? faint-hearted person when one says Yes! But without forgetting about to him: resist the temptations of this this intimate dimension of the hu- 4. Medicine in the Light century, the Lord will free you from man spirit which continues to slip of the Mystery of Pain everything if your heart does not out of the hands of medical science. draw away from him. Because pre- ‘You should know that the human This observation brings us to an- cisely to strengthen your heart he being infinitely rises above the hu- other mystery in which medicine came to suffer, he came to die, to be man being’.6 How tragic it must be finds itself at the end of this century spat on in the face and to be for a paediatrician to see the life of a – the mystery of pain. The man of crowned with thorns, to listen to in- child slip out of his hands! the twentieth century is averse to sults, and to be, finally, crucified. gg

DOLENTIUM HOMINUM N. 46/1-2001 15

Everything that he did, he did for ourselves in such conditions, after self, without reserve, without atten- you, while you were not able to do recognising our faults and abandon- uations, and without falsehood. anything for him, only things for ing the use of medicine we must The Pope also said that pain is al- yourself’.12 bear this suffering in silence, in con- so a test,23 a test that gives proof of ‘For two thousand years, from the formity with he who proclaimed: “I love, which makes the love of God day of the Passion, the Cross has will bear the disdain of the Lord be- in the world present. Human suffer- shone forth as the highest expression cause I have sinned against Him”;18 ing is often an expression of love. of the love of God for us. The person and we must also correct ourselves Pain felt for the loved being who is who knows how to receive this, in to the point of eating the fruits of reno longer near to us is a new way to his life experiences how pain, illu- pentence, once again remembering express our love for him. The same minated by faith, becomes a source the Lord who declared: “Behold love which previously was borne thou hast recovered thy strength, do witness to in caresses or embraces not sin any more, for fear that worse now becomes pain provoked by an shall befall thee”.19, 20 In this instance absence. illness is also the path which leads Love and pain constitute a tan- to conversion. dem which is closely bound up with His Holiness John Paul II is a our Christian faith. Love and pain teaching master of the meaning of are realities which exist in a way pain, and he has taught us to find the which is closely bound up with the meaning of this mystery which tor- Christian images which fill our ments man. He is a Pope who is churches, our times, and the deepest very near to human suffering. He part of the Christian heart. Love easily identifies with the pain of which has become pain and pain sick people, shares the misfortune which is always alive in love, fol- of others, is concerned with all those lowing the example of Christ. Pain men who seem to be afflicted in a without love generates only afflic- physical or spiritual way. I remem- tion and desperation, rebellion and ber, for example, a moment when, dejection. Love without pain is frag- during an apostolic visit to Brazil, a ile, superficial, incomplete, and street child broke through the secu- changeable. The culture in which rity barrier and drew near to the we are immersed promises happi- Holy Father to ask him for alms. ness in this life and presents it as be- The Pope took off his ring and gave ing something which is near to it to the child. Through this gesture hand, something which it is easy to we discover the heart of a compas- build up without the expenditure of of hope and salvation’.13 The sign of sionate man who is near to the pain further effort, but we human beings the disciples of Christ is this gener- of other people. know by experience that happiness ous acceptance of suffering, some- Seeing John Paul II one can use in love requires sacrificial personal thing which is absurd for today’s that phrase of St. Paul: ‘in this mor- self-giving. Pain can be a path to- man and for the man of all times, tal frame of mine I help to pay off wards love and it is authentic and something which is foolishness,14 the debt which the afflictions of complete love only if it is arrived at perhaps because, as St. Paul said, Christ leave to be still paid, for the through the pain of personal self-de- ‘Mere man with his natural gifts sake of his body, the Church’.21 It is nial in favour of another person. cannot take in the thought of God’s precisely with this sentence that the Pain is also a path of hope thanks Spirit; they seem mere folly to him, Pope begins his apostolic letter to the Resurrection of Jesus Christ. and he cannot grasp them, because Salvifici Doloris. It captures his It is what is reflected in the face of they demand a scrutiny which is deep reflections on human suffering the Pietà by Michelangelo – here we spiritual’.15 But let us return to the united to the cross of Jesus Christ. encounter pain provoked by the spirit of man, something which goes Suffering, in the profound dead Son, and at the same time a beyond the progress of science. thought of Pope John Paul II, is ‘re- serene hope that everything does St. Basil observed that ‘often, de- ally supernatural and at the same not finish here. There is something spite themselves, illnesses are pun- time human because it is rooted in which comes after. Pain is not the ishments for sinners, sent for our the divine mystery of the redemp- purpose of human existence but a conversion. The Lord, it is written, tion of the world, and it is, equally, stage, an Easter towards salvation. punishes those he loves’.16 And later profoundly human because in it Pain is salvific in nature. on he goes on to add: ‘It is for this man finds himself, his own humani- Pain lived out with a sense of reason that in your midst there are ty, his own dignity, his own mis- eternity is a sign of hope for the many sick and infirm people, and a sion’.22 Pain is the profound moment world of today. Just as the ‘Good good number who have died. If, when the human being finds himself Thief’ of the Gospels is moved and however, we carefully examine our- with himself. Those who have becomes converted when he sees selves, we are not judged. When, worked in the field of pastoral care the suffering of Jesus Christ,24 so the however, we are judged by the Lord in health know the very dramatic Christian response to human suffer- we are rebuked for not having been truth to be found behind this state- ing is certainly one of the greatest condemned together with this ment. Pain is a moment when man signs working for the credibility of world’.17 For this reason, if we find is presented face to face with him- the Gospel. To accept pain and to gg

16 HEALTH CARE AND SOCIETY serve those people who suffer are Medicine is a discipline which dis- we have also been offered the help the great messages of contemporary covers in man his highest dignity of medicine so that in certain con- Christianity for a world which is not and turns to God as the ultimate ref- texts and to a certain extent the sick inspired by solidarity and which of- erence of this dignity in order to go can be healed. ten despises the person who suffers. beyond the limits of its knowledge: Thus it is no accident that in the Pain lived out in sacrifice for others ‘What or who was the motive lying earth plants have been created is the sign of the disciple of Christ: behind why you made man with which are destined for the treatment ‘to celebrate the Eucharist by eating such dignity? Certainly, nothing that of every illness, More than this, they his flesh and drinking his blood was not the inextinguishable love find their origins in the will of God, means to accept the logic of the with which you contemplated your so that they could reduce our mal- cross and of service. It means to be creature in yourself and you al- adies. Precisely for this reason, that ready to sacrifice oneself for other lowed yourself to draw near out of natural curative effectiveness found people, as he did’.25 Pope John Paul love for him. You created him out of in roots, in flowers, in leaves, in II sees his suffering as service to the love, out of love you gave him a be- fruits, and in juices, as in everything Church. To suffer is to serve, he ing able to experience your eternal that minerals or the sea have which says in the apostolic letter Salvifici Goodness’.28 The sick person is not is therapeutic, is not different from Doloris.26 It is the completion of Je- only an object of study of medicine, similar elements discovered in food sus Christ in favour of the Church. but a neighbour who must be served or drinks... Christians must seek to The Pope sees his suffering as a way with the generous dedication of use medicine when this is necessary of living his own identity as the ‘ser- one’s own life and with the admira- so that they do not attribute to it all vant of the servants of God’. A man tion of one who knows that he is be- the causes of good or bad health, whose vocation is not that of living fore a being who has his own digni- and use the means that medicine of- for himself but that of living for oth- ty and his own mystery: the dignity fers us to render glory to God... In er people. of the son of God and the mystery of no case, and certainly not because the triune dwelling place. some people use medicine in a stu- In this sense, medical science is a pid way, should we renounce its 5. Medicine in the Light gift of God which allows man to re- usefulness. In reality, it is not be- of the Mystery of Love deem one of the most visible effects cause certain intemperate persons, which sin has left in his nature – ill- in practicing the art of the kitchen or This last thought introduces us to ness. St. Basil explained this with the bakery or clothes, engage in the core of the medical profession, language which it seems to me was abuse in their approach to volup- today and always – love for man. very eloquent in its simplicity: tuous things, going beyond the lim- Medicine is not a theoretical sci- ‘When our body is sick, reduced by its of necessity, that all arts should ence which proclaims simple laws infirmity or disturbances of various be rejected by ourselves... The ben- and theories following the empiri- kinds, for external or internal caus- efits of good health are given to us, cal-theoretical method. It is some- es, because of food eaten, because both by wine mixed with vinegar,30 thing more, it is science placed at of its excess or its lack, God, the as in the case of he who found him- the service of man in relation to moderator of our existence, has self with the thieves, and by figs, as what is most valuable in him, life, granted to us the gift of medical sci- in the case of Ezekiel’.31, 32 because life is the basis of other ence, thanks to which the superflu- The medical doctor and the health gifts. Medicine is a science which ous is cut down to size and what is care worker work together in the becomes service and ‘service’ is the found in reduced measure is in- fight against the effects of sin, the best word to define the approach of creased. Indeed, if we were in heav- ultimate cause of illness. Medical Christ adopted towards man during en we would not in any way need to doctors know what this redemption his life amongst us – to serve and know or practice agriculture, and at of our bodies referred to by St. Paul give his life to redeem many.27 The the same time if we were immune to means.33 Their struggle against biomedical doctor, the health care illness, as was the case before the logical malady is a sign of the love worker, place their own lives at the Fall, we would not need the help of of God which continues to recon- service of others in sacrificing medicine to heal us. Despite this quer the creation through man. The themselves. How many forms of fact, after being expelled from that health care worker uses the gifts of care and treatment for the sick per- place and heard declared: “with the man to serve his brothers and sis- son, how many hours of dedication, sweat of your brow you will eat ters. If man, each and every man, how many deprivations, and how bread”,29 after making a great deal can co-operate with man in his many sacrifices made out of love in of effort to cultivate the land, we in- salvific action, then it also the case the attention paid to neighbours vented the art of agriculture to miti- that medicine struggles against the who suffer! gate the harmful effects of divine disorder that sin left in the world. Medicine is love which provides malediction, while God himself fos- Medical doctors and health care a remedy for pain. It is compassion, tered in us intelligence and knowl- workers: you should be signs of this loving drawing near to the sick per- edge of that art. Then, in the same love of God for man. You should be son, who is seen as a neighbour who way, given that we were ordered to men and women who place their suffers. It is a technical reality return to that same clay from which own lives at the service of man, which studies how to provide a rem- we were formed and given that we fighting against evil and triumphing edy to pain. It is a science that draws are bound to our suffering flesh, over it with love. You should be in- near to the human being, a sinner, destined for death because of sin struments of the mercy of God, you but a very much loved son of God. and subject because of it to illness, should be the presence of the re- gg

DOLENTIUM HOMINUM N. 46/1-2001 17

demptive love of Christ who wel- richness which is manifested to us 11 Cf. Matthew 16:24; Luke 9:23. 12 ST. AUGUSTINE, Sermons on Pastors, Ser- comes and cures. You should not al- in his works, and they would also be mon 46:10-11. low your vocation to become lost in worth nothing if this fact escaped 13 JOHN PAUL II, ‘Omelia in Occasione del a cold and distant pragmatism our instruments of study. We respect Giubileo dei Malati e degli Operatori Sanitari’ (‘Homily on the Occasion...’), Rome, 11 Febru- which does not go beyond technolo- man, we love man, we protect his ary 2000. gy and natural laws. The medical mystery, and we protect his spiritu- 14 ‘To those who court their own ruin, the doctor, the health care worker, can ality. message of the cross is but folly; to us, who are be a sign of the love of God amongst I would like to finish by referring on the way to salvation, it is the evidence of God’s power. So we read in scripture, I will men, people who place their own to the Most Holy Mary, the Mother confound the wisdom of wise men, disappoint heart amidst human misery. This is who gave her generous ‘yes’ to the the calculations of the prudent. What has be- compassion, the weakness of God, Incarnation of the Word,34 and who come of the wise men, the scribes, the philoso- phers of this age we live in? Must we not say and our strength. accompanied the wounded Christ in that God has turned our worldly wisdom to fol- his trial,35 when he was covered with ly? When God shewed us his wisdom, the wounds, ill-treated, and had the world, with all its wisdom, could not find its 36 way to God; and now God would use a foolish thirst of the dying. The reality of thing, our preaching, to save those who will be- this ordeal is the reality which we lieve in it. Here are the Jews asking for signs live out in many first aid wards. and wonders, here are the Greeks intent on their philosophy; but what we preach is Christ cruci- Mary accompanied the bleeding fied; to the Jews, a discouragement, to the Gen- and bruised wounded Jesus, who tiles, mere folly; but to us who have been looked at his Mother, from whom he called, Jew and Gentile alike, Christ the power received comfort. For this reason, of God, Christ the wisdom of God. So much wiser than men is God’s foolishness; so much we Christians, when we feel op- stronger than men is God’s weakness’. (I pressed by pain, have learnt from Corinthians, 1:18-25). Christ to find refuge in the arms of 15 I Corinthians, 2:14. 16 Proverbs, 3:12. Mary, like a baby who finds himself 17 I Corinthians, 11:30-32. in front of a danger and runs to the 18 Michea, 7:9. arms of his own mother and gives 19 John 5:14. 20 BASIL THE GREAT, Regole Lunghe, 55, 1-5. way to crying. May Mary, the con- 21 Colossians 1:24. soler of the afflicted, the help of the 22 JOHN PAUL II, Apostolic Letter Salvifici infirm, accompany us in this con- Doloris, 31, 11 February 1984. 23 Cf. Salvifici Doloris, 23. gress and help us to investigate 24 ‘And one of the two thieves who hung everything that can be investigated there fell to blaspheming against him; Save thy- and at the same time silently and self, he said, and us too, if thou are the Christ. 6. Conclusion humbly venerate what cannot be in- But the other rebuked him; What, he said, hast thou no fear of God, when thou are art under- vestigated! going the same sentence? And we justly In two thousand years, the human enough; we receive no more than the due re- being has learnt many things. He H.Em. Cardinal DARÍO ward of our deeds; but this man has done nothing amiss. Then he said to Jesus, Lord, remem- has a established a deeper relation- CASTRILLÓN HOYOS, ber me when thou comest into thy kingdom. ship with the reality which sur- Prefect of the Congregration for the Clergy And Jesus said to him, I promise thee, this day rounds him. One could say that to- the Holy See. thou shalt be with me in paradise’ (Lk 23:39-43). day he knows the created world 25 JOHN PAUL II, ‘Omelia durante la Chiusura with greater exactness, from the della XV Giornata Mondiale della Gioventj’ macrocosm to the microcosm. He (‘Homily during the Closing of the XV World Day of Youth’, Torvegata, Rome, 20 August has discovered the laws which 2000, 5. maintain life and the causes of ill- 26 Cf. Salvifici Doloris, 27. ness, laws which followed on from 27 Cf. Matthew 20:28; Mark 10:45. 28 Cf. ST. CATHERINE OF SIENA, Il Dialogo ancient conjectures which had no della Divina Provvidenza, 13, ed. G. Cavallini scientific basis. In recent centuries (Rome, 1995), p. 43. he has made gigantic steps forward 29 Genesis, 3:19. in the penetration and understand- Notes 30 Cf. Luke, 10:30-34. 31 Cf. 2 Kings 20:7. ing of the processes of human life. 1 Cf. the Niceno-Constantinopolitan creed. 32 Cf. BASIL THE GREAT, Regole Lunghe, 55, Precisely because of this, now that 2 Cf. John 1:14. 1-5. we know man better, now that med- 3 Luke 1:35. 33 ‘Created nature has been condemned to 4 Cf. Congregation for the Doctrine of the frustration; not for some deliberate fault of its icine has entered more into the se- Faith, the declaration Dominus Iesus 12-15, 6 own, but for the sake of him who so condemned cret of the transmission of life, now August 2000. it, with a hope to look forward to; namely, that that we advance in medical technol- 5 Cf. Colossians, 1:15-16. nature in its turn will be set free from the tyran- 6 B.PASCAL, ‘Apprenez que l’Homme Passe ny of corruption, to share in the glorious free- ogy and science, we also advance Infiniment l’Homme’, in PensJes. dom of God’s sons. The whole of nature, as we and go forward with greater respect 7 R. GUARDINI, ‘Etica, Lecciones en la Uni- know, groans in a common travail all the while. for this wonderful gift of God. All versidad de Munich’, c. 11,2, BAC, Madrid, And not only do we see that, but we ourselves 1999, p. 715. do the same; we ourselves, although we have our scientific efforts would be worth 8 Cf. Genesis, 1:28-30; 9:7. already begun to reap our spiritual harvest, nothing if they were not translated 9 JOHN PAUL II, ‘Omelia in Occasione del groan in our hearts, waiting for that adoption into a more complete service to- Giubileo dei Malati e degli Operatori dei Malati which is the ransoming of our bodies’ (Letter of wards each and every human being e degli Operatori Sanitari’ (Homily on the Oc- St. Paul to the Romans, 8:20-23). casion of the Jubilee of the Sick and Health 34 Cf. Luke 1:38. with respect for his integrity and in a Care Workers’), Rome, 11 February 2000. 35 Cf. John 19:25. compassionate view of the spiritual 10 Cf. Matthew 26:39. 36 Cf. John 19:28. gg

18 HEALTH CARE AND SOCIETY Section I A Conflicting Reality

ALFONS HOFSTETTER I: The Limits of Technology

The topic of my lecture is “The when technology has reached its should be surmounted, the barrier limits of technology as illustrated limits, all human activities and ad- to cloning human beings is no by an example from medicine – vances will come to a halt. That longer very great, i.e. this would the development of a vaccine cannot be. open the way to contravening es- against kidney-cell and prostate tablished moral conventions. carcinoma”. Genetic engineering is not to be Limits of technology equated with transcending moral boundaries. This is shown inter Technology without limits The limits of technology are alia by our endeavors in the field contingent on the laws of nature of carcinoma research. This re- New scientific knowledge and and the laws of civilization, ethics search is absolutely necessary to- the feasibility of technical solu- and morality. If we consider tech- day because cancer therapy in its tions suggest that today technolo- nology in the individual scientific present form appears to have gy has no limits, and that it can disciplines, it is evident that there reached definite limits in its pre- enable human beings to penetrate are plenty of constraints on the im- sent form of surgical operations, the endless depths of space and to plementation of scientific ideas. chemotherapy and radiotherapy, analyze the microcosmos down to However, it does not mean that or at least has not advanced fur- its molecular structures. This has these boundaries will be swept ther in recent decades. led not only to enormous changes away tomorrow or the day after in our scientific view of the world, and that the ostensible boundless- but it also of course affects the hu- ness will reappear. Experience in Gene therapy manities, and even religion and past decades has confirmed this spirituality. Are there not sects time and again. The concept of gene therapy who claim to have direct contact was originally developed to treat with the Godly on the basis of diseases based on genetic defects. new scientific knowledge? Ambivalence of genetic The intention was to correct the With its discoveries, the last engineering defective gene sequences by in- century made quantum leaps in troducing copies of healthy genes. technological progress. Today, we May I refer in this connection to This definition of gene therapy have to ask ourselves whether this the developments in genetic engi- was very quickly extended so that progress is only the beginning of neering, where gene-manipulated the term gene therapy now com- unlimited development or whether forms of agricultural plants sud- prises both therapy of genes and there are limits to these advances. denly develop properties of pest therapy with genes. Therapy with Space research, molecular biology resistance as well as resistance to genes is based on the specific in- and the quite unlimited possibili- environmental and climatic stress, troduction of new genes into the ties of the communication media so that there is justified hope that afflicted cell in order to achieve cause many people today to be- the problem of feeding the therapeutic effects. lieve that there will no longer be world’s population will be re- any progress without technology. solved. Further examples are the Are the humanities therefore sub- development of certain animal Gene therapy and cancer ordinate to natural sciences? Is it breeds and the cloning of animal only technical advances which en- species as well as the experiments In cancer therapy, various able social development, cultural to create spare organ stores by genes are currently being used and civilizational progress? If so, cloning stem cells from human with different mechanisms of ac- this would ultimately mean that embryos. If the latter boundary tion. The greatest role is played gg

DOLENTIUM HOMINUM N. 46/1-2001 19 by genes which modulate the im- the attempt to convert tumor cells vivo gene therapy. For example, mune system. Attempts are made into cells presenting good anti- the vectors which have been test- to stimulate immune cells (cells of gens by gene modifications. For ed so far and proved very suitable immunological defense) that rec- this purpose, genes for the costim- for in-vitro gene transfer (e.g. ognize and destroy tumor cells. ulation molecule (e.g. B7) and retroviral vectors) are not unsuit- Besides this, suicide genes are various cytokine genes are intro- able for gene transfer in vivo, used. Tumor cells which express duced into the tumor cells and since these only effectively trans- these genes die under the action their expression is induced. These fect dividing cells. New vector of certain dru gs. This kind of gene-modified tumor cells are systems which are derived from drug sedisitization is already used then administered to the patient as herpes simplex viruses and simi- in the treatment of melanomas, tumor cell vaccines in the hope lar viruses do not show these lim- various brain tumors and colon that the defense cells are activated itations and are currently under cancer. via the antigen-specific signal in development. Other approaches are based on combination with the costimula- In improving the efficiency of the expression of tumor suppres- tion and the cytokine secretion so in-vivo gene transfer, criteria such sor genes, e.g. p53, the overex- that the tumor is destroyed. as the safety of the vector system pression of which leads to apop- In our in-vivo and in-vitro in- used, regulation of gene expres- tosis (natural cell death). The vestigations, we encountered two sion and gene dose must be con- most recent approaches in gene different gene-modified tumor sidered. In this regard, vector sys- therapy are exploring the use of cell lines in kidney cell carcinoma antisense DNA, which is intended that express interleukin 2 and in- to suppress e.g. the expression of terleukin 7 in combination with protooncogenes such as c-myc or the costimulation molecule B7. factors of angiogenesis (angio- Both tumor cell lines have been statin, endostatin). available for some time in a multi- The currently high expectations center clinical phase I study as a of immunotherapy have resulted vaccine for treatment of metastat- from the constant increase in ic kidney cell carcinoma. knowledge of the signals required In using gene-modified tumor for efficient immunostimulation. cells as vaccines, the tumor cell is In the meantime, one is aware of used as a carrier for the tumor the central importance of im- antigens which obviates the need munological synapses, i.e. the to identify antigens leading to im- tems are being created with tissue- close contact between the anti- munostimulation. Tumor cells can specific and inducible promotors. gen-presenting cell and the de- produce immunosuppressive fac- A prostate-specific expression can fense cell (T cell). However, the tors (e.g. inhibitory cytokines), so be attained for example by using contact only leads to activation of that no immunostimulation is pos- the promotor for the prostate-spe- the defense cell when a second sible despite the presence of anti- cific antigen (PSA). Promotors in- signal arises via the interaction of gens and also after gene modifica- ducible with heat or promotors surface molecules (B7) on the tion of the tumor cells with cos- which are induced by means of antigen-presenting cell and the re- timulation molecules and activat- estrogens or tetracyclines can also ceptor on the defense cell. With- ing cytokines. However, this is specifically switch therapeutic out this costimulation, the de- not the only problem in our re- genes on and off. fense cells are not activated, but search. There are further prob- Genes which code for cy- are in contrast inactivated. lems which have not yet been re- tokines, costimulation molecules Molecular investigations indi- solved today. For example, anoth- or tumor antigens are suitable for cate that many tumor cells present er drawback in the use of turnor in-vivo gene transfer. The use of antigens that can be recognized cells as vaccines is the great ex- RNA (ribonucleic acid) isolated by specific receptors of the de- pense in terms of equipment and from tumor material is also con- fense cells. For this purpose, the time which is needed to produce ceivable. These genes can be di- tumor cells usually express suffi- an adequate number of cells for rectly administered in vivo or also cient adhesion molecules in order vaccination of many patients. Ex- charged ex vivo on antigen-pre- to stabilize the immunological perience so far with cellular vac- senting cells. The data available synapses mentioned above. How- cines shows that the cost factor up to now suggest that both a hu- ever, most tumor cells lack the and the elaborate technology does moral antibody response and cel- costimulation molecules that not allow broad-scale application. lular immunity can be induced in were also mentioned above, so Limitations accelerate the de- an in-vivo injection. that the defense cells are not acti- velopment of new concepts of Developments in recent years vated. Irrespective of this, most gene therapy. A promising con- have enabled ex-vivo charging of tumor cells do not secrete any cept is based on the introduction antigen-presenting cells with tu- substances promoting cell growth of immunostimulatory genes di- mor antigens, tumor lysates or (cytokines). This in turn prevents rectly into the tumor. New techno- heat shock protein-peptide com- an immune response. logical and methodological chal- plexes especially by creating the This definite information led to lenges result from this kind of in- conditions for in-vitro culturing of gg

20 HEALTH CARE AND SOCIETY antigen-presenting cells. The ad- ty of experience and new knowl- been predetermined. Despite all vantage is that the modified anti- edge which will bring us closer to the successes of research, human- gen-presenting cells can be inves- solving the problem of cancer. ity will not succeed in a real cre- tigated for their immunostimula- ation, that is to say creating some- tory properties before they are in- thing from nothing, not even in jected into the patients. The disad- Technical limits of gene the future. Notwithstanding all vantage is that the tumor antigens therapy technological progress, humans or peptides must be known. For will always only be discoverers example, many antigens are al- The example from our cancer and possibly inventors, but never ready known in melanoma so that research has demonstrated the creators. this concept is currently being technical limits and our efforts to tested with promising results in surmount them. These technical clinical studies. Knowledge of the limits can be overcome. However, Research as a human relevant antigens for most other there are other more important mission tumor types is still very scanty, so limits, namely moral and ethical that the challenge of the future is constraints which must be ob- We know from the first page of to identify antigens relevant for served and which must focus on the Bible that God called on hu- other tumors. the value and the dignity of human beings to care for His cre- Experience of the first clinical man life. ation while observing His laws. studies of vaccines produced Creation is hierarchical. At the top from tumor cells altered by genet- is the human being and his inner ic engineering and in-vivo admin- vocation – for the nonbeliever – istration of tumor peptides shows but for the believer the human be- that it is entirely possible to stim- ing and his divine calling. For this ulate a clinically relevant antitu- reason, technology should never mor immunoreactivity. However, produce anything which destroys at the same time it became evi- the integrity of the human being, dent that tumor variants arise un- his natural development and his der the selection pressure of the personal dignity. This is a maxim induced antitumor immune reac- against which every technological tion which are resistant to the im- advance must be measured. mune responses elicited. The The task of technology is to mechanisms of this immune es- serve humanity, the individual hu- cape are multifarious and include man being and especially those turning off the expression of rele- who feel marginalized owing to vant tumor antigens, loss of anti- debility and disease. If research gen-presenting MHC molecules Dangers of technological loses sight of this objective and and the expression of immunoin- progress succumbs to “creative delusions”, hibitory factors. this would rapidly transform the These results underscore that If we consider the progress in benefits of research so that they be- the successful induction of antitu- technology today in very general come detrimental. I believe that the mor immune reaction is only one terms, it must be observed that the limits of technological progress in parameter in the complex interac- welfare and integrity of the indi- medicine are well defined by the tion between the tumor and the vidual human being is now often words of the Holy Father on the immune system. In the final not the first priority of research. Day of the Sick Person on 11th analysis, long-term results with For whom is such research of ben- February 2000: “Research and gene therapy can only be attained efit, for whose welfare and for technology must avoid creating when the multifarious interactions what kind of human being? new forms of alienation for the between tumor and immune sys- weak, the elderly and the incurably tem are understood and we learn ill”. In complete agreement with to modulate these interactions Limits of progress the Pope I would like to erect a specifically. I have no doubt what- boundary stone for technology, es- ever that this will be successful. However great its scientific in- pecially for my specialty, medical The only open question is how terest, any technological advance research. long it will take to achieve the must be subject to morale con- breakthrough in the climate inimi- straints since personal integrity Prof. ALFONS HOFSTETTER cal to research with which genet- and dignity requires limits. Apart Scientific Director of the Urological Treatment Center of Monaco ic engineering is confronted. from this, I am convinced that Head of the Urology Department With genetic engineering we what is regarded as “technological at the University of Monaco have reached the frontiers of what progress” cannot ultimately create (Germany) is technically feasible in the strug- anything new. All that it produces gle against cancer. It is now nec- that is apparently new on the basis essary to find the right approach of painstaking experiments with taking into account the multiplici- failures and mistakes has already gg

DOLENTIUM HOMINUM N. 46/1-2001 21

JOANNES P.M. LELKENS II: Dehumanization in Intramural and Extramural Health Care, its Underlying Causes and Expectations for the Future

Introduction nity which does not derive from discoveries in genetics, the clon- his physical or mental health, but able man, to mention just a few. The themes of this international exclusively from the fact that he When we speak about the tech- conference on health care and so- was created in God’s image. nologizing of health care, the ciety are: technological chal- This dignity also entitles him to word itself has a negative under- lenges and the humanization of respect. In fact, dehumaniziation tone. In itself, that is not right, for medicine. The latter indicates that is nothing but not respecting the if we mean by technology the use at present treatment of patients is other person in his otherness1 and of tools to make things outside to a greater or lesser extent inhu- especially with reference to our ourselves fit for human purposes, man; there is a certain degree of subject: not respecting the patient technology in itself may very well dehumanization that ought to be as a person in his sickness. serve man and nature and even be redressed. The degradation of a patient an enrichment to our culture as However, before we can speak manifests itself in many forms Pope John Paul II says in his en- successfully about the humaniza- and may vary from paying insuf- cyclical Laborem Exercens.2 tion of medical treatment, it is ficient attention to him or giving However, since Francis Bacon first necessary to define dehu- him insufficient care to regarding (1561-1626), the first advocate of manization, to survey broadly its him as an animal or a thing, an organized scientific research for manifestations and to investigate object that may be used as a the ultimate purpose of subjecting by what they were and are caused. means to an end and which may, nature, the originally Christian I shall do this by speaking about if necessary, be destroyed or Western culture has gradually be- dehumanization in medical prac- helped to kill itself. come a secularized culture under tice and medical care in general. the influence of the progress of Where and when this evil conscience and modern technology. cerns intramural or extramural 2. Cause of dehumanization A culture which would prefer to care will be evident to everybody. tackle all problems – including In the second place, I will confine On closer inspection virtually medical ones – in a technical way myself in this lecture to the West- all cases of dehumanization ap- ern industrialized world, because pear to have their origins in the the problem originated there, spectacular scientific progress even though sooner or later the and technological developments Third World will also be faced of the last century, the influence with it. of the economy, increasing bureaucracy and, possibly the most important factor, the ongoing 1. What is dehumanization? process of secularization in society and consequently also in med- What do we mean by dehuman- icine. ization? Briefly speaking, it is a There is no denying that pre- degradation of the human person. sent health care is rapidly tech- Every human being, every patient nologizing. In the first place in is a person from the fertilized egg the hospitals with their high tech (zygote) and remains one until provisions for transplants of prac- death, however miserable his tically all organs, intensive care, mental or physical condition may prenatal diagnostics and artificial sometimes be. As a human person insemination, and soon perhaps he has an intrinsic dignity, a dig- the makable, or, because of new gg

22 HEALTH CARE AND SOCIETY and which at times does not omization and rationalization of elements have been joined: life- shrink from using even euthana- health care were and are disas- expectancy (in years) and the sia as a technical solution to end trous to both patients and doctors quality of this life, which also inhuman suffering. In other words, and nursing staff, especially in volves an estimation of the it has become a culture that may hospitals. Hospitals are regarded restoration of his productivity. be called technicistic.3 By techni- as commercial enterprises that History teaches us that speak- cism we mean man’s presumption must obey the criteria of profit. ing about the (remaining) value of to manage all reality as lord and Just a few examples: the care giv- a human life is not new. As early master with the aid of the scientif- en has become a product and the as 1920, a publication by Binding ic and technological method of patient a customer; the quality of and Hoche, a lawyer and a psy- control in order to solve all old the product that is to be delivered chiatrist respectively, appeared in and new problems in this way and must be measured, must be pro- Germany entitled: ‘Die Freigabe thus to guarantee growing materi- duced as cheaply and efficiently der Vernichtung lebensunwerten al prosperity – progress.4 as possible according to a set pro- Lebens’.8 Translated into English: Here, too, the connection be- tocol so that it will fit within an ‘The release of the destruction of comes apparent between secular- approved budget. The conse- life devoid of value’. This was the ization (which is actually de- quences of all this are, among first time that the quality of life sacralization) and technicism: other things, an increasing bu- had been openly written about. Western man accepts less and less reaucracy caused by the appoint- There is no need to explain how that he lives in a reality created by ment of so-called care managers the economization and the ratio- God. On the contrary, he thinks and stopwatch care through im- nalization of health care inevitably this reality only becomes meaningful by applying his technology to it and by making improve- ments. Closely related to technolo- gization in general – and to that of health care in particular – is its economization. It is a well-known fact that under the influence of the First In- dustrial Revolution in the late eighteenth century and the resulting rationalization, technologiza- tion and economization, 16th. and 17th. century mercantile capitalism changed into the liberal capitalist market economy.5 This liberal capitalism, which has devel- posing time limits on treatments had to lead to dehumanizing utili- oped into financial capitalism and care given by nurses. tarian ethics. over the last few decades, flour- It is understandable that the If we look for the deeper causes ished especially in the countries quality of the care given is mea- of this dehumanization, as a result where the influence of Protes- sured, but it is ominous that they of which less than full justice is tantism was strong, such as Eng- have gone further and now also done to man’s dignity in medical land, Holland and later also in want to determine the quality of actions nowadays, especially in America, notably through the cot- the patient’s life. But this, too, is a the industrialized Western coun- ton and slave trade. direct consequence of rapidly tries, we are forced to conclude In fact, this market economy spreading desacralization. For a with Weber that the seeds of 20th. was made possible only by a de- Christian, human life has only century capitalism, of present- sire to control things by technical one qualification, namely that it is day technicism and of econo- means. Fascinated by the results sacred. The postmodern manager, mization (and of our whole pre- of rationalized processes in trade on the other hand, wishes to ex- sent-day political philosophy) and industry, governments started press in measure and number were sown in the Reformation also to apply them to health care, what a certain patient’s life is still and notably in Calvinism.9 Con- where costs rise considerably worth with a view to starting or sequently the resulting dehuman- every year as a result of the pur- not starting a treatment. That is ization in medicine, in my view, chase of more and more expen- why from an economic point of has its origins in the religious sive equipment, the higher wages view a cost-benefit or cost-effec- doctrine propagated by Protes- of the workers and the increased tiveness study is made and calcu- tantism. This position requires demand for care (amongst other lations are made in QUALY’s6, 7 further explanation. things caused by the so-called which a patient must score before The Reformation occurred in doubled increase of the ageing he can get a certain treatment or the 16th century as a reaction to population). test. QUALY is short for Quality the decay and the corruption The consequences of this econ- Adjusted Life-Year, in which two within the Roman Catholic gg

DOLENTIUM HOMINUM N. 46/1-2001 23

Church. Calvin (1509-1564) them. Who, then, were these also supported, in my view, by the preached – contrary to the preach- Calvinists, also called Huguenots fact that the Netherlands, the ing of all the previous centuries – in France? The social class from country where Calvinism had a that Holy Scripture is the sole which the first adherents to great many adherents, was the source for faith and that man can Calvinism in France came, was first nation to permit and legally be saved only through faith. Fur- the middle class: civil servants, regulate euthanasia. thermore, man can only accept scientists, merchants, artisans and this faith if he is predestined by bankers.10 When the persecution God to do this by means of His of these Protestants began in 3. Humanization grace. The experience of faith France, many fled the country. of health care then became a non-sensory, ab- It was not just anybody that stract and mental, solely rational left, for everywhere they settled, If we are to rehumanize health (or, on the contrary, irrational) technology and trade flourished. care, we shall have to bear in matter. Not only faith, but also This progress was so remarkable mind that we are living in a post- moral values thus became a sub- that many are inclined to view not modern culture, a transitional cul- jective matter and multi-inter- Adam Smith and his book ‘In- ture from the industrial, modern pretable. quiry into the nature and the caus- age to an information society. The loss of the sacrality that es of the wealth of nations’, pub- Fukuyama describes this transi- could be experienced through the lished in 1776, as the founder of tion as a clear break with the past, senses and thus the feeling for the classical school of economic a great disruption, characterized what is sacred and holy, stemmed liberalism, but the Calvinists. by a breakdown of the social val- from the denial of the real pres- Most of them went to Switzer- ues in the society of the middle of ence of Christ in the Eucharist, land, Germany, Denmark, Swe- the last century.11 He points out the abolition of all sacraments den, England and especially to that these moral values and social (save Baptism) and the almost to- the then Holland, where they rules, which he and other sociolo- tal reduction of the splendour of were hospitably received and had gists call ‘social capital’, are not the liturgy and the paraliturgy. many followers. From here and simply restrictions on individual Church offices, too, such as the from England a large number em- freedom of choice, but the main office of minister, were desecrat- igrated to America, and one of the condition for any co-operative ed by opening them up to ordi- places where they settled was by venture.12 Fukuyama is also con- nary citizens. With desecration, the mouth of the Hudson River, vinced that people – because they which deprives the world of the the present New York. Later, are in his view autonomous – will appeal of holiness, secularization when they had become rich be capable on their own of draw- inevitably creeps into Calvinist colonists, they mingled with the ing up new rules which will im- theology. local population. Together with prove the present situation again. Inevitably, because the Calvin- other Protestant groups, such as However, this is a view which I ists were thrown upon their own Presbyterians, Baptists and cannot share. resources to prove their predes- Methodists, they also entered pol- Not only because it is baseless- tined status, for it was only itics and not without success: they ly optimistic about the makability through success in their work (i.e. contributed to the American Dec- of the moral reality, but especially material prosperity) that they laration of Independence of because morality without God is knew that God blessed their work Thomas Jefferson on Indepen- an idle concept which at best and that they could be certain of dence Day (July 4th, 1776), leads to moralism. Only a true their salvation. among other things, and nine Christian faith can liberate man Contrary to the Roman Catholic Presidents rose from their ranks. from sin and make him truly free. Church, Calvin denied the use and It was especially this group of What is needed, therefore, is re- the necessity of good deeds be- colonists and their descendants evangelization, so that God, and cause faith alone had restored the that – deliberately or not – insti- thus the sacred, can be given a bond between God and man. gated the development of the pre- central place again. But not only good deeds were sent-day financial and capitalist The greatest hindrance to (re-) lost as a means of salvation, work ideology and the global economy evangelization is not so much the as a whole was desecrated, de- that spread globally from the resistance Christianity meets, nor sacralized (and ultimately over- United States. In other words: the presence of other ‘competi- rationalized) for, so they rea- present-day capitalism with all its tive’ religions, but rather the in- soned, if good deeds cannot hal- excesses stems from Protestant difference which comes from an- low man, in the light of predesti- individualism. ti-doctrinal post-modern rela- nation, evil deeds cannot damn It is, consequently, not a bold tivism which increasingly tends him. It was therefore not surpris- proposition that the underlying to emotionalism. Consequently, ing that, partly as a consequence cause of the present dehumaniza- Christianity will not be able to of their autonomous ethics, all tion in general and of health care convince present-day man by sorts of things (such as the slave in particular is the rise of Calvin- means of a theoretical approach. trade) were justified, for if so ism and not, as is often thought, Maybe the world will be struck much profit could be made, God’s the Enlightenment, which only again by the faith of the Chris- blessing was bound to rest on served as a catalyst. This thesis is tians, notably those who are ac- gg

24 HEALTH CARE AND SOCIETY tive in health care, if in their work Notes Ethical Aspects, in: Dolentium Hominum, Vatican City (1995), nr. 28, pp. 154-160. and in their faith they bear wit- 1 G. CHANTRAINE S.J., Zieken begeleiden 7 W. EIJK, Ethical Models for Health ness to something that has made in een pluralistische wereld, in: Communio, Management, in: Dolentium Hominum, Vat- them profoundly happy and free. Oudenaarde (1997), nr. 4, p. 267. ican City (1998), nr. 37, p. 59. 2 POPE JOHN PAUL II in: Encyclical La- 8 K. BINDING und A. HOCHE, Die Freigabe borem Exercens, Vatican City (1980), par. 5. der Vernichtung lebensunwerten Lebens Professor JOANNES P.M. 3 E. SCHUURMAN, Gebven in wetenschap (The Release of the Destruction of Life De- LELKENS, M.D., PH.D. en techniek (Belief in science and technique), void of Value), Leipzig: Felix Meiner 1920. Emeritus professor of Anesthesiology Amsterdam: Buijtenen Schipperheijn, 1998, 9 MAX WEBER, The Protestant Ethic and p. 59. the Spirit of Capitalism, London: Allen and at the University of Maastricht 4 (the Netherlands) E. SCHUURMAN, Identiteit of uniciteit Unwin, 1930. (Identity or unicity) in: Pro Vita Humana 10 I. and K. BRANDENBURG, De Hugenoten (1998), 4, pp.10-11. (The Huguenots), Amsterdam: De Bataafse 5 In the days of mercantile capitalism Leeuw, 1992, p. 9. money was still a means and not an end in it- 11 F. FUKUYAMA, De grote scheuring (The self as in financial capitalism. Great Disruption), Amsterdam/Antwerp: 6 E. SGRECCIA, Respect for Life and the Contact, 1999, p.17. Search for the Quality of Life in Medicine: 12 Ibid. p.26.

ORVILLE B.R. ADAMS III: The New Health Care Workers

Human resources – the different male and female adult mortality. creasing, with reversals in some of kinds of clinical and non-clinical For example, the probability of the poorest parts of the world.”2 staff who make each individual dying under age 5 years for males WHO argues that mortality and public health intervention in Canada in 1999 was 6 per 1000 alone is insufficient as a measure happen – are the most important and 5 per 1000 for females. The of health. WHO uses the criterion of the health systems inputs. The figures for Germany were the of health expectancy, measured performance of health care sys- same as for Canada, and similarly through disability-adjusted life ex- tems depends ultimately on the New Zealand’s figures were 9 per pectancy, which takes into acknowledge, skills and people re- 1000 for males and 7 per 1000 for count not only premature mortali- sponsible for delivering services.1 females. ty but also time spent in health In stark contrast, countries in states that are less than full health. sub-Saharan Africa had high lev- The main causes of ill health can Working context els of both child and adult mortal- be grouped into three categories: ity. Most of these countries also 1) injuries; 2) noncommunicable Before further discussing hu- experienced extremely high levels diseases; and 3) communicable, man resources it may be helpful to of female mortality, attributable in maternal, perinatal and nutritional briefly outline the environments in large part to AIDS.2 The probabili- diseases. While the major causes which health care providers work. ty of dying under age 5 for males of ill health in the WHO African and females in Mali in 1999 was region are in the third category, the 240 per 1000 and 229 per 1000, Americas, Europe and the Western Health status respectively; in Malawi the fig- Pacific are dominated by noncom- ures were 222 per 1000 for males municable diseases. The health status of the popula- and 215 for females.1 WHO has developed health sce- tion differs substantially across the A report to the 105th Executive narios in order to assist policy- world. Countries such as Canada, Board meeting of the World makers in the health sector in the United States of America, Health Organization states: “Mor- making decisions about invest- most of the countries of Western tality has declined across the ment in human capital, physical and Central Europe, Australia, globe, for both children and infrastructure, and research and New Zealand and Japan have low adults, yet heterogeneity in the development. One such scenario levels of child mortality and both rates of decline appears to be in- suggests that “the leading causes gg

DOLENTIUM HOMINUM N. 46/1-2001 25 of the global burden of disease are the following impact on health needy countries to wealthier ones expected to change from a pattern workers:5 is already a serious problem. dominated by the communicable – downward pressure on wages Adams and Kinnon also suggest disease killers of poor children to (e.g. Cameroon, Uganda); that if barriers to this type of a pattern dominated by non-com- – unemployment of health per- movement are reduced as a result municable diseases and injuries. sonnel or low motivation due to of the GATS without an appropri- Projected leading causes will in- uncertain employment conditions; ate regulatory framework and im- clude ischaemic heart disease, de- – labour unrest, expressed in provement in working conditions pression and road traffic accidents slowdowns and strikes; in the domestic health system, eq- followed by stroke, obstructive – migration of workers from the uity, quality and efficiency will all pulmonary disease and then lower public sector to the private sector, suffer. respiratory infections, tuberculo- often resulting in an overall reduc- sis, possibly war, diarrhoeal dis- tion in the level of skill and com- eases and HIV/AIDS.”2 petence in the public sector. The changing health sector has had and will continue to have a Health system reform significant impact on the way in which health workers are trained, Most developing countries and the work they do and how they are countries in transition have under- organized and paid to do that gone and are undergoing process- work. es of health sector reform. Exter- nal forces due largely to macroeconomic conditions have stimu- Globalization lated these reforms. Civil service reforms and the restructuring of The emigration of health per- economic institutions in compli- sonnel has been a major issue for Globalization will also have an ance with requirements of the In- both industrialized countries and impact on health workers in other ternational Monetary Fund and developing countries for many ways, such as the potential influx the World Bank are intended to years. Each year large number of of foreign firms in the health sec- achieve efficiencies in different doctors and nurses trained in de- tor and the demands they may sectors. Reforms typically aim to veloping countries leave. Adams place on the public domestic improve equity, effectiveness, ef- and Kinnon6 report that although labour market. An increase in ficiency and the satisfaction of skilled health personnel tend to go cross-border trade in health ser- users.3, 1 to the industrial countries of the vices such as telediagnosis and Bennett et al. in their 1997 book North, there is also considerable telemedicine via information tech- Private health providers in devel- South-South flow. In order to nology will have an impact on ed- oping countries4, identify the re- overcome its shortage of physi- ucation and training and on the form agenda promoted by the cians, Ghana is recruiting physi- availability of support to health World Bank in Financing health cians from Cuba on limited-term care workers in non-urban areas. care: an agenda for reform (World contracts between the two coun- The environment in which Bank 1987) as that of a smaller tries. Jamaica is recruiting nurses health workers are educated and role for governments. This has from African countries, including trained and in which they live, taken the form of increased pri- Ghana. James Buchan and Fiona work and are themselves con- vate-sector activity, such as con- O’May, in a study focused primar- sumers of health services, has a tracting for health care services (in ily on movement of nurses, con- profound impact on their morale, the United Kingdom), increased clude that: “the globalization of motivation and productivity. The competition among providers, markets and the development of production of health workers of managed markets, autonomous free trade blocs (e.g. North Ameri- different types, although often dri- hospitals and growth in private can Free Trade Agreement (NAF- ven by professional interests, hospitals. Decentralization has al- TA), European Union (EU), MER- should in part be a function of the so been identified as a stimulus for COSUR), with associated free mo- health conditions in the county, growth of the private sector. bility of labour, represents a factor the macroeconomic changes, the These reforms have often had of significant and growing impor- health sector reforms, and the unintended consequences for the tance when examining the interna- broader global changes. There is health sector, especially for the tional mobility of nurses.”7 little research on the relative im- poor. A “Round Table on Public The General Agreement on portance of these different envi- Service Reforms and their Impact Trade in Services (GATS) defines ronmental factors. on Health Sector Personnel”, host- four modes of trade: cross-border, ed by the German Foundation for movement of consumers, foreign International Development and commercial presence, and move- Current issues for co-sponsored by the International ment of persons supplying ser- human resources for health Labour Organisation and the vices. With regard to the latter, the World Health Organization, found loss of health personnel from Poor working conditions, inade- gg

26 HEALTH CARE AND SOCIETY

prepared by country teams in all with the many actors involved, WHO regions found that each cat- such as the state, employers, pro- egory of imbalances can take dif- ducers, regulators, service ferent forms in the different re- providers, representative bodies, gions and countries. For example, consumers and external funders,11 in Africa the cause of the problem make the development of health appears to be low training capaci- workers very difficult, complex ty and very low pay, which result and politically sensitive. in retention and production problems. In the WHO South-East Asia region, the problem is due Who are the health workers? more to poor distribution than to production. Health workers are of- There is a wide range of health ten reluctant to practise in rural ar- workers, categorized by their level eas. of education and training, the The issues facing policy-makers tasks they perform, the degree of and managers in ensuring appro- autonomy of decision-making and priate investment in health work- the systems in which they work. ers are affected by many complex Health workers can be found in quate pay, lack of appropriate in- factors. Some of these factors the public sector, the private for- centives, poor management and have been discussed above. Gilles profit sector and the private not- shortages of working materials Dussault, formerly of the Univer- for-profit sector. They work in the such as essential medicines and sity of Montreal Faculty of Medi- personal provision subsector of consumables, are among the most cine and now with the World the health system and in the popu- pressing problems facing health Bank, identifies the following en- lation subsector of provision. The workers in developing coun- vironments that have an impact latter group is often referred to as tries.8, 9, 1, 10 This translates into im- health worker development:3 public health providers. balances in human resources for – Legal factors: including the Health workers are also found health in most developing coun- existing laws and regulations and in the voluntary sector. Tradition- tries. Adams and Hirschfeld8 di- the ways in which they are en- ally the providers of health care at vide these imbalances into four forced. home have been women, who care categories: – Economic factors: the avail- for children and the elderly. This – Imbalances in overall num- ability of resources in both the type of care can be considered vol- bers: differences between the public sector and the private sec- untary care. A report prepared by number of health care providers of tor, and the economic priorities of WHO for the World Health As- various categories and the num- the government. sembly, May, 1997, examined the bers a country or community – Organizational factors: the state of health professionals other needs and can afford; distribution between the central, than nurses and doctors (the two – Imbalances in skills or skill regional and local authorities of categories most commonly identi- mix: a mismatch between the type responsibilities and of power to fied). The report states that “the or level of training and the skills make decisions. The number and number of health personnel other required by the health system; nature of ministries involved in than doctors, nurses and midwives – Imbalances in distribution: a making policy are also important. can vary from one country to an- mismatch in geographical, occu- – Technological factors: this in- other from a dozen to several hun- pational, public/private, institu- cludes the use of new communica- dred. In the United States of tional or specialty mix; tions technologies such as the In- America, as an example, there are – Imbalance between human re- ternet and applications such as about 250 different types of allied sources for health policies and the telemedicine. These tools can health personnel alone. Tables 1 national health policy: a mismatch have a significant impact on edu- and 2 show the wide range of cat- in the priorities of the health sys- cation, training and practice. egories of health personnel and tem and the training or employ- – Sociocultural factors: the so- the variation that occurs from ment of the appropriate health cial status of the occupations is an country to country as exemplified workers. important variable that carries by data from the WHO Eastern These imbalances appear to be with it a certain degree of power Mediterranean and South-East chronic problems in most devel- and political influence. The per- Asia regions.”12 oping countries, if not all. While ception of male and female occu- The report demonstrates how shortages of health care profes- pations is also influential. differences in nomenclature and sionals have been reported in most – Political factors: the status of classification from one country to countries of the world, whether in- health issues on the agenda, the another make intercountry com- dustrialized or developing, short- degree of political consensus as to parisons of health workers very ages appear to be more severe in the need for change, and the prox- difficult. Designations can be mis- Africa and Asia. A survey of 40 imity of some health worker leading: a given category of health countries conducted by WHO and groups to the political process. personnel can have different train- 18 in-depth country case studies These environments, coupled ing and responsibilities in differ- gg

DOLENTIUM HOMINUM N. 46/1-2001 27

Table 1: Distribution of various health personnel in the South-East Asia Region Category Bhutan Indonesia Myanmar Sri Lanka Thailand Medical laboratory technologists (MLT) X X X X Laboratory technicians X X X X Radiographers X X X X Physiotherapists X X X X Occupational therapists X Pharmacists X X X X X Dental technicians/assistants X X X X Entomological assistants X School dental therapists (nurses) X X Public health inspectors (supervisors) X X Lady health visitors X Microscopists X EEG recordists X ECG recordists X Compounders (dispensers) X X Auxiliary midwives X Health assistants X X X Community health workers X Basic health workers X X Nutritionists/assistant nutritionists X X Medical records staff X X Source: World Health Organization Regional Office for South-East Asia

Table 2: List of health care providers in the Eastern Mediterranean

Professionals Paramedicals/technicians Auxiliaries Physicians Assistant pharmacists Medical orderlies/aides Dentists Medical health assistants Sanitary assistants Pharmacists Physiotherapists Medical records clerks/card clerks Graduate nurses Sanitarians Community health workers Physiotherapists Radiographers Traditional birth attendants Environmental health officers Laboratory technicians Lady health visitors Laboratory technologists Refractionists Vaccinators Medical records officers Medical records technicians /assistant medical records technicians Herbalists Statistics officers CSSD technicians Traditional healers Nutritionists Dental technicians Medical equipment engineers Statistics technicians Medical social workers Audiometricians Psychologists ECG technicians Microbiologists EEG technicians Biochemists Operating-room assistants Dietitians Prosthetics technicians Medical equipment technicians Dental prosthetics technicians Food technologists Anaesthetics/ICU technicians This list is illustrative but not necessarily exhaustive. Source: World Health Organization Regional Office for the Eastern Mediterranean ent countries. And categories of by modifying the focus of their tion. In several Latin American health personnel have been adapt- work. countries, primary health care ed to evolving needs and priorities Examples can be found in such workers have been specifically and new job opportunities, either diverse places as Latin America, trained to help improve environ- by changing their designations or Pakistan and the Russian Federa- mental sanitation, a move that was gg

28 HEALTH CARE AND SOCIETY stimulated by an outbreak of In many developing countries Conclusion cholera in the region. In Pakistan there is a well-established number and Bhutan large numbers of fe- of traditional health providers. The development and use of male family health visitors have There is an attempt in some health workers is affected by the been trained in order to improve African countries (e.g. Ghana and context in which they work and access to health care by house- Uganda) to more closely incorpo- the environments that define how holds in remote areas. In Russia, rate these providers in the health and where, with how much auton- feldshers – whose role as medical system by developing mecha- omy and with whom they practise. assistants and public health work- nisms to control standards of Changing demographics, epi- ers mainly in rural areas has been providers. In the industrialized demiology and technology, as well known for decades – have countries there is an increase in well as shortages and cost, have now assumed new functions such the use of traditional medicines resulted in the creation of new cat- as staffing emergency care units in and providers such as acupunctur- egories of health workers. The in- big cities or serving as occupation- ists, herbalists and massage thera- troduction of these new workers al health officers in factories. pists. has, however, often not been The report further discusses the based on careful study and evi- spectrum of the responsibilities of dence of the effectiveness of the health workers: promotive, pre- New health workers new category. ventive, curative and rehabilita- There is a need to map the cur- tive services. In some cases, pro- Industrialized and developing rent situation with regard to the in- motive and preventive services countries alike have begun to use troduction of new workers. Their constitute the major part of the or consider using so-called “new” impact on patient care and cost-ef- work of some categories of health health workers, such as multi- fectiveness should be assessed. In personnel (e.g. public health in- skilled “generic” care assistants, addition, the different rationales spectors, health educators, envi- nurse practitioners, nurse anaes- and methods for introducing new ronmental health officers). Com- thetists and doctors’ assistants. workers must be analysed in order munity-based rehabilitative care is Buchan and Dal Poz13 suggest that to determine what works and what increasing in importance with a the new worker is in fact often an does not, and under what condi- growing elderly population, an in- existing occupation or grade with tions. creasing burden of chronic and de- additional skills or an expanded WHO is embarking on a two- generative diseases, mental disor- role. Many of these types of year programme to develop the ders and accidents. amended roles are in one of four knowledge base on the implemen- At the same time as we see a categories: tation and impact of introducing growth in community-based – “multiskilling”, or extended “new” workers in health systems. providers, there is also an increase roles for a “traditional” support This effort is intended to result in in specialization in the more devel- worker: catering, patient transport, decision-making tools to assist oped countries. This results in part cleaning and clerical duties; policy-makers, health systems from the increase in medical tech- – multiskilling – “cross train- managers and health workers to nology and scientific knowledge. ing” – or extended roles for care determine the likely impact of in- As health systems try to respond assistants and auxiliaries (e.g. troducing specific types of new to demographic, epidemiological health community agents of the workers and to identify and help and technological changes a family health programme in weigh options on effective meth- greater emphasis is being placed Brazil); ods of introduction. on other professionals such as so- – extended roles for current cial workers, school health educa- health care professionals (e.g. Dr. ORVILL B. R. ADAMS tors, nutritionists, environmental- nurse practitioners); Director, Department of Organization ists and other providers more as- – new technician roles (e.g. in of Health Services Delivery sociated with prevention rather surgery or anaesthesiology, as in World Health Organization than cure. Mozambique). Geneva, Switzerland

References

1 The world health report 2000 – health systems: improving performance. Geneva, World Health Organization, 2000. 2 Trends and challenges in world health. World Health Organization Executive Board, 24-29 January 2000. Geneva, World Health Organization, 2000 (unpublished document EB105/4). 3 DUSSAULT G. Human resources develop- gg

DOLENTIUM HOMINUM N. 46/1-2001 29

ment: the challenge of health sector reform. 7 BUCHAN J., O’MAY F. Globalization and man resources for health in 40 African coun- Washington, DC, World Bank, 1999 (unpub- healthcare labour markets. A case study from tries. Geneva, World Health Organization (in lished document, prepared for Human Devel- the United Kingdom. Edinburgh, Queen Mar- preparation). opment of the Latin American and the garet University College, 1999 (unpub- 11 MARTINEAU T, MARTINEZ J. Human re- Caribbean Region. ). lished). sources in the health sector – guidelines for 4 BENNETT S, MCPAKE B, MILLS A., Pri- 8 ADAMS OB, HIRSCHFELD M., Human re- appraisal and strategic development. Brus- vate health providers in developing countries. sources for health – challenges for the 21st sels, European Commission, 1997. London and Atlantic Highlands, New Jersey, century. World Health Statistics Quarterly, 12 Reorientation of the education and prac- USA, Zed Books Ltd., 1997. 1998, 51:28 – 32. tice of health care providers other than doc- 5 Public service reforms and their impact 9 EGGER D, LIPSON D, ADAMS O. Human tors, nurses and midwives. Geneva, World on health sector personnel. Round table, resources for health. Issues in health services Health Organization, 1997 (background doc- Berlin, 13-15 October 1999. Berlin, German delivery. Discussion paper no. 2. Geneva, ument prepared for the 48th World Health Foundation for International Development, World Health Organization, 2000 (unpub- Assembly, resolution WHA48.8, “Reorienta- 2000. lished document WHO/EIP/OSD/00.2; avail- tion of medical education and medical prac- 6 ADAMS O, KINNON C., A public health able on request from Department of Organi- tice”). perspective. In: Zarrilli S, Kinnon C, eds. In- zation of Health Services Delivery, World 13 BUCHAN J M’D, DAL POZ MR., Role de- ternational trade in health services – a devel- Health Organization, 1211 Geneva 27, finition, skill mix, multi-skilling and “new” opment perspective. Geneva, United Nations Switzerland). workers. Geneva, World Health Organiza- and World Health Organization, 1998:35-54. 10 BERCKMANS P. Initial evaluation of hu- tion, 2000 (unpublished).

MARY HEALEY-SEDUTTO IV: New Emerging Infectious Diseases: The Globalized Public Health Crisis of the New Millennium

As we rapidly approach the clo- entitled Demolition Man, which profound political, economic, so- sure of our Jubilee Year 2000, it is for painfully obvious reasons, was cietal, ethical and public health most appropriate that we now not a great success in American consequences. look towards the health of our so- theatres. Yet in many ways, it was While Demolition Man was a ciety with a futuristic eye, and hauntingly prophetic in its vision satire, its message remains a valid challenge ourselves to envision of what the world would be in the one. The impact of globalization how we, as Church, need to give year 2032. Demolition Man takes on society – specifically on the witness to our beliefs through ac- us on a futuristic journey in time, public health of society – poses tions which will advance the well- to a place in southern California significant justice, ethical and being and health of our globalized where the forces of unchecked economic questions for the inter- family of mankind. When our globalization have firmly taken national community. As the num- Holy Father addressed us on Feb- control. It is a time with little gen- ber of people living in and travel- ruary 11, 2000, he so beautifully uine joy or humor or happiness. ing freely throughout the world and so simply reminded us that, According to the film makers, in increases, and many of our mega- “like the Good Samaritan, every the year 2032 there were extraor- cities have pronounced over- believer must offer love to those dinary limitations on personal crowding and poor sanitation; as who live in suffering. It is not freedoms, including the fact that it we increasingly alter our natural right to “pass by” those who are was illegal to have children with- environments and their climates tried by sickness. Instead, it is out a permit. Why? Because a ful- and genetically manipulate our necessary to stop, to bend down to ly globalized society had become livestock and food chains; as we their illness and to share it gener- so fragile, extreme government rapidly transition peoples into ar- ously.”1 We who have been given control was seen as the only solu- eas of exposure to diseases previ- the gift of being permitted to serve tion to the threat of complete ously unknown to them and in- in the healing ministry of Jesus global collapse. The movie pro- crease insect vectors into greater need to challenge ourselves and ceeds to show us how society areas of population density, we creatively look at how we, too, evolved, homogenizing, standard- accelerate the overall phenome- can ‘stop, bend down and share’. izing and sanitizing itself, and it non of globalization and experi- Back in 1993, the California becomes clear to the viewer that ence both its advantages and dis- film industry produced a movie the forces of globalization had advantages. gg

30 HEALTH CARE AND SOCIETY

The Good News and the speak about its cost or global health controls and policies gov- Bad News of Globalization availability. erning international travel. Cases of yellow fever which Professors Alan Feranil2 and appeared in both the United David Fidler3 of the United States States and Switzerland in 1996, What are EIDs and what are remind us that while globalization were traced to tourists who trav- the Factors Contributing has resulted in greater sharing of eled to yellow fever endemic re- to their Proliferation? medical knowledge and technolo- gions without the necessary yel- gy and the removal of many inter- low fever vaccinations. Upon re- Emerging infectious diseases or national barriers, it has also turn to their countries of origin, EIDs are diseases which result opened a Pandora’s box with its they brought with them a disease from newly identified infections, detrimental effects on public most infectious disease special- both viral and bacterial, with the health. International travel is now ists thought to be long eradicated potential for causing public health fast paced, and diseases tradition- in these countries. This case ex- problems either locally, nationally ally confined to specific regions ample is sadly becoming all too or internationally. The human im- are being transported by the trav- common place. munodeficiency virus (HIV) which eler to far distant lands. The glob- In the summers of both 1999 causes AIDS was first isolated in al nature of food processing, han- and 2000, New York City and sur- 1983 as an EID, and by June of dling and distribution have ex- rounding areas saw the emergence 1998 (only 15 years later) it was posed the entire world to microor- of West Nile Fever disease, a mos- estimated that 30.6 million people ganisms previously indigenous quito borne encephalitis, which worldwide were infected and the and limited to restricted parts of has caused the death of over life expectancy for babies born in the globe. Regional overpopula- 10,000 birds and other animals as sub-Saharan Africa is now less tion and overcrowding lead di- well as seven elderly people. Epi- than 40 years.5 rectly to poor sanitation and the demiologists have traced the virus A new variant of Creutzfeldt- spread of communicable diseases. to travelers visiting from Africa. Jakob disease was first identified As a result, both scientists con- This very same virus is now close in the United Kingdom in 1996 tend that globalization has shat- to epidemic proportion in Israel, and is thought to be the same tered the traditional distinctions with eight deaths and over 120 agent responsible for the bovine between national and internation- confirmed cases diagnosed with spongiform encephalitis or “mad al public health, and while they the disease. In New York City, cow disease” epidemic of the cite many examples of why they widespread aerial and ground 1980s, which affected thousands feel this way, the most compelling spraying of insecticides every two of cattle throughout the United perhaps is their reference to the to three days throughout the sum- Kingdom and Europe. The signif- global crisis of emerging and re- mer months has placed a financial icance of this particular viral mu- emerging infectious diseases. It is strain on the local public health tation is that diseases, initially precisely about this topic that we budgets in these regions, to say known harmful and thought to be will be speaking today. nothing of the disruption caused limited to animals, evolve to be- Dr. Anthony Fauci, Director of to normal living. As residents of come known dangers to humans the National Institute of Allergy the area, we were advised to turn as well. It is also significant that and Infectious Diseases of the off air conditioning, close all win- what began in England quickly United States, a noted epidemiol- dows, stay in doors and not even spread throughout all of Europe. ogist and infectious disease spe- allow our pets to be near the areas One of the many effects of global- cialist, was scheduled to be here impacted by the spraying. The ization has been the destruction of with us today. Unfortunately discouraging news is that the vec- trade and commerce barriers. It is scheduling difficulties arose, and tor of disease identification in sobering to remember that 70% of clearly I am not Dr. Anthony Fau- 2000 was far greater than that all the fruits and vegetables con- ci. However, his message to us found in 1999, and public health sumed in the United States are im- were he here, would I am sure be officials are already trying to fig- ported from developing countries one of caution, as he has repeat- ure out what they can do for the and that over 45% of all the fish edly stated that he feels that mu- summer of 2001. And while in the consumed internationally comes tated microbes, resistant to in- beginning only the elderly and from developing countries. There creased numbers of drugs, repre- frail were found to be infected, can no longer be a comfort level sent the real crisis for our new most recently diagnosed cases in- about food handling and process- millennium. Alarmed by the clude several middle aged, other- ing practices specific to a single African and Asian AIDS epi- wise healthy individuals. nation. National boundaries are demics, Dr. Fauci’s agency has Yellow Fever and West Nile fast becoming meaningless. dedicated over half of its total Fever are but two examples of Not only are we seeing the HIV spending budget towards the how globalized travel has resulted emergence of new viral and bacte- development of an AIDS vaccine. in disease transmission from third rial diseases, we are also experi- While he personally is optimistic world countries to first world encing a rapid growth in the num- that a moderately effective AIDS countries4. Clearly much needs to ber of bacteria which are now vaccine will be available within be done to better educate interna- dangerously and increasingly re- the next decade, he does not tional travelers as well as public sistant to an alarming range of an- gg

DOLENTIUM HOMINUM N. 46/1-2001 31 tibiotics. Escherichia coli, Neisse- and expect to leave with a pre- provide $100 million of vaccine ria gonorrhera, pneumococcus scription. The President of the to the poorest children in Sub-Sa- and staphylococcus aureus often American Medical Association, hara Africa and South East Asia,8 no longer respond to the lower Dr. Randolf Smoak, Jr., sadly ad- the challenges still far outweigh cost drugs of traditional first line mits that when physicians are the solutions. Together with Mer- defense. The resultant effects of “pushed and pressed to see pa- ck & Company, Smith Kline such viral and bacterial mutations tients more rapidly, it’s a great Beecham, American Home Prod- is a longer and more costly treat- temptation to just write an antibi- ucts, and Aventis have all ment regime, often out of the otic prescription rather than spend promised that they will increase reach of the majority of people five minutes explaining to a moth- their research and development living in third world countries. er why it might be better in the efforts in their search for new vac- The burdens on third world coun- long term not to prescribe it”.6 cines. The Global Alliance for tries in obtaining access to appro- Even in cases where patients are Vaccines and Immunizations, a priate and adequate supplies of told that their illness is viral, such not-for-profit organization sup- therapeutic drugs and vaccines are as a cold or flu, where antibiotics porting such efforts, recognizes now being exponentially com- will not be helpful, patients still that it will take the combined ef- pounded by the effects of such insist on receiving a prescription fort of government, industry and mutations. But the effects of mi- for them. A microbiologist for the philanthropy to ensure that new crobial mutation are felt in devel- pharmaceutical company Eli Lily vaccines are developed rapidly oped nations as well. In the Unit- has recently completed research and brought to the market at which indicates that over 40% of prices which are affordable to the antibiotics prescribed for res- those most in need. piratory and ear infections are in- A third, and perhaps the most appropriate and that more than troubling aspect of EIDs, is that 90% of the staph aureus strains which is associated with environ- are now resistant to penicillin and mental or climate changes. Rift related antibiotics.7 Valley Fever is a disease which In third world countries we see principally affects cattle and an inappropriate utilization and sheep and is predominately found under-utilization. It is all too com- in Africa. People in contact with mon to find that many of the peo- infected animals themselves be- ples who live in third world coun- come infected and in turn suffer tries buy their drugs from local from retinitis, encephalitis, hem- “drug shops” where the amount of orrhage, blindness and ultimate medication they purchase is insuf- death. In 1997 and 1998, Kenya ficient for the necessary length of and Somalia suffered unusually treatment, and the quality of the heavy rainfalls, and this change in drugs themselves leave a great climate and environment affected deal to be desired. Taking medica- the livestock of these countries, tions for only two to three days directly resulting in vast out- until the outwardly visible symp- breaks of this disease. Dengue toms are abated is often the prac- fever, known to be a major prob- tice for the medically and finan- lem in South East Asia since the ed States, over 14,000 people die cially poor, and such practices mid 1950s, has now re-emerged each year from drug resistant mi- simply allow the diseases from with a vengeance in Central and crobial nosocomial infections – which they suffer to fulminate in- South America in the 1990s, and those infections which are ac- to even stronger sources of infec- by 1997 epidemics were identi- quired in hospitals secondary to tion – recurrent infections which fied in 24 countries. In 1998, dur- the reason for the hospitalization. may not respond any longer to the ing a brief trip to Costa Rica, I had The mutation of viral and bacte- initial – and preferred – and less an opportunity to meet with gov- rial strains is closely related to yet expensive – drugs of choice. ernment public health officials, another problem: that of too much Many of these for-profit and pri- and one of their chief concerns at and too little. In first world coun- vately operated “drug shops” will the time of my visit was how to tries we see a very disturbing pat- contend that they sell these drugs provide medications for the peo- tern of overutilization and inap- full well knowing that a longer ple in a remote and mountainous propriate utilization of antibiotics. treatment regimen is needed, but village where an outbreak of In the United States and Western do so because the patient can only Dengue had erupted. As our glob- European countries we see very afford to buy drugs for a one or al temperature rises, diseases alarming patterns of physician two day regimen. which were limited to certain prescriptions for antibiotics where While some relief with regards warmer, more tropical regions, there is often no real evidence to the unavailability of drugs in are now spreading up the moun- supporting the appropriateness of third world countries has recently tains into lands which were previ- the medication. Patients go to been promised, such as the com- ously too cool to support mosqui- their physicians with a complaint mitment of Merck & Company to to infestations, mosquitos often gg

32 HEALTH CARE AND SOCIETY being the mode of transmission of future. Their conclusion that in- affected by global warming, but the diseases in question. Coun- fectious diseases will be con- who indirectly have the power tries already challenged by the trolled if current efforts continue and/or resources to be instrumen- costs of maintaining active mos- to be maintained presupposes that tal in its abatement? And I would quito control in traditional high- the international community has add to this list, what is the moral risk areas, simply cannot handle the ability and commitment to do imperative of the Church and its the costs of expanding their pro- so. Sadly, the evidence to support healthcare leadership to join in ac- grams to greater geographic cov- this supposition seems lacking, tive defense against the prolifera- erage. and the enormous body of litera- tion of illness and disease. And as if the above problems ture available since 1996, includ- Organizational and corporate were not enough, we additionally ing documents from WHO itself, ethics must also be examined in a must contend with the growing appear to support this observa- discussion such as we are having practice of feeding livestock low tion. here today. As Pfizer Pharmaceu- ticals donates millions of doses of their antibiotic Zithromax in an effort to treat various forms of disease in Africa and Asia, they do so with trepidation. Zithromax is one of the most successful and popular antibiotics of our times, and its sales generate an income in excess of $1 billion a year for Pfizer. Their fear is that these drugs do- nated to Africa and Asia will find their way back to first world countries through the channels of the black market and will significant- ly undermine their sales in these levels of antibiotics to promote Justice and Ethics countries where a five day supply greater and faster growth. This as Applied to EIDs of tablets can cost well over $50. practice results in the ability of One can well understand their po- bacteria, viruses and parasites to There is also an emerging body sition. On the other hand, can they become drug resistant in these an- of literature which examines the refrain from assisting with the imals, mutating and surviving and moral and philosophical aspects global crisis of EIDs because of then infecting humans. Recogniz- of globalization and its particular this? The 1994 Treaty on Trade- ing the effects of the globalized effects on international public Related Aspects of Intellectual destruction of many international health. Perhaps one of the most Property Rights was written with trade barriers, the European intriguing approaches to this sub- the intent of controlling the prac- Union has identified the alarming ject has been provided us by the tice of producing look-alike potential for continent-wide epi- philosopher, Professor Dale drugs, circumventing patent pro- demics and has already banned Jamieson,10 in his treatise “Global tections. As recently as May 2000, the use of several antibiotics and Responsibilities: Justice and the Office of the President of the feed supplements. But in the Unit- Ethics in the Era of Global Public United States issued a statement ed States, the Food and Drug Ad- Health”. One of the many exam- indicating that it would no longer ministration has been slower to ples of ethical dilemma which he oppose African nations that vio- react, to a large degree as a result cites for us addresses the paradox late American patent laws in order of great lobbying pressure from of there being currently 270 mil- to obtain AIDS drugs. The Secre- the pharmaceutical and livestock lion people in the world today suf- tary of the Department of Health industries. Economic considera- fering from malaria. Due to glob- and Human Services in the United tions and price protection policies al warming and the resultant in- States, Donna Shalala, referred to appear to be outweighing national crease in spread of the malarial this position as a delicate “balanc- and international public health parasite, another 620 million ing act” between intellectual concerns. could easily become affected over property rights and the human The focus of the 1996 World a relatively short period of time. rights of peoples in third world Health Organization (WHO) Re- What are the moral obligations of countries.11 It is interesting to note port was the globalized nature of those who have the power and au- that two days after the President’s emerging infectious diseases.9 thority to mitigate or prevent such proclamation, five of the largest While WHO points to the signifi- global warming? What are the pharmaceutical companies an- cant progress the world communi- moral obligations of those who nounced their voluntary willing- ty has made following World War choose to use their economic, po- ness to cut prices of their AIDS II in battling infectious diseases litical and/or legal resources for drugs sold to Africa – including and bringing to market new another purposes, e.g. greater profit their anti-retroviral cocktails – by tibiotics, they are not quite as attainment? What are the moral as much as 80%. The quid-pro- glowing in their optimism for the obligations of those not directly quo which these companies may gg

DOLENTIUM HOMINUM N. 46/1-2001 33 insist on is a commitment from both individual as well as social rise and face this issue, and lend the African countries that they and common, and must be consid- our voices and our determina- will not proceed to violate Ameri- ered in both the singular as well as tions, with justice and compas- can patent rights in the production social context. The decisions sion, to the cause of reversing the of these medications. which individuals, communities, tidal wave of EIDs. Any discussion of ethics and corporations and nations make justice must focus not only on a have both direct and indirect ef- Dr. MARY HEALEY-SEDUTTO, national and international perspec- fects on the overall common good PH.D., tive, but be inclusive of individual of our global society. The U. S. President and CEO, Catholic Health Care System responsibilities and behaviors. It Bishops’ pastoral on the economy of the Archdiocese of New York cannot be overlooked that changes very precisely states that: in individual behaviors during the “Nearly half a billion are chron- past decades have also greatly con- ically hungry, despite abundant tributed to the EIDs problem. Dur- harvest world-wide. Fifteen out of ing the last 20 to 30 years we have every 100 children born in third seen a proliferation of sexual be- world countries die before the age havior, often referred to as the of five, and millions of the sur- “sexual revolution” where multi- vivors are physically or mentally ple partner sexual unions and same stunted. And their misery is not sex unions have resulted in an ex- the inevitable result of the march plosion of the transmission of sex- of history or of the intrinsic nature ual diseases. Poor personal and of their cultures, but of human de- 13 community hygiene, the use of il- cisions and human institutions.” Notes licit drugs, overcrowding in family In summary, all the above fac- residences, and even, I would ar- tors, the emergence of new bacte- 1 Homily of the Holy Father, on the occa- gue, the lack of responsibility for rial and viral strains, the mutation sion of the Jubilee of the Sick and Health- Care Workers, Friday, February 11, 2000, one’s own health and well being in of existing strains into drug resis- Vatican City. the areas of adhering to proper di- tant species, climatic and environ- 2 FERANIL, ALAN B., PH.D., The Other Side ets, medication regimes and bal- mental changes, global over- of Globalization; A Threat to Public Health?, Philippine Council for Health Research and anced life styles, have all con- crowding and poor sanitation, the Development, 1998, www.pchrd.dost.gov.ph/ tributed to the emergence and re- inappropriate usage of antibiotics press_release/globalization.html. emergence of infectious diseases in livestock and the misusage of 3 FIDLER, DAVID P., The Globalization of Public Health; Emerging Infectious Diseases and illness. antibiotics in both first world and and International Relations, Proceedings There is yet another facet of third world countries, the in- from the Symposium on The Public’s Health looking at the inter-relationships creased transmission of pathogen- in the Global Era; Challenges, Responses and Responsibilities, Harvard Law School, 1997. of emerging infectious diseases ic microbes because of globaliza- 4 TANGLEY, LAURA, Germs and Sickness in and social justice, and that is the tion and increased international a shrinking World; Are Beasts and Humans debate of individual liberty versus trade, travel and production, the Too Close for Comfort?, U.S. News & World Report May 22, 2000. the common good of society. If I changes in personal and societal 5 World Health Report 2000 – World Health choose not to have an annual flu behaviors and the public policy Organization Assesses the World’s Health shot and am clearly a person of decisions of nations and corpora- Systems, www.who.int/whr/2000/en/press_re- lease.htm high risk for contracting the flu, tions, all contribute to our global 6 KAUFMAN, MARC Microbes Winning the am I free to do so if I will also en- inability to control the rampant War; Resistance to Antibiotics Raises Dis- danger the health of others? My evolution and spread of diseases, ease Peril, The Washington Post, June 13, 2000. decision not to take a precaution- a phenomenon which we today 7 Countryside and Small Stock Journal, ary step may endanger the health refer to as EIDs or “emerging in- Another Warning on Antibiotic Overuse, of others who, given the opportu- fectious diseases”. September/October 1998. 8 World Street Journal, Merck & Company nity, would willingly want to be The literature flows with data Will Pledge $100 Million of Vaccines to protected from infection. Is there suggesting that EIDs represent an World’s Poorest Children, Tuesday, March a moral imperative to take public international public health crisis 2, 2000. 9 JAMES W. LEDUC, World Health Organi- health precautions not only for of daunting and grim proportions. zation Strategy for Emerging Infectious Dis- yourself, but for the good of your Clearly the international commu- eases, 275 JAMA, 318, January 24, 1996. family and community as well? nity must rise to recognition that 10 JAMIESON, DALE, Global Responsibili- ties: Ethics, Public Health and Global Envi- There are those who would argue the globalization of public health ronmental Change, 12 5, Indiana Journal of in the affirmative. has presented us with challenges Global Legal Studies, Vol. 99, No. 118, of enormous size and complexity. 1997. 11 MCNEIL, DONALD G., Do the Poor Have The World Health Organization a Right to Cheap Medicine?, The New York Summary Conclusions and the Church are leading forces Times, June 25, 2000. in the international community, 12 GRABENSTEIN, JOHN D., PH.D., The So- cial Benefits of Vaccination, Ethics and Health is a fundamental good and is sounding the alarm about Medics, Vol. 25, No. 8, August 2000. which each human has a right to this crisis, and we as Church, one 13 Economic Justice for All: Pastoral Let- expect and a personal duty to proof the major purchasers and ter on Catholic Social Teaching and the U.S. Economy, National Conference of Catholic tect and nurture. The rights and providers of healthcare through- Bishops, U.S. Catholic Conference, Wash- duties associated with health are out the world, must continue to ington DC, 1986, #25. gg

34 HEALTH CARE AND SOCIETY Section II The Illumination of this Reality

ANGELO BRUSCO I: Theology and Medicine

In the opinion of a well-known the light of medicine itself. This is 2.1. The Greatness and Limits theologian, the believer must draw because the God of the Creation of Man and Medicine near to reality having open before and of redemption is constantly ac- his eyes, on the one hand, a news- tive in the heart of the experience of During its history, medicine has paper, and on the other, the Bible. man. The Word of God in relation always enjoyed great prestige. Be- This theologian wanted to empha- to the health care professions has cause of its links with life and sise that in order to acquire an ade- been revealed in a special way health it has often been endowed quate understanding of the ques- through Holy Scripture. Down the with an aura of sacredness. Even tions and issues with which man is centuries it has been interpreted in those literary or audio-visual works faced one should not only know the an authoritative way by the Magis- which have employed satire to Word of God but also the situations terium of the Church; theologians bring out the negative aspects of to which this Word is addressed. If have made it the subject of their re- medicine have stressed its pre-emi- this twofold reading is not engaged flection and thought; and it has nent role in the life of individuals in, one runs the risk either of falling found expression in the sensus fi- and societies. into an abstract theology which is delium and in the witness of a very In the Bible2 we encounter a addressed to a culture which does large number of workers in the limpid echo of this positive view of not exist or no longer exists, or to world of health. Outside the context the art of medicine which is pre- confine oneself to engaging in what of Christian revelation and the sented as co-operation between the is mere sociology. Christian denominations there are creative and redemptive work of the The application of the suggestion also numerous traces of the vision Lord. The person who is involved made by that theologian seems to of God in relation to that activity of in taking care of sick people, in fact, me rather appropriate in tackling man which is directed towards car- strives to respond to the groans of the subject of the relationship being for, and treating, the sick per- the Creation to which St. Paul re- tween theology and medicine. In- son. ferred (Rom 8:10), thereby writing deed, this is a subject which in- Three guidelines for the behav- his action into an eschatological di- volves both theological doctrine iour and conduct of people who are mension in the search for new heav- and the development and evolution engaged in the practice of medicine ens and a new earth (cf. 1 Pt) which of the art of medicine during the emerge from theological reflection. are the aspiration of every individ- course of its history. ual and of mankind. In proposing a number of ele- In a frequent and fulsome way ments of theological reflection re- 2. The Word of God the documents of the Church em- garding the subject of medicine, I and Medicine phasise and outline this vision of will fix my attention on the Bible, medicine, reacting with joy to the without, however, ignoring what is A large number of guidelines great advances achieved by medical written in the newspaper.1 emerge from what is said about science and technology. In the in- medicine in the Bible and in other troduction to the rite of the anoint- sources (the Magisterium, theology, ing of the sick one thus reads: ‘the 1. Theological Reflection etc.). In this paper only some of Church encourages and blesses all these guidelines will be examined research and every initiative under- To reflect in a theological way on and discussed. First of all, the great- taken to defeat infirmity because the subject of medicine means, on ness and the limits of man and med- she sees in them a collaboration of the one hand, to become aware that icine will be analysed. Then the af- man with the divine action of strug- words of God have already been fective dimension of caring for and gle against, and victory over, pronounced on the science and art treating the sick person will be in- evil’(n. 134). of medicine, and, on the other hand, vestigated. And lastly, attention will At the same time, however, these to reinterpret the Word of God in be paid to the promotion of health. documents do not hesitate to con- gg

DOLENTIUM HOMINUM N. 46/1-2001 35 demn the deviant aspects and fea- cussions at the psychological and endows his corporeal impediment tures of the practice of medicine. In spiritual level. Indeed, the drama of with mysterious meaning by push- the first place, they condemn a the clash between limitless techni- ing beyond our gaze’.11 Indeed, as Promethean tendency which leads cal advance on the one hand, and Pius XII observed: ‘the Catholic large sectors of the science and art the inescapability of death on the physician knows that his patient of medicine to ignore the inherent other, has a negative effect on re- and he himself are subjected to the limitations to the human condition.3 search into the meaning of life, and law of conscience and the will of The development of increasingly on the drawing up of a scale of val- God. But he also knows that all the powerful means and instruments, in ues which respects the human per- resources of nature are placed at his fact, helps to cultivate and to make son and nature. This does not fail to disposal to protect and defend men increasingly explicit that wish cause existential dramas and noo- from illness and infirmity. He does which slumbers in the unconscious logical neuroses that are at the root not make nature or medicine divine, of man – to be invulnerable and of so many disturbances.9 he does not see them as absolutes, eternal. Cloning, for example, can The help offered by the Word of but he sees in them a reflection of be seen as one of the expressions of God and theological anthropology the greatness and the goodness of the mythical desire for immortality. in order to escape this drama in- God and perceives that they are en- If it is possible to be cloned when volves first of all the affirming of tirely subordinated to his service’.12 we become old is this not a way of the greatness and beauty of the human being. An ephemeral creature 2.2. Vulnerability, Human and destined for immortality, limited in Spiritual Growth, and Healing space and time and at the same time thirsty for the infinite, an animal In addition to being a guideline in and an angel, as Pascal says, man relation to the limits of the human does not stop provoking exclama- condition, in the light of theological tions of amazement on the part of reflection human vulnerability, the Psalmist: ‘When I look at thy when taken on and assimilated, can heavens, the work of thy fingers, also be transformed into an instru- the moon and the stars which thou ment of healing and human and hast established; what is man that spiritual growth for oneself and for thou art mindful of hum, and the other people.13 Indeed, as Carl Jung son of man that thou dost care for observed: ‘only the wounded physi- him? Yet thou hast made him little cian can heal’.14 That is to say, the less than God, and crown him with medical doctor who is able to wel- escaping death, a way of being eter- glory and honour. Thou hast given come and assimilate his own nally reborn? Secondly, they con- him dominion over the works of thy wounds. demn the move of the subjects of hands; thou hast put all things under This belief, which is rooted in the health, suffering, and death away his feet, all sheep and oxen, and al- culture of past and present mankind, from the terrain of meaning and val- so the beasts of the field, the birds finds an admirable expression in the ue to that of what is technical.5 With of the air, and the fish of the sea, Bible. After describing a day spent much precision Buytendinck ob- whatever passes along the paths of by the Lord in serving sick and in- serves that: ‘the enormous possibili- the sea. O Lord, our Lord, how ma- firm people, Matthew (cf. 8: 16-17) ties of medicine have removed the jestic is thy name in all the earth!’ quotes some of the words of the problem of pain... from the meta- (Psalms, 8:4-9). prophet Isaiah (52:13; 53:12) and physical, moral and religious sphere Medicine is called upon to strive applies them to Christ: ‘Surely he and have transferred it to the practi- to defend the integrity of the human has borne our griefs and carried cal sphere’.6 At the existential level, being, as was well expressed by away our sorrows; yet we esteemed this detachment of medicine from John Paul II when he addressed a his stricken, smitten by God and af- its mission as a collaborator of the gathering of medical doctors: ‘I en- flicted. But he was wounded for our creation and redemption strengthens courage you to continue your re- transgressions, he was bruised for the tendency to want to achieve hu- search fervently, to care for and our inequities, upon him was the man destiny without reference to the treat with the greatest skill, to fight chastisement which made us whole, design of God for humanity.7 But it illness in all its forms and the natur- and with his stripes we were healed’ does not do only this. It also opens al and human causes which bring it (Is 53:4-5). The suffering of Christ up the road to a ‘generalised algo- about. All this is a part of the plan of has a power of healing and salvation phobia’, that is to say to horror of God who gave man the intelligence because it is the sign of that mysteri- suffering, to obsessive worry and and ability to advance his discover- ous movement which led the Son of concern – which, indeed, is almost ies connected with the human or- God to share the human condition in pathological in character – about ganism and to place its fruits at the all its aspects and features, even in health, and to a narcissistic ap- service of man’.10 To a recognition its dimension of night time, made up proach which is derived from an ex- and defence of the greatness of of physical and spiritual trials. St. cessive attention and care being di- man, medicine must, however, add Paul described this process in a rected towards one’s own body.8 an attempt to accept and respect his wonderful way in his letter to the The rejection of the finite condi- ‘creatural weakness which does not Philippians: ‘His nature is, from the tion of man is not without its reper- wound his ontological dignity but first, divine, and yet he did not see, gg

36 HEALTH CARE AND SOCIETY in the rank of Godhead, a prize to be cation, and a direct relationship be- pain will be able to offer only emp- coveted; he dispossesed himself... tween the medical doctor and his ty consolation to other people’.19 accepted an obedience which patient, is technological progress To create peace and a synthesis brought him to death, and death on and the consequent increasing use within oneself with the nocturnal the cross’(Phil 2:6-9). It is this inte- of machines and laboratory tests to dimension of life – suffering, ill- rior movement, given substance by carry out a diagnosis’. ness, death, immaturity, and sin – is love, which makes Christ the physi- In addition, how can one forget a difficult process. But it is a liber- cian par excellence of souls and the wound created by the feeling of ating experience which leads the in- bodies. He ‘suffered our darkest powerlessness which is experi- dividual to overcome the illusion of nights: corporeal death and the night enced in the face of situations being an invulnerable and immortal of faith. Nothing which happens to which are beyond the medical doc- being. His suffering reveals to him man will be extraneous to his cre- tor’s possibilities to engage in ef- the thin boundaries which separate ator. Jesus took on the full fective action? It is not easy to life from death, health from illness, non-sense of suffering and death’.15 recognise one’s own limitations, an and good from evil. It also helps Although he struggles constantly inability to save a life, to help a sick him to discover the value of exis- against suffering and death, the person overcome impulses to de- tence which is brought out by his medical doctor is, therefore, also pression, or to accompany a person own fragility. Of illumination here called upon to reconcile himself in the taking of a decision at dra- is the episode of the struggle be- with the nocturnal dimension of matic moments of his existence. tween the angel and Jacob which is life, which, despite scientific and The feeling of powerlessness narrated in chapter XXIII of the medical progress, will always form wounds human narcissism, that Book of Genesis. Returning from a part of human existence. idea of being all-powerful in solv- Palestine after a long absence, Ja- What are the wounds of the med- ing the problems connected with cob crosses the Yaboc brook, a trib- ical doctor? Sharing human destiny the destiny of man.17 utary of the River Jordan. He sends is the first door through which fac- When the medical doctor is not his caravan on ahead and remains tors burst forth which lacerate the aware of, denies or rejects his own on his own on the bank of the human person in all his dimensions. brook. Towards the end of the night The health care worker, like every he engages in a struggle with a mys- individual, must deal with the suf- terious figure. This figure is unable fering linked to loneliness, illness, to defeat Jacob and so hits him on growth, separations, physical and his sciatic nerve, something which emotional loss, existential empti- leaves him with a limp. The myste- ness, immaturity, and sin... In addi- rious figure, when the night is about tion to these wounds there are oth- to come to an end, asks Jacob to let ers connected with his profession: him go but this latter refuses unless daily contact with pain, death, crisis the mysterious figure gives him his situations, and spiritual debate and blessing. discussion with individuals. There The most evocative symbolism is a kind of process by which the wounds he can have a number of of this episode is that of the struggle wounds of the sick person, the ten- different reactions. One author lists of the people of Israel with the mys- sions of the client, the desperation among these that of flight, that is to tery of God, especially his way of of the family relatives, all become say not wanting to engage in dia- acting in relation to human suffer- thrown, after a certain fashion, onto logue with the sick person or the ing. Why does pain exist? How can health care workers. dying patient, giving him only a it be reconciled with the omnipo- Turning to more specific aspects, technical or impersonal form of tence and goodness of the Lord? Sgreccia16 stresses certain factors treatment, or a disproportionate and This struggle takes place in the full which disturb the ethical-profes- obstinate assault through drugs or night of mystery and lasts as long as sional identity of the medical doctor surgery which constitutes a kind of the night. Pain is connected with the and cause disturbance and suffer- titanic struggle against realities darkness of the night which is not ing. For many health care workers which are rejected and perceived as seen as a negative value but as a there is in the first instance ‘the a threat not only to the patient but to mystery, to which only God knows abandonment, effected by law, of the deep and unconscious self of the the answer. The night is the moment the defence of the value of life’. medical doctor himself.18 when God condenses to the highest Born to serve life, the medical pro- When there is an aspiration to in- degree his mysterious action. But fession ‘is requested and required’ vulnerability or a denial of the hard every night is followed by dawn...20 to eliminate it. Secondly, there is and painful realities of life and The dawn of the Old Testament the social organisation of health one’s own limitations, there is little proclaims the day of redemption ef- care which ‘places the medical doc- space for compassion and a lack of fected by Christ. Although it does tor in front of depersonalising situa- a recognition of the freedom of the not lose its mysterious character, the tions or situations of a company or patients and their ability to take part suffering of man acquires meaning bureaucratic character which are in the process of healing. As when it is ‘closely connected with alien to the traditions of his profes- Nouwen observes on this point: ‘the the suffering of God himself’. In sion’. A third ‘factor which endan- person who in his own life is always other words, what man suffers, gers or reduces dialogue, communi- protected against experiences of whether of an intense or minor na- gg

DOLENTIUM HOMINUM N. 46/1-2001 37 ture, is an experience which, far refers to the need to adapt as much from the sick person. This is even from being isolated, is connected as possible the being of care for, more the case given that they are with the very suffering of God. With and treatment of, the infirm, to its tempted to protect themselves great exactness Nouwen observes having to be. In this debate, the re- against the image of themselves that Christ heals our pain by remov- lationship between health care which is reflected in the faces of ing it from our egocentric, individu- workers and the sick occupies an their fellows, afflicted, as they are, alistic and private context and con- important position. by suffering.24 necting it with the pain of the whole The person who suffers lives out This relational disturbance, of mankind which he takes upon the experience of a laceration of the which reflects a general tendency himself. In this sense ‘to care for body and the spirit. His suffering, and not necessarily the behaviour of and treat does not, therefore, mean which is expressed in pain, illness individual health care workers, is above all else to eliminate pain but and death, is a sign, a ‘coded mes- encouraged by the tendency to re- to reveal that our pain forms a part sage’, a cry which speaks to the hu- duce service to a mere function. of a greater suffering, that our expe- man person. The sick person needs From this point of view, the other rience is a part of the experience of his appeal, which speaks of human person is not seen as a person but he who said: ‘Did not Christ have to finiteness and the mortal condition only as somebody who gives or re- undergo this suffering so as to enter of the individual, to be listened to; ceives services. Attachment, inter- into his glory?’(Lk 24:26).21 the emotions which accompany est, and love tend to be replaced by The efforts of medicine to com- him – anxiety, fear, and hope – the rules of the contract of work. bat illness, with the risks that ac- should be taken notice of. The cry There is a lack of passion and com- company such efforts of making of the sick person is not suitably un- passion,25 that is to say that ‘inti- medicine fall victim to unrealistic derstood in a society that tends to mate emotion – deep identification aspirations, is a stimulus in favour treat suffering in a merely technical with those who suffer or who are in of a re-reading of the Word pro- way, that is to say by trying to elim- need – which is the beginning of nounced by God on human pain. inate it before trying to understand every real form of moral responsi- One of the guidelines which its meaning. Removed from the bility and thus of responsibility in emerges from this re-reading leads consciousness in which it is experi- the field of health and health care’.26 to an emphasis on the need to over- enced, suffering is reduced to a In fact, as the psychoanalyst Fran- come ‘painism’, that is to say an at- mere symptom, and it is thereby Hoise Dolto well observes: it is ‘the titude involving ‘interpreting pain alienated and dehumanised. In this emotion of compassion which en- as an element in itself of value, at case it is suffering rather than the genders inter-psychic communica- times even exalting it, or in extreme person which is the subject of care tion between people; there is care case even searching it out’.22 As En- and treatment. for the body which requires skill zo Bianchi correctly observes: ‘Je- Although pain is fought and com- and which is paid for, and there is sus opposes evil and tries to liberate bated with medical means it is im- the emotion which makes us human, who is its victim, from it. Je- portant to understand that it is a sign man. When this is absent it is be- sus never preaches resignation, he for the conscience. In this way the cause service has become an insti- never displays a search for suffering monopoly of technical action is tution, or because the encounter is for its own sake, he never advises broken and pain can to a certain ex- not unique but has become a remu- ‘painist’ approaches. Instead, he intent speak about and transmit its nerative work or an occupation volves himself in a struggle against meaning because it is a cry of without passion. The person who is evil and illnesses, responding to nu- meaning. There can be no doubt treated in this case is nothing else merous supplications for recovery that ‘health treatments’ of every but an object. A human relation no that the many miserable people who kind have multiplied in number and longer exists’.27 draw near to him direct towards that maladies are fought and com- In the face of this phenomenon, him’.23 bated with great force. But will all which expresses itself in a variety this be enough to meet the expecta- of forms, theological reflection in- 2.3. The Emotional Dimension tions of the sick person? Does he vites us to turn our gaze to Christ, of the Exercise of not often feel, even amidst all these the divine Samaritan of souls and the Health Care Profession forms of treatment, harshly re- bodies. This title captures all the turned to his loneliness, not under- work carried out by Jesus in favour The acceptance and assimilation stood in relation to his requests, be- of the sick – ‘moved by compassion of one’s own wounds, which are cause he has become a thing, a con- he drew near...’ About a third of the linked to the limited human condi- sumer without a voice? Listening to Gospels deals with the healings car- tion, not only makes us able to lis- the song that the patient sings is ried out by Christ and has observa- ten to the message which comes made difficult by a number of fac- tions made at the time of these heal- from suffering. It also enables the tors. Professional training, the or- ings. ‘Of the 3,779 verses of the health care worker to draw near to ganisation of work, and profession- Gospels, 727 specifically refer to those people who suffer in a way al or corporate interests, all have the the healing of physical and mental which displays greater humanity. effect of leading those responsible illnesses and to the resurrection of One of the subjects which has for care and treatment to engage in the dead. In addition, we find 32 been debated during our time has technical tasks more than other general references to miracles been that of the humanisation of kinds of task. They must react which involve healings’.28 From all service to the sick. This neologism strongly in order to avoid fleeing these texts it is clear that the taking gg

38 HEALTH CARE AND SOCIETY part of Christ in human destiny is cian and his patient’.31 The exclu- dry up and to die in a rocky soil not neutral but full of a strong affec- sion of providing health care was which offers no sustenance’.32 tive intensity. In the Gospels the applied to incurably ill people and In the light of the observations verb splanechnizomai is used to those who were dying. made above one can more effec- twelve times to describe the ap- Since the beginnings of Chris- tively understand and appreciate – proach adopted by Christ. The tianity the cardinal elements upon from a Christian anthropological meaning is the following: ‘to feel which theological reflection on point of view as well – the move something in one’s own guts’. In his compassion as a element in the from treating (which involves the contacts with people who suffer and practice of medicine has been based elimination of the illness) to taking are in need Jesus reacts with emo- are the incarnation of Christ and the care of.33 In the concept of taking tions: he strongly feels their suffer- idea that man is imago Dei, the im- care of are to be found both profes- ing to the point of being moved in age of God. On the basis of these sional competence and scientific his whole person by them and to truths, the Christian community has training, and the personal involve- weep at them, as happened to him directed its therapeutic activity to ment which leads us to concentrate in the company of the widow Naim every category of suffering people, on the person of the patient, whose and at the tomb of Lazarus. The whether believers or not, and has experiences, even though they can- emotion of Jesus, which is ex- managed to transform service to the not be penetrated by us to the full, pressed in concern and compassion, sick into a mediation of divine ten- can, however, move us deeply. This is already a source of healing. In derness and compassion, and into is because we share the same hu- Salvifici Doloris John Paul empha- an authentic experience of the Lord manity as the patient. To paraphrase sises this concept and states that the – ‘I was sick and you visited me’. Kant, we can say that if profession- readiness to help expressed by the The impulse to insert compassion al competence without the moral Samaritan towards the wounded into the practice of medicine en- quality of life is empty, for its part man was accompanied by an ex- tered into the health care philoso- incompetent treatment is blind. To pression of emotion: ‘If Christ, who phy of the West and transformed the take care of the patient is then a syn- knew man from within, emphasises health care act not only into treating thetic act in which intelligence no this emotion this means that it is im- but also into taking care of, some- less than the heart has its role and its portant for the whole of our ap- thing which implies a personal in- place.34 proach to the suffering of others. volvement of the health care worker In a significant book which was One should, therefore, cultivate with the person who is suffering – written in the early 1980s (entitled within oneself this sensitivity of the an involvement expressed through In a Different Voice),35 the Ameri- heart which bears witness to com- compassion, concern, encourage- can Carol Gilligan expresses the passion towards a suffering person. ment and support. need for such a synthesis in a very At times this compassion is the on- With the advent of scientific significant way. The different voice ly or principal expression of our medicine, treatment of the sick per- that the author talks about involves love and solidarity with a suffering son has become increasingly en- (in the world of health and health man’(n. 28).29 trusted to technology, and at the care) drawing near to people with Through his way of acting on be- same time care for the sick person an approach of participation rather half of sick and infirm people, Jesus in his totality has grown weaker. In than one of detachment, of agree- demonstrated with clarity that the opinion of a historian of medi- ment and compassion rather than union with God ‘is obtained and cine: ‘an unintentional but in- abstract rationality. This is a voice maintained through compassion to- evitable result of the secularisation which emphasises the primary im- wards others and in particular tor- of health care institutions has been portance of the person, his singular- wards the sick’.30 Breaking the tra- to separate them from the source ity, because he asks to be taken into ditions of the time in which he which gives rise to compassion. It is consideration for his own sake. This lived, Jesus drew near to lepers, no accident that compassion, leav- is a voice which down the centuries who were considered impure and ing aside obvious individual ex- has been largely expressed by contagious, placed his hands on pressions, is absent from modern women, but which does not belong many sick people, and commanded medicine’. And yet, this authority to women alone, even though our his apostles to do likewise (cf. Mt continues: ‘compassion is a quality tradition has confined it to them.36 9:25; 10: 7-8). which is fully compatible with sci- In moving from treating to taking The example of Christ had a de- entific medicine and the advance of care of professional behaviour cisive influence on the ethos of technology. But it does not come based only on the rights of the sick medicine at the dawn of the Christ- from them. Compassion is the wish person and the duties of those who ian era, inserting within that ethos to treat the sick person not only in a treat him becomes overcome. One the elements of philanthropy, chari- competent and professional med- reaches, that is to say, an experience ty, and compassion. In fact, in ical way but also to treat him with of what it means to decide to listen pre-Christian medicine ‘even when love and tenderness because he is a to the appeal which comes from the the ethical model of virtue derived human being worthy of being at- special condition which is being from the ideal of philanthropy tributed great love, and who bears lived out by the person who is in a reached its highest maturation and the image of God. Compassion can situation of illness. In answering expression one observes that there be wished for, encouraged, and cul- this appeal, therefore, one engages is a notable distance and coldness in tivated. But without a transcenden- in more than the mere performance the relationship between the physi- tal and spiritual base it is destined to of one’s ‘duty’. In the concrete real- gg

DOLENTIUM HOMINUM N. 46/1-2001 39 ity of a precise human relationship The activity of the health care further enriched by those character- there is not only brought into play workers is thus written into human istics which are typical of the femi- the rules which structure the health activity in general, thus becoming nine personality: receptivity, readi- care profession; at a deeper level one of its most meaningful expres- ness to help, welcome, a capacity to one gives form to the specific moral sions. Animated by faith, it repro- listen, the ability to understand situ- identity of people.37 The experience duces in an effective way the be- ations, the capacity to take on the of the health care professional haviour and conduct of the Good problems of other people, and the makes the epiphany of otherness Samaritan.39 inclination to offer their help? possible, that epiphany of otherness The situation of disturbance pro- Proposing the institution of ‘a min- to which Levinas refers and which duced in the context of the health istry of the pastoral care of the makes the essence of moral experi- care world by the difficulty of har- sick’, Melitello believes that ence an experience of encounter monising treating with taking care women above all should be active with another person, with the face of is an invitation to investigate in it: ‘because of their closeness to of another person.38 That face, for from a theological point of view the the mystery of life which is born or believers, has the features of Christ. importance of affective involve- life which passes away’. Indeed, In order to achieve this objective ment, and in particular to give ‘the closeness of women to the we need to enter into harmony with greater value to the feminine di- strong moments of life is more felt the sick person and his family rela- mension of society in general and than is the case with men’.40 tives through that approach which the world of health and health care is called empathetic listening. The in particular. Here the Mulieris Dig- 2.4. Which Health? nitatem of John Paul II offers important guidelines for reflection. Scientific and technological ad- ‘The moral strength of women’, ob- vance and socio-cultural evolution serves the Pope, ‘their spiritual have opened up new paths for med- strength derives from the awareness icine. ‘If, indeed, until yesterday that God entrusts man, the human there was only a medicine of needs being, to her in a particular way. (which was practiced through the Naturally, God entrusts man to triad of prevention-treatment-reha- everybody and everyone. However, bilitation), today there also exists a this entrusting refers above all else medicine of wishes, whose social to women specifically because of incidence is no less marked. In ad- their femininity’. Later on he adds: dition, if yesterday’s medicine ‘In our epoch the successes of sci- could at the most restore the human ence and technology allow us to organism to its previous complete- achieve in ways which are still un- ness, today it is able to improve it, known a material well-being which, to alter it, even to manipulate its ge- while favouring others leads others netic arrangements. Moreover, if to marginalisation. This material until yesterday the primary objec- progress can also lead to a gradual tive of medicine was to make peo- new medicine – which is similar in disappearance of the sensitivity of ple live, today there is also the goal this respect to the good medicine of man towards what is essentially hu- of making people live well, some- yesterday and of any time – begins man. In this sense, our time expects thing which involves not only the with a listening which enables us to above all that manifestation of the quantity of life but also the quality establish who the person is who genius of women which ensures of life’.41 We are face to face with a must be treated, what his moral sensitivity towards man in every new concept of health according to world is, how the search for his hap- circumstance because of the simple which it is no longer sufficient to piness should be organised, what fact that he is a man!’(n. 30). fall ill and then get better, but it is his preferences are, and what a If what the Pope maintains is necessary to strive for ‘a fullness in good life and a good death are for valid for every context, this is espe- which not only our primary needs this individual. cially the case in relation to the are satisfied, but also those which During his experience of infirmi- world of health where man, in expe- we could define as secondary be- ty, the sick person is placed in the riencing the fragility of his own ex- cause they are subordinate, thereby hands of health professionals so that istence, can easily fall victim to in- imperceptibly entering into the they can take care of him, that is to difference and violence. A more ac- realm of wishes’.42 say so that they can help him to keep tive and co-responsible participa- The panorama of the new direc- himself whole, to reacquire his lost tion of women in the mission of the tions of medicine is very wide. One humanity, ‘to reconnect his infirmi- Church in the health care world need only think of the medicine of ty to the story of feelings it gener- would lead to significant changes in reproduction, of aesthetic medicine, ates in the lived experience of the the approach to people and prob- of the medicine of sport, of genetic person’, to escape his loneliness, to lems in the world of health. Would engineering which aims at im- find a meaning... beginning with the it not be a good thing to see the provements, at forms of treatment knowledge that what wounds the presence and the action of the directed towards the body... body of an individual equally Church, its language, its theology, The increase in the kinds of ap- wounds his soul at a deep level. its perception of reality and of God, plication of medicine and the re- gg

40 HEALTH CARE AND SOCIETY sults to which it gives rise undoubt- ment of the full well-being of the harmony possible between the edly produce positive results. In- person? forces and the energies of man, the deed, as Leone Salvino rightly ob- In considering these question, most advanced spiritualisation pos- serves: ‘well-being and quality of which are increasingly frequent in sible of his corporeal aspects, and life cannot but refer to that existen- our society, theological reflection the most beautiful corporeal expres- tial fullness and that qualitative ab- begins with Christ. Jesus, in carry- sion possible of the spiritual. True soluteness which characterise the ing out his mission, also aims at the health manifests itself as the self-re- eschatological dimension of exis- fullness of the life of man: ‘I have alisation of the person achieved by tence’.43 However, they also give come so that they may have life; that freedom which mobilises all rise to negative consequences, such and have it more abundantly’ (Jn his energies for the fulfilling of his as a weakening of respect for life 10:10). It is true that the salvation overall human vocation’.48 It is also and a reductive concept of health. brought by him has the aim of rais- the case that the overall and holistic Indeed, while major and intense ef- ing man to taking part in divine life approach present in taking care of forts are made to prolong life or cre- along a path of alliance through a and treating the sick person and in ate it artificially, the person who has relationship which leads us to move programmes for the growth of the already been conceived is not al- out of ourselves and assume our re- human person – an approach which lowed to be born and there is a ten- sponsibilities in the world. This, is today being constantly examined dency to marginalise those who are however, does not mean that this is in the world of health and in society a disembodied salvation, something in general – finds an impulse to be- which is not called forth by joyous coming more complete in the teach- experience of living and of living to ings of Christ. This is not a matter the full. ‘The experience of faith, in of only becoming aware of the dif- fact, involves the whole of the hu- ferent dimensions of the person but man person, in his unity of body of knowing how to relate them in and spirit. The whole of Biblical terms of a scale of values which is revelation bears witness to the fact increasingly rich. This scale of val- that every experience of God is an ues, which finds its highest expres- experience of life, of liberation sion in the teaching of the Gospel, from every form of slavery to evil helps us to make choices and also to and the promotion and raising of make those sacrifices by which to life to the point of taking part in the respect life, and to defend the digni- fullness of divine life.’46 Maggioni ty of one’s own person and that of observes: ‘The salvation of Jesus other people, in order to maintain always reaches the deepest part and vital the tendency towards the tran- touches man at his centre. To redi- scendent. rect man in his relationship with Secondly, the action of accompa- not believed to be useful – the hand- God, Jesus worked through the nying the person towards well-be- icapped, the dying, the elderly... body – he healed. But he did not ing must be guided by an awareness Furthermore, although on the one confine himself to helping bodies – that the goal of human life is to be hand health is rightly endowed with he liberated man from sin and not located well beyond the immediate- value and there are efforts to in- only from illness, loneliness and ness of perfect well-being, even crease the ways of promoting it, on non-sense, not only from need.’47 through the human being is des- the other hand it becomes an ab- From an evangelical perspective, tined to know happiness from that solute value of consumption and it therefore, the promotion of psy- moment. This is a question above is reduced to its mere biological di- cho-physical health and well-being all else of entering into friendship mension or to vitality and is in large can become signs of the Kingdom with God, of being received by his measure associated with beauty and installed by Christ, openness to the tenderness in trust, even when we youth.44 welcoming of salvation, indicators are faced with the limits which are In the face of these negative de- of a condition which will find its inherent in the human condition, velopments a whole host of ques- full realisation during the eschato- something which is very visible tions arise: how can we harmonise, logical era. when the body falls into disrepair. in caring for and treating the person Bringing about everything that is Despite the limits of illness or hand- and his growth, technical logic and legitimate to ensure increasingly icap the human being can fulfil ethical logic, scientific-technical better conditions of life for all hu- himself and acquire that beauty that advance, and the order of values man beings is, therefore, a part of remains such even when it does not and ends?45 Is it possible to have a the divine plan. This endeavour, correspond to the cultural parame- form of medicine which is con- which bears upon the responsibility ters which exist. It is in this sense cerned with the person in the totali- of man, must in the first place seek that St. Augustine refers to the ty of his bio-psychic-spiritual be- to achieve the growth of the human beauty of Christ who was resplen- ing? How should we assess all person at the level of all his dimen- dent not only in the happy and ex- those movements which use spiritu- sions, opening him as well to that alting moments of his life but also ality and religion as therapeutic fac- call to transcendence which is writ- during those moments on the tors, capable that is to say of pro- ten into every human being. In this cross.49 If, indeed, the salvation moting healing and the achieve- approach health involves ‘the best achieved by Christ is a source of gg

DOLENTIUM HOMINUM N. 46/1-2001 41 health, it is such in the dynamics of dark burdens, its violence and nar- Notes his paschal mystery, his death, and cissism, of the thirst to possess’.54 1 What is said in this paper in relation to his resurrection. This involves a Furthermore, perhaps the time has medicine also refers to the world of health care necessary moderation of desires, an come to ‘return to the analysis of and health in general. overcoming of selfishness in order the relationship which theology dis- 2 Cf. P. GUAER, Le Christ Médicin: Soigner, la Découverte d’une Mission à la Lumière di to achieve a better distribution of cerns between responsibility and Christ-Médicin (CLD, Chambrai-lès-Tours, resources, agreement with reality, hope within the believer, also un- 1994). that indispensable condition for au- derstood as a commitment to per- 3 Cf. Evangelium Vitae, n. 15: ‘On a more general level, there exists in contemporary cul- thentic growth. ‘This approach of ceiving the cause of the malady, ture a certain Promethean attitude which leads agreement with reality is not exclu- promoting a lifestyle which fosters people to think that they can control life and sively Christian, given that it is al- the psycho-physical and spiritual death by taking the decisions about them into their own hands’. ready present in most of the sys- well-being on the one hand and an 4 Cf. A. KAHN, Et l’Homme dans tout ça? tems of wisdom in the world. The approach of trusting in, and entrust- (NIL, Paris, 2000), p. 233. difference lies in the fact that for the ing oneself to, God, on the other.55 5 CF. J.M. VELASCO, ‘Mundo de la Salud y la Evengelizaciòn, in AAVV, Congresso Iglesia Christian this path reaches a culmi- y Salud (Madrid, 1994), pp. 218-219.6. F.J.J. nating point in profound adherence BUYTENDICK, ‘El Dolor’, in Revista de Occi- to a filial approach’in relation to the Conclusion: dente (Madrid, 1958), pp. 23-24. 7 A typical example of this orientation is Lord. ‘Then divine grace – the the Lessons of Witnesses once again the cloning of humans, a paradig- freely-given love of God – can col- matic subject of this move from one millenni- laborate fully with a profoundly re- Between medicine and theology um to another. It brings into question the deep anthropological meaning of the way in which a spected human freedom in a rela- a fertile relationship can be estab- man and woman co-operate in the birth of a tionship of otherness... It is then that lished. History bears witness to acts new created being. salvation is received to the full, of drawing near and to fractures. 8 J.M. VELASCO, op. cit., p. 218. 9 A. BRUSCO, Umanità per gli Ospedali even though healing is not perceiv- From the literature on the subject, (Salcom, Varese, 1983), p. 23: ‘In the world of able from the medical point of which is at an advanced stage al- medicine, more than in other sectors, the con- view’.50 Acting outside this ap- though not yet systematically tradiction breaks out between the dream of absolute progress and reality. The real of death proach one runs the risk of trans- worked out, comforting results may penetrates the imagination of technological hu- forming faith into a medical ser- be expected. Positive results have manism and reveals its illusory character. This vice, or into a ingredient which can arrived and continue to arrive from is the modern tragedy in which the progress of science and technology clash against the pow- only bestow greater serenity on the the witness of very large numbers erlessness of the human person in relation to person, or into a good relationship of health care workers – medical finiteness’. with oneself. In this case one runs doctors, nurses, and so forth – who 10 JEAN PAUL II, ‘En Etant les Défenseurs de la Vie vous etes les Coopérateurs de Dieu’, Do- the risk of exploiting faith in order have lived out their profession with lentium Hominum, 3 (1986), p. 20. to achieve the psycho-physical a mission directed both towards 11 L. SALVINO, op. cit., p. 1097. well-being of the human person, healing the wounds of sick people 12 PIO XII, ‘Radiomessaggio al VII Congres- so Internazionale dei Medici Cattolici’, in Pio deceiving him in relation to his and promoting human health in the XII, Discorsi ai Medici, edited by F. Angelini wish for invulnerability and immor- light of the principles of the Gospel. (Orizzonti Medici, Rome, 1966), p. 504. Cf. L. tality.51 Their practical teaching has helped, BUCCI, Cristo Medico, Implicazioni Etiche di un Motivo di Antropologia Teologica nel Con- To bring out the salvation he ef- and continues to help, to deepen the testo del Dibattito Bioetico Recente (Camil- fected, Christ worked miraculous intelligence of faith of the health liane, Turin, 1998). healings which were signs of the care profession. Some of these have 13 Cf. A. BRUSCO, ‘Vulnerabilità Personale e Servizio a chi Soffre’, Camillianum 8 (1993), transformation achieved in the in- been proposed as models for the pp. 223-241. nermost part of the human being. veneration of the People of God; 14 C. JUNG, ‘Fundamental Questions of Psy- Today, as well, signs are needed, others have followed the divine chotherapy’, in Collected Works, vol. XVI (1951), p. 116. probably not along the lines of the Samaritan of souls and bodies with- 15 G. CINÀ, ‘Il Linguaggio della Sofferenza’, miracles performed by Christ, but out having been explicitly aware of Anime e Corpi, 165 (1993), p. 78. in the spirit in which he brought the fact. In Salvifici Doloris (nn. 16 E. SGRECCIA, Pastorale Sanitaria, Istanze Etiche e Culturali (Salcom, Varese, 1987), p. them about – love. ‘Faith and love 28-30) John Paul II recognises the 207. can really heal, in relation to the ex- value and strength of such witness. 17 Cf. C. NOTATO, ‘Il Guaritore Ferito’, tent to which they restore the unity Uniting skill with compassion, and Camilliani, 67 (1993), pp. 311-312. 18 E. SGRECCIA, op. cit., pp. 203-204. of the person, without this involv- being able to see the face of Christ 19 H. NOUWEN, Il Guaritore Ferito (Querini- ing necessarily physical or mental in the sick person, they have made ana, Brescia, 1982), p. 98. healing... Community is the sacra- of their health profession an expres- 20 Cf. J.L. CARAVIAS, Fe y dolor, Respuestas 52 Biblica ante el Dolor Humano (Selare, Santafé ment par excellence of healing’. sion of the charity of God and an di Bogotà, 1993), p. 18. The context in which contempo- authentic realisation of the Christ- 21 H. NOUWEN, La Memoria Viva de Jesu- rary medicine finds itself and its ian vocation, thereby also demon- cristo (Guadalupe, Buenos Aires, 1987), p. 23. 22 L. SALVINO, ‘Salute: Approccio Etico e commitment to improving the hu- strating that man created in the im- Pastorale’, in Dizionario di Teologia Pastorale man condition through the promo- age of God, of a God who is love, Sanitaria (Camilliane, Turin, 1997), p. 1096. tion of a growing fullness of life is can only be authentically fulfilled 23 E. BIANCHI. ‘Preghiera’, in Dizionario di 53 Teologia Pastorale Sanitaria (Camilliane, an invitation. ‘An act of salvation in love. Turin, 1997), p. 931. can only take place with a body, in a 24 Cf. Salvifici Doloris, n. 30: ‘The Gospel is Rev. Dr. ANGELO BRUSCO, the negation of passivity in the face of suffer- body, and not against a body, even Superior General of the Minister ing. Christ himself in this field is above all else though this involves progressive of the Infirm (Camillians), active’. liberation, or an assimilation of its Italy. 25 J. PROULX, ‘Santé, Sense et Salut’, gg

42 HEALTH CARE AND SOCIETY

Critière, 14 (June 1976), p. 113. Cf. P. Cattori- 33 Cf. E.D. PELLIGRINO and C.D. THOMAS- 41 S. LEONE, ‘Salute: Approccio Etico-Pas- ni, Malattia e Alleanza (Florence, 1994), p. 19: MA, Medicina per Vocazione (Dehoniane, torale’, in Dizionario di Teologia Pastorale ‘The interpretation of the medical act to the ef- Rome, 1995); W.T. REICH, ‘Curare e Prendersi Sanitaria (Camillianium, Turin, 1997), p. fect that it is a technical service, an interpreta- Cura. Nuovi Orizzonti dell’Etica Infermiearis- 1097. tion which corresponds to the reduction of the tica’, L’Arco di Giano 10 (1996), pp. 11-24; S. 42 Ibid., p. 1093. therapeutic act to a commercial negotiation, to SPINSANTI, Curare e Prendersi Cura (CIDAS, 43 Ibid., p. 1093. an exterior supply and use of services, almost Rome, 1998). 44 The encyclical Evangelium Vitae of John an action of mechanical repair, has obscured 34 In the document of the national consultati- Paul II describes in exhaustive fashion the at- the original dimension and the radical spring of be body for pastoral care in health, La Pas- tacks on life which are present in contemporary the institution which provides care and treat- torale della Salute nella Chiesa Italiana, it is culture and which are visible in a particular ment – the call for help addressed by a suffer- stated that professionals of health are called up- way in the world of health. ing person to another man’. on ‘to acquire the broadest profesional ability in 45 Cf. D. VASSE, ‘La Parole e la Souffrance’, 26 Ibid., p. 18. the belief that honesty and professional compe- Medicine de l’Homme, 82 (1976), p. 30. 27 F. DOLTO, L’Evangile au Risque de la tence... can only with difficulty be substituted 46 G. CINÀ (ed.), Medicina e Spiritualità Psychanalyse (Delorge, Paris, 1977), pp. by another kind of apostolic zeal’ (n. 53). (Camilliane, Turin, 1998), p. 9. 162-163. 28. C. Vendrame, ‘Le Guarigioni dei 35 C. GILLIGAN, In a Different Voice: A Psy- 47 G. MAGGIONI, ‘Sofferenza, Approccio Malati come Parte Integrante dell’Evangeliz- chological History of Women’s Development Biblico (NT)’, in Dizionario de Teologia Pas- zazione’, Carmillianum, 2 (1991), p. 30. (Harvard University Press, Cambridge, Mass., torale, p. 1171. 29 In the fifth chapter of the encyclical Evan- 1982). 48 B. HAERING, Perspectives Chrétiennes gelium Vitae the role of compassion in service 36 Cf. W.E. LECKY, History of European pour une Médicine Humaine (Fayard, 1975), p. to life and suffering people is masterfully ex- Morals, vol. 2, pp. 361-363. 157. pounded. 37 Cf. ibid., p. 12. 49 Cf. Exposition on the Book of Psalms, 44, 30 A. VANHOYE, Vita Consacrata Sanitaria, 38 Cf. E. LEVINAS, Totalità e Infinito (Jaca 3; PL 36, pp. 495-496. Fondamenti Biblici (DTPS), p. 1390. Book, Milan, 1980), p. 73. 50 B. UGUEUX, op. cit., pp. 192-193. 31 S. SPINSANTI, L’Alleanza Terapeutica 39 Cf. Salvifici Doloris, n. 29. 51 Cf. G. CINÀ, op. cit., pp. 10-11: cf. B. (Città Nuova, Rome, 1988), pp. 67-68. Cf. 40 C. MELITELLO, ‘Donna e Mistero’, Camil- Ugueux, op. cit., p. 204. G.B. FERNGREN, ‘Medicine and Compassion in liani, 65 (1993), p. 110. See in this article the 52 Cf. B. UGEAUX, op. cit., p. 203. Early Christianity’, Theology Digest, 46, 4 pertinent reflections on Mary of Nazareth, the 53 G. Cinà, op. cit., p. 9. (1999), pp. 315-316. model of priestly and royal prophetic ministeri- 54 B. UGEAUX, op. cit., pp. 27-28. 32 G.B. FERNGREN, op. cit., p. 324. ality (pp. 110-111). 55 G. CINÀ, op. cit., p. 11.

WILLEM J. EIJK II: Contemporary Questions of Moral Theology

Catholic moral theology has as Autonomy and Pluralism universal norms cannot be derived its point of departure a vision of from the essence of man. Attempts man based upon Revelation or This fundamental approach was to do this, in his opinion, were Christian philosophy, above all of challenged above all else during the based upon images made by man of the Thomist kind. God, in creating last century by a series of coincid- himself and memories of the past, man in his image and likeness, ing factors which made it almost or were things which came from an had a certain plan for man which impossible for modern society to apparent world. All this, thought corresponds to his being. This ap- provide an answer to what man is Grisbach, distracted man from the proach means that man, reflecting and thus to the question of how he concrete situation in which he acts. on his own being, either rationally should be and how he should act. Each and every situation is for him or in the light of Revelation, is The founder of situation ethics, the so unique that no universal rule able to know what behaviour is German thinker Eberhard Grise- could be applied to it. In this appropriate or not appropriate to bach (1880-1945), Professor of the- thought one can recognise the ap- his being. In other words, man is ological ethics at the Faculty of proach of nominalism, something for this reason able to discover Protestant Theology of Zurich, which has always greatly influ- what is needed to strengthen his wrote in his book Gregenwart, enced Protestantism. During the likeness to God. This is realised which was published in 1928: ‘It last century there was added the in- through the virtues, above all cannot escape the critical thinker fluence of existentialist philosophy those infused in him as a grace of that scientific ethics, notwithstand- which placed even greater empha- God. Gregory of Nyssa said that ing their fundamental absolute, do sis on the unique and the concrete. ‘the end of life led in line with the not tell any man what at any mo- It is clear that nominalism, which virtues is to become similar to ment he must do here and now, they reduces human knowledge to the God’.1 Thomas Aquinas saw the cannot guarantee that they will lead empirical, is a very attractive phi- virtues as moral characteristics somebody to ethical existence in losophy in an epoch when science which strengthen within man his the contemporary situation’.3 and technology still enjoy very likeness to God.2 Grisebach was convinced that great authority, although such au- gg

DOLENTIUM HOMINUM N. 46/1-2001 43 thority is less than it once was. The the last century, it was lost during the man whom Mark Twain called law of David Hume (1711-1776), the epoch of the hippie movement “a good man in the worst sense of which is often referred to, says that and the sexual revolution. A very the word”’.6 Most of contemporary there is an insuperable leap between important factor in bringing this sets of ethics and moral theologies what is and what ought to be.4 That about was the prosperity which are today inclined to see norms is to say that a knowledge of the arose in the United States of Amer- such as ‘I would not engage in in- facts can never tell me how I must ica during the nineteen fifties and duced abortion or direct euthanasia’ act (in English this is described as emerged in the second part of the as general norms, that is to say as the fact/value dichotomy). This is a nineteen sixties in Western Europe. norms which are valid in general logical consequence of Hume’s em- Prosperity and technology made but which are not without excep- piricism. This should not lead us, daily life less harsh and more com- tions (‘valent ut inpluribus’), and however, to close our eyes to the fortable and caused a major change which are therefore in opposition to fundamental weakness of empiri- in norms and values. What was se- absolute norms. cism, which is in fact based upon a vere and demanding easily became Discussion on the foundations of blind and self-contradictory dogma. seen as something which had to be the moral norms of moral theology Indeed, it cannot be demonstrated avoided in a moral sense. Catholic advances in two stages at an overall in an empirical way that only em- moral doctrine was thus often seen level. Situation ethics, which is pirical knowledge is real knowl- as inhuman – how could one, for favoured for the most part by liber- edge, although according to the fun- example, require a girl who had beal Protestants, dominated during the damental dogma of empiricism this come pregnant against her will to fifties and sixties. Amongst in fact is the only way by which to carry that pregnancy to its natural Catholic moral experts who found arrive at real scientific knowledge. conclusion? The consequences for traditional morality too restrictive, Another very important factor is her life, it was thought, were too se- proportionalism was generally ac- that according to the natural and rious and severe for such a thing to cepted from the middle of the nine- technological sciences every be required. Indeed, many people teen sixties.7 Leaving aside its vari- method, every result of research, who say that they reject induced ous variations, this current of and every natural physical law for- abortion generally make an excep- thought had as a principle the asser- mulated in a certain period can also tion in such a case. tion that in the concrete act both the be subjected to proof or further ex- positive and the negative effects perimentation. This gives the im- have to be considered in order to es- pression that almost every form of tablish whether an act is good or human knowledge is always bad. One has, for example, to weigh changeable, not only in the field of the death of an unborn child against science and technology but also in the negative consequences for the that of philosophy and theology, life and career of a girl who has be- and – and this is an important fact – come pregnant against her wishes. in the field of ethics as well. The Intrinsic evil, that is to say evil theory of evolution, which presents which should never be done, how- man as a non-intentional product of ever good the goal aimed for, is said an impersonal causal biological to involve only the approach of the process, has taken the place of the agent or a virtue in general – one creationist vision and for this rea- should not, for example, ever act son has also displaced the concep- unjustly or imprudently. However, tion of the plan of creation as the proportionalism was rejected by the basis of morality. Magisterium in the encyclical Veri- The positivist mentality also has tatis Splendor (nn. 71-83). as a consequence that Holy Scrip- An absolute norm, that is to say a Whilst classic utilitarianism and ture is often interpreted only ac- norm which prohibits a concrete in- proportionalism – which was to a cording to the criteria of the posi- trinsic evil, allows of no exception, certain extent its expression in tive sciences and that its specific and for this reason arouses suspi- Catholic moral theology – saw ethi- message is rejected. Fundamental- cion in our society. A doctrine cal judgement, that it is to say the ism, which is present above all else which still upholds the existence of drawing up of a suitable balance of in orthodox Protestants but which at absolute norms is rejected as legal- positive and negative conse- times is to be found in certain ism and thought to be overly rigor- quences, as being not only the task Catholic groups as well, tries to ous.5 Fletcher, a Protestant adherent of the individual moral conscience, maintain faith and traditional Chris- of situation ethics, has described the but in large part also as being the tian morality by taking the Bible lit- approach of society towards those task of society or the public author- erally. This, however, is in the final who proclaim absolute norms in the ities, in actual fact their evaluation analysis an expression of the same following way: ‘even if the legalist and assessment has become in- empiricist and nominalist approach. deplores the fact that the law re- creasingly something for the indi- Whilst classic morality, although quires hard and disastrous deci- vidual. The crisis of authority in it had lost its basis, continued to be sions, he still shouts “Fiat justitia, general, which at the present time generally accepted within society ruat caelum” (let justice be done is, however, somewhat diminish- until the last twenty-five years of even though the heavens fall). He is ing, makes the acceptance of public gg

44 HEALTH CARE AND SOCIETY authority and ecclesiastical authori- consensus which can then act as a Given that autonomy and plural- ty above all in ethical questions dif- leading plan for the legal system it ism exclude a priori fundamental ficult. Individualism and the lack of becomes necessary to confine our- discussion in the public forum it is solidarity which are so conspicuous selves to those empirically verifi- first of all necessary to demonstrate in Western society have as their able principles which are accepted their difficulties, and even their in- consequence that man becomes in- by everyone as constituting a ‘high- trinsic impossibilities. creasingly more closed up within est common denominator’.8 These himself. Each and every man has principles are as follows: his own standards by which to 1. The principle of autonomy or – Illusory Ethics judge the meaning of his behaviour in a somewhat attenuated way – the and the consequences of his actions, principle of permission. Precisely in relation to those and for this reason he is said to be in 2. The principle of doing good principles which should lead soci- large part autonomous. The ethics (the principle of beneficence). ety to a consensus, the ethics of au- which seek to support this develop- 3. The principle of not doing tonomy demonstrate a fundamental ment are known as the ethics of au- harm (the principle of non-malefi- defect. Above all else the principles tonomy. cence). of doing good and of not doing Such ethics prevail in secularised 4. The principle of justice. harm and of doing justice have no society but they have also had a Nobody can deny the principle of meaning unless one knows first of great influence upon religious be- autonomy because man is obvious- all what good and harm are, or what lievers. Every pastor of souls is ly a free being. Many people see rights are, or what justice is. What faced with this attitude among his this principle as the fundamental do these principles listed above ac- parishioners and hears said to him ‘I principle which always and every- tually involve when such concepts can determine what I believe’. In where requires obedience and do not have any objective contents? public life, medical doctors, nurses, which has a priority over the princi- In 1988, the Court of Luxem- teachers, social workers and many ple of doing good. If a person wants bourg gave a judgement in the case others have to conceal their own be- to end his own life through euthana- of men who had damaged the exter- liefs behind the mask of their pro- sia or change his sex nobody has the nal genitals of some members of fessional role and activity. In health right to stop him. This means that a their group during the carrying out care it can easily happen that a med- medical doctor, in trying to save the of sado-masochistic rites. Both ical doctor does not agree with his life of a person who wants to take those responsible and the victims customer but every ethical discus- his own life, does a good but does themselves defended themselves by sion draws to a halt before the au- this against the will of the patient. saying that everything had taken tonomy of the patient – ‘this is This means that he commits the sin place with the consent of the vic- something that he himself wanted’. of paternalism. If somebody, in- tims. The Court, seemingly con- Given that the balance of the vari- stead, does not accept euthanasia in vinced that a citizen does not have ous relative values is often based principle he must not impose it. In the right to dispose of his or her upon the emotions of the moment this way a traditional Catholic and a own body in an unlimited way, re- the result is not communicable to liberal can live together peacefully jected their arguments. However, other people. It is very significant within the same society. there remains a certain contradic- that here one does not speak about Through democratic consensus, tion in the legal system because an- an ‘ethical judgement’, which can society tends to establish certain other action in which the body is be communicated through rational goods in order to distribute them wounded in a marked way because discourse, but of an ‘ethical deci- among the population in line with of a wish which takes place at a sex- sion’ – this is an example of ex- the principle of justice, and this ual level, that is to say the sex treme voluntarism. with a view to allowing all people change operation, is generally ac- Western society was still experi- able to live out their autonomy to cepted because it is seen as a form encing during the years of rebellion the highest degree possible. Soci- of treatment. And some countries and conflict – that is to say during ety, in the same way, does not have tolerate the use of light drugs, the nineteen sixties – a frequently the right to impose on an individual which in actual fact are not light at severe struggle between the various a good against his wishes. The prin- all, or heavy drugs, even when sup- currents of thought and indeed be- ciple of not doing harm functions as plied free in desperate cases, to pre- tween the generations. But we have a negative barrier in relation to au- vent theft or other forms of crime. now accepted that autonomy and tonomy – to cause harm to another This is done within the framework pluralism are indispensable person is not acceptable because of so-called ‘harm reduction’ in or- pre-conditions for peaceful co-exis- this can be understood as a limita- der to protect the principle of not tence despite the presence of a dition on that person’s autonomy. doing harm. But what is the criteri- versity of ethical opinions and It is clear that it is impossible to on for the evaluation and assess- choices. We are dealing here with reconcile the ethics of autonomy ment of the various effects? There deontological ethics in the sense with Catholic morality. This latter is a lack of logic when we compare that a series of principles (normally takes as its point of departure an an- the two cases: if we accept the mod- four in number) are taken as a point thropology which has certain fixed ification of gender why should we of departure, and these are based co-ordinates which are themselves not accept sadistic wounding which upon a simple model. Given the im- independent of any possible subjec- is practiced in order to enable cer- possibility of achieving an ethical tive preference. tain people to satisfy their deviant gg

DOLENTIUM HOMINUM N. 46/1-2001 45 sexual desires which would other- sharing the philosophy of Sartre, sion of being tired and the answer is wise become uncontrollable? Why one must agree with his description to cut”. This operation involves the should we not see this as well as a of the contemporary mentality, by removal of a lay of fat – ‘one of the sort of therapy or preventive mea- which he, too, was oppressed. We most popular operations among sure? The impression remains, often feel that we are being watched middle aged women, and in addi- therefore, that the ethics of autono- as objects by other people who re- tion not very expensive. It can be my are not without a certain major duce us to an object and a posses- done for 3000 florins (2.500.000 arbitrariness, in the social field as sion.9 Shame comes into play when Italian lire)’.10 well. This makes one fear that one we become a thing appreciated ac- Many things done to the body day the approach to sadistic harm cording to its value in the eyes of come from feelings of inferiority, could, on the basis of mutual agree- another person. This approach con- something which is rather frequent ment, become positive in character. cerns the body. If the gaze of the in a demanding society such as In his encyclical Evangelium Vitae other person threatens to destroy ours. A choice determined by these (n. 70), John Paul II asks whether me, I have to remove the cause. feelings which function in the ulti- such an arbitrariness, which denies mate analysis as forms of social even such fundamental goods as pressure is not completely free or life, does not in fact lead to a demo- autonomous. The problem with the cratic society becoming its oppo- ethics of autonomy is that these are site: ‘when a parliamentary or so- ethics without a subject – the au- cial majority decrees that it is legal, tonomous man which they envisage at least under certain conditions, to is an abstraction or perhaps even an kill unborn human life, is it not real- illusion. ly making a “tyrannical” decision Even if the autonomous individ- with regard to the weakest and most ual existed he would have a task defenceless of human beings?’ which could not be met – he would Side by side with the problem be ‘condemned’ to engage in a con- that the lack of an anthropology stant comparison between the vari- which supplies objective criteria by ous relevant goods in his situation. which to distinguish good from evil There are those who train the body, Without a fixed co-ordinate this is in fundamental terms makes any have plastic surgery, engage in impossible. How could one com- moral evaluation impossible, auton- piercing and tattoos, and they do pare the weight of the various omy in itself appears to be a fiction. this voluntarily, indeed are not con- goods involved in a human act giv- We discover this when we analyse strained to do so. However, the en that they are not commensurate certain cases which are seen as be- body functions in our culture as an with each other when there is no ing examples of autonomous deci- object which attracts the attention common denominator? How can sion-making. We should we think of other people. In what we do with one assess the value of a step for- about the autonomy of the transsex- our bodies we are led by the prefer- ward in one’s career or a trip to ual who wants to modify his pheno- ences of other people. Fashion is Thailand rather than having a child typic gender? Is it or is it not a com- not a personal choice – it is deter- or the importance of procreation for pletely autonomous decision? It is mined and imposed by a group or demographic balance?11 One is not certainly the case that he has not by collective pressure. dealing here with goods of the same chosen the condition of being a In more intellectual circles, as order. Demmer looks for such a transsexual – according to the ex- well, man is rather like a saleable common denominator in ‘openness perts this is both the result of a psy- object. In a recent article in a Dutch to eternity’ (Ewigkeitserschlossen- chological development and the ex- review a survey was described heit): ‘the temporal with the eternal pression of a biological/genetic which had been carried out into the are not compared or even mutually condition. Whatever the cause may extent to which external beauty and assessed, but rather distinct degrees be, the decision to undergo an ex- attractiveness influenced levels of of intensity, awareness and freedom ternal sex change seems, however, income and the ability to achieve of openness to eternity’.12 This pro- at least partly, to be determined by advance in one’s career. Such fac- posal, however, is a solution which factors which evade free will. Can tors were found to be proportional. gives rise to a certain perplexity. we not say the same about all cos- A plastic surgeon at Schevengen for The ethics of autonomy impose on metic operations? this reason regularly treats individuals a task which is psycho- In truth, why do people want to well-known high-level managers logically too difficult to perform. engage in piercing and have tattoos from the world of business. The individual in himself is not able done on their bodies? Why is it a Amongst them was to be found a to have an overall vision of things. pleasure to go outside in a sleeve- man in his forties whose face was in Freedom of choice has in addition less shirt despite the cold so as to no way ugly. In the IT industry other disadvantages. Life no longer show people one’s muscular arms where he worked ‘among young has an obvious path but a series of and shoulders. Why do people have people’ he wanted to appear more personal choices for which the indi- face-lifts and cosmetic implants? ‘cool’. ‘He did not fail to notice the vidual himself is totally responsi- Why is there this dissatisfaction fact that one’s eyelids begin to ble. The consequence of this is that, with one’s body as it is when there droop a little as one approaches the no longer supported by society, al- is no illness or defect? Without age of forty. This gives the impres- though he is personally appreciated gg

46 HEALTH CARE AND SOCIETY for his success he is also held per- St. Alphone of Ligorio the greatest creation is still seen as a good. sonally responsible for his own fail- moral theologian after St. Thomas There are other goods which man ure. Aquinas, called suicide a sin against wishes to have. Solzhenitsyn him- The drama of the illusion of the the love of man towards himself be- self describes how the interrogators autonomous man becomes even cause life is ‘substantia et funda- in the Communist system used tried clearer when we consider what hap- mentum aliorum [bonorum]’ – and tested methods to force prison- pens to him in his social relation- ‘how can I love myself if I do not ers who were often completely in- ships. In public discussion it is al- want for myself at least being nocent to sign confessions as to most impossible to speak about which is the basis of every good and their guilt – they made a number of one’s own religious or political be- without which I cannot wish for false promises (‘if you sign we liefs because they are limited to the myself any good?’14 Without life guarantee that you will be treated in private sphere. The consequence of one cannot achieve freedom. a mild way’), they deceived them this is that in social and political life Whilst in contemporary Western by pretending that their families we become forced to discuss only society there is a strong tendency to had also been arrested and that they those values which are important for prefer freedom over choice, there fate depended on a rapid confession everybody. In practice this means are also other experiences. We can of guilt, or they tortured them so economic values. As a result man really be amazed at the fact that peo- that they could no longer think. By himself is practically reduced to an ple in terrible and apparently un- economic value. The English bearable circumstances strive even philosopher MacIntyre observed in extremis to survive. The concen- how the leading social models of the tration camp prisoners of the period past – professors, medical doctors, of Nazism and Communism lawyers and pastors – have been demonstrated a strong will to sur- substituted today by bureaucratic vive, despite the fact that their situa- managers.13 The manager is the per- tion was desperate. In his famous son who must manage a company, a book, The Gulag Archipelego, hospital, a school, or a public entity A.Solzhenistyn gave many mean- by utilising the minimum of re- ingful examples of this.15 During sources, money and employees. imprisonment in a concentration From this point of view, man is of- camp the Viennese psychiatrist Vik- ten assessed only in terms of his tor Frankl had an opportunity to car- economic value and not primarily ry out research into his logotherapy, according to his being, which, how- the model of the third school of psy- ever, he has wanted to put forward chotherapy of Vienna, in observing by emphasising his autonomy. This that prisoners managed to survive contrary consequence shows that by keeping their hope alive and by the ethics of autonomy in the final perceiving a meaning to life.16 When analysis are only an illusion. they lost such things they were no longer able to live and they usually died, without being killed or com- An Objective Support mitting suicide. This shows that depriving them of objective rational man, even in circumstances which consciousness they prevented them The fundamental question is if are much more severe than those ex- from acting in a human way, that is there exist objective goods which perienced by our terminally ill pa- to say as free and responsible be- function as fixed co-ordinates for tients, has a propensity to live and ings. Hence the principle of in- an ethical evaluation of human be- thus to see life as a good. formed consent which requires that haviour. Human freedom is certain- The same holds true for procre- a patient must not undergo treat- ly such a good but it is exalted to the ation – there was a great love for, ment or take part in an experiment state of being almost the only fun- affection towards, and wish to have if he has not been sufficiently in- damental human good without ref- children even in epochs in which formed about the advantages and erence to the others. Modern man, good diets and education could be disadvantages involved, or if he has in living with the illusion that with- achieved only with great effort and been subjected to pressure. Other- out health life is deprived of all val- many difficulties. Although during wise he could not take a really free ue, surrenders when the technology wars the birth rate falls, there is of- decision. In this context, knowl- is not there and increasingly choos- ten a rapid increase during the im- edge, too, is a fundamental good in es the active termination of life in mediate post-war period. Despite the achievement of freedom. the form of assisted suicide or (vol- the very low birth rate to be en- The newly-born children of the untary) euthanasia. The freedom to countered in our society, a major experiment carried out by Frederick evaluate the value of life is pre- part of the 20% of the couples who II during the thirteenth century ferred to life itself. Although free- cannot have children in a natural were not caressed and nothing was dom is the highest good of man way are ready to undergo a large said to them. This was to see if the should we not state that life is a number of medical exams and op- original language of man was He- more fundamental good? Cardinal erations in order to procreate. This brew. They all died. One reason for De Lugo (1583-1660), according to means that even in our society pro- asking for euthanasia is often the gg

DOLENTIUM HOMINUM N. 46/1-2001 47 feeling of being abandoned and iso- tain basic propensities towards terion in a way that is a more ac- lated. Despite prosperity, many things which reason spontaneously ceptable to modern man. Finnis, people in our society suffer from perceives, for this reason, as goods, taking not only the question known loneliness, the illness of the West- and these are as follows: as 94.2 of the Summa Theologica ern world. Practical knowledge or 1. The propensity to maintain his but also all the other writings of wisdom in themselves are not own being, something that man has Thomas Aquinas as a point of de- enough to enable us to live, as in- in common with the other sub- parture, identifies seven fundamen- deed Frankl points out: ‘in a con- stances, from which it follows that tal goods: life (including procre- centration camp I once found the life is a good. ation), knowledge, play, aesthetic body of a woman who had commit- 2. The propensity to maintain his experiences, social life or friend- ted suicide. Amongst her posses- species through procreation and the ship, practical rationality, and reli- sions was a piece of paper on which raising of children, something that gion. Other goods can be listed but the following words had been writ- he has in common with the animals. these can be reduced to one of these ten: “Courage to bear destiny is 3. The propensity specific to seven.19 These last are fundamental stronger than destiny itself”. Well, man, namely his aspiration to ratio- in that they cannot be reduced to despite this motto, she had taken nal knowledge and to live in soci- each other. All seven are equally her own life. Wisdom is diminished ety. fundamental – there is no hierarchy if there is an absence of human Many people have difficulty in amongst them and one of them can- touch’.17 accepting this explanation of not be sacrificed to another. An- All this shows that affection and knowledge of moral principles thropological research, amongst relationships with other people, as based upon human propensities. non-Western peoples as well, has in part emotional and in part spiritu- Does this not reduce man to the lev- indicated that these values can be al goods, are indispensable for man el of an animal which has deter- found in very different cultures de- in order to live in a human way. mined behaviour? Let us not forget spite the concrete differences that These reflections show that the ab- that the concept of nature and of nat- exist between them. As has already solutely autonomous man, in the ural law makes modern man think been pointed out, a comparison of sense that he can determine what a that one is dealing here with biolog- goods is only possible if there is a good or otherwise may be for him, ical/natural nature and physical nat- common denominator – the human is a total abstraction in relation to ural laws which imply determined person. The goods which are intrin- reality. Whereas many people think functions or effects. Modern man sically rooted in the human person that the classic doctrine of natural has precisely the belief that he has can not be compared to each other law is too abstract to form the basis overcome physical and biological when a violation is involved. Only of ethics, in actual fact it also corre- nature, which often has a large num- at the level of achievement can a sponds to the concrete experiences ber of limitations. He gets angry or comparison be made. In this way it of man during the twentieth centu- he gets irritated when reality seems is possible to engage in a compari- ry. A ‘sine qua non’ condition, how- to be the opposite. The concept of son which is realistically based up- ever, is that this should not be pre- natural law is for this reason less on fixed co-ordinates. sented in the voluntaristic and es- popular. Whatever the case, aver- The reader might be amazed to sentialist way as was done by the sion towards this concept is based read that fundamental goods are in moral thinkers of the second upon a misunderstanding – propen- themselves known, that is to say not scholastic period. This explanation sities are conceived as blind tenden- demonstrable. However, we are of natural law lost ground during cies, which they obviously are not. speaking here about the philosophi- the nineteen sixties of the last cen- They are, in fact, the beginning of cal approach to ethics which, like tury because of the accusation that moral action because they place metaphysics, is based upon evident it was biologistic and physicistic. man face to face with a choice. principles as a point of departure. Indeed, one cannot deduce moral Without the existence of certain Basing ourselves on Revelation we norms merely from biological facts things that man automatically per- would encounter no difficulty in in- without referring to the being of the ceives as goods requiring his posi- dicating what these fundamental person in his wholeness. tive or negative answer there would goods are. Holy Scripture calls The original Thomist interpreta- be no freedom. Without an objective man’s life a special gift of God. Re- tion did not see a norm as the basis point of view man can only follow ferring primarily to Genesis, the en- of morality – this basis was, rather, his passions, his emotions and his cyclical Evangelium Vitae affirms the end written into the being of the biological instincts, which obvious- that ‘the life which God offers to human person as such. Thomas ly determine his behaviour because man is a gift by which God shares Aquinas formulated the first pre- they are blind. In other words: if an something of himself with his crea- cept of natural law in the following objective criterion is lacking man is ture’ (n. 34). He himself is created way: ‘good is to be done and to be condemned to behave in a blind in the image of God: ‘The life sought for, evil should be avoid- way. The denial of every objective which God gives man is quite dif- ed’.18 Like Aristotle before him, criterion thus means the death of au- ferent from the life of all other liv- Thomas Aquinas identified good tonomous man. ing creatures, inasmuch as man, al- with ends. The precept formulated One can, however, speak about though formed from the dust of the in this way seems abstract but it ac- natural law and avoid this term. earth (cf. Gen 2:7, 3:19; Job 34:15; tually receives concrete contents Some people have tried to formu- Ps 103:14; 104:29), is a manifesta- through propensities. Man has cer- late the objective fundamental cri- tion of God in the world, a sign of gg

48 HEALTH CARE AND SOCIETY his presence, a trace of his glory is not enough. We must also know human freedom: they are valid al- (cf. Gen 1:26-27: Ps 8:6)... Man has in which way we have to realise ways and everywhere, without ex- been given a sublime dignity, based these ends because they can be ception. They make it clear that the on the intimate bond which unites known in a non-ordered way. One choice of certain ways of acting is him to his Creator: in man there can realise the good of knowledge radically incompatible with the love shines forth a reflection of God by treating human beings as instru- of God and with the dignity of the himself’(Ibid.). However violated, ments in medical experiments, that person created in his image. Such modest and insignificant, living is to say by violating the good of choices cannot be redeemed by the man remains a ‘manifestation of their life and their physical integri- goodness of any intention or of any God’ in this world and has a ‘sub- ty. The first level of natural law consequence; they contradict the lime dignity’. would not be complete if it did not fundamental decision to direct Not only the specific origins but also contain some indications to one’s life to God’. also the ultimate end of man this end. Thomas Aquinas lists the This second level of natural law demonstrate that life is an essential following as being at this level: the is known by most people who have good. On the basis of the promise of golden rule ‘do unto others as you learning and formal education – up eternal life, made to us by Jesus, we would have them do unto you’ (Lk to a certain point in no culture are know that final destiny consists of 6:31); Tob 4:15; Mat 7:12);21 the human life, procreation, marriage, blessedness in a friendship with principle of not doing harm or dam- honesty and social order seen as be- God where we know Him and love age;22 and that of practicing love for ing completely neutral. This does Him face to face (ibid., n. 38). All one’s neighbour and love for God.23 not remove the fact that individuals this upholds and affirms the goods Here there are certain principles and at times entire peoples can be of life and knowledge. The fact that proposed by the ethics of autonomy blind to certain values, and this is a man exists in the final analysis for a but Thomas Aquinas does not fail to fact that the Christian tradition sees relationship with God means that first indicate the contents of good as one of the consequences of orig- inter-subjectivity is also a funda- and harm. Some moral experts have inal sin. Whereas during the last mental good. broadened this list with principles century Western society found a Despite the clear answers provid- which bear upon how these goods more or less satisfying answer to ed by Revelation and by the doc- can be realised. For example, the social question of the West, to- trine of the Church, we cannot, Grisez lists eight, which he calls day it is not sufficiently aware of however, disengage ourselves from ‘modes of responsibility’24 and the value of human life or of mar- proceeding also at a philosophical which are embodied in the virtues.25 riage as a stable pact. For this rea- level because the religious ap- The fundamental values are still son, God expressly revealed natur- proach easily gives rise to misun- not norms but only ends. How can al law in the decalogue although it derstandings and resistance but we draw up concrete norms? One of is in principle knowable to all above all else because Holy Scrip- the requirements of practical ratio- men.26 This continues in the task ture itself directs us to the order of nality, which comes from the prin- which befalls the Church – to pro- the creation in order to establish ciples mentioned in relation to the claim natural law, as well, as a basis ethics (Rom 2:14-15). way in which the seven listed goods of moral action (cf. Dignitatis Hu- Moral action is to be placed in the can be realised, is that they must be manae, n. 14). following perspective: man must respected in every action and never An obvious objection would be not violate these corporeal, psychic, be violated. On this, for example, is that although most men see life as a social and spiritual goods, but re- based the norm according to which good, there are some who, in ex- alise them in the right way. Other- one cannot kill an innocent person treme situations, do not see it as wise, he will not be able to really through abortion or direct euthana- such: a terminal illness involving contribute to the objective happi- sia in order to realise another good. unbearable suffering, for example, ness of man. Thus one comes to the formulation or an unwanted pregnancy. It is not of the conclusions which spring di- our intention to condemn those who rectly from the first level of natural resign themselves and trade their From Goods to Norms, law and which belong to the second lives. To understand the situation Virtues and Spirituality level of natural law. One is dealing does not mean, however, to approve here with the norms of the deca- everything. Quite apart from the The goods listed above belong to logue (with the exception of the theological explanation, which says the first level of natural law which third which concerns the Sabbath that because of original sin emo- we know in the form of a ‘habitus’ day), which prohibit the violation of tions can make a person blind to an given to man through the creation. the fundamental goods and which objective good and impede him The precept that one must do good are, therefore, absolute – that is to from responding to that good in the and avoid doing harm is known say they do not allow any excep- right way, we must ask ourselves: if through instinctive perception, tions. They are called the absolute a person is no longer able to recog- whereas the experience of propen- minimum limit of love in the en- nise a good – and this is something sities to various things makes them cyclical Evangelium Vitae (n. 75): which is always the case when he known spontaneously as goods. ‘The negative moral precepts, has lost hope and courage – must The fundamental goods, therefore, which declare that the choice of cer- we accept his situation and do noth- are evident in themselves (‘per se tain moral actions is morally unac- ing? Euthanasia in such a situation nota’).20 This knowledge, however, ceptable, have an absolute value for is to affirm hopelessness rather than gg

DOLENTIUM HOMINUM N. 46/1-2001 49 to affirm the loss of the value of life. should such a man in such a condi- ethics in a pluralistic society than Here we encounter once again an il- tion be happy? His happiness, the so-called ‘Georgetown mantra’ lusion. The choice of death as a man which led to an inter-subjective – the principles of autonomy, of do- is not in the least an autonomous therapeutic result and which was ing good, of not doing harm and of choice because the fact is that hope- very communicable, is certainly not justice, which are not enough to de- lessness and loss of courage take to be found in health understood as fine the contents of both autonomy away freedom. complete well-being. The answer is and of good and harm, and close In applying the norms of the sec- that the presence of any kind of man up in illusory ideals, which are ond level of natural law to more physical imperfection in the final in fact determined or socially im- concrete cases we pass to the third analysis does not matter in relation posed, as we have already observed level of natural law. Here a choice to happiness – what counts is the ap- (these principles are called the must be made in relation to the real- proach of the person towards it. Suf- ‘Georgetown mantra’ because they isation of goods, for example in the fering, although it is a natural reac- are almost used as a kind of magic case where it is asked for how long tion of man to the harm he receives, formula – mantra – to solve every one should prolong the life of a pa- ethical dilemma, and in addition tient using medical techniques. The were produced at Georgetown Uni- norms of the third level are not ab- versity). solute but general – they are valid in The autonomy of man in this most cases but involve exceptions sense is also necessary in order to (they are valid ‘semper, sed no pro open oneself up to absolute happi- semper’ or ‘ut in pluribus’). In the ness. Since suffering in the ultimate application of these norms one must analysis is violated love between evaluate and assess which act is man and the Creator, the path by proportionate to the realisation of which to defeat it involves giving the good in question and which an affirmative answer to the salvific good should preferably be realised. love offered to us by God through To violate a good always implies Jesus. To open oneself to love is al- the abandoning of a good because ways a free act, that is to say it is au- one lacks the hope that it will be re- tonomous. The core of the Christian alised or continued. It implies, message is that man, having re- therefore, a negation of oneself as ceived the theological virtues and an autonomous person. To require is not a determined reaction: man, the gifts of the Holy Spirit and hav- the legalisation of euthanasia does because he is a spiritual being en- ing been redeemed and re-estab- not mean to affirm real autonomy, dowed with freedom, and not mere- lished as the image of God through that is to say the intrinsic autonomy ly in the hands of emotional-physi- being on a level with the Son of of man, but only to ask for extrinsic cal emotionalisms, has the opportu- God (Jn 13:15-34; Eph 5:2; 1 Jn autonomy, negative liberty, the nity to guide his reactions. The 2:6), finds his full happiness in in- freedom to kill oneself without the pre-condition to this, however, is ter-subjectivity with God through law intervening. To deny funda- that he is able to dominate them whom he becomes a participant in mental goods and thus to deny real through the spirit. This is possible to absolute love. human freedom can never lead man the extent to which he knows how to One should observe that we are to real happiness. The solution can- relate his decisions to concrete real- crossing here the bridge between not be the negation of the good as ity through prudence, relate his fear morality and spirituality. During such, but finding the path of real and anxiety to reality through Easter 1990 I was admitted to a hos- freedom so as not to violate, but strength, and resist the seduction to pital in Rome. The internal doctor rather to realise, this good, even exploit human biological nature who treated me told me that a little though this latter course is certainly with reference to justice for ends time beforehand he had heard a difficult. But how can we find that which are often illusory. To sum- conference of a moral expert on in- real autonomy and that real free- marise, the person in question must duced abortion. During the discus- dom which lead to real happiness? have the virtues to be free, that is to sion which followed he got up and After the death of a man caused say to be really autonomous. The in- said: “I am very sorry but what we by aphasia who had been in a hos- stinctive perception that man must medical doctors need is not a pice for many years, all the other pa- be free in order to be happy is right speech on moral norms but a spiri- tients in his ward felt sad. They but what human autonomy actually tuality for medical doctors”. He did missed this man although they had constitutes is quite another question. not want to say that morality did not not been able to exchange a word For every man the virtues are the convince him. Neither spirituality with him. The reason was that al- essential necessary condition for nor the virtues are in themselves a though he was suffering from apha- autonomy, the capacity to take deci- source of moral norms. Both come sia he always had a radiant face with sions which are proportionate to his from the first level of natural law in which he encouraged them. In this own being in order to obtain happi- the sense that they are so to speak case every form of utilitarianism or ness. At the same time they are ‘the embodiment’ of the principles functionalism of human dignity and communicable, as is shown by the which point out the path by which of inter-subjective relationships man afflicted by aphasia, and thus we can realise fundamental goods. does not know what to say. Why offer a more solid basis for shared This does not remove, however, the gg

50 HEALTH CARE AND SOCIETY

fact that my doctor was right – one bers of the various churches there is 4 D. HUME, A Treatise of Human Nature, III, 1, 1 (London, J.M.Dent & Sons), Vol. 2, pp. cannot provide a complete frame- a greater adherence to traditional 177-8. work of medical ethics without moral beliefs than is the case with 5 B. SCHÜLLER, Die Begründung Sittlicher speaking about the spirituality elderly people (whether members Urteile. Typen Ethischer Argumentation in der Katholischen Moraltheologie (Dusseldorf, Pat- which is realised in the virtues, both of a church or not). 18% in 1991 mos-Verlag, 1973), p. 141. in those acquired and those which and 22% in 1998 of young mem- 6 J. FLETCHER, Situation Ethics. The New are infused through grace, that is to bers rejected the idea of sexual rela- Morality (Philadelphia, The Westminster Press, 1966), p. 20. say the theological virtues (faith, tions between those who intended 7 Proportionalism was applied for the first hope and charity) and the gifts of to marry each other, against a figure time by the Dutch Domenican Willem van der the Holy Spirit. The acquired of 7% for those people born before Marck in his book (W.H.M. VAM DER MARCK, Liedfe en Vrichtbaarheid. Actuele Bragen over virtues strengthen the likeness of 1930. The same results were ob- Geboorteregeling Roermond/Maaseik, J.J. the image of man to God, increas- tained in relation to views on homo- Romen en Zonen, 1964). Proportionalism as ing his freedom and his adherence sexuality and selective abortion.29 such was systemised by the German Jesuit Peter Knauer in his classic article on the principle of to the fundamental goods, the Although the difference is not very the action with a double effects (P. KNAUER, ‘La virtues which are infused identify great the statistics demonstrate détermination du bien et du mal moral per la him with the Son of God, who was nonetheless that one should not to- principe du double effet’, Nouvelle Revue Théologique 87 (1965), pp. 356-376). Other made man, the Perfect Image. tally exclude a return to a morality known followers of proportionalism are: Josef which is more compatible with Fuchs, Louis Janssens, Richard A. McCormick, Charles Curran, Bruno Schhller, Franz B`ckle Christian morality. Even in a coun- and Klaus Demmer. Prospects and Suggestions try which is very secularised such 8 The American philosopher and medical as Holland one can detect a certain doctor Engelhardt directly introduced the ethics We should not think that post- wish to rediscover fixed co-ordi- of autonomy into bioethics: H. TRISTRAM EN- GHELDARDT, The Foundations of Bioethics modernism will last for ever. I be- nates in which to ground the impor- (New York/Oxford, Oxford University Press, lieve that during the next decades tant choices of life. 2nd. edn.). In this second edition he replaced the principle of autonomy of the first edition of people will become increasingly Empiricist culture, although it in- 1986 with the principle of permission. aware of the void brought about by volves serious difficulties for the 9 J.P. SARTRE, L’Etre et la Néant. Essau the lack of a metaphysically based metaphysical grounding of morali- d’Ontologie Phénoménologique (Paris, Galli- mard, 1943), p. 413. anthropology which provides ty, also has its own strong points. 10 TH. VASSEN, ‘Hoe Mooier, Hoe Rijker’, meaning and thus a fixed principal Although today an abstract theory HP/DE Tijd (2000), b. 30, pp. 27-33, quotation direction for our lives. We have on- or doctrine is not able to get to peo- p. 31. 11 B. VAN DER HAAK, ‘Bevolkingspolitiek’, ly to think of the history of the people, biographies and the examples Trouw, 21 October 2000, p. 19. ple of Israel described in the Old provided by real people certainly 12 K. DEMMER, Gottes Anspruch Denken. Die Testament. This history shows an do. People today are wary of words Gottesfrage in der Motraltheologie (Freiburg-Scweiz/Vienna, 1993), p. 94. undulating movement between ad- – as was observed above, up to a 13 A. MACINTYRE, After Virtue. A Study in herence to God and a lack of faith- certain point this is more than justi- Moral Theory (London, Duckworth, 1997, 2nd. fulness which leads onto a state of fied given that they were often de- edn.), pp. 23-25. 14 J. DE LUGO, Disputationes Scholasticae et uncertainty, crisis, and absence of ceived by the great ideologies of the Morales (editio nova, ed. by J.B. Fournais, leadership. One survey has demon- twentieth century – but they love Paris, Lodovicus Vivès, 1869), C, I, n. 5, tomus strated that the percentage of people the language of visible facts. Wit- VI, p. 38. 15 A. Solzhenitsyn, Arcipelago Gulag (Mon- who do not belong to a church has nesses are trusted more than mas- dadori, 1975), three volumes. 30 been constantly increasing. In 1958 ters. In opposition to moral theolo- 16 V.E. FRANKL, Man’s Search for Meaning. the figure was only 24%; in 1999 it gians, a Mother Teresa of Calcutta, An Introduction to Logotherapy (New York, Si- mon & Schuster, 1975). was 63%. During the same period in strongly rejecting induced abor- 17 V.E. FRANKL, Senso e Valori per l’Esisten- the percentage of Catholics fell tion and at the same time in offering za. La Risposta della Lagoterapia (Rome, Città from 42% to 18%.27 We should not effective help to all women and Nuova Editrice, 1994), p. 23. 18 THOMAS AQUINAS, Summa Teologica I-II, be surprised at this decrease given girls who found themselves preg- 94, 2. that an entire generation has failed nant without wanting such a condi- 19 J. FINNIS, Natural Law and Natural Rights (Oxford, Clarendon Press, 1988, Clarendon to transmit its faith to its children. tion, also had a notable impact on Law Series), pp. 86-92. However, although in large part contemporary public opinion. 20 THOMAS AQUINAS, Summa Teologica I-II, outside the Christian framework, in 100, 3. 21. Ibid., 94, 4 ad 1. 22 Ibid., 95, 2. those in particular who were born H.E. Mons. WILLEM S. EIJK, 23 Ibid., 100,11. after 1960 there has been growing a Bishop of Groningen, 24 G. GRISEZ, The Way of the Lord Jesus. Vol- belief in life after death, heaven, The Netherlands. ume I: Christian Moral Principles (Chicago, 28 Franciscan Herald Press, 1983), pp. 205-228. hell, and religious miracles. One 25 Ibid., p. 192 ‘the virtues embody the can observe that although the more modes’. traditional mentality which sees the 26 THOMAS AQUINAS, Summa Theologica I-II, 98, 6. mother working outside the home 27 Notes J.W. BECKER AND J.S.J. DE WIT, Secular- as a burden for the family, and isatie in de Jaren Negentig. Kerklidmaatschap, which rejects adultery and fiscal 1 GREGORY OF NYSSA, Orationes de Beati- Veranderingen in Opvattingen en een Prognose tudines, 1 (PG 44, 1200). (Den Haag, Sociaal en Cultureel Planbureau, fraud, has lost ground, opinions in 2 THOMAS AQUINAS, Summa Theologica I-II, 2000), p. 24. relation to sexual relations before prologus; 55, 2-3; 68-70; Expositionis in Lucam 28 Ibid., p. 46. marriage and homosexuality have Liber, V, 49 (PL 15, 1734); cf. CCC, n. 705. 29 Ibid., pp. 48-51. 3 E. GRISEBACH, Gegenwart. Eine Kritische 30 Madre Tekla Famigletti, forword to M.G. remained more or less the same. Ethik (Halle, Max Niemeyer Verlag, 1928), p. MASCIARELLI, Beata Maria Elisabetta Hessel- Above all amongst the young mem- 187. blad (Turin, Elledici, 2000, 2nd. edn.), p. 8. gg

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friday 17 DIEGO GRACIA GUILLÉN november III: Medicine and Cultural Change

Introduction 1. Health and Illness thentic ‘creation’. Opportunities do as Historical Realities not, in general, exist. It is necessary The first day of this international ‘to create them’ and ‘to invent conference on ‘health care and so- History is the result of the inter- them’. The human being is an au- ciety: technological challenges and action of human beings with na- thentic creator of opportunities. the humanisation of medicine’ was ture. Human beings make history However, he does not create them dedicated, in its first part, to a re- beginning with what they en- from nothing, in the way that God view of the contemporary situation counter, and what they encounter does. He can create opportunities of medicine and an analysis of the is, above all else, nature. Nature but he can only do this by taking so-called ‘emergent illnesses’ of bears within it what are called ‘nat- natural resources as his point of de- these last ten years, the new type of ural resources’. Man, to live, needs parture. He is not God, but, as patient, the new health care profes- to transform these resources into Leibniz observed in his Monadolo- sionals, the new place of health opportunities for the maintenance gia, he is a ‘little God’, or as the care, and new technology and its of life. For this reason, such oppor- Judeo-Christian tradition has it, he limits. After analysing the whole of tunities are always human cre- is the ‘image and likeness of God’. this impressive panorama, the or- ations. Human beings create these History is made up of the cre- ganisers of this international con- opportunities by taking resources ation and the transmission of op- ference then dedicated a session to as their point of departure, and by portunities. The opportunities that a critical and illuminating analysis this route they develop culture and we bring into existence, whether of the whole of this new and com- make history. ‘Resources’ are nat- negative or positive in character, plex reality beginning with a dual ural, but ‘opportunities’are cultur- once they have been created, come approach of a historical and theo- al and historical. to have a life of their own, and be- logical character. History, for this reason, is the come independent of their creator My paper seeks to locate the process by which natural ‘re- – they become, that is to say, objec- complex health care realities in sources’ are transformed into ‘op- tivised. This process is what Hegel which we find ourselves by portunities’ for maintaining life. called ‘the objective spirit’. analysing them from a historical The earth has resources which can Michelangelo sculptured the won- perspective, with a glance back be transformed into opportunities, derful ‘Pietà’ which we can admire over the past and a glance at the fu- but this can only be done through here in the Vatican, located as it is ture. This paper is divided into the action of man. Thus, for exam- in the basilica of St. Peter’s. Once three parts and such will be its aim. ple, coal is a mineral which enables sculptured, the statue became In the first part I will seek to de- us to produce fire, and with fire we transformed into a cultural fact scribe the role of illness in history, can move locomotives, or heat which was endowed with its own or of health and illness as historical houses. This, however, only hap- life. It became independent of its realities. In the second part I will pens if man transforms natural re- artist and maker, who passed away, attempt to identify the historical sources into historical opportuni- and this image has continued to be stages through which the relation- ties through the invention of fire, a fundamental part of our cultural, ship of human beings with illness the steam engine, etc. Oil remained artistic, and religious life. has passed. Lastly, in the third and in huge underground lakes for Precisely because they become final part, I will address myself to many centuries. As a resource, it objects, cultural creations consti- the contemporary situation and the existed many years before the ori- tute a kind of ‘deposit’ which is prospects for the future. My hope gins of man, but it became a way of handed down to us by the genera- is that this panorama will enable us maintaining life with the invention tions which preceded our birth and to achieve a better understanding of the combustion engine. At the which allow us to maintain life of that complex phenomenon, hu- outset it was merely a natural re- through the creation of new oppor- man illness, and to approach it source, and not a historical opportunities which also come to be a from other perspectives – the ethi- tunity. part of the deposit and which will cal, the philosophical, the theologi- The transformation of resources be handed down to the next gener- cal, the political, and all the rest. into opportunities is an act of au- ations. gg

52 HEALTH CARE AND SOCIETY

‘To hand down’, ‘transmission’ and this is something which has time, one can understand how – in the parlance of specialists the been repeated down the centuries – medicine itself also generates ill- term parádosis is employed, a term that he does not know how to pro- nesses. It is well known that to en- which was translated in Latin by duce them without in collateral ter a hospital means to run a risk, the word traditio. Parádosis come fashion giving rise to negative op- not to speak of the risks run by en- from the ancient Greek root dído- portunities, that is to say opportu- tering an operating theatre or an in- mi, which means to give, to give a nities which have bad conditioning tensive care unit. It is no accident present, to offer, and to hand over. effects on the life of human beings, that there are illnesses called iatro- The ancient Greek verb dídomi and which make them less human, genic, or that these reach surprising corresponds to the Latin do, to less perfect, less happy. Man does levels of incidence – always above give, to hand over. From do comes not know how to create only posi- 10%. Like pharmaceutical prod- the Latin trado, which means to tive opportunities, without at the ucts, medicine, too, always has bring, to transmit. Hence the noun same time generating ones of a secondary effects. traditio, which is thus a perfect negative character. He has not translation of the ancient Greek managed to do so so far, and prob- term parádosis. Perhaps it is a ably he will never manage to do so. 2. Health and Illness good idea to recall that the same In history there happens what hap- in History Latin root, from the word do, gave pens in the case of drugs and med- rise to many other words which are icines, which, although they heal The history of mankind can be related to others which emerged certain illnesses, also give rise to analysed from many points of before it. For example, credo, to others. There is no drug or medi- view. But, if we wanted to be con- believe. One always believes in a cine which does not have negative sistent with what has already been trusted deposit, in a tradition. or undesirable effects. There is no observed in this paper, the logical Hence faith is also a historical phe- drug or medicine which does not thing to do would be to see history nomenon. One believes in a de- have both positive and negative ef- as a process by which human be- posit which has been handed down fects. The same happens in history. ings are ‘provided with opportuni- to us. What we hand down to our descen- ties’, or as a process which trans- History is thus the handing down dants are positive opportunities, forms natural resources into oppor- of opportunities, of ways of being but we also transmit to them nega- tunities of life. In this way it is pos- located in reality. This, indeed, was tive opportunities. Illness can and sible to argue that a fundamental how history was defined by the must be defined as a negative way and historical cultural and histori- Spanish philosopher, Xavier Zu- of life. This means something that cal change takes place when hu- biri, a few decades ago. We are dif- is very important, that is to say that man beings find a new way, or a ferent from all the other human be- illness is not in the majority of cas- revolutionary way, of transforming ings who belonged to previous es a merely natural phenomenon, a resources into opportunities. For generations because we are present human resource. There are really this reason, we can describe in reality in a way which is differ- very few illnesses which are only episodes when men discover a new ent, precisely because we have natural. In general, they are the re- way of transforming resources into been entrusted with a deposit sult of the action of human beings opportunities as epochs or periods which, at least in part, is different in relation to nature, and for this of change. and which offers us opportunities reason they are historical in char- These periods of change have so which are different from those pos- acter. Illnesses are not mere re- far been two or three in number, or sessed by every other previous sources but negative opportunities at the most four. In general they generation. We can do things that of life. Not to see them in these are seen as constituting revolution- they could not do. For example, we terms is a very serious mistake, ary periods. Thus reference is can go to the moon and carry out which, even though not very fre- made to a ‘Neolithic revolution’ operations involving organ trans- quent, is equally pernicious. and an ‘industrial revolution’. plants, and modify the genome of When has just been said about These periods of change were not animal species or even of human illnesses also applies to the fight political revolutions in the way beings themselves. against them, to medicine, and to that the French revolution of 1789 What should be borne in mind is health care. These, too, are human was. Nor were they scientific revo- that the opportunities that human reactions, negative opportunities lutions, along the lines of the revo- beings create in their relationship generated by man in his attempt to lutions to which Thomas S. Kuhn with nature can be positive or neg- combat illness. Neither health nor called our attention a few decades ative in character. Not all opportu- illness nor health care can be seen ago. These revolutions were deep- nities are positive, that is to say not as being on the confines of history. er and more radical in character all opportunities condition in a The objective of these reactions is because they involved the discov- positive manner the life of human to fight those negative opportuni- ery of new ways of transforming beings. Not all opportunities allow ties of life which we call illnesses. resources into opportunities, them to live better or to attain their But, as has already been observed, which in turn involved another ideals of perfection, happiness, etc. given that human beings do not kind of revolution, which was po- with ease. Certainly man has al- know how to produce positive op- litical, social, cultural, or scientific ways sought to generate positive portunities without generating neg- etc. in nature. opportunities but it is also a fact – ative opportunities at the same The ‘Neolithic’ revolution gave gg

DOLENTIUM HOMINUM N. 46/1-2001 53 rise to history in a real and authen- opportunities is called ‘wealth’, we can conclude from this that the tic sense. Indeed, the peoples and can say that the Neolithic revolu- whole of the history of mankind cultures which existed prior to that tion enormously increased the can be located around them and event have, because of this fact, wealth of mankind and that the in- thus divided into four historical pe- been placed in the general category dustrial revolution increased it still riods or epochs. The first, which of the ‘pre-historic’. This is due to further. goes from the origins of the human the fact that the Neolithic revolu- For many historians these were species to the Neolithic revolution, tion taught human beings the fun- the two fundamental revolutions of is generally known with the name damental ways and routes by the history of mankind. However, of the ‘pre-historic epoch’. The which resources could be trans- one should go further and add an- second is designated ‘agricultural formed into opportunities, that is to other which took place about a society’. The third receives the ap- say the practices of agriculture and century ago when there was a pellation ‘industrial society’. The stock-raising. Indeed, one might move from industrial society to an- fourth, and last, is post-industrial say that the birth of the so-called other kind of society, which we society, which is also called the term ‘post-industrial’, a society of ‘consumer’ or ‘well-being’ society. well-being or consumption. This Each of these four historical change was less obvious or less epochs had very different dura- surprising, but its consequences tions. The only characteristic have been no less important. In- which they share is to have a dura- deed, it gave rise to an exponential tion which is shorter than that of growth of another sector of eco- the historical epoch which went nomic activity – the tertiary or ser- before. For this reason, the periods vice sector. Some good services are of each of these stages became in- fundamental to the process by creasingly short. Pre-historic soci- which human beings come to en- ety lasted about three million joy adequate life opportunities, and years. It went from the origins of they thus constitute wealth. This is the human species, three or four something which is less readily million years ago, until the appear- perceivable at the simple level with ance of agricultural or pastoral so- regard to this revolution than is the ciety, which certainly did not take case with the two previous revolu- place before 10,000 BC and which tions. Everybody knows that the we can locate with certainty to the advance of the primary and sec- sixth and fifth millennia BC. Agri- ondary sectors necessarily in- cultural society goes from this date volves an increase in life opportu- until the middle of the eighteenth nities. However, this is something century. It thus lasted thousands of which is less clearly the case with years. Industrial society lasted a the tertiary sector. This is due to the much shorter period of time, about fact that people do not sufficiently a century and a half. Finally, understand that history is a process post-industrial or consumer society involving ‘the provision of oppor- has lasted half a century, and it is tunities’. Wealth, and I repeat the still with us. The acceleration of point, means a spectrum of oppor- history has meant that each stage tunities. Wealth does not mean lasted for a much shorter time than money, and even less natural re- the one which preceded it. sources. Wealth is not resources After dividing up the history of but life opportunities. There can be mankind in this way we can now no doubt that a healthy tertiary sec- describe the fundamental charac- tor is fundamental in the process of teristics of each of these historical ensuring and increasing the life op- epochs. portunities of human beings. At the 1) During the first stage, which ‘primary’ sector was another out- roots of this new kind of society involved the pre-historic popula- come of this revolution. A revolu- there was another industrial revo- tions, human beings almost did not tion of the same importance and lution, the so-called second indus- know how to transform resources significance was not to take place trial revolution, which emerged at into opportunities, or in other terms until the eighteenth century, when the beginning of the twentieth cen- they did not know how to create the so-called ‘industrial revolution’ tury and was based upon the devel- wealth. More than engaging in the began. This involved the discovery opment of the combustion engine creation of wealth, they destroyed of a new way of transforming re- and the spectacular development it. These were predator peoples – sources into opportunities, and and advance of communications similar in behaviour and lifestyle gave rise to the exponential growth and transport. to animals – who could feed them- of that economic sector which we If these are the three great peri- selves only on what nature pro- call ‘secondary’. Given that the ca- ods of change, or the three great duced spontaneously for them. pacity to transform resources into historical revolutions of history, we Hence their nomadic character and gg

54 HEALTH CARE AND SOCIETY way of life – they depended on nat- medicine was of this kind. Like an- important of these occurred be- ural resources and when these be- imals, human beings learnt to se- tween 300,000 and 200,000 BC, came exhausted they moved on to lect certain herbs which had a depending on the region, during other locations. They did not create purgative or laxative effect. It the middle Palaeolithic period, wealth but plundered nature of seems that these were the first when Neanderthal man discovered what it produced spontaneously. drugs and medicines. It is no acci- the use of fire and begun to bury They were, therefore, hunters and dent that the ancient Greek word his dead. These two events were of gatherers. pharmakon originally meant an immense historical importance. Because they did not know how purgative or laxative. They must The first allowed an enormous im- to transform these resources into have also known about certain provement in food and diet by opportunities, these people lived very elementary surgical tech- making many things eatable within a so-called ‘mere subsis- niques, such as cauterising wounds through the use of fire and water tence economy’. This meant that or the binding of fractures and lux- which in the natural state could not they dedicated the whole of their ations. be consumed. In this way these labour to mere subsistence. They populations became omnivores. were not able to create surplus The burying of their dead demon- wealth. Hence the absence of great strates the existence of belief in a cultural, political, religious, scien- life beyond this one and thus testi- tific etc. institutions. However, it fies to the appearance of religious does not seem that mere subsis- rites in the strict sense. This also tence was an easy matter. In fact, had enormous importance in the they led a very dangerous life, and sphere of medicine because from were exposed to the hardship of the that moment onwards empirical weather and engaged in a struggle medicine began to co-exist with against wild animals. Their food another form of medicine, which and diet must have been very poor. was of a religious character or in- The fossil remains that are avail- volved faith. These two dimen- able to us indicate that they suf- sions would never disappear from fered from a condition generally human history. known as ‘defective’ – they often 2) The appearance of the Ne- lived on low caloric diets and fell olithic period is usually described into a state of malnutrition. Unfor- as the moment of the agricultural tunately, this phenomenon is still revolution. Perhaps, however, it present in the third world. A specif- would be more correct to see this ic culture such as pre-historic cul- event as the result of the slow and ture had a specific pathology, that Under-nourished populations continual development of certain of food deficiency. But there were fall easy prey to illnesses and primitive societies. It seems that other pathologies. For example, a death. Their defences are weak and some of these societies gradually great number of wounds or frac- their biological resistance is low. established themselves in more fer- tures, the pathology of the body This probably explains why the tile areas, locations which offered structures, which was a conse- population growth rates of these greater life opportunities. These quence of hunting and the fight people was almost zero, and in societies learnt to cultivate the land against wild animals. However, most cases actually negative. It al- and to domesticate animals, and for this protected them against those so enables us to understand why al- this reason laid the bases for a new forms of illness created by abun- most all of them, with the excep- way of transforming resources into dance or civilisation and which are tion of Cromagnon man, disap- opportunities, and as a result for a today so frequent. peared from the scene. This raises new way of generating wealth. Their form of medicine was an interesting question – why did They began a new kind of society – very elementary. The most primi- Cramagnon man not disappear, so-called ‘agricultural society’. tive was called ‘empirical medi- that is to say why was he able reach They were more sedentary than cine’, that is to say the form of the moment when the Neolithic previous societies had been and medicine which animals possess. revolution begun, and above all gave rise to more populated settle- Experience, as Aristotle observed, why was he able to generate that ments, from which cities then de- was the result of the senses accom- revolution? We do not know the rived. The Neolithic revolution panied by memory. This is some- exact answer to this question but it created an important process of ur- thing which human beings share seems clear that it had something ban concentration. These new with the animals. As the Italian to do with his greater intelligence cities arose in specific zones which proverb has it: ‘the scalded cat and thus with his greater control in general were marshy and near takes refuge in cold water’. The over his environment. Indeed, dur- the mouths of great rivers, such as sensation of very hot water pro- ing this vast epoch, which goes the Indus, the Nile, the Euphrates duces pain, and the memory of this from the appearance of the first hu- and the Tigris. Indeed, it seems that pain means that the cat is subse- man beings to the Neolithic revolu- agriculture was born in an area of quently afraid of hot water. This is tion, there took place events of im- the so-called ‘fertile crescent’ an experience. The first form of mense transcendence. The most which goes from the north of the gg

DOLENTIUM HOMINUM N. 46/1-2001 55 desert of Arabia to Egypt and the tious diseases through water, dis- something which led on to the Persian Gulf. eases which were very frequent in ability to build heavier and more The economy of these popula- the marshy areas where in general powerful machines and to install tions was much richer than those of these populations settled. The path- them in factories. Of essential im- the societies which had preceded ogenic effects of water consump- portance in this process was the them and this enabled them to es- tion led these populations to look discovery by James Watt of the cape subsistence and to generate for alternative drinks, for example steam engine between 1769 and surplus wealth. This, in turn, began fermented drinks such as wine (in 1784, an invention which stimulat- to be transformed into new forms the western part of the Mediter- ed the consumption of coal and of activity, giving rise to political, ranean) or beer (in central Europe). steel, the basis of the whole of the religious, cultural, scientific etc. Another system was the use of fer- first industrial revolution. The cre- institutions. This explains why mented water with infusions of ation of heavy industry based upon great religious, architectural, liter- coffer or tea, as was the case with coal and steel gave rise to an im- ary and scientific monuments have eastern cultures. provement in communications and been handed down to us from these Another novelty was the appear- transport (as a result of which raw societies. Sumer, Assyria, Babylo- ance of social strata which were materials arrived at their place of nia, Israel, Greece, and Rome – all much more marked than had been transformation at a lower cost) and these were great agricultural soci- the case during the previous peri- the development of many other in- eties and all of them produced in od. Intellectual and manual work- dustries, such as the textile indus- their own ways great cultures. ers began to be differentiated in a try. Western culture was born specifi- very clear fashion. Another charac- The industrial revolution was cally in this environment, as a re- teristic of many of these societies followed by many others. There sult of the encounter between what was the existence of a specific kind was the revolution in economics were the three great cultural phe- of poor person, represented para- expressed by the emergence of lib- nomena of that period – the reli- digmatically, to begin with, by the eral economics, the work of the gion of Israel, ancient Greek phi- slave, and then by the servant. Scotsman, Adam Smith. Accord- losophy, and Roman law. The cultural institutions of agri- ing to the ideas he proposed, the Agriculture and stock-raising cultural society generated a form wealth of nations is fundamentally were very powerful instruments in of medicine and health care which based upon labour, something the transformation of resources in- lasted until the eighteenth century. which allows resources to be trans- to opportunities and thus in bring- One of its characteristics was a formed into opportunities. The lib- ing about an increase in wealth. close relationship with religious in- eral economy was based upon the These societies then began to have stitutions. Thus it was, for exam- morality of work and savings. This better diets: they could eat a ple, that in most of these cultures was obtained through hard work, greater number of carbohydrates there was a form of medicine low expenditure on goods, and the because of the extensive cultiva- which was clearly priestly in char- investment of surplus wealth in tion of cereals, and a greater num- acter, although there was also a products. In this way, that capital ber of animal proteins. This inform of medicine which was secu- was accumulated which was nec- crease in wealth allowed them to lar or lay in profile. The first was essary to the birth of heavy indus- feed a greater number of people more or less concerned with the try. In the approach of Adam and thus encouraged an increase in treatment of internal illnesses and Smith, this produces goods which population levels which from that the second with external or surgical must compete on the market with point on began to grow arithmeti- maladies. Gradually, with the pas- the products produced by other cally. This did not mean, however, sage of time, the first lost influence people. According to the funda- that periodically there were not in favour of the second. However, mental law of liberal economics ‘subsistence crises’caused by peri- it should not be forgotten that hos- the market regulates supply and ods of bad harvests. pitals were religious institutions demand in the best way possible Certain pathologies became until the beginning of the modern and always reaches the optimal more common, such as those world. point. This means that for this out- brought about by hunting large an- 3) The industrial revolution con- look the market is the agent which imals. Others appeared or in- stituted the point of departure for a ensures that the highest quality creased in incidence. The high con- new way, the industrial way, of products at the lowest cost always sumption of carbohydrates in- transforming resources into oppor- triumph. To intervene in the market creased the presence of certain tunities and thus of generating and to impose a self-regulation was metabolic illnesses such as dia- wealth. A new society thus came thus seen as something which was betes. From the literary evidence into being, industrial society, and not only economically wrong but that is available to us we know that this society was based upon the de- also morally reprehensible. health problems caused by the con- velopment of the secondary eco- The appearance of new indus- sumption of alcoholic drinks also nomic sector. tries in the outlying areas of the increased. These drinks had been The industrial revolution began cities of central Europe generated made possible by the technique of in the middle of the eighteenth new problems and hardships. In fermenting cereals. In their turn century with the substitution of hu- fact, the industrial revolution gave these drinks enabled these popula- man or animal power by mechani- rise to new pathologies which were tions to control the spread of infec- cal power in industry and mining, specific to industrial activity. This gg

56 HEALTH CARE AND SOCIETY revolution was the cause, for ex- make itself felt, that is to say the rate economic theory which was ample, of an increase in the inci- geometric increase in gross popu- different from classical liberal the- dence of tuberculosis from the lation figures, a phenomenon ory. John Maynard Keynes intro- middle of the eighteenth century which had been unknown up to duced the concept of ‘aggregate onwards. Furthermore, it generated that point in the history of demand’ in the early 1930s and as- a great number of illnesses caused mankind. serted that it was the central feature by the unhealthy conditions of the of economic activity. In this out- outlying areas of cities. A new kind look, aggregate demand includes of poor person appeared, the the expenditure of consumers, pri- so-called proletarian, and new vate investment, and public expen- kinds of illnesses rooted in urban diture. In Keynes’s view wealth acute poverty, the concentration of grew in proportion to aggregate de- the population in cities, and job- mand, and for this reason it was work also came to the fore. necessary to increase it by increas- A new form of medicine also ing the purchasing power of con- came into being. It was no accident sumers, lowering interest rates in that this revolution coincided with order to stimulate private invest- the appearance of so-called ‘mod- ments, and increasing public ex- ern science’. With the increase in penditure. As a result of this ap- wealth more money was invested proach, consumption was held to in universities and centres of re- be the engine of the economy and search. Modern medicine arose at the producer of wealth. It was the end of the nineteenth century therefore thought necessary to cen- and developed and advanced for tre every economic process around the whole of the next century. consumption and not around in- Medical practice, for its own part, creasing production as had been also specialised. As George Rosen recommended by classical theo- demonstrated some decades ago, ries. Keynes asserted that con- specialisation could take place sumption automatically brought when an important increase in 4) After the First World War a about an increase in production, at knowledge occurred and technolo- new phase began – that of post-in- least in societies which had already gy came into being which required dustrial or consumer society. This passed through the first stage of the specific training, and in addition was brought about by the creation industrial revolution. In these soci- when all this coincided with an in- of a new way of transforming re- eties, he thought, it was without crease in, and concentration of, the sources into opportunities, some- doubt necessary to preach austerity population, developments which thing which took place within the in consumption in order to increase allowed the full professional em- tertiary or service sector. This the investment of capital in pro- ployment of the new specialists. spectacular increase in life oppor- duction goods. Keynes, however, This took place in the industrial tunities through the development thought that in developed societies cities of the nineteenth century. and growth of the tertiary sector this theory was not only useless but Lastly, health care also changed as was made possible by the develop- actually damaging. This economist two new phenomena came onto the ment of the ‘second industrial rev- thought that in stimulating savings historical scene. On the one hand, olution’, which in turn was based and frugality in consumption, eco- there was the ‘medicalisation’ of upon the combustion engine and nomic development and growth hospital care which meant that hos- the exploitation of oil. This devel- were checked and the emergence pitals moved from being seen as opment revolutionised communi- of crises was encouraged. In order charitable institutions to being con- cations and transport and allowed to avoid such realities, he argued, sidered centres of medical care. On the rapid movement of goods and there was no other possibility than the other hand, there was the birth services at prices which up to that that of changing the mentality and of public health provision and pub- time had been thought to be unob- the morality of the population, lic health care policy and thus a tainable. This increase in the ser- which had to see that consumption marked increase in the involve- vice sector was not only the out- was positive and savings were a ment of the state in the world of come of the private sector of the moral vice – avarice and miserli- health and health care. economy. It was also, and above all ness. For this economic thinker, The increase in wealth, the im- else, the result of state enterprise consumer society not only required provement in health care condi- and action. The state began to grow a new form of economics but also a tions, and the advance and progress and to be responsible for tasks new form of morality. of medicine led to a major increase which liberal theory had prohibit- Keynes argued that in order to in population levels and to a raising ed. From the liberal state one stimulate the consumption of the of the rates of life expectancy passed to the interventionist state population it was important for the amongst the citizens. In fact, in the which defended the life of citizens state to protect the citizens from middle of the eighteenth century against the negative events of life – the negative episodes of life, from the phenomenon known as the the so-called ‘welfare state’. unemployment, from illness, from ‘population explosion’ began to This new stage had its own sepa- death, and so forth. Such were the gg

DOLENTIUM HOMINUM N. 46/1-2001 57 origins of the systems of social in- cycle of renewal which is very in a development which cannot be surance and social security which slow. sustained without end and which were extended to the whole of Eu- Hitherto it has been believed that will not be sustained for a long pe- rope during the first half of the resources were more or less inex- riod of time. twentieth century. Social health haustible and that in some cases Now the fundamental concept is care was a consequence of this new they greatly exceeded the opportu- that of ‘sustainable growth’. This model of society. It is no accident nities provided by their use. The concept begins with the principle that such a phenomenon did not classical problem of the human that both the growth of the first exist before the twentieth century species had always been the same world and the under-development and that this model of society be- – the lack of effective procedures of the third world are ‘unsustain- gan to display signs of crisis in by which to transform resources able’, and that it is necessary to ef- 1973 when criticisms of the social into life opportunities. The prob- fect a global change of policy and insurance system and of the health lem, therefore, was not the re- practice in the direction of service care began to be heard. sources but the procedures of so-called sustainable growth. This It is important to observe, lastly, transformation. Only from the ear- is an economic theory which is an that consumer society generated a ly 1970s was the problem begun to alternative to the Keynesian ap- new concept of health, namely, be seen in a clear way. The famous proach and to that of classical lib- health as a consumer good. In in- report of the Club of Rome entitled eral economics. It is also a political dustrial society health was always ‘the limits to growth’, which was model. For this reason the United understood as a production good, published in November 1971, Nations has made it its own politi- in the same way as a healthy per- called attention to the excessive cal philosophy. But it is much son was a person who could work exploitation of the resources of the more. It is an ethical theory, and re- and a sick person was a person who planet and to the mortgage which quires, without doubt, great ethical could not work. Now, in contrary in the medium term was being commitment. The doctrine of sus- fashion, it was seen as a consumer placed on the quality of life of the tainable growth asserts that in the good. The welfare state defined future generations of the inhabi- processes of decision-making one health in new terms and along lines tants of the planet. The problem should not only take into account which were different to those was not, as it had always previous- individuals, a society, or a country, which had been adopted by previ- ly been, one of how to find a new but the whole of mankind, both ous societies. This definition iden- method by which to transform represent and future. Lastly, it is also tifies health with well-being. It is sources into life opportunities in a a medical theory. In fact, the Hast- no accident that the World Health better or more productive way, but ings Center has been working over Organisation defined health as rather, in contrary fashion, one of recent years on a project entitled ‘state of perfect physical, mental measuring the process of the cre- ‘sustainable health’. and social well-being and not the ation of opportunities and at the Sustainable growth must neces- mere absence of illness’. The soci- same time conserving and recy- sarily be ‘global’. Hence the im- ety of well-being sees health as cling resources. portance during this new phase of perfect physical, mental and social The Keynesian approach was development of the concept of well-being. In other terms, the con- based upon the principle according ‘globalisation’. Globalisation be- sumption of health can be stimulat- to which wealth is the same as con- gins to be possible thanks to a new ed and increased indefinitely. sumption, and as a result of which revolutionary fact, that phenome- the greater the consumption the non called the ‘third industrial rev- greater the estimable wealth. Now olution’, that is to say the electron- 3. The Contemporary Situation: a different approach began to be ic and digital revolutions which the Problem of the adopted. Unchecked consumption will be able to make a new world Exploitation and the Excessive was seen to lead to the deteriora- possible, a world which is more in- Use of Resources tion of the environment and as a re- tegrated and reasonable, and also sult to the deterioration of quality more just. Here, too, it is clear that The Keynesian model began to of life. Quality of life and con- we are face to face with a new eth- be called into question in the early sumption were held to be terms ical challenge upon which, proba- 1970s. The economic crisis of which were not directly inter-relat- bly, will depend our future, the fu- 1973 was seen by many people as ed. An increase in consumption ture of humanity. the end of a phase. As is known, could, it was held, be followed by a This is our situation. We are liv- this crisis, which is also known as reduction in individual and collec- ing in a critical epoch in which we the oil crisis, was the first crisis of tive quality of life. In fact, this is need new concepts both in the eco- resources. Our generation was the what was thought to be happening. nomic and in the political sphere, first to have to face up to the curi- The same group of researchers and in the moral and in the medical ous and surprising phenomenon of who produced the report ‘the limits realms as well. Here we encounter the excessive use of natural re- to growth’ published twenty years our great challenge and also our sources. Opportunities have grown later, in 1991, another report, this first moral obligation. to such an extent that for the first time with the title ‘beyond the lim- Prof. DIEGO GRACIA GUILLEN, time resources have been threat- its’. In their view, mankind has Professor of the History of Medicine, ened, whose renewal in many cas- gone beyond the limits of growth The Complutense University of Madrid, es will be difficult or which have a and at the present time is immersed Spain. gg

58 HEALTH CARE AND SOCIETY

IV: Light in Inter-Religious Dialogue

YOSEF LAMDAN IV.1 Judaism and Health Care

It was the English poet, Alexan- Ezekiel’s famous phrase (addressed sacrosanct; and, second, the obliga- der Pope, who wrote “... fools rush to God): “The spirit is yours and the tion to offer medical treatment and in where angels fear to tread”. I body is yours”. In other words, God health care to all. In Jewish thinking, greatly appreciated the invitation to creates and controls everything in both of these religious imperatives address this International Confer- man’s being, both spiritual and are anchored in no less a framework ence. But, to tell you the truth, I am physical. than the “Ten Commandments”. not at all sure of the wisdom of my In the Temple period, the priests, “Thou shall not kill” is rendered accepting it. in addition to their ritual duties, positively as an injunction to pre- After all, this is a highly profes- were custodians of public health and serve human life at all costs. To il- sional conference of health care spe- ministers of health care (even if lustrate its overriding importance, cialists of one kind and another. I, on these terms would have been totally the Talmud rules that saving human the other hand, am a career diplo- foreign to them). From Talmudic life takes precedence over the Holy mat, prepared as Queen Elizabeth I times to the Middle Ages, physi- Sabbath (Yoma, 85 A). And how do of England quaintly put it “to lye cians were very often Rabbinical you “Honour your father and your abroad”, and to put my own health at scholars. That is to say, a tight nexus mother”, especially in their ad- risk by going to endless official re- remained between Rabbinical learn- vanced years, if not by offering ceptions, cocktails and dinners. But ing, reflecting a devotion to God, health care, among other things. there is nothing in my training and medical science reflecting a de- Again, the Talmud holds that in or- which has equipped me to speak au- votion to the wellbeing of man cre- der to treat the elderly and the sick at thoritatively on Judaism, Health ated in the image of God. large, the sanctity of the Sabbath can Care and Society. Understand there- This Jewish involvement in medi- be set aside, even if the situation is fore my apprehensions. cine required a conceptual frame- not completely life-threatening. With your permission, I shall di- work – in our case, a religious one – If one looks at the 613 command- vide my remarks into three parts: from very early on. The well-known ments in the Pentateuch, one finds 1) Some general observations debate over the propriety of human an extraordinary emphasis on social about Judaism and health care; intervention in sickness and physical medicine and public hygiene and on 2) Some Jewish principles in con- suffering, perhaps against God’s what would be regarded today as as- temporary Applied Health Care will, barely arose. There are numer- pects of health care in general. Ethics; ous references in the Old Testament Indeed, as many as 213 of the 613 3) Some illustrations regarding to God as a healer: “I am the Lord Biblical injunctions are of a medical care of the aging. that healeth thee” (Ex. 15:26). or quasi-medical nature, setting out In all of these areas, I am greatly Priests and later medical practition- strict dietary requirements, regula- indebted to Jewish scholars whose ers were the instrument through tions for personal and public hy- works I have consulted.* I hope that whom God could effect the cure: giene, rules for the prevention of I will represent them accurately, but “He (man) shall surely heal” (Ex. epidemics, isolation, quarantine, etc. if I slip up, the errors and responsi- 21:19). These Old Testament standards are bility are entirely mine (and fore- This was not merely a “license to remarkable even for today. bearance is yours!). cure”, as it were, but a divine com- However, it was not until the 12th mandment, obliging physicians to century that a certain concept of treat the sick without discrimination. “Health Care and Society” was ar- 1. General Remarks As instruments, or messengers of ticulated by Maimonides, the great God, the highest moral standards Rabbinical scholar, philosopher and It is no great revelation to observe were demanded of Jewish doctors, physician to the Court of the Sultan that in Biblical times, religion and especially in their operative guide- of Egypt. It was he who divided medicine went hand in hand, as they lines. And in Jewish medical ethics, medicine in three broad categories: did in so many other ancient cul- two principles, highly relevant to 1. Care of the healthy; tures. But for the Israelites, there your conference, reign supreme – 2. Curing of the sick; was a fundamental theological ratio- first, the obligation to preserve hu- 3. Treatment of the convalescent, nale for this, summed up in man life, which is God-given and including the aged. gg

DOLENTIUM HOMINUM N. 46/1-2001 59

Starting in 14th century Spain, his body and health as best as he can ble, a middle path or 99 “golden Jews often offered informal health and to seek out professional help mean” is advocated. Hence, princi- care and support within their own and care for the purpose. ples compete, as it were, for priority, society through voluntary associa- Conversely, no one has the right and when conflicting medical values tions for “Bikur Holim” (visiting the to refuse health care. Putting reli- are encountered, each case, each pa- sick), which also was regarded as a gious observance above medical tient, must be considered individual- religious duty. In many European treatment is not regarded as an act of ly and decisions reached on the spe- communities, Jewish hospitals and piety, but the reverse. Thus, it is not cific clinical and ethical/legal cir- independent health services were set to be tolerated. cumstances, within the framework up in the 18th century, frequently of the Halachah. due to lack of access to non-Jewish b)Health care decisions ones. In other words, Jewish health and autonomy. d) Beneficence. care systems emerged, in part, as a The Jewish model for decision- To benefit a fellow man (or function of their historical and social making in medicine is based on a tri- woman) is a moral and religious im- circumstances. At all times, howev- ad. First, the physician (who is perative in Judaism, based on sever- er, they were administered within obliged to treat the patient and offer al Biblical injunctions. the framework of Jewish religious the best available medical advice); In the patient-physician relation- law (the “Halachah”), based on a second, the rabbi (required to ad- ship, the notion of beneficence is deep understanding and sometimes dress ethical questions and medical strongly emphasised in the positive far-reaching interpretations of the problems relating to religious law); commandment to physicians to treat Old Testament (the Torah). and, third, the patient himself. The and assist every patient, without dis- latter has the independence to crimination. The patient-physician choose his medical and rabbinical relationship is in fact regarded as a 2. Some Principles in advisers, to whom he then abdicates quasi-religious covenant, based on Applied Health Care Ethics a great measure of his autonomy, beneficence, rather than a civil con- while remaining free to decide tract, based on mutual agreement. Allow me now to make the leap to mainly on non-medical and non-eth- modern times and briefly address ical/legal matters. e) Non-maleficence. some contemporary health care is- The assumption is that, through Harm and injury to body and soul sues (from the orthodox Jewish per- this dynamic triad, with each person are defined very widely in Judaism, spective). pronouncing on his own area, opti- and the avoidance of maleficence is mal decisions will be reached to a positive duty within the broad cat- a) Seeking care. complex medical and ethical issues, egory of religious injunctions gov- In present-day society, one tends judged on their own merits and ac- erning relations between man and to think of health care in terms of cording to their specific circum- man. giving. However, in Judaism, the stances. From a philosophical point In medical and health care situa- sick are morally obliged to actively of view, the model requires the pations, the clear obligation placed on seek medical attention and health tient to make a free choice to waive a physician is never to use his care. From our religious point of much of his decision-making power knowledge to harm or injure some- view, man is given his body as a to others, in line with his voluntary one. Health care professionals are trust from the Creator to use and to acceptance of the Torah and the Ha- required to be experts and keep up carry out His will. Man has no man- lachah. In effect, observant Jews with the highest standards of knowl- date to harm it or abuse it. Quite the make a conscious choice to limit the edge and skills in order to avoid, or opposite, man is required to preserve scope of their autonomy in medical at least minimize, any potential matters to rather narrow areas, damage to a patient, resulting from which can be deemed “neutral”, necessary medical intervention. both morally and religiously. From the Jewish perspective, non- For example: maleficence also includes causing I. If there are several equally ef- bodily harm or damage to one’s self. fective medical options and one op- As already mentioned, every indi- tion is preferred for non-medical vidual is commanded to watch over reasons (eg. financial or cosmetic his own life and health and thus is considerations), the patient has the enjoined against any form of self- choice to refuse that option. harm, injury and suicide. II. A patient may decline a treatment which entails great suffering or has significant complications, if oth- 3. Judaism and Aging er options exist. The treatment of the Jewish elder- c) When principles clash. ly and the health care offered to In general, Judaism is opposed to them is of course bound by the reli- “absolutizing” any single religious gious and moral framework I have principle or ethical precept (beyond just sketched. giving supremacy to the preserva- In the Old Testament, ages were tion of human life). Wherever possi- recorded with some fascination and gg

60 HEALTH CARE AND SOCIETY in detail. In the Talmud, the “ages of aggravate the patient’s already grave as plain murder, with all that that im- man” are vividly defined (60 is el- condition and possibly shorten his plies from a religious and ethical/le- derly and 70 is distinctly old) and life. Moreover, any information of- gal point of view. there are elaborate discussions of fered in such a situation must be giv- However, Judaism does make a factors which bring on old age, in en in a way which does not cause the distinction between medications, addition to the passing of the years. patient to lose all hope or compro- treatments and equipment designed There are physiological and socio- mise his will to live. According to to prolong life, as against those logical descriptions of elderliness, certain authorities, it is absolutely which aim to delay death. It is far and broadly speaking, old age is forbidden to inform a terminal pa- beyond my competence to define clearly seen to be a varying physical tient how long he may be expected the sometimes narrow line between condition, not simply tied to chrono- to live – even if a lie has to be told. the two, but I do understand that, logical age. One must continue to feed and tend when death is imminent, the Ha- There is, however, one constant: for the terminally ill, and placebos lachah is prepared to sanction, per- the proper attitude to advanced years are to be administrated if all other haps even require, the withdrawal of – respect and honour. “Rise before medication would be futile. any factor, whether extraneous to white hair and give honour to the the patient or not, which may artifi- old” (Lev. 19:32). That constant, b) Relieving pain cially delay his demise in the final that fundamental respect, is to be ex- Unlike some other religions, Ju- stage. (In making this statement, I tended to all the elderly, no matter daism does not regard pain in illness have drawn directly form Jewish their religion, status and moral as a punishment to be endured. For Medical Ethics, pp. 123-124, by worth – and it requires that their us, pain is a kind of moral and med- Rabbi Dr. Emmanuel Jakobovits, health needs be looked after, thor- ical challenge to be grappled with. the former Chief Rabbi of the Unit- oughly and with compassion. The Lord is to be served in joy and ed Kingdom). Like charity, health care of the not in agony; ongoing pain and suf- This issue, and several others I aged begins at home. On the basis of fering are regarded as worse than have touched upon, are profoundly the Old Testament, children are en- death. Hence, so long as a medica- complex and being unqualified in joined to look after all aspects of tion helps relieve pain, especially for these matters, I shall go no further. I their parents’ well-being “until the the aged, it is to be utilized – even if only hope that having been so bold Lord has mercy on them”. If the it may have some life-threatening to venture thus far, I have been able child cannot care for his parents at side effects. to convey some insights to Jewish home, he is required to find a suit- attitudes and approaches to Health able alternative – giving a clear basis c) Preservation of life, Care and Society. For the rest, you in Judaism for the provision of old as against quality of living must turn to specialists! age homes and assisted living. A For Judaism, this is virtually a child is forbidden to go against the “non-issue”. Life, being God-given, H.E. Mr. YOSEF LAMDAN wishes or demands of his parents is to be preserved and prolonged al- Ambassador of Israel to the Holy See and hence, in various circumstances, most at all costs. The value of any he is obliged to entrust their care to life cannot be measured in terms of physicians and health care profes- quality, based on comparative or rel- sionals. There is no question of chil- ative factors, often reflecting transi- dren trying to treat the ailments tory social norms. Since life is holy, which afflict the elderly by them- man has no authority to shorten it for selves, on the grounds of honouring the sake of the quality of living. their father and mother. Hence, in Israel there is no arbi- Notes Now let me try to outline some trary cut-off age for receiving inten- Jewish positions on various predica- sive care. Old age homes and facili- * I am particularly endebted to Professor ments often encountered in dealing ties are required to have equipment Abraham Steinberg, author of the standard En- cyclopedia of Jewish Medicine (in Hebrew) with the elderly (but not only them). for resuscitation of patients, includ- who consented to my free use of his material. ing those in advanced states of de- I am also grateful to Dr. Aharon Cohen, a) Information giving mentia. In the attempt to preserve Head of the Geriatric Division in the Israeli Ministry of Health, who sent me a wide selec- Frequently, modern approaches to life, aggressive procedures such as tion of materials on aging, including a lecture this question suggest that the sick naso-gastric tube feeding are ad- (on tape) by Chief Rabbi Israel Meir Lau; and must be fully informed of their con- ministered to those in need thereof. also to Rabbi Yaakov Weiner, Head of the Jerusalem College for Research, who spent ditions, no matter how grave. Ju- In the case of certain terminal pa- valuable time with me. daism takes the position that neither tients, the use of powerful medica- Of the printed works consulted, I would es- the doctor nor the family can make tions may be relaxed, while the pecially mention: 1. JAKOBOVITS, IMMANUEL, Jewish Medical any final medical decision so long as obligation remains to feed and care Ethics (New York, 1975). the patient himself is capable of be- for these patients as long as med- 2. SHULMAN, NISSON E, Jewish Answers to ing involved. Thus, information giv- ically possible. Medical Ethics Questions (New Jersey and Jerusalem, 1998). ing is called for. However, in the 3. Weiner, Yaakov, Ye Shall Surely Heal case of terminal patients, the Ha- d) Euthanasia (Jerusalem, 1995). lachah imposes certain limits on In the light of everything said, it 4. Encyclopedia Judaica (Jerusalem, 1972, what information can be given, pri- will be clear that in Judaism any 12 vols.) - several authoritative articles. For the serious searcher, the Internet is re- marily to prevent mental anguish form of active euthanasia is strictly plete with material (of mixed quality) on the and psychological stress which may prohibited. This is in fact regarded topic at hand. gg

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MAURICE BORRMANS IV.2 A Light in the Inter-Religious Christian-Islam Dialogue: the Virtue of Compassion

Two years ago I was able to de- Muslims no doubt have much to three surgical operations the disease scribe the importance of the support share, even though the former can- spread throughout the body. From given to serving the cause of health not make the latter understand the December 1998 we accompanied and sick people in Muslim societies redemptive value of every example her first in her home and then in the – classical Islamic civilisation, like of suffering lived out in union with obstetric wards of the hospital until the civilisations which preceded it the suffering of the crucified Christ. her end... with tenderness. and followed it, made its own con- At the least they can help them to Here are two documents left be- tribution to medical science. In its give to their suffering a profoundly hind by Soumia and which we en- own way it also took care of sick religious value where faith manages trusted to her mother eight days af- people. The modern states where Is- to express itself, leaving a secret ter the burial. We have here a school lam is the official or unofficial reli- space to the work of the Holy Spirit. exercise book in which she wrote gion, faithful to this centuries-old It is in this perspective of accompa- three poems which were written af- tradition, have thus developed – im- nying and mutual exchange that I ter she had been discharged from itating the health care systems of would like to invite you to reflect the hospital of Mecheria after Western countries – a set of institu- upon the values of compassion that knowing that she had been con- tions and structures in order to guar- all sincere believers can live out to- demned... and a letter which was antee to all their citizens access to gether, with words or in silence. written to her by the surgeon of preventive and curative medicine. To this end, it seemed to me that Mecheria who had operated on her. A year ago, speaking from with- the best thing to do would be to re- I have translated these documents in the same perspective, I recalled call with you the posthumous mes- from Arabic into Italian. the privileged place that elderly sage of Soumia Lamri, a young Al- These texts are worthy of note people have in the popular mentali- gerian woman who was ill with because of the authenticity con- ty and in public opinion in these cancer and who died recently at the ferred on them by nearness to death Muslim societies. Times have cer- age of seventeen and a half in Ain and the deep faith which underlies tainly changed and these people of- Sefra (Algeria) after years of great them. They are precious examples ten run the risk of being margin- suffering, and accompanied by a of witness to the approach and atti- alised, as indeed is often the case in priest, a friend of mine. The texts tude of a real believer in the face of Western societies. It is still true that written by Soumia in her own hand suffering and death. ‘elderly people’ in the Muslim con- and left to her family, the Soumias, Here, first of all, is the letter writ- text still have the right to be re- can inspire us in our reflections and ten by the medical doctor to spected by everybody, if not to re- thoughts. Certain observations Soumia: ‘In the name of God, the ceive the care of the whole of the made by the priest who went to vis- All Merciful, the Merciful, To community. Euthanasia is not yet a it her almost every day are for us an Soumia, my poor daughter, do you problem for Islamic societies – life invitation to act to ensure that every despair of the mercy of God? remains an essential value, from hospital becomes a holy temple of a Everything that comes from God is conception to death, even if the merciful compassion in which mercy, even though it is illness and Sharia (Islamic religious law) au- Christians and Muslims say many suffering. We do not see nor do we thorises the death penalty in three things to each other under the gaze know the root of things and what specific situations (talion, adultery, of God. Many lights can shine in the Creator wants. Praise God for and apostasy). the sky, which is at times cloudy, of the fact that He has brought a reme- But in the world of health and so- Islamic-Christian relations! dy for every malady. What you ciety, amongst the needs of the indi- have learnt in your trials others vidual and the care provided by the have taken many years of their exis- community, there is suffering and The Posthumous Message tence to understand. ‘It is possible pain, and these are inescapable hu- of Soumia Lamri that you do not love anything, but man experiences which sick people this for you is good’. Try, therefore, experience or are subjected to, and Soumia Lamri was a young to find usefulness in your suffering. which medical doctors and male high-school student in Ain Sefra Because in your suffering there is and female nurses accompany. At (Algeria). She was born on 23 July mercy and you will find the wisdom the cross-roads of health and soci- 1981 and died on 25 March 1999 of God, patience, and healing, if ety, there is thus to be found human after struggling for a number of God so wants’. My greetings, your suffering where Christians and years against bone cancer. Despite physician!’ gg

62 HEALTH CARE AND SOCIETY

The absence of a date means that You do not know what it con- most of her school companions had we do not know if the letter by this ceals, nor what it proposes, left her)... Few references to faith medical doctor came before or after but the bitterness of time sudden- and God, but a passage which the composition of the poems. It is ly falls on you. refers to ‘destiny’, the invocation of little importance! What is certain There are jealous people, gener- of the beginning: ‘in the name of is that this letter is an answer to a ous people, the bearers of gifts, the first Cause of everything and message of the sick girl (who for there are unjust people. the Inspirer...’ (references to the that matter confirmed the fact). If However, time changes neither Koran) and the final wish and hope: the medical doctor thought he could my destiny nor my days, and does ‘may it please God, O time, that be so direct this is because between not reduce my pain. you go back on your paces, And them there was friendship and trust, Ah! O Time! that you make me forget what has and he knew the qualities of the Time for me was constant, a happened to me’. It is probable that soul of the person he was writing painful devastation. this poem was written before the to... His letter seems to have made a It has made me lose every de- shock created by the letter from the great impression on this adolescent scription of my trials, surgeon. girl, as is borne out by the tears on it has led me to the heights of my Here is the second poem by the paper. pain and my suffering. Soumia: This letter joins conciseness with Time has changed my appear- great elevation of the soul. In it God ance and dispersed my knowledge. ‘How difficult are the moments is omnipresent (He is referred to It has made me lose my beauty that I live’ seven times). It refers us constantly and youth. Ah! Time, you have be- Ah! A thousand sighs that come to His mercy (five times), to His trayed me. from my pain, my pain that has pity omniscience and to His providence: What was sweet for me you have neither for my heart nor for my ‘to every malady He brings a reme- made bitter; my adolescence has heart. dy’ (Yadith from the al-Bukhari or been handed over to medicine. A pain that was decreed for me, kitab al-ibb). We, instead, poor hu- O time, amazing, extraordinary, in the book of my destiny. mans, do not see or know the root of you who darken family and friends. A pain that is not like the ardent things, and hate illness and suffer- You in whom the innocent sick desires of my heart, nor like the ing, whereas ‘for you it is a good’ person is wounded and the proud torment of my body. (The Koran 2:216). It is an appeal, oppressor is praised. A pain that has thrown my rea- without any concession, to a vision O time during which the brother son into amazement and turned my of naked faith about suffering, becomes an enemy because of the arteries into embers. which has its own usefulness and burden, and the child becomes un- Oh this painful suffering, how enables us to enter the wisdom of just for his father. much it has made me suffer and God. Ah! O Time! forbidden sleep to my body! This is a sharp and direct mes- Time who plays with the nations. Suffering in my heart and in my sage which could not but provoke You who break up a family and intelligence, suffering in the deep- tears... fertile tears, as is borne out bring the end of children, the seed est part of my profundity. by the little school exercise book. of pain and suffering. Suffering that no medical doctor Most Algerian adolescent girls have If it is true that you reap what you heals, and which time does not re- a school exercise book or an album have sown, may it please God, O duce. in which they keep documents, time, that you go back on your My pain does not come from a photographs, letters, texts, and all paces, desperate love, nor from a pas- the rest. Soumania was no excep- And that you make me forget sion, but from the Lord of the tion, and in beginning this school what has happened to me. worlds. exercise book she made clear, after An illness was decreed for me, in the bismillah, that she was doing This first piece is a long rather it for me there is no hope. this to write down her poems, to ex- than desperate reflection on the An illness has seated itself in my press her thoughts, and also to con- passing of time. ‘Time passes, the soul, my foot withdraws from my serve her memories. days go by...’ It is a reflection movement. Here is Soumia’s first poem: which evokes certain emphases to An illness which has made me be found in Wisdom or Job in the lose the breath of youth, and has In the name of God, the All Mer- Bible. Time is referred to sixteen killed within me all my dreams. ciful, the Merciful, times. It is the deceiver, the betray- My dreams as a girl, dreams of In the name of the first Cause of er whose bitterness falls on you all quiet and tranquillity. everything, of the Inspirer of poetry, of a sudden. It is the seed of pain, of An illness which frightens me of He who speaks to friends, I, suffering, of bitterness, and of trial during the day and obsesses my Soumia Lamri, write for the first (ten times). It neither changes des- nights with the torments of tomor- time with a blue pen on a white tiny nor reduces pain... You have row. sheet, to give free expression to made me lose beauty and youth... Will there perhaps be a healing, my feelings and to record my My adolescence passes in the Lord, a healing which comes from thoughts. The first idea is: hands of medical doctors... One has You, for me and for all my brothers ‘What comes into my mind’ or to flee from relatives and friends and sisters? ‘Time’ (she complained of the fact that You, Lord, are our Shepherd, gg

DOLENTIUM HOMINUM N. 46/1-2001 63 our Benefactor, He who makes us ceiving the letter from the surgeon? which now stares her in the face: live and die, Lord. Whatever the case may be, it re- ‘You are welcome O death! I am Lord, answer my prayer, and the flects the spread of the illness, the not afraid of you’. She is afraid on- prayers of all my brothers and increase in suffering, and a certain ly of her encounter with her Lord, sisters. psychological evolution in relation who will judge her. O Lord of the worlds, O Creator to her own malady. What a magnificent unfolding of the whole Creation. This is the third poem by and development! The disenchant- Soumia: ed reflections, almost desperate in This second poem is dominated character, of the first texts, are fol- by illness (cited four times): an ill- ‘The Faint Light of my Hope’ lowed by faith, courage and lucidi- ness decreed in her destiny (three Ask the set of times, they will ty. In these lines she starts on her times), an illness without hope, speak to you about my pain. way to her meeting with her Lord. which neither time nor a medical Ask all men about my suffering An observation was often made af- doctor can heal. An illness ‘seated’ and my trial. ter her death: ‘God purifies, through in her soul and which frightens her I am ill and bear my pain, but in suffering, those that He loves in a day and night. It has made her lose all ways I am strong. special way’ (Yadith from her youth and all her dreams as a God has given me enough faith. al-Bukhari to the kitab al maral). girl. This text lays emphasis on the I am not afraid of my fate, but of Her young sisters, nine and eleven consequences of the illness, which the trials of my path. years old, know her poems by heart are pain, suffering, and trial (waja’ My song is my prayer, O Lord, my and used to recite them on my seven times, alam five times). healing. shoulders, as they gradually discov- Physical pain in her body, moral I say and say again, in my loudest ered them in her school exercise suffering in her heart, in her reason, voice: “You are welcome, O book. in her intelligence... in the deepest death!” The impact of the long weeks of part of her profundity! I am not afraid of you, but of suffering and courage of Soumia Differently from the first poem, meeting my Lord. was very great for all those – rela- this second poem refers to God tives, friends and hospital staff and quite often (eight times) and on dif- This third and last poem, whose personnel – who accompanied her ferent occasions with phrases from rough copy bears the line ‘my suf- until the end. Everybody remem- the Koran: ‘Lord of the worlds’, fering and my tribulation’ bears the bers her pained smile during the ‘Creator of the whole Creation’. In title in her school exercise book of course of her trial, and of her radi- another passage God is called ‘our ‘the feeble light of my hope’. This ant faith. May these poems which Shepherd and our Benefactor’. This was the last title wanted by Soumia, she left behind her help others to text twice evokes the prayer of the and indeed best reflects the charac- face up to and to tackle life with heart (du’a) and thus sees the faith ter of the contents. Indeed, if illness, greater courage, because it is those and placing oneself in God’s hands pain and suffering are still present, who are about to die who teach us as the only way out. It is not there- they are no longer present in a dom- how to live. fore without hope, and healing is inant way, in the form of a leitmo- seen as the last hope (four times). tiv, as is the case in the other poems. ‘Will there perhaps be healing, She upholds, on the contrary, her An Added Note on Compassion Lord, a healing which comes from own soul: ‘I am ill and bear my as the First Word You’... It is you who make live and pain, but I am strong’. She prays: of a Muslim-Christian Dialogue die (this is another allusion to the ‘O Lord, my healing’. Finally, she by Francois Cominardi Koran). Answer my prayer!’ says and says again that she is not Was this poem written after re- afraid of her fate or of death – death 1. On the Track of Pierre Claverie and Christian Chessel

Observing the failure of a large number of attempts at inter-religious dialogue, Pierre Claverie declared: ‘We have a shared vocabulary, but the meaning of the words is different. We must take everything from bottom up, and live together, not only in words and books, but in the words lived out together, in the right words, a shared experience...’1 Beginning with this observation and the shared experience of suffering that Christians and Muslims in an Algeria in crisis are now living, Christian Chessel asked himself whether ‘compassion is not the first word of a discourse and the first gg

64 HEALTH CARE AND SOCIETY gesture of a commitment with an- follow in the breach opened up by ing with him, putting oneself in his other person and for another person, Soumia, not at the educated and position, suffering with his suffer- whatever his or her faith may be’.2 cultured level of an expert on Islam ing, entering into his suffering per- When speaking about compassion, or on the Bible (which I am not), sonality, making oneself draw near Christian had in mind above all else but at a simple basic level, as a man to him to the point of being at one that compassion which the Chris- in fraternal contact with his Muslim with him, in order to live out his ‘brothers and sisters’. suffering. For this reason, there is no need for words: it is enough to 3. What is Compassion? be there, to be with him, to hold his hand, to dry his forehead, to be for I have consulted the dictionaries. him a sign of the tenderness of God. The Petit Robert defines ‘compas- A sign is more easily understood sion’ as a ‘feeling which leads one than words, especially if it comes to experience and share the nega- from the depths of the heart... It di- tive experiences of others’. It refers rectly reaches the heart of the other to concepts such as compassion, person: it is a dialogue between mercy, pity, and consolation. The hearts... a level which is not en- Petit Larousse, for its part, defines trapped by words. ‘compassion’ as a ‘feeling of pity When one accompanies a person which makes us sensitive to the who is at the terminal stage, and negative experiences of other peo- above all if he knows that he is con- ple’. demned to die, this dialogue is des- The Bible, as Christian makes tined to succeed because it is born clear in a detailed fashion, speaks amongst people who are aligned at about mercy, consolation, and ten- the level of the essential by the tians who have chosen to remain in derness. This message culminates nearness of imminent death – that Algeria since 1992 experience as in the parable of the Good Samari- level of life and death. People in they share the trials and tribulations tan (Lk 10:30-37) who was ‘moved this situation are after a certain of the Algerian people, a decision by compassion’ for the unfortunate fashion forced to rid themselves of taken despite their lack of security, man who was lying at the side of all accessories... Naked we left the their precariousness, their poverty, the road ‘half dead’. His tenderness breast of our mothers, naked we etc., and indeed often with their drew him near, or better made a will return to God. This is remem- lives in serious danger.3 neighbour of him, in relation to the bered by the person, without any poor man who had been come words, by the person who prepares 2. At the School of the Sick across. Is it an accident that Jesus to appear before his own Creator. puts on the scene a ‘half dead sick He places at the same level all those Personally, it was at the end of man’? I do not think so. In the Ko- who take part in this experience of accompanying Soumia Lamri, a ran we find as a leitmotiv the bis- compassion. The dialogue which is young sick woman who was seven- millah al-Rayman al-Rayim, ‘in the established enables them to engage teen years old, that I connected liv- name of God, the All Merciful, the in a very deep level of communica- ing at the bedside of sick people Merciful’. I would like the listener tion which goes beyond words... All with the reflection on compassion to refer here to Christian who has the reserve, all the obstacles, are re- which was begun by Christian. This explained this point very well. moved... The way is open. This ac- accompanying was effected with Compassion, therefore, is a part companying, which can only be constant contact with the family of ‘a vocabulary which belongs to done where there is a team, also and the medical team. This was a Christians and Muslims alike’. One places all those who take part in it in daily contact, and rather wounding is not dealing here solely with pas- great harmony with each other, to for those who for over three months sive compassion, through which we the point that a single word, a single surrounded the young Soumia with are moved by another person, but name, is enough subsequently to tenderness. above all else with active compas- evoke this ‘state of grace’. At the end of this shared experi- sion, that compassion which ence, lived as a Christian with my pre-supposes a commitment to the 5. When a Young Sick Woman Muslim friends, the emptiness left other person. As St. John said: ‘We Troubles Muslims by the death of Soumia and a spe- do not love with words or language, and Christians after her Death cial grace which I owe to her pro- but with facts and in truth’ (1 Jn duced the ‘impetus’, that is to say 3:18). Soumia Lamri has left us three that ‘shared experience’, ‘that first poems written after knowing that act of commitment with the other 4. Compassion towards she was condemned, in addition to a person and for the other person’that a Sick Person letter which she sent to the surgeon I experience at the bedside of sick who had operated on her. These people, especially at the bedside of To express one’s own compas- documents were entrusted to her those who no longer have any sion in the presence of a sick person mother eight days after the funeral. hopes of getting better. It is there- means to share everything with the The texts are worthy of note before the sick people who lead me to person who suffers. It means suffer- cause of the authenticity bestowed gg

DOLENTIUM HOMINUM N. 46/1-2001 65 on them by the nearness of death the heart of Soumia and the heart of and died because he protected him.4 and the deep faith which underlies her medical doctor. This ‘shock’ is something I owe to them. All those who have come into Given the demand which existed, Soumia, and I am not the only one. contact with these letters – rela- it was necessary to reproduce this As Christian Chessel realised, tives, friends, acquaintances, mem- dossier and circulate photocopies of compassion is the language of the bers of the health care staff and per- it. This dossier has provoked, in ad- hearts of Christians and Muslims sonnel, and helpers – have been dition to emotions and tears, reflec- who – in a shared experience of touched very deeply by them. tions and private communications, God and man, well beyond words – Many people have seen in them a in both oral and written form, reso- discover that they are ‘believers’. real instrument for Muslim-Christ- lutions to be committed to sick peo- ian dialogue. A dialogue manifested ple, and in certain cases a real psy- Rev. MAURICE BORRMANS, on the Muslim side by the trust chotherapy which has brought out Professor of the Institute shown towards me as a Christian by painful things about which it had of Islamic Studies of Rome the health care team which asked not been previously possible to talk. me to take part in this accompany- It is clearly the case that Soumia has ing, and by a mother who entrusted not stopped bringing about little me with these valuable documents ‘miracles’. Notes so that they could bring light and 1 ‘Forum des communautés chrétiennes à courage to other people. A dialogue 6. They Discover that they are Angers. Pentecoste 1994’. Cf. La Croix, 25 manifested on the Christian side by ‘Believers’ May 1994. 2 Cf. ‘La compassion, premier mot d’un lan- my absolute respect for the beliefs gage islamo-chrétien pour temps de crise’, in and convictions of Soumia and by In provoking compassion in Riba al-Salam, n. 21. the emotional welcoming of the Muslims and Christians alike, 3 Christian and his three brothers – White Fathers – experienced this compassion to the thirty delegates of the diocese of Soumia has greatly helped to point of giving their own lives on 27 December Laghouat who had come together in change the way in which these two 1994. Cf. Duvan Armand, C’était une longue Ghardia for the Ascension and who groups see each other. Christian de fidélité (à l’Algerie et au Ruanda) (Paris, Médi- aspaul ed., 1998). were able to touch with their hands Chergé experienced this shock 4 Cf. MARIE-CHRISTINE RAY, Christian de this posthumous message, the in- when an Algerian land warden, who Chergé, prieur de Tibhirine (Paris, contestable action of the Spirit in was a friend of his, risked his life Bayard-Centurion, 1998), pp. 47-8.

ELENA DE ROSSI FILIBECK IV.3 Hinduism

In the introduction to Strofe del find it in most of Indian mysticism. be found in the religious practices Samhkya or Smhkyakarika by Is- Everywhere, that is to say, where of the Hindus which constitute not varakrsna Isvara, Prof. Raniero we find manifested the need for a only the most forceful aspect of the Gnoli observes how there are some reflection on the world we en- religiosity of India but also the most ideas in the history of mankind counter the distinction of these two important. This is because such which become a nucleus towards fundamental concepts’. practices ensure the creation of a which the tendency of a whole cul- sort of ideal unity of all Hindus in- ture moves. The distinction be- dependently of their membership of tween matter and form has per- What is Meant by Hinduism this or that school of the various In- formed such a role in the West. The dian doctrines. dual idea of prakrti and purusa has This quotation enables us to un- It was the Sampradaya, literally done the same in Indian civilisation. derstand how certain philosophical the conferers, who formulated over The first term refers to a sort of concepts, born in the Vedic world, time the various doctrines. They did natura naturans, the manifestation then elaborated in Brahminism, and this by returning through their own of being to be found in every thing; which then converged in Buddhism, personal experience to the facts of the second expresses the idea of are present and traceable in the mil- tradition. man/soul. lenarian history of Indian thought, At the highest level this involved ‘This idea’, he adds, ‘which over albeit in a very large number of re- sacred knowledge, or rather specu- time has animated the whole of In- flections and solutions, and this fact lation on the concept of Brahman or dian thought can be found adum- confers upon such thought a line of the absolute, the ancient impersonal brated in certain Upanisad, we can continuity and a specific character. power connected with rites, rising read it in the Purana, and we also This specific character can also then to the physiognomy of one/all gg

66 HEALTH CARE AND SOCIETY and coinciding with the inner being able differences and where during lish that the Atharvaveda was com- of man or atman. the course of time different reli- posed after the Rgveda, whose dat- From the various schools there gions, ranging from Christianity to ing goes back to 1500-1000 BC. arose the phenomenon of the yogin Islam, and from Mithraism to This last is considered the oldest (or renouncers), the sadhu (or the Parseeism, have spread throughout collection of the Veda (it contains good), and the varaigin (or those the population. hymns, magical formulas, spells to who practice detachment). Their life example, directed towards living to the utmost the teachings that they had received, was the soul of Indian spirituality. For everybody, however, it was incumbent to put into practice the principles of the Hindu dharma which was based upon two fundamental elements. On the one hand the elements of ahimsa (non-violence) and satya (or truthfulness), and on the other the svadhana, or the specific duty of each caste. By Hinduism we mean the traditional religious culture of India, whose territory, we may remember, was divided into the two states of the Indian Union and Pakistan in 1947 on the basis of a religious criterion, with the allocation of the areas with an Islamic majority to Pak- istan and those with a Hindu majority to India, where, indeed, the over- whelming majority of Hindus now Medical Science heal people of illnesses and to ob- live. tain a long life etc. in ten books or We should remember that the Medicine is certainly an expres- cycles containing 1017 hymns). term ‘Hindu’ has geographical ori- sion of the cultural context of Hin- To refer to the ancient world of gins. It comes from the Iranian form duism. Since very ancient times it the Veda means to refer to those ‘Sindh’ and is thus handed down to has been considered a science to be concepts such as Brahman, atman, us through the Muslims. At the time placed on the same level as gram- samsara, and karman which are an of the Islamic conquest the invaders mar, mathematics, and astrology. integral part of Indian philosophical applied it to all those who did not The tradition called Ayurveda is thought and which concern the fun- accept the religion of the Prophet. the basis of the teachings of Indian damental principles on which the In reality, the term is inversely medicine. This tradition has con- various Indian doctrines are based exclusive in the sense that for a per- nections with the Veda, that is to say in their analysis of the spiritual and son to be considered a Hindu it is the corpus of the most ancient texts material world. necessary for him or her to belong in India of a religious and ritual The links of the Ayurveda with to a caste, and a person does not be- character. They are in their present the Vedic substratum have been long to a caste unless he has been form thanks to the result of a well established. For example, in born in India. The disappointment process of centuries-old develop- the idea that the body and the spirit of many Westerners who, attracted ment and re-elaboration. are realities which penetrate each by Hinduism, subsequently realised Indeed, the Ayurveda or science other. that in India no traditional commu- of longevity is considered at times The importance of medicine in nity could welcome them in their as a secondary (upanga) part of the the Brahmin context was deter- midst, is more than well known. Atharvaveda and at times as a sec- mined above all else by the wish to There is thus a strong impulse to ondary Veda or (upaveda) of the acquire material and spiritual im- identify Hinduism with the Indian Rgveda. mortality. world. The Atharvaveda is a collection Health and a long life – which Even today India is called by its of hymns (made up of twenty books had to last at least a hundred years – educated members tapobhumi or with 731 hymns and prose) contain- were a condition which was re- the land of asceticism. In this sense ing spells, blessings, curses, songs quired not only because of the mate- one can talk of Hinduism within In- for ceremonies and so forth. In this rial advantages involved but also dian civilisation as constituting a collection there are also theological because of the future life ahead – continuum – despite the coming and and cosmogonic observations and good health was seen as being es- going of events and peoples over reflections. sential in order to perform the duties thousands of years – in a territory in From studies conducted on the of this life and the duties of reli- which the multiplicity of races language and the contents of the gious practices. The disciplines of seems still today to create unbridge- hymns it has been possible to estab- yoga – Tantrism – and the study of gg

DOLENTIUM HOMINUM N. 46/1-2001 67 alchemy developed the idea of an in the first centuries of our era) and enriched with new acquisitions. imperishable soma: health and Vagbhata the elder, who was active Down the ages, for example, the longevity were seen as the means roundabout the seventh century AD. Indian pharmacopoeia has assimi- by which to transcend the transmi- Of these collections only the first lated foreign forms of medicine. gratory condition, and to obtain fi- has come down to us directly, in a In the presence of and because of nal immortality or the uniting of single and incomplete manuscript, so much scientific literature belong- oneself with the absolute. whilst the others have come down ing to Indian medicine produced in This aspiration was determined to us in subsequent versions due to different epochs, the subsequent ex- by the belief in the constant flow of revisions carried out by different position of Ayurvedic principles re- births and deaths, the chain of suc- authors or compilers. ferred to those drawn up during the cessive existences or samsara, Their tracts constitute the subject classical period. This period, which moved by the karman, an iron law of large commentaries by scholars, constituted the high point of Indian of causality applied to morality. and have inspired specialist works civilisation, was the Gupta, and a This generated the idea of a cer- on diseases and treatment and have post-Gupta period which covered tain automatism of good and bad as been the basis for subsequent com- the years 320 to 740 AD. a result of which, in Indian thought, pilations on medicine. man had only the hope of escaping In reality none of these collec- them by achieving through various tions constitutes a first attempt at a The Principles of Ayurveda techniques and various methods a systematic description of medical higher world where his individuali- science. On the contrary, all are I referred at the beginning of this ty would finally be able to be dis- based upon an already established paper to the idea of prakrti and pu- persed (moksa). tradition, in relation to the founda- rusa because these two terms, in ad- tions of which the authors and com- dition to having a philosophical pilers seem extraneous. They con- meaning, refer to what we call man Ayurveda: Texts and Tradition fine themselves to collecting and in terms of his physical make-up handing on the facts in their posses- (prakrti), which he receives at the Ayurvedic science has come sion which they have received from moment of his conception and is his down to us through an abundant tradition. essence as a person (purusa). And it Sanskrit literature. It should be re- The Ayurveda is made up of eight is indeed man who is the subject of membered that in India Hindi, the parts – this division was so famous medical care and treatment. official language of the Indian that the expression ‘eight parts’ or In the Indian approach genetics Union, is the contemporary point of astanga is normally used to denote are only responsible for the corpo- arrival of a long tradition which the Indian science of medicine. real individuality, and this in turn comes from dialects spoken by the They are: surgery, internal medi- supplies a body (with its psycholog- Aryan invaders of India, dialects cine, demonology, paediatrics, toxi- ical instruments including the sense which we call ancient Indian and of cology, methods to prevent ageing, organs) to the transmigrating psy- which Sanskrit, or ancient Indian and andrology. chic being. par excellence, is one. Sanskrit is The sources on the origins of the The psychological continuum is known to us from the second mil- Ayurveda are very complex but one bestowed with a new body at the lennium BC from the most ancient thing is certain: the tales on its ori- moment of the new birth. The psy- hymns of the Rgveda. gins are inseparable from those con- chic individuality of the living be- Over time this language crys- cerning the origins of the other sci- ing is independent of its perishable tallised and has remained the same ences, that is to say the belief that material vessel which comes from from the third century BC to our the first teachings go back to the the person’s parents. times, becoming the language used gods. The being is seen as being com- for literature for the longest period On the one hand we find the posed of five material elements of time. But it is not only the great mythological tales concerning the (mahabhuta) and a psychic element age and the continuity of Sanskrit Ayurveda , whilst the exposition of (cetana) or consciousness which is which have made this Indian lan- Ayurvedic principles based upon raised by the atman. During trans- guage the most important but also the observation of normal and migration the atman remains asso- the fact that thanks to the greater pathological facts confers a strong ciated with the psychic being in or- conformity of the various Indian connection with reality on this tra- der to descend with it in the embryo civilisations to Brahminism, San- dition. I would like to add that the when it takes a new body at the mo- skrit, the language of the Brahmin Vaidya or medical doctors are divid- ment of conception. caste and culture, became the na- ed into two categories according to The nature of psychic individu- tional pan-Indian idiom used for lit- who studied the texts directly and ality has provoked major contro- erary works not only by linguisti- who practiced medicine on the basis versies among the followers of the cally Aryan peoples but also by the of knowledge which had been hand- Brahmins who believe that there is dravidic populations. For this rea- ed down orally. a transmigrating substantial princi- son scientific literature also came to The Ayurvedic tradition is still ple, that is to say an ontological use Sanskrit. rather alive in today’s India, not substratum to psychism. The Bud- The principal and oldest texts of least as a popular doctrine which, dhists for their part reject the idea Indian medicine are the Samhita or although at times it is said to be un- of substance (with some excep- the collections attributed to Bhela, changing, in reality has undergone a tions, however – for example the Caraka, Susruta (who perhaps lived certain development and has been Pudgalavadins). gg

68 HEALTH CARE AND SOCIETY

The state of health or of illness is tridhath (or the three elements) and Good health is a concept ex- determined by the interconnec- tridosa (or the three defects/ill- pressed by the word svastha which tions between the elements which nesses) of the organism. literally means one who is inside his make up the body. Diet, behaviour, The wind makes up breath own normality, understood in a the influence of the weather and of (prana), fire is present in the organ- physical and mental sense. the climate, are also influential. ism in the form of bile (pitta), and To conclude this paper we should Experience has a very important water is in the phlegm or mucous remember that the cultural ex- role in establishing treatment but secretions (kapha or slesman). changes between ancient Greece the medical practice of the Ayurve- Each of these elements also takes and India, which took place thanks da is not empirical – the facts of on in turn a variety of forms and has to the mediating role of the Persian experience are organised accord- a number of names. empire and the Greek colonies of ing to a general theory of phys- The health of each person de- Asia minor, allowed the interchange iopathology. pends upon the balance between of a reciprocal knowledge of med- In some texts (or Samhita) the these three elements. The meaning ical science. constituent elements of the uni- of the term dosa, which at the outset Certain similarities between the verse are like the elements of the meant an affliction and above all a Ayurvedic principles and the medi- human body. Indeed, the mass of pathological affliction of the breath- cine of ancient Greece can be recog- existing substances, however ing apparatus, of bile, or of phleg- nised in a special way in the Hippo- small they may be, both organic ma, became under the influence of cratic texts Per Cumèn e Per Fusèn. and mineral, are the result of a the philosopher Samkhya a In the first we encounter the four combination in varying propor- defect/illness because in general use humours or fluids (cumo or juices), tions of the five fundamental ele- the term established an opposition blood, phlegm, yellow bile and ments which make up the whole of with guna which meant a quality or black bile, while in the second a the universe – earth, fire, wind and virtue, the opposite of a defect. rather similar principle to that of the space. In the commentaries on the texts wind of the Ayurveda is expounded, The body is fundamentally a of classical medicine we can see that is to say that the organism lives complex and diversified aggregate philosophy unite with medicine. and moves thanks to internal organ- of these five elements. To summarise we could say that ic breathing which is identical to the To these should be added according to the philosophical-reli- wind in the atmosphere. thought (cetana) which resides in gious vision of Ayurveda the world But the similarity between these the heart. These principal elements and man make up an organism two systems, which today we call make up the substance of the or- whose parts are connected to each holistic or psychosomatic, becomes ganism called dhatu. other by a constant exchange of in- more evident in the relationship be- They are seven in number and formation and reactions which to- tween medicine and philosophy. more specifically: organic liquid day we could define as the subject Despite the due differences to be (rasa), blood (rakta), flesh (mam- of the study of bio-rhythms. found between the two systems, this sa), fat (medas), bone (asthi), car- For this reason, in assessing the can be seen in the affirmation for- tilage (majja), and sperm (sukra). state of the illness the Ayurvedic mulated in the world of the Ia- From the rasa come all the oth- medical doctor also assesses other trosophists of late Hellenism, ac- ers because this is seen as being factors such as the sex of the pa- cording to whom philosophy was the primordial substance. Further- tient, his age, his diet, his mental the medicine of souls and medicine more, in everything that exists and emotional life, and the season was the philosophy of bodies. there is a rasa (taste) which be- then underway because there is a stows properties and virtues on close link between the environment Prof. ELENA DE ROSSI FILIBECK, every individual thing. and physiology. Lecturer in Tibetan Studies, This liquid has the characteristic If we dwell in detail upon the The ‘La Sapienza’ University of Rome. of possessing a life force which is forms of treatment proposed by the in the heart. Breathing (prana) is Ayurveda we realise that they are based upon this force which is dis- based in the first place upon the pro- tributed through the body through vision of medicines based upon 24 channels called dhamani which herbs and minerals. What should be carry blood and organic liquid. observed is that the use of these Bibliography We should also remember that medicines is not seen as having a ISVARAKRSNA, Le Strofe del Samhkya in addition to ensuring breathing contrary pharmacological action (Smhkyakarika),(Turin, 1968, 2nd. edn.) the prana also takes sensations and but as having a natural synergism J. FILLIOZAT, The Classical Doctrine of In- thoughts to the heart. which can re-establish the balance dian Medicine (Delhi, 1964). S. PIANO, ‘Lo Hinduismo II, La Prassi Reli- The interconnection between between the three elements. giosa’, in Storia delle Religioni, vol. IV, edited the three principal elements – that The basic elements of the Ayurve- by G. Giloramo, pp. 133-194. is to say wind, fire, and water – da to keep people in good health are M. PIANTELLI, ‘Lo Hinduismo I, I Testi e le Dottrine’, in Storia delle Religioni, vol. IV, gives life and movement to the not based upon special require- edited by G. Filoramo, pp. 49-131. body. When these elements are ex- ments but essentially involve com- V. PISANI and L. PRASAD MISHRA, Le Let- cited or stop, illness and death in- mon sense – personal hygiene, a terature dell’India (Milan, 1970). A. ROSU, Les Conceptions Psychologiques tervene. correct diet, daily exercise (which is dans le Texts MJdicaux Indiens (Paris, 1978). It is for this reason that they are considered indispensable for every- P. V. SHAMA, Indian Medicine in the Clas- called at one and the same time one), and sufficient hours of sleep. sical Age (Varanesi, 1972). gg

DOLENTIUM HOMINUM N. 46/1-2001 69

RONARONG NOPAKUN IV.4 Light in the Inter-Religious Dialogue: Buddhism

Introduction to Buddhism ing as preserved by the elders and conceived notions, nor merely be- Mahanyana, the later develop- cause it seems acceptable, nor Buddhism may be defined and ment. The former is practised in thinking that the recluse is our explained from various stand- Sri Lanka, Thailand, Burma teacher.” And then the Buddha points: Buddhism, the teaching of (Myanmar), Laos, Cambodia and further instructed people to con- the Buddha, the Enlightened One, parts of India and Nepal. The lat- sider everything carefully. He said proposes to develop mankind ter is more prevalent in China, “When you know that these things through purity, by means of Japan, Korea, Vietnam, Taiwan, are bad; these things are blame- morality, calmness, by means of Tibet and Mongolia. In the First able; these things are censured by concentration and clarity, by Sermon, the Discourse of the the wise; undertaken and ob- means of wisdom. Buddhism is a Turning of the Wheel of Dhamma served, these things lead to harm religion founded by the Buddha or Truth, the Buddha pointed out and ill; abandon them. And in con- for the welfare of many, for happi- the Middle Way which gives vi- tradiction, when you know that ness and for helping the world. sion, which gives knowledge, these things are good; these People from all walks of life can which is conducive to calmness, things, undertaken and observed , apply the teaching in practice ac- insight, enlightenment and Nir- lead to benefit and happiness, en- cording to their ability and free wana, the state of being free from ter on and abide in them.” will. Buddhism is a religion of all defilement and suffering. In We can live happily without be- reason and practice for self-help brief, the Buddha taught people lieving in any religion if happi- and self-reliance and for extend- how to be happy and prosperous ness means physical well-being. ing a helping hand to others out of in a worldly as well as spiritual But a human being consists of two kindness and compassion. Bud- sense. Those who follow His major aspects: body and mind. To dhism is both philosophy and teaching can select their way of have a fully developed and happy practice. Though it accepts the ex- life practicable for themselves. life, one needs to nourish both istence of divine beings, it does The Buddhist symbol is in the body and mind. In this case reli- not put belief in a supreme being form of a wheel with eight spokes gion can provide the guidance and as a significant part of the reli- representing the Noble Eightfold the path to develop the mind and gion. Instead it teaches the follow- Path, which means the way lead- spirit along with the body. Ac- ers to have qualifications such as ing to the cessation of suffering. cording to Buddhism, everyone is moral shame and moral fear, mak- This Path consists of: Right View, free to consider and investigate ing one divine in the Dhamma in Right Motives, Right Speech, Buddhist teaching before accep- this life; to be endowed with prop- Right Action, Right Effort, Right tance. Even after acceptance one er faith, morality, learning, gen- Mindfulness and Right Concen- is free to select any particular part erosity and wisdom. Furthermore, tration. of the teaching to put into prac- Buddhism teaches that one who is The Buddha is the Enlightened tice. The Buddha has given vari- free from the defilements of One who discovered the Supreme ous practical formats suitable to greed, hatred and delusion is seen Truth. He did not force anyone to people of different tastes and ten- as a superior being. believe in His teaching with blind dencies. faith. The reasonableness of the The Five Precepts are not laws Buddha’s teaching, lies in the fact but they are self-training rules Historical and geographical that it welcomes any critical ex- that lead to moral practices and background of Buddhism amination at all stages of the path right behaviour. Since one does to enlightenment. He said “Do not not live alone, living in society re- Buddhism came into existence accept anything on mere hearsay, quires self-awareness, self-con- in India some 2,600 years ago nor by mere tradition, nor on ac- trol, adaptability, a non-violent at- when the Indian Prince Siddharta count of rumours, nor just because titude and good will. The Five became enlightened and hence it accords with your scriptures, nor Precepts are to abstain from came to be known as the Buddha , by mere suppositions, nor by mere killing, stealing, sexual miscon- meaning the Enlightened One. inference, nor by merely consider- duct, false speech, and intoxicants There are two major Schools in ing the appearances, nor merely which cause carelessness. One Buddhism: Theravada, the teach- because it agrees with your pre- should be kind, honest and mind- gg

70 HEALTH CARE AND SOCIETY ful. Then our society will reach ligion pleased him, and he be- longkorn’s contribution to educa- the goal that persons can live to- came a great patron of Buddhism. tion was also to prove of great sig- gether peacefully and in mutual During his lifetime he sent out nificance to modern Thailand. trust. These are the five com- Buddhist missionaries to various “Public instruction” or education, mandments: You must not kill, countries to preach Buddhism in- health and medicine became more You must not steal, You must not cluding Thailand. Buddhism was secular than ever before in Thai tell a lie, You must not commit then flourishing in Ceylon and a history. The King was eager to adultery and You must not take learned Buddhist priest came to send Thais abroad for their educa- strong drinks. Nakorn Sitammarat in Thailand tion partly because the country Buddhism teaches that loving- from where King Rama needed skills and knowledge from kindness should be diffused to all Kamhaeng of Sukhotai (1275- the West and partly because the sentient beings, be they human or 1317) invited a learned Ceylonese Thai students abroad could come non-human. If the world follows monk, so that he could help him to into direct contact with Europe’s the teaching of diffusion of uni- teach his people the new religion. elite. King Chulalongkorn kept versal loving-kindness, conflicts Siam an independent sovereign may be solved not by confronta- state in spite of all crises, and all tion but through peaceful means. The Reign and Reforms of King the while he strove to uphold Thai Buddhism denies the attachment Chulalongkorn (1868-1910) cultural, artistic, and religious val- to the permanent soul, but admits ues. When King Chulalongkorn the continuity of life from one to King Mongkut (Rama IV) was died in 1910 a new Siam had come another, as long as one does not the first Chakri King to embark se- into being. The Thai kingdom was reach Nirwana or the utter extinc- riously on reforms based on West- now a more centralised, bureau- tion of the fire of defilement and ern models. He concentrated on cratic state partly modelled on the fire of suffering. Whenever the technical and organisational Western examples. It was also a human or animal beings continue aspects. He was a scholarly, con- society without slaves, with a rul- to transmigrate in the cycle of life scientious and humane monarch ing class that was partly Western- from birth to death and from death who ruled at a difficult time in ised in outlook and much more to rebirth, kamma still continues Thai history. The reforms and for- aware of what was going on in Eu- to give its results to the doer. The eign policy of King Mongkut were rope and America. Technological- Buddha points out practical ways carried on by his son and succes- ly, too, there had been many ad- and means to achieve the three sor, King Chulalongkorn (Rama vances: there were now railroads levels of advantages and benefits. V) who came to the throne a frail and trams, postage stamps and First: The Present Benefit, youth of 16 and died one of Siam’s telegraphs, public health and med- which means economic and social most loved and revered kings, af- icine. profit by the effort of earning a ter a remarkable reign of 42 years. livelihood, protection of what one Indeed modern Thailand may be has acquired, having good com- said to be a product of the compre- Buddhism in the Kingdom panions and a moderate way of hensive and progressive reforms of Thailand today living. Second: The Future Bene- of his reign, for these touched al- fit, which means the profit based most every aspect of Thai life. Thailand is the country located on morality and virtues by faith, During this reign, King Chula- in the central part of Southeast morality, generosity and wisdom. Third: The Absolute Benefit, which means the highest profit through freedom from defilement and suffering by morality, concentration and wisdom. The practice of this triple study will lead one to deliverance.

History of Buddhism in Thailand

As we know Buddhism reached its height of prosperity in India during the reign of Emperor Aso- ka (273 BC-233 BC) He founded a big empire in India through con- quests and at the cost of numerous lives. The sight of so much blood- shed disgusted him. He gave up fighting and lived ever after in search of peace. The Buddhist re- gg

DOLENTIUM HOMINUM N. 46/1-2001 71

Asia. Its landscape covers 514,000 crimination, should therefore ed between Hindus and Sikhs. square kilometres with a popula- come as no surprise to any serious The Hindu community is mostly tion of 60 million people. The na- student of Thai society concentrated in Bangkok, where it tion is governed by a constitution- Muslims comprise Thailand’s worships at four main Hindu tem- al monarchy, with the king as head largest religious minority and are ples. There are also several Brah- of state with a representative legis- concentrated mainly in the south- man shrines at which Hindus and lature. Buddhism plays a large part ernmost provinces of Thailand. Buddhists alike worship. The in all spheres of public life from Islam is said to have been intro- Hindus operate their own school birth to death, in all states of life, duced to the Malay peninsula by where the curriculum is based on on happy as well as on sad occa- Arab traders and adventurers dur- the Thai education system, though sions. Although Buddhism became ing the 13th century. Most Thai in addition to Thai it teaches Hin- the primary and state religion, Muslims are of Malay descent, redi, Sanskrit and English. The Thais have always subscribed to flecting the common cultural her- Sikhs, too, are concentrated main- the ideal of religious freedom. itage. Ninety-nine per cent Sunni ly in Bangkok. They operate a Thai constitutions have stipulated and one per cent Shi’ite, Thai free school for poor children, re- that Thai kings must be Buddhists, Muslims enjoy inspirational and gardless of caste, creed, or reli- but monarchs are invariably enti- financial support from His gion, and through several charita- tled “Upholder of all Religions”. Majesty the King, who provided ble associations they support the Consequently, the government, money for translating the Koran aged and the sick. through the Religious Affairs De- into Thai. Moreover, His Majesty partment, annually allocates funds appoints a respected Muslim reli- to finance religious education and gious leader as Chularajamontri, Healthcare to construct and restore monaster- or State Counsellor for all Islamic ies, mosques and churches. affairs. The government also pro- Healthcare at the According to the Constitution vides funds for building and reno- Buddhist Temples in Thailand of Thailand BE 2540 (1997) the vating mosques. In some southern right of the people to freedom of provinces family and inheritance Since the old days, Thai people religion is protected and organ- cases are judged according to Ko- have aspired to establish Bud- ised as follows: Section 38. A per- ranic law with a Muslim judge, or dhism as the core of Thai culture son shall enjoy full liberty to pro- kadi, presiding. There are approx- and a pillar of society. It is cus- fess religion, a religious sect or imately 2,000 mosques in Thai- tomary to build a pagoda contain- creed, and observe religious pre- land, about 100 of which are in ing relics of the Lord Buddha at cepts or exercise a form of wor- Bangkok. Some 200 Muslim the heart of each principal city. As ship in accordance with his or her schools offer secular as well as re- the societies evolved and became belief: provided that it is not con- ligious instruction. more secure and communities ex- trary to his or her civic duties, Christians Christianity was in- panded, the Thai also built tem- public order or good morals. In troduced to Thailand by European ples within their communities, exercising the liberty referred to missionaries in the 16th and 17th which were the centres for Thai in paragraph one, a person is pro- centuries. These early Catholic life and used to be the school of tected from any act of the State, missionaries were later joined by Thai children for the basic educa- which is derogatory to his or her Protestants of the Presbyterian, tion. The Buddhist Temples have rights or detrimental to his or her Baptist, and Seventh-Day Adven- been the centre of the medical and due benefits on the grounds of tist sects. Their converts mainly health care of the Thai people for professing a religion, a religious came from ethnic minorities such a long time and the monks used sect, or creed or observing reli- as the immigrant Chinese. Despite plants and herbs as medicine to gious precepts or exercising a the small number of Thai con- cure people. form of worship in accordance verts, Christians have made sever- with his or her belief from that of al major contributions in the fields High quality of research others. of health and education. Thai- of medicinal plants in Thailand land’s first printing press was introduced by Christians, and King According to Her Royal High- Other Religions Mongkut (Rama IV) learned Eng- ness Professor Dr. Princess Chu- in Thailand lish and Latin from Christian mis- labhorn of Thailand, president of sionaries. Christians introduced the Chulabhorn Research Insti- Considered an essential pillar of Western surgery, made the first tute, we can explain the useful- society, religion is not only the smallpox vaccinations, trained the ness of plants and herbs for the major moral force of the Thai first doctors in Western medicine, medicine in Thailand as follows: family and community but has al- and wrote the first Thai-English throughout the ages, humans so contributed to the moulding of dictionaries. Thailand’s Christian have exploited the cornucopia of this freedom-loving individualis- population is estimated at 0.5% of nature as a source for medicines tic and tolerant people for many the total population. for the treatment of a variety of centuries. That there is complete Hindus and Sikhs The approxi- diseases. In Asia several thousand freedom of worship in Thailand, mately 20,000 Indians residing in plants species are utilised for without any ethnic or racial dis- Thailand are almost equally divid- medicinal purposes. We estimate gg

72 HEALTH CARE AND SOCIETY that for some 3.4 billion people in been used in Thai folk medicine porting good health and well-be- the developing world, or 88% of as a skeletal muscle relaxant and ing. If it is done in combination the world’s population, plants an analgesic. Peroxide com- with taking nutritious food and represent the primary source of pounds have also been isolated leading a healthy way of life, it medicine. Our country, Thailand, from some plants of Thailand surely provides fitness and com- as a tropical country, has long en- which have been used in Thai fort your body. joyed the luxury of an innumer- folk remedies for malaria. Phyl- able variety of tropical plants. In lantus amarus has been tradition- High standard of health care this regard, the Thais have a long ally used for the treatment of today jaundice and other hepatic diseases. The active principle of Thai private hospitals are wide- Gloriosa superba is the alkaloid ly accepted. Many multi-national “Colchicine”, which is isolated industries have signed contracts from the dried tuber of the plant for their employees to receive and has been used for the treat- medical check-up and treatment ment of arthritis. in Thailand. Being confidential and worthy, Thai medical doctors Thailand’s world famous are able to treat foreign expats and traditional treatment employees residing in the ASEAN countries. Thai hospitals Thailand is not only famous for today have a standard equivalent its high standard of modern med- to Western Europe and USA. The ical treatment, which is part of standard of physicians, specialists Ayurvedic medicine. Thai mas- and of nursing is excellent and sage has a long history of thera- covers every medical field. Under peutic healing and is the product the Ministry of Public Health’s of ancient oriental medicine. Its strict regulations and control, the origins date back to India 2,500 mission of the hospitals is to be years ago. The founder of the the leader in high standard ser- tradition of folklore medicine, massaging art was “Master Chio- vice. utilising medicinal herbs and vak Kormar Phaj”, a doctor in plants. Natural remedies that, al- Northern India, who was a disci- though undocumented, may have ple of Buddha. These massage Conclusion been used for many thousands of techniques were handed down to years by the human race must be Thailand along with the expan- In conclusion we can say that appropriately catalogued to en- sion of Buddhism throughout the Thailand of ancient times was sure that vital ethnomedical infor- Asia by Buddhist practitioners. under the influence of Buddhism mation is not lost forever. Due to Thai massage was mentioned in and that the Buddhist temple its paramount importance, it is medical scriptures written on played an important role in the life thus a matter of utmost concern to palm leaves onwards from the of the Thai people. It is the pillar public health and indeed to hu- 17th century onwards. These old of society and it is the centre of man life that urgent action is tak- massage texts seem as important social welfare, education, health- en to prevent further diminution as Buddhist scriptures, but most care and medicine. When the of actual and potential availability were destroyed and disappeared Muslims, the Catholic Missionar- of medicinal and biological during the destruction of Ayud- ies and the Protestants arrived in agents. Drug discovery from nat- haya, the old Thai capital, in 1767. Thailand they also became cen- ural products can address the inter- The remaining scriptures were re- tres in the fields of health and ed- dependent issues of biodiversity utilised in 1832 by King Rama III. ucation and of the social life of the conservation, economic growth, He ordered all available knowl- people who obeyed and respected and human health. Many clinically edge to be inscribed on stone slabs them in their own communities. useful anti-cancer drugs have been which were set in the compound That was until Thailand had a discovered from various plants. of the Temple of the Reclining great social reformation in the The potential of natural products Buddha or Wat Po in Bangkok. reign of King Rama V more than as therapeutic agents in the treat- These stone inscriptions can still 120 years ago. Since then Thai- ment of malaria is enormous. be seen there today. land has developed modern tech- Quinine, from the barks of the Thai massage is considered to nology and with it the system of cinchona tree which grows in be an excellent method of self- health care and medicine, which large plantations in Asia, was in- care. In practical Thai massage we today is similar to Western Euro- troduced as an antimalarial more usually use the instinctive acts of pean Countries and the United than a century ago. The Asians touching, rubbing, kneading and States of America. have a long history of use of a stretching different parts of the herb called Qing hao (Artemisia body when there is pain or dis- H.E. RONARONG NOPAKUN Annua) for the treatment of comfort. Thai massage is certain- Ambassador of Thailand malaria. Stephania erecta has ly an invaluable method of sup- to the Holy See gg

DOLENTIUM HOMINUM N. 46/1-2001 73 Section III Action to be Taken

MARIO BIZZOTTO I: Pastoral Care in Medicine Today

The title of this paper in Italian that it was not an organ but the In the United States of America (‘azioni da realizzare: la cura pas- whole man with his own physical studies have appeared based upon torale nella medicina oggi’) lends and mental components which fell inquiries carried out into believers itself to a lack of clarity and to ill this could have been something and non-believers, rigorously hopes which may not be realised. rather new. Now, far more than practicing believers, and believers For this reason it would be a good being a novelty that has become a who are rather lukewarm to such idea to begin by clarifying mat- stereotype. This statement, which practice. The results have pro- ters. This title might make one began in part with philosophical duced facts which are clearly in think of the set of forms of techni- anthropology, has brought into favour of those who translate their cal organisation which should be play other disciplines: sociology, religious beliefs into an actual set in motion in the sphere of pas- psychology and not least pastoral way of life. The examples pro- toral care: for example the admin- theology. Health and illness have duced are very large in number. istration of the sacraments, the en- thus acquired a much broader Prof. Matthews has recently pub- couragement of the staff who pro- meaning than that to be found in lished a large volume entitled ‘il vide services, and the promotion traditional medicine. fattore fede. Il potere della and fostering of groups for the hu- This fact could not escape the pregiera per guarire’ (‘the faith manisation of hospitals. ‘Nota’of the Italian Bishops’Con- factor. The power of prayer to But it could also refer to the reference (1989) which bore the title heal’).2 This text is rightly highly definition of religious activity ‘la pastorale della salute nella regarded both because of the new- which has been proposed follow- Chiesa italiana’ (‘pastoral care in ness of its argument and because ing the ongoing revision of the health in the Italian Church’). In of the scientific rigour which it concept of health and illness ad- sections 6-7 of this document we employs. vanced by psychosomatics, both read: ‘the concept of health... is Some facts can be presented in relation to the updating of the not to be related only to physical here by way of example. Taking a figure of the spiritual assistant in or organic factors but also in- large sample of 91,909 individu- the hospital environment and with volves the psychic and spiritual als, the number of deaths of reli- regard to his possible integration dimensions of the person... The gious people who practiced their into the organism responsible for concept of illness has also faith as opposed to non-believers care and in response to the re- changed. It is no longer definable was 50% in the case of cardiovas- quirements needed for effective as a mere pathology, to be per- cular diseases, 56% in the case of contact with the sick. It is upon ceived through laboratory analy- emphysema, 74% in the case of these subjects, issues and ques- ses. Illness is also understood as hepatic cirrhosis, and 53% in the tions that this paper wishes to existential ill-being’.1 case of suicide.3 Another example: dwell. Indeed, to such subjects the This psychosomatic conception death rates in patients affected by title translated into French and marks a major change in medical serious heart disease who then un- English more explicitly refers – science and thus in pastoral care derwent an operation was 9% but ‘la prise en charge pastorale dans as well. A field of analysis has in the case of believers the figure la médecine d’aujourd’hui’ and been opened up which at one time fell to 5%. The same differential ‘pastoral care in medicine today’. was unthinkable. Recently, at- relationship can be found in other The emphasis is on the meaning tempts have been made to clarify, other areas such as prevention, the of pastoral care in medicine today. on the basis of sociological obser- family, divorce, and drug-taking.4 vations, whether the factor of reli- The statistical picture, although gion effects health and the devel- expressed in mathematical terms, 1. Rethinking the Concept opment and evolution of an ill- lends itself to many interpreta- of Health and Illness ness. The answer as expressed in tions. One could advance the hy- statistical facts and data allows of pothesis that the advantages of the A few decades ago if one said no doubt on the matter. believer are not so much due to gg

74 HEALTH CARE AND SOCIETY his faith as to the consequences sent in the world of health merely grounding of spiritual assistants, which derive from that faith, or in the form of a visitor – he is the lack of sensitivity of certain rather to a serious lifestyle, to there as a part of the helping and diocesan hierarchies, and the fact good diet, and to moderation in caring personnel. If illness in- that pastoral care amongst the sick habits. In other terms, that one volves the whole man and this is is often entrusted to people who could think that if another value to be defined as a religious com- are no longer young and effective took the place of faith, for exam- ponent, it follows from this that in their work. Because of this cri- ple, sport, fitness, physical effi- the contribution made by the sis we have before us an especial- ciency or care for one’s health, chaplain or on his behalf is highly ly favourable opportunity to at- then one would obtain the same beneficial. tribute to pastoral care its due im- results. One would then arrive at portance. Its practice postulates the conclusion that the well-being inescapable requirements of a reli- of an individual should not be at- gious, intellectual and psychologi- tributed to religious belief in itself cal character. but to the observation of the hy- The person who commits him- gienic norms which come from self to assistance to the patient that belief. It has been observed, must feel committed to the task. In however, that although such an ascetic context one talks about norms are scrupulously observed vocation or charism. This is a fun- by everyone the results and the damental point of departure. Upon above-mentioned differences do it is built technological knowledge not change. It should be added and above all else through it one that in the process of the recovery discovers the means by which the of people who are practicing be- message can be communicated. lievers, the medicines and drugs The level of creativity and adapt- have different effects and there is ability, which are able to meet the a great possibility that especially various situations, determines the difficult operations will be over- effectiveness of the pastoral ac- come by the patient. tion. Every sick person has his or Matthews in particular lays her own story to tell which is not stress upon the effectiveness of equal to other such stories. The praying in therapeutic treatment, ability to understand cannot be and to such an extent as to propose 2. The Redefinition and Practice learnt from lessons at school for that the medical doctor should not of Pastoral Care the simple reason that this is not limit the exercise of his activity to something which can be taught. prescribing medicines and a rele- The reference to the connection The application of acquired vant diet but should also engage in between medicine and religion knowledge is only achieved prayer with those patients who acts to place the figure of the reli- through personal experience; it is want to do so. This rather unusual gious assistant in a new light. something which is learnt inde- proposal could be accused of hav- Meyer-Scheu, the author of a pendently. There are no teachers ing a lack of realism, but it could large number of publications on who can teach it because there are not be accused of having a low the subject, complains that the reno pre-prepared answers. Every level of logical consistency. In- ligious worker within hospitals is individual has his or her own deed, it follows on from what is now undergoing a crisis of identi- questions and each person reacts demonstrated by the statistics. ty. The concept of traditional med- to them with his or her own an- Once the health-inducing role of icine previously confined such a swers. prayer has been observed and figure to the margins and made The danger is that in some way demonstrated it is logical for the him superfluous. The effective the ancient docetist heresy is re- person involved in care and treat- function being able to contribute produced, which in our case leads ment to use all the means he has to the process of healing was not to a failed embodiment of the available to accelerate the pa- attributed to him.5 The new con- message, to a sterile presentation tient’s recovery. It is known, how- cept of illness has involved certain of principles, or to a desire to save ever, and the author himself points amendments to a concept which at doctrinal consistency rather than this out, that the proportion of be- one time held total sway. Pastoral the individual involved. People lievers amongst medical doctors is care is now acquiring a precise become worried about the wishes much lower than amongst ordi- importance which is almost uni- of God, like the friends of Job, and nary people. It is not possible, versally recognised. There are forget about the concerns of the therefore, to ask a medical doctor thus favourable premises for an person who is being spoken to.6 to engage in a religious practice in overcoming of the ‘external and Doctrinal concern is more than le- which he does not believe. internal crisis’ observed by Mey- gitimate, however it should be If this task cannot be performed er-Scheu. counterposed by the duty to en- by a medical doctor, it can howev- In discussing this crisis, its gage in solidarity. The right time er be performed by a religious as- causes are also brought to mind, and place should be found for sistant. Such a person is not pre- for example the poor scientific such solidarity. Christ can be gg

DOLENTIUM HOMINUM N. 46/1-2001 75 reached by touching the hem of cation but also through ascetic, are around him – specialists, sur- his cloak, and then from the cloak theological and humanistic train- geons and scientists – can draw at- itself (Mt 14:26) one goes on to ing. The ‘Nota’ of the Italian Bish- tention to successes which under- meet his face. First must come the ops’ Conference calls for people line the indispensable nature of person with his or her human rich- to be ‘in harmony with the devel- their work. The chaplain can asso- es which must come out into the opment of learning and medicine ciate himself with their successes. light; the role emerges only con- and the development of theologi- His work, which is not easily no- comitantly. cal reflection on ecclesial practiced, must express the humble Benevolence and readiness to tice’, and the apostolic letter spirit of the Gospel.8 help belong to the same postulates ‘Salvifici Doloris’ devotes its last Ascetic training is flanked by of evangelisation. One cannot sections to the subject of profes- professional expertise, something evangelise with doctrinal formu- sional training. which is called for by a list of au- las, and even less by using general The assimilation of the evangel- thorities who have campaigned phrases which cannot match up to ical spirit which sends out its mes- for psychosomatic medicine. the unrepeatable nature of the sengers by disarming them forms Frankl, Weizsäcker, Plhgge, and contingent situation. The same a part of ascetic training. The dis- Balint are some of the many fig- biblical quotation is not always ciples dedicated themselves to ures who have lain stress on the equally effective, and a facile use their mission without having the importance of the personal rela- of such a reference gives the im- right to engage in revenge. They tionship with the patient. Gebsat- pression that the speaker does not were without defences, they pre- tel in particular has laid stress in want to express himself with his sented themselves in the form of the training of the spiritual assis- own words but wants to use the poverty and humility. Similarly, tant on the need for his co-opera- Bible as an instrument which acts the religious representative in a tion with the psychotherapist. In as a shield in relation to his own hospital is an envoy who does not his activity this authority has en- feelings. The relationship then go down the corridors like the countered pathological cases merely skates the surface and fails medical doctors or other person- whose solution in his opinion he to establish a contact which goes nel. His presence is different, and believed required the knowledge from soul to soul. Going directly can be refused. This possibility of a theologian. And such help is to the language of faith and moral- places him in a humble condition. mutual. The therapist can discern ity provokes reactions of rejection He is sent out with the task of whether his patient is sustained by on the part of the patient and gives proposing and offering a service, authentic faith or disturbed by a the impression of mere declama- whose function is left to the free false religious experience. In the tion without there being any shar- choice of those people he is talk- first case faith becomes a stimulus ing in the suffering of the other ing to. for the promotion and liberation person. Faber speaks about the chaplain of the person; in the second case it The patient asks for neither as having a role similar to that of has an oppressive meaning and is learning nor erudition from the the clown in a circus. The compar- seen as complex of exterior prac- person who draws. He or she asks, ison at first sight might appear tices, cults, rites, rules, prohibi- rather, for nearness and participa- rather disorientating. However, if tions, and a collection of artificial tion. When learning is used to one reflects for a while one realis- elements. The patient who is conceal one’s own emotions, one es that the comparison is an effec- called upon to establish clarity in remains outside the situation of tive one and can bring out certain relation to himself or himself, also the suffering person. One is in meaningful details. More than any establishes clarity with his or her front of the patient and the near- other figure, however serious and faith. The theologian intervenes to ness is of a mere physical kind, committed that figure may be, the demonstrate what to believe what Adorno defines as the near- clown enables us to understand means, and to direct the patient to- ness of two geometric points.7 the lowness and the powerless- wards the centres of gravitation of The first pre-condition in order ness of man. Whereas everything the religious experience with his to reach the patient and to redefine and everybody are involved in salvific message.9 pastoral care is vocation. This is striving for success, he shows the The person who provides care, what leads to the approach which other side of the coin, puts the whether he or she is a psychother- should be engaged in, the creation events of life in their right place, apist or a theologian, co-operates of answers which are more suited he interprets them through their in re-establishing a new equilibri- to the specific situation, to sharing failings and their dire aspects, and um within the patient, and this is in the condition of the other per- takes part in them. The presence always done on the assumption son and to choosing channels of the priest in a hospital is some- that the patient possess an inner through which the message can be thing of a similar nature. He is an harmony and is at peace with him- communicated. individual who places himself self or herself. The person who is next to suffering people where he, disturbed by conflicts and lives in too, is weak and involved in the an anxious state is not able to 3. Training and Co-operation disorientating unfolding of a mal- communicate what he himself, or ady. In sharing their suffering his she herself, does not actually pos- The requalification of religious approach is to bring the words of sess. His or her action will not assistance is achieved through vo- solidarity and hope. Those who have a healing effect. The person, gg

76 HEALTH CARE AND SOCIETY for example, who has had nega- vation of a patient in relation to with God? – but to another ques- tive religious experiences is not this point: ‘if the chaplain comes tion, namely how should I organ- able to reassure people who have near to me with his morality he ise my life without God?14 Aware- the same disturbances.10 A scrupu- will not give me any help... he will ness of contemporary hegeme- lous spiritual director, a formalist, chain me up, for this reason I nous culture forms a part of the or a fanatic, needs to take care of refuse to seek him out’. One sick training of the religious assistant himself or herself before he ap- woman dreamt that the priest was and is an indispensable require- proaches other people. In the placing a suffocating vase on her ment of that training. training of the spiritual assistant head. This image needs no com- The theologian and the thera- common sense and psychological ments and explicitly communi- pist often find themselves in- stability are basic requirements. cates the unpleasant impression of volved in relationships involving Gebsattel lays great emphasis the person who feels intimidated necessary interchange. Their on the need for the professional and that he or she is approached co-operation is required by situa- and humanistic training of the with impositions.13 tions in which the religious expe- spiritual assistant. It is not enough The difficulties of a doctrinal rience and psychic mechanisms to make oneself available in a self- character cannot be resolved with- are intertwined. The theologian less way. It is important to have a out reference to the situation of administers grace – which acknowledge of psychic mecha- the person who is being talked to. cording to the ancient adage pre- nisms, otherwise the form of help Indeed, a proposal which is wise supposes nature – not, however, that is offered is only apparent, takes account of the understand- nature distorted in its balance but and will by-pass the problem ing and the level of receptivity of nature which has reached a level rather than getting to its roots.11 the other person. The point of de- of maturity. It is upon this basis The authenticity of the action that parture for communication does that one can build an authentic is taken should be subject to veri- not confine itself to safeguarding experience of faith. Co-operation fication. Behind the feeling of sol- orthodoxy or to moving from out- between the theologian and the idarity other motivations can con- side in a coercive way. Faced with therapist becomes indispensable ceal themselves – vanity, pride, an an individual who rebels when in cases of neurosis connected to impulse to self-assertion, and faced with every religious idea I religious factors. Both have their flight from personal problems. cannot speak to him or her about own field of specific action. The Behind the mask of altruism the love of God. Another task has former is called upon to explain equivocal motivations can often to be performed first of all – to see the contents of faith; the other is be found to be concealed. the causes of his or her resentment required to discover the causes of There are guiding techniques and only after neutralising his a mental disturbance. The obser- and strategies which are the nec- psychologically disturbed condi- vation made by Jung is more than essary premises for engaging in a tion is it possible to approach the relevant: ‘if you ask me why you fruitful dialogue. The chaplain religious side of things. must be the custodian of your knows how to act in a suitable In order to be meaningful in car- brother, I cannot provide you with way when he accepts the conflict rying out his religious activity the an answer. I can, however, tell between the religious message chaplain or the person who acts on you me why you have asked me and reality and he elaborates it by his behalf must have an ascetic, this question.’ placing it in experience and per- theological and humanistic train- In the analysis of the psyche sonalising it. He thereby becomes ing. His contribution will be more one can see how certain dysfunc- its authoritative and credible wit- effective in terms of the healing of tions with presumed religious ori- ness. He does not need to turn to the inner person the more he is gins are in reality caused by fac- outside sources. His word is born able to place himself in tune with tors which have nothing to do from an internal source and is the other forces working in the with religion. Religion is called communicated through a personal field of health and health care. For into play as a cover-up which con- travail of difficulties and suffered this reason, the approach of faith ceals the real reasons for the dis- questions. The person who has is something which is especially turbance. One knows for example struggled to overcome the diffi- arduous and goes beyond merely how a child who is morbidly at- culties which are encountered in theological information. tached to his mother feels con- the presentation of faith is better The role of the chaplain, how- stricted in his relationships with able to understand the difficulties ever, remains a difficult one even other women. It can happen that of others.12 after he has met the essential re- he attributes his disturbance to a One of the most frequent temp- quirements of an ideal training. moral motive – to the fear of sin. tations, and most damaging in Contemporary man breathes in a Freud located the cause of many pastoral terms, is recourse to secularised climate which is deaf neuroses in religion. He did not polemics or to forceful defence in to the transcendent perspective. understand that a good religious relation to one’s own points of He is led to resolve his problems education contributes to making view. All this conceals a badly by entrusting himself to exclu- the individual responsible and suppressed inner turmoil and this sively terrestrial means and instru- free. At times the neurosis can be is something which ends up by ments. It seems that he directs his caused by the removal of the reli- blocking every possibility of dia- attention not to the question – how gious element. In this case as well logue. Gebsattel relates the obser- should I shape my relationship the work of the therapist takes gg

DOLENTIUM HOMINUM N. 46/1-2001 77 place at the side of that of the the- emerge and the most frequent ing of false hopes or the telling of ologian.15 question concerns the meaning of lies, things which are convenient It remains to us to find the way illness. The chaplain acquires the to those who are defeated by sci- by which to reach the other person role of a person who is called up- ence and above all to those who and open up a relationship of on to provide answers and this is assist such people. The suffering communication with him or her. no easy task. Its performance goes person is really accompanied Diedrich has dealt with the ques- beyond knowledge; the chaplain when he or she is helped to clarify tion which has been posed to him is involved as a person with his his or her situation and to adapt by many religious assistants – own sensitivity. himself or herself to that situation. what should I do? He has no other The question of the sick person This is a work which has its price answer than the following: you is a pseudo-question and says but it is also something which should go and see the sick per- more than its literal form actually leads to maturity. The question son.16 expresses. It real meaning is to be which has always been debated, found more in what is behind the namely whether the truth should words spoken than in the words be communicated to the sick per- 4. Visiting the Sick Person son, generally applies to those who run the risk of dying. The presence of the religious However, this is not the only assistant means that the visit to the task that the spiritual assistant is sick person is the most relevant called upon to perform. There is moment for the expression of his also the case of the person who training. Here something decisive suffers a major physical handicap comes into play; here the human- – the amputation of a limb, paral- istic meaning of his task of evan- ysis, or the loss of sight. The sick gelisation comes to the fore. person who previously lived a full Knowledge is at work – one and vital life is forced to radically speaks, one sees, one stays, com- change his or her lifestyle. The munion takes place accompanied crises which await him or her will by an intense gamut of emotions involve him in a struggle which he of the most varied kinds – suspi- or she will not be able to over- cion, caution, trust, openness, come on his or her own. The spir- sympathy, confidence, and joy. It itual assistant, with his experience is within this framework that the accumulated in the world of pain, opportunity presents itself to tack- can be at the side of the patient le the religious question and the and be a companion in that pa- situation arises when it is possible tient’s struggle. The appeal to to follow the advice of Prof. transcendence, a necessary leap in Matthews to pray with the sick order to give meaning to the mis- person and administer the sacra- themselves. It does not have the fortune which has occurred, helps ments. meaning of an observation made the patient to resign himself or From a Christian point of view by the student to the teacher. It herself to the situation and to re- visiting the sick is one of the does not come from the bench of a cover peace of mind. This, how- works of mercy (Mt 25:31-40; Jn school but from a bed of pain. It ever, should be done with consid- 5:14). The more frequent the visits transmits the desire for nearness. eration and without speeding mat- the more likely that there are op- It is certainly the case that all this ters up. Then the time comes for portunities to engage in dialogue, is not yet transcendence or open- the moment of prayer and for the setting in motion of which re- ness to the religious side of things. hope. quires the prior overcoming of On the other hand, the theologian Today, medicine raises hopes in prejudices and the creation of a does not begin by offering doctri- the chaplain. These can be ful- new basis of understanding. If nal concepts but by sharing the ex- filled above all in the encounter pastoral care is called upon to take perience of the other person. He with the infirm person. The visit to active part in the process of heal- thereby follows the example of the hospital is centred on the sick ing, this should be expressed in Christ.17 person and the patient is the pri- drawing near to the sick person The encounter with the reli- mary individual with whom he and dedicating time to service to gious message has psychological talks, but this is not the only such the patient. A fleeting and perhaps aspects which stimulate effective person. Others are then added – rare appearance cannot have any resources in the sick person which the relatives of the patient, the beneficial effect and becomes in turn work towards a successful nursing staff, technicians, and something reduced to a mere for- end to the illness. This malady, medical doctors. The chaplain al- mality. In order to know each oth- however, can be incurable and so has a task to perform in relation er it is necessary to spend time in have no other epilogue than death. to these people. In an epoch which each other’s company and to lis- The expression of brotherhood re- is fascinated by technology, the ten to each other. In the exchange mains equally valid but it must not idea of service runs the risk of be- of conversation many questions become an occasion for the raising reduced to a mere act of work. gg

78 HEALTH CARE AND SOCIETY

quillity. For this reason, amongst veals the inner man – that is to say the suggestions made to those the world of the soul. To visit a who visit the sick is to be remem- sick person is to be aware of an- bered that of sitting down so as other person and at the same time not to give the impression of being to communicate oneself. A mask in a hurry. One does not come to communicates nothing, indeed it go away immediately; one comes conceals and leaves the individual to make oneself available. closed up within a wounding self- All this is required not only by ishness. Once a real relationship the rules of good behaviour but al- has been created, prayer and the so by the duty to engage in Chris- suggestion that the sacraments be tian witness. The service of the re- administered have meaning. Out- ligious figure in hospitals is per- side the context of knowledge in Hospitals increasingly tend to be formed by a person trained in rela- the contemporary secular environ- secularised and end up in a level- tionships with other people and ment, religious action runs the risk ling process which resembles the educated in the spirit of the of being reduced to an isolated climate of the factory. In this envi- Gospel. The religious figure pre- episodic experience which is de- ronment the spiritual assistant sents himself with the badge of tached from the heart of existence keeps alive the appeal to the per- 18 faith which is expressed in his and suffering. son. In representing the Gospel way of behaving and speaking The message which the witness he represents man with his human rather than in the performance of to the Gospel bears in the world of and religious needs. Indeed, his rites or in the saying of prayers. pain is supported by hope and the action is not based upon technolo- This much is clear – the chaplain prospect of life beyond. It be- gy but is directed towards the reli- is really himself when he brings comes difficult in a culture domi- gious and moral values of man – and revitalises the sacred action; nated by the contingent and cap- the conscience, brotherhood, love however, he has to do this without tured by the reality of the senses. for one’s neighbour, and the un- falling into the artificial. In this The messenger himself is a part of derstanding which exists between epoch of secularisation everything the world of the person he is one soul and another. The danger that is external apparatus or mere speaking to; he perceives the diffi- of turning the other person into an ceremony stands out, and rigid at- culties of his mission and does not object is counterposed by the real- tention is paid to playing every- hide them. With humility he pre- ity of the person who is encoun- thing to the book. In this way the sents himself as a person who be- tered with his specific rhythms 19 creative and personal action lieves and who has learnt amidst and emotions. which is suited to the contingent the sad events and episodes of life The patient is certainly a subject situation is forgotten about. to hope and to pray. who needs services which tech- The Christian message imposes The visit to the sick has always nology administers with the help itself when it is expressed through been seen as the salient point of of amazing discoveries. However, a spontaneous approach. It does pastoral care. Today it is recog- he or she also needs psychological not need to be sought for inten- nised as being valid by medicine supports and clarifications of the tionally. It is born naturally like itself, and this despite the influ- problems of his or her life. Per- the breathing in and out of the ences of secularisation. It is an in- haps for the first time, tied to a bed lungs. This is true not only in rela- strument which is more necessary and forced to pass hours on his tion to what is said but also as re- than useful, and which is required own, the patient finds that he or gards the way in which one’s own not only in extreme situations but she is taken by surprise by a num- beliefs are communicated. Secular by the very constitution of man ber of questions, he or she discov- culture does not reject authentic who loves good for good’s sake, is ers needs that the exercise of his witness – it rejects it if one halts at happy when he discovers it and in or her profession had concealed mere outwardness or the commu- discovering it can realise it. Visit- from him or her. In drawing near nication of contents which are not ing the sick achieves its final ob- to the religious assistant the pa- expressed in one’s own experi- jective when it moves over into tient encounters that help and ence. There is no need to talk di- faith, is expressed in prayer, or those clarifications that his or her rectly about Christ, nor to move takes place through sacramental situation of crisis requires. immediately to suggestions that action. This is certainly the most In all the services provided by the sacraments should be adminis- gratifying moment for the chap- hospitals are to be found anxiety tered. ‘What is decisive is not so lain. The appearance of religious and hurry, the rationalised time of much that we speak about Christ need brings about the achieve- technology which puts us in a line, but that we make him present as ment of a psychologically optimal making us wait for our turn. Once our partner’.20 Everything that is situation with regard to healing. this has come we are pressed by mere outwardness does not find a The reference to prayer brings those who are behind us. Such place in the Gospel. If one were to this paper to its point of departure. cannot be the case in the conversa- try to present the Gospel while Matthews includes prayer in his tion with the pastoral worker who wearing masks, a betrayal would medical practice. He observes is called upon to interpret human be committed towards it. External among other things that it is irra- time, that time which is suited to expression has meaning if it re- tional to speak about the spiritual need. It provides calm and tran- gg

DOLENTIUM HOMINUM N. 46/1-2001 79 character of medicine and not to world of injustices, violence and Notes take advantage of prayer. disasters. The praying person 1 See the text and commentary of the ‘Nota’ knows this and for this reason in A.BRUSCO (ed.), Curate i Malati. La Pas- opens himself or herself up to a di- torale della Salute nella Chiesa Italiana (Ed. Camilliane, Turin, 1990). 5. Human Promotion alogue with God, in whose hands 2 D.A. MATTHEWS, Glaube macht Gesund. and Prayer he or she places himself or herself. Spiritualità und Medizin (German translation, The sick person then becomes Herder, Freiburg, 2000). On the same subject of faith and healing see the chapter by M. GOTT- When illness pushes a person to aware of his or her real being, SCHICHN in his Spracloses Leid (Springer, Vien- pray an experience of special an- which up to that point his period na-New York, 1998), esp. pp. 95-104. thropological value takes place. of health had been concealed. 3 Cf. ibid., p. 32. 4 Cf. ibid., p. 37. The man afflicted by pain and Illness and prayer go well to- 5 Cf. J. MEYER-SCHEU, Seelsorge im Kran- who is open to invocation sees gether. They are an experience of kenhaus. Entwurf für eine neue Praxis (Grhn- himself for what he really is – a authenticity. Our human condi- ewald, Mainz, 1974) and J. MEYER-SCHEU, See- lsorge im Krakenhaus (1977), pp. 921-28. weak and precarious being. tion, threatened by nothing (Hei- 6 H. THIELICKE, Leiden an der Kirche (Fur- There is much talk about the hu- degger), finds its real character by che, Hamburg, 1965), pp. 97-103. 7 See on this point D. CASERA, ‘L’Assistente manisation of medicine. Such hu- opening itself up to invocation Religioso nelle Istitutzioni Sanitarie’, in A. manisation never touches its high- which gives a word to weakness BRUSCO (ed.), Curate gli Infirmi, pp. 125-134. est form more than in situations of and beginning from the bottom, And see above all M. Gottschlisch, Sprachloses trial and difficulty when it frees from the humble situation of Leid, pp. 39-44. 8 H. FABER, Der Pfarrer im Modernen Kran- thought and raises it to God. Peo- poverty, acquires its strength. kenhaud (Ghterslosher Verlaghaus, Ghtersloh, ple have always prayed in the The infirm person is forced to 1970), pp. 13ss. presence of disaster – in concen- enter into a relationship with the 9 Cf. V.E. GEBSATTEL, Imago Hominis. 22 Breiträge zu Personalen Anthropologie, Mhller tration camps, in war, during cata- end. In this sensitive difficult sit- Verlag, Salzburg, 1968), p. 44, and V. FRANKL, clysms, or in prisons when a per- uation prayer enters the scene to Ärztliche Seelsorge (Kindler, Munich, 1975), p. 220. See also the criticism of Frankl in E. RIN- son is waiting to meet the death keep that person still anchored to GEL, Selbstschädigung durch Neurose (Herder, penalty. In every place of pain the life. In essential terms it offers the Freiburg, 1973), pp. 208 and 238. voice of prayer is the most perti- prospect of salvation from death. 10 Cf. ibid., pp. 240ss. 11 Cf. V.E. GEBSATTEL, Imago Hominis, p. nent and the most authentic. It Faced with death the instinctive 31. brings out the confines of man reaction is flight – to close one’s 12 D. CASERA, ‘Visita al Malato’, in Diziona- which are usually ignored. The eyes to one’s own fragility. Prayer rio di Pastorale Sanitaria (ed. Camilliane, Turin, 1997), esp. pp. 1378ss, and A. Brusco, person who is healthy is usually blocks every attempt at evasion, it Guaritore Ferito, p. 47. instinctively led to think that he is enables things to be called by their 13 Cf. V.E. GEBSATTEL, Imago Hominis, p. 47. self-sufficient and he does not re- proper name, and in revealing 14 Cf. ibid., p. 48. 15 Cf. E. RINGEL, Selbstschädigung durch alise that he is the victim of an il- their vanity opens up a breach to Neurose, pp. 235-248. On the relationship be- lusion. It is suffering that tells us what is high above us. Those who tween the therapist and the religious assistent the truth and invites us to engage pray are asked to engage in sincer- see the comments in V. FRANKL, Ärztliche See- lsorge, pp. 217-227. in prayer. It is said that it co-oper- ity with themselves and sincerity 16 Cf. H. DIEDERICH, Der Krankenbesuch ates in the improvement of a per- is the clarity which reflects the (Seelsorge Verlag, Freiburg, A.B., 1965), p. 6. son’s state of health. And this is world as it is without disguises. 17 Cf. A. Reiner, ‘Seelsorger und Pazient’, in Lexikon Medizin, Ethik, Recht (Herder, Frei- well said. However, even though From the relative world it raises us burg, 1992), pp. 1004ss. it may not produce any result at a up to the absolute world. In prayer 18 R. GUARDINI, ‘Der Dienst am Nächsten in physical level it is always a great there is what is above this world Gafahr’, in by the same author, Sorge um den Menschen, Vol. II (Wekbund-Verlag, Whrz- achievement at the psychological and the beyond, there is the whole burg, 1966), pp. 66-93, and H. THIELICKE, Wer and spiritual level. It gathers man universe in which the infirm per- darf Leben? (Goldmann, Munich, 1970), pp. up and places him before God. son finds his or her place as a be- 146-151. On the subject of humanisation see A. BRUSCO AND S. PINTOR, Sulle Orme di Cristo In praying we ‘raise ourselves ing loved by God. From this he or Medico (EDB, Bologna, 1999), esp. pp. up above ourselves and above she draws hope and courage.23 161-169, and above all P.L. MARCHESI, ‘Uma- nizzazione Sanitaria’, in Dizionario di Teologia what surrounds us, and we carry Matthews has discovered in Pastorale Sanitaria, pp. 1327-1340. I would our gaze into the distance towards prayer a healing force which is like also to refer to a very well organised study; a far off horizon, towards a sphere beneficial for the organism itself. C. CASALONE, Medicina, Macchine e Uomini (Gregorian University Press, Morcelliana, beyond time and space, a sphere This, however, is only a conse- Brescia, 1999), esp. pp. 43-48 and 292ss. full of greatness and clarity, but al- quence of a much more important 19 Cf. L. SANDRIN, ‘Nella Vigna del Signore so of mystery’.21 The sick person order for the spirit which provides anche il Malato Deve Lavorare’, in A. BRUSCO (ed.), Curate i Malati, pp. 107-125. who prays precisely because he the right way of measuring man. 20 Cf. H. DIEDERICH, Der Krankenbeseuch, wants to rise above himself or her- Illness is not only required so that p. 17. self, does not feel desperately we can become healthy. The reality 21 E. MINKOWSKI, Il Tempo Vissuto (Italian edition, Einaudi, Turin, 1971), pp. 105ss. caught up in the situation of crisis is much greater than this: if it 22 Cf. ibid., p. 108. See also the question of in which he or she finds himself. teaches us to pray it is required prayer and suffering as approached by G. Despite the fact that the ground simply so that we can become men. MORETTO in his incisive work Giustificazione e Interrogazione. Giobbe nella Filosofia (Guida, goes from beneath his or her feet Naples, 1991), esp. pp. 199-207. 23 he or she does not lose trust be- Rev. MARIO BIZZOTTO, Cf. D.A. MATTHEWS Glaube macht Ge- cause he or she has a solid point to sund, esp. pp. 202ss and 256ss. On the same Lecturer in Philosophy at the ‘S. Zeno’ subject see also E. Bianchi, ‘Preghiera’, in Di- which prayer directs him or her. Theological Institute of Verona, zionario di Teologia Pastorale, esp. pp. The world is not reduced to a Italy. 932-936. gg

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MICHAEL D. PLACE II: The Hospitals of the 20th Century: Ancient Charity and Modern Technology

Before addressing the topic I Current Situation macology (i.e., designer drugs), have been assigned, “How hospi- we are at the cusp of a new revo- tals in the year 2000 are to re- Like so many of you this “es- lution that will result from the spond to the technological and sential ministry” in the United mapping of the human genome. other challenges before them”, al- States is facing daunting chal- Genetics and cell research will low me a word about Catholic lenges in addition to those that fund an entirely new way of prac- health care in the United States. arise from technology. Allow me ticing medicine and delivering The ministry began some 223 to mention a few: health care. years ago in New Orleans found- The result of these challenges ed by “the Ursuline Sisters.” Funding: The continuing at- and those of technology is that the From that humble beginning it tempts at the state and federal lev- very face of Catholic health care spread across the emerging na- el to contain government expendi- has changed. The hospital which tion. Through the efforts mostly tures for health care as well as the in recent times has been the center of religious women and men, of- fiscal constraints emerging from of health care delivery today often ten coming to the United States to the realignment of private insur- is described as a dinosaur: A relic serve the immigrants from across ance through managed care have of the past that stands in the way Europe, health care was provided challenged the financial stability of a vibrant future. Patient health to those who otherwise would of the ministry. care increasingly is provided have been without. Today there along a “continuum of care” that are over 600 Catholic hospitals, Labor: The combination of sig- includes ambulatory care centers, over 700 long-term care facilities nificant pressure from labor freestanding diagnostic services, as well as 700 other expressions unions and other forces to signifi- rehabilitation centers, outpatient of Catholic health care delivery. cantly increase salaries as well as surgery programs, home care ser- Each year one out of six patients the emergence of a critical short vices, assisted living, long-term admitted to a hospital in the Unit- supply of nurses and other health care, and hospice. Social services ed States enters a Catholic hospi- care professionals puts an incredi- often are needed to help, especial- tal. Often we are present caring ble strain on the delivery system. ly in the hospital setting, the pa- for the poor and the marginalized tient and family plan for and ac- where others will not go or do not Consumerism: The expansion cess the services they will need stay. Increasingly we also are of access to the Internet with its once discharged from the hospital. working with our colleagues in wealth of medical and other infor- There also is an expanding atten- Catholic Charities and other mation has resulted in a more in- tion to what are described as “al- church ministries to better serve formed and pro-active patient/con- ternative forms” of medicine such the particular church and local sumer. More and more a patient as massage therapy, acupuncture, communities. The bishops of the arrives armed with a self-diagnosis and herbal therapy. The relation- United States affirmed and gave and treatment options. They also ship of spiritual care to successful direction to the ministry in their “shop” physicians and providers physical recovery is an emerging 1981 Pastoral Letter, Health and based on available information field of study and service. Even as Health Care. We also were from various public rankings of these changes cascade across the deeply honored when His Holi- quality, etc. landscape of the ministry, the role ness, Pope John Paul II, during his of the physician is both challenged second pastoral visit to the United Genetics: Similar to previous by the fiscal demands of managed States, spoke to a gathering of revolutions in health care delivery care and made more important be- health care leaders from across that resulted from the discovery of cause there is no effective continu- the country. It was in his remarks anesthesia and penicillin, as well um of care without partnerships that he declared: “Health care is as the current revolution in prac- with physicians, nurses, and other an essential ministry of the tice patterns associated with re- practitioners. church.” markable achievements is phar- The result of these and other gg

DOLENTIUM HOMINUM N. 46/1-2001 81 forces is that the ministry can eas- despite the limitation of the Dark orrhage, or the irritating lunatic ily become bureaucratic, frag- Ages staffed the monastery infir- confined to caves outside of town. mented, and impersonal. A word maries, or to hospitallers of St. Catholic health care in the Unit- on each: John of God who cared for Chris- ed States has consciously decided tian pilgrims in times of great ad- that it too must be about libera- Bureaucratic: Both public and versity. Despite the insurmount- tion. It finds itself called, indeed private insurance and providers able odds they faced, they carried compelled, to be an agent of so- have been forced to develop an on and, indeed, flourished. Why? cial transformation that like Christ abundance of regulations and Because long before John Paul II reverses the contemporary as- forms that confuse and anger pa- enlightened us with the image of sumptions and biases that isolate tients and their families. the Gospel of Life, they practiced and alienate those who are sick or the Gospel of Life. They saw in whose health status is threatened. Fragmented: Even as the un- the vulnerability of each human Three examples. derstandable evolution of other- being an inalienable sacredness of Environment: In recent years a than-hospital forms of delivery life as well as an unbreakable body of data has been developed have developed, these emerging bond of solidarity that made them that clearly demonstrates a causal dimensions have lacked coher- part of the community that is the relationship between environmen- ence or cohesiveness. The physi- human family. And the source of tal toxicity and diminished health cian at times has been reduced to their inspiration for being servants status. Though the exact nature of just another “cog in the wheel” of the Gospel of Life is none other the linkage in many instances is with the result that patients, if they than the image and reality of yet to be determined, the causal re- are to successfully navigate this Christ healing or, in other words, lationship is not in question. For fragmented terrain, must become the healing Christ. Clearly the example, especially disconcerting their own advocate. Obviously soul of what in the United States is the dramatic increase in the inci- this is a task easier to accomplish we speak of as “the healing min- dence of asthma and related pul- for the “near healthy” than the istry” is to be found in the multi- monary problems among the critically ill or socially vulnerable. ple Gospel stories of Jesus healing young, especially the poor. the lame, the blind, and the leper Impersonal: The end result is as well as the ultimate healing of that the face of health care deliv- restoration to life. ery can be quite impersonal. If the healing Christ is the soul Once noted for the “hands on” of the ministry, then I would sug- care of women religious, Catholic gest it is to the healing Christ that health care is challenged not to be we should turn to seek guidance the same as secular health care. as to how we might best respond Despite the best of intentions, this to the technological and other is increasingly difficult when the challenges we face. To that end, length of the encounter is marked Father Donald Senior, CP, recent- by minutes and hours, not days or ly offered a reflection on three dif- weeks. Similarly the patient often ferent modalities we find when is viewed in isolation rather than we study the Gospel stories of the as a member of a family or part of healing Jesus: liberation, solidari- a community. ty, and hope. I will utilize these modalities as a basis for my re- Inspiration: flections on how Catholic hospitals and, indeed, all of Catholic Clearly these adversities when health care can and should re- combined with the post modern spond to the current challenges. At the local level Catholic world fascination with the techno- providers have developed pro- logical imperative: if it can be Liberation: grams that, while treating the asth- built, build it; if built, buy it, puts matic or pulmonary conditions, al- Catholic health care delivery in Father Senior posits that in the so work to remove environmental the northern First World in a diffi- first instance Jesus came to free threats either in housing stock or cult situation even apart from the people, in the context of a faith re- in local hazards such as toxic unaddressed reality that the Unit- sponse, from sickness and illness. waste sites. On a more national ed States and the other industrial- And, as so often is the case in the level, health care systems utilize ized nations consume an inordi- Gospels, he reversed the custom- their financial investments in a nate amount of global health care ary religious and cultural expecta- “socially responsible” way to ad- resources. tion that sickness was a sign of vance stock holder resolutions that In this environment, despair, personal failure or divine judg- will reform detrimental corporate cynicism, and skepticism easily ment as well as the justification policy on matters such as the use can take hold. As an antidote we for the alienation or separation of mercury as well as advocating need only turn for inspiration and seen so visibly in the case of the for state and federal policies to en- motivation to those monks who leper, or the woman with the hem- hance air and water quality. gg

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Social Conditions: It is not sur- access to health insurance. It is a and death. Even in glory Jesus re- prising that for a person without moral outrage that in the wealthi- mains one with those who suffer. access to housing, it is difficult, if est nation of the world nearly 44 In modern times perhaps our not impossible, to have a positive million persons currently are most vivid reminder of this soli- health status. Similarly, inade- without insurance and conse- darity is Mother Theresa and her quate nutrition, drug and alcohol quently excluded from access to community. From the streets of addiction, and mental illness are the full range of health care ser- Calcutta to the boroughs of New directly related to diminished vices. It is especially lamentable York she and her sisters have health. Though made more diffi- that 10 million of the uninsured washed, fed, and carried the sick cult because of an increasingly are children who are reduced to and the outcast in a silent testimo- fragile financial condition, receiving their health care in the ny to the solidarity of the human Catholic health care delivery has emergency room. family. moved into the community to ad- In response to this reality, Clearly that same spirit must be dress these problems. Working, Catholic health care has been, and a hallmark of the many and varied often in partnerships with others, will be, an aggressive advocate expressions of the Catholic heal- Catholic health care labors to pro- not just for access to basic health ing ministry. If we are to heal as vide affordable housing, often for care but for a reform of the entire Jesus healed then both literally the elderly, to establish communi- health care system so that accessi- and metaphorically we must ble and affordable health care for touch as Jesus touched the human all will be provided in a delivery body, mind, and spirit. “High system that is marked by quality, technology” without “high touch” safety, justice, and compassion. is lacking the solidarity that is at This is accomplished through the the essence of our ministry. With- credibility of our presence as a out a doubt this restoration of an “voice for the voiceless,” by en- authentic personalism to the doc- couraging our 800,000 employees tor’s office, the emergency room, and their families to use their bal- the surgical suite, and patient lot as an instrument of change, room must be accomplished. The and by being present to the White obstacles, as noted earlier, are nu- House, the Congress, and the state merous. And I wish I could share legislature. Working without the with you some dramatic examples benefit of “miraculous power,” of success. Unfortunately, I can- we are committed to our goal of not. We have a long way to go. social transformation. But we are moving. Physicians more and more are speaking out Solidarity: against the structures of managed care that require them to allocate Personalism: Even as Jesus but a few minutes per patient no broke the bonds of illness, he did matter their physical, emotional, not eliminate all the human suf- or spiritual condition. Adminis- fering that comes with sickness trators are developing programs and pain. The one who suffers of- whereby a patient or family mem- ten experiences a sense of isola- ber can call attention to an em- tion or separation. This isolation ployee who has given exemplary stands in stark contrast to the true “personal” care. And governance solidarity that should be a mark of bodies are using “patient satisfac- ty outreach centers that in addi- a human community that reflects tion” as one of the critical compo- tion to making available on-site the communal nature of the Tri- nents in determining executive meals also provide “meals on une God in whose image and like- compensation. wheels” to the homebound as well ness we are made. As Jesus trav- All good beginnings, but so as providing outpatient services eled the Holy Land he witnessed much more must be done. and support for those with addic- to that solidarity as he ate with Allocation: Before closing this tions and mental health chal- sinners, cured the centurion’s ser- section I want to make note of, al- lenges. In all of these efforts vant, and worked miracles among beit briefly, of another challenge Catholic health care seeks to free the Samaritans. Similarly that to an authentic sense of human people from the shackles of mar- same solidarity of spirit was ex- solidarity. Even as we have failed ginalization by providing services emplified when he wept with on the macro or universal level to and supports that both respond to Lazarus’family. Perhaps the most have an appropriate discussion their sacred dignity and draw profound witness of solidarity about the allocation of the world’s them back into the community. with those who suffer was pointed health care resources, in the Unit- Government Policy: Perhaps out again by Father Senior when ed States, and I suspect elsewhere, the most inexcusable restraint on he reminded us that the body of we also have failed to engage in a positive health status for persons the glorified Jesus continued to systematic and informed dis- in the United States is the lack of bear the wounds of his suffering course about a national health gg

DOLENTIUM HOMINUM N. 46/1-2001 83 care policy that would provide for moral vision and a profound sense ed it remains an important, if not a fair and equitable distribution of of the interlocking and interde- well articulated, issue. In fact, if limited health care resources. pendent obligations and responsi- the efforts of groups such as the The Roman Catholic tradition, I bilities of human solidarity we Catholic Health Association and would suggest, compels us to can help to bring about the needed others to make accessible and af- work for and participate in such a conversations. fordable health care a national pri- discussion. We are informed by Last year in a lecture at the ority are successful, how we allo- an understanding of human soli- Catholic Theological Union of cate health care resources will re- darity that, as Blessed Pope John Chicago, building on work previ- quire attention. XXIII taught us, understands ac- ously done by the Catholic Health Such a conversation will not cess to fundamental health care to Association, I offered some initial come easily. Allocation is often be a human right and consequent- reflections that might well serve taken as being the same as ra- ly, also, as a social good — social such a discussion. I began by tioning, and the concept of ra- good that speaks to the existence noting that this is a quite complex tioning does not sit well with the of interlocking personal, social, issue. Currently, 13.5 percent or popular sense of America’s dedi- and governmental responsibilities $1.1 trillion of the U.S. Domestic cation to a certain understanding to preserve and ensure the realiza- National Product is spent on the of liberty that is presented in tion of that same social good. Ab- various aspects of health care. American ethics. sent such a discussion, the in- Just 18 years ago, it was 8.9 per- As we consider either the ne- creasing cost of health care deliv- cent of the DNP. Such an increase cessity or the eventuality of a dis- ery, fueled in no small measure by raises the question: Should there cussion of how we allocate health the escalating costs associated be any limit on these expenditures care resources, I suggested that with “high tech” as well as drugs, and, if so, how as a nation would the prism of the consistent life has led to what, in fact, is an indi- we make such a determination? ethic will be of assistance. For ex- rect or implicit process of alloca- For example, should how much ample, our rich understanding of tion. The absence of insurance is we spend on health care be deter- human dignity would require any one example of such an indirect mined simply by market forces or discussions of allocation to be ap- allocation. Significant variance in by federal mandate, or some other plied equitably and free of dis- practice patterns and health care source? And if such a decision crimination because of our shared outcomes according to race, gen- should be made, what would be human dignity. Similarly, be- der, and geography are indices of the criteria that would guide such cause access to adequate health other implicit patterns of alloca- a decision-making process? For care is a fundamental human tion. Another is the decisions example, is national defense more right, there is a baseline of ser- made by health plans, or the em- important than the nation’s vices that cannot be subject to po- ployers who purchase them, as to health? If so, by how much? As if litical trade-offs. That same in- what will be covered. An exam- those questions were not complex alienable dignity would require an ple is the limitations frequently enough, I pointed out that there is open and participative process placed on behavioral health bene- the parallel issue of how we allo- that involves all those affected by fits. At other times, allocation de- cate the existing resources, the allocation decisions. Turning to cisions have been made by Con- $1.1 trillion dollars, in a just and the stewardship of human life and gress or state legislators when equitable manner. resources, any allocation must they mandate coverage of ser- I noted that in recent years, have an ethical priority ensuring vices such as fertility treatment. there have been various proposals that the provision of these re- While the reasons for the con- in the United States to develop sources are provided to the disad- tinuing attachment in the United more explicit criteria for allocat- vantaged. Good stewardship also States to this “implicit allocation” ing health care resources. Perhaps requires there be a demonstrated is fueled by multiple factors (such one of the most famous of these need for allocation decisions or as a capitalistic belief in the pow- took place in Oregon, which re- processes and that the social and er of the market and a fear of ceived a federal waiver to develop economic effects of allocation de- “big” government) on a more the- a statewide health system for cisions be monitored to see that ological level it is fed by an unnu- those on Medicaid with a guaran- they reach their stated goals and anced understanding of the indi- teed “basic benefit package” set do not have unintended conse- vidual and an impoverished sense by state policy. In other words, it quences. of human solidarity. was proposed – and eventually Finally, an integral understand- Though clearly affected by adopted – that those whose eco- ing of the common good will pro- these larger cultural forces, nomic status qualified them for vide an important framework for Catholic health care, most espe- Medicaid would be guaranteed a decision making. It will require cially in those countries where it range of services and also would that allocation decisions focus not has a significant social presence, be explicitly denied some treat- just on individuals but also on the must be an aggressive participant ment options. health status of communities and in the social discourse that can Although there have been no those social forces that can better lead to a more rational and just other recent examples of as public enhance personal and communal distribution of health care re- a discussion of resource allocation health. A rich understanding of sources. Nurtured by a coherent as there was in Oregon, I suggest- the common goodwill change gg

84 HEALTH CARE AND SOCIETY limited understanding of human ian health care is not so much to liberty that would assert that indi- heal better or more efficiently viduals should be able to receive than anyone else; it is to bring whatever health services they de- comfort to people by giving them sire even if, medically speaking, an experience that will strengthen those services are considered fu- their confidence in life. The ulti- tile. mate goal of our care is to give to those who are ill, through our Hope: So far in our reflections care, a reason to hope”. we have reviewed the current It is no wonder that this vision technological and other chal- has found a deep resonance with- lenges facing Catholic health care in Catholic health care in the Unit- in the United States and consid- ed States. Truly we are called in a ered how, inspired by the Gospel cancer, as the leitmotif for profoundly pluralistic society to stories of the healing Christ, Catholic health care. Allow me to be, as the Cardinal said, a multi- Catholic health care is responding quote: faceted “sign of hope.” For our from the perspective of liberation “Let me be clear what I mean fellow Christians we are a living and solidarity. In his writing Fa- by “hope.” It is not a hope for witness to the ever hopeful Easter ther Senior identified a third something. It is not the expecta- Alleluia; to the one who believes modality which for my purposes I tion that something will happen. in a good God, we are a living tes- will speak of under the title Although some people hope for a timony to a gracious, but as Paul “hope”. physical cure, not everyone does. said in the Acropolis, yet un- As believers we are quite aware Often people believe that a cure is named God; and to the one who of the essential relationship be- not possible, or they are too tired believes not, we offer the experi- tween body, mind, and spirit. In to hope to be restored to their for- ence of a transcendent power of fact, in these reflections we dealt mer state of health. But, even the spirit that can draw one be- with one aspect of that relation- when a cure is not to be expected, yond human limits to an ultimate ship when we spoke of the sense one can still hope. The hope of sense of benign purposefulness. of separation from community which I speak is an attitude about Indeed, to be such a “sign of that can be associated with sick- life and living in God’s loving hope” is a daunting responsibility ness and illness. In the final sec- care. Hope, rooted in our trust of especially in light of all we have tion I want to reflect on another God’s love for us in Christ, gives noted. But a challenge we avoid consequence of illness, most es- us strength and confidence; it at great peril. I say this because pecially debilitating chronic ill- comforts us with the knowledge liberation and solidarity without ness or terminal illness. Both that, whatever is happening to us, the hope that is essential to the most often carry with them a deep we are loved by God through Christian faith can easily become and, at times, a devastatingly pro- Christ. So, we need not grieve or nothing more than a well-inten- found alienation of the human despair in the same way as those tioned political movement or an spirit. As bodily energies drain who do not share in this hope (1 enlightened form of psychosocial away or are permanently depleted Th 4:13-18). Illness need not therapy. the normal harmony of body and break us. Even if we remain ill, For Catholic health care to be a spirit comes to an end: the cus- even if we are to die prematurely, “sign of hope” is to make its own tomary relationship with physical we can still be courageous and the evangelical dimension of the surroundings is altered; interper- confident of God’s enduring love healing ministry. While we honor sonal relations are changed and, in for us (2 Cor. 5:6-10). the conscience of those we serve face of death, near an end as we As Christians, we are called, in- and never use our ministry to know them. And often the result deed empowered, to comfort oth- proselytize, ultimately through of all this is a sense of alienation ers in the midst of their suffering experience, witness, and testimo- within the human spirit itself from by giving them a reason to hope. ny we are hope-filled evangelists. the sources of meaning or purpose We are called to help them experi- Even as I say this, I am aware of that had served as the raison ence God’s enduring love for the difficulties. In the United d’être of an individual’s exis- them. This is what makes Christ- States as there are fewer religious tence. ian health care truly distinctive. women and men in the ministry To all these forms of alienation, We are to do for one another what and the laity assume legitimate and most especially to the alien- Jesus did: comfort others by in- leadership roles in fulfillment of ation of spirit, Christ the healer spiring in them hope and confi- their baptismal responsibilities we came. Answering once and for all dence in life. As God’s ongoing, must find new ways to nurture a the lament of Job, Christ through creative activity in the world and rich and vibrant faith-filled cul- his death and resurrection gave to the love of Christ make it possible ture across the continuum of our humankind his greatest healing for us to continue to live despite services. With co-workers who gift – hope. It was to this hope the chaos of illness, so too our increasingly are not Christian and which Joseph Cardinal Bernardin work in the world must also give a patient population equally di- turned, even as he was facing the hope to those for whom we care. verse we need to make explicit personal challenge of pancreatic Our distinctive vocation in Christ- our commitments and values. gg

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And in a society profoundly con- founded and remain present in Bibliography flicted about the sacred nature of various ways to the ministry. For unborn life and now debating the example, if rooted in the simplici- BERNARDIN, JOSEPH CARDINAL, A Sign of Hope, Archdiocese of Chicago, Chicago, IL, legalization of euthanasia we ty of Francis of Assisi, the hospi- October 1995. must be faithful servants to a con- tality of Mother McCauley, and National Conference of Catholic Bishops, sistent ethic of life. the inventiveness of Vincent de Health and Health Care, A Pastoral Letter of the American Catholic Bishops, United As I move about our country Paul and Louise de Marillac, how States Catholic Conference, Washington, and visit the richness of the min- can we fail to meet the challenge DC, November 1981. istry we steward I am optimistic of technology and the many oth- PLACE, MICHAEL D., “Healthcare: Essen- tial Building Block for a Free Society,” the about the future. And that opti- ers we have noted? Eighth Annual Joseph B. Brennan Lecture, mism has two sources: first, and Georgetown University, Washington, DC, most importantly, the Gospel Rev. MICHAEL D. PLACE, STD April 20, 1999. promise “I will be with you al- President and Chief Executive Officer ways” and, second, the inspiration of CHA(Catholic Health Association) of the religious communities that U.S.A.

ANTHONY FISHER III: The New Frontiers

1.Introduction Buoyed up by faith, family and region to visit little Tom, to touch friendship, this young couple still him and be touched by him, to A few years ago I met a young found the vigil of their pregnancy know him a little bit and share in couple who had had some terrible a terrible strain. Yet they were de- his short life and his parents’ joy news: their unborn baby was se- termined to resist the pressures of and tears. Every moment of his verely handicapped. He had anen- their surrounding society to write life he was held tightly by some- cephaly in fact, and as soon as it off the life of their little one as one who loved him. He packed so was diagnosed their ‘Catholic’ nothing, indeed less than nothing, much into his eighteen hours. It doctor at a Catholic hospital pro- a negative value on the quality-of- was long enough to have his posed that the baby be aborted. life accounting scale. They ap- clothes changed several times and The doctor called it ‘induction’ proached the future with appre- to be hugged and kissed and and explained that it would be hension but hope, with common stroked. Long enough to give performed at a non-Catholic hos- sense and love. Clare and Tom some time with pital. The couple ‘smelt a rat’ (= Their little boy was born at the him, to celebrate little birthdays as were suspicious). Short of a mira- hospital and immediately baptised he achieved each new hour and cle they knew their baby’s life ‘Thomas Walter’ by his father; especially their private one with would be brief, yet Clare and Tom when I arrived I confirmed him. him at midnight when, against all were determined to see their preg- He lived another eighteen hours. the odds, he saw in a new day. He nancy through and give their little He had a beautiful little face and a even gave them a night of dis- boy every chance. They ap- perfect little boy’s body; his heart- turbed sleep with their child, proached the forthcoming birth beat was strong and he breathed which is every new parent’s right. with all the excitement and appre- easily; but his head was incom- And he gave them time to say hension of new parents, but with- plete and his fate therefore sealed. goodbye. out the expectation that most Occasionally he made little Before I left on the night of his have, that their child will be sounds and would hold tightly on- birth we prayed the prayers for the healthy and will outlive them. to someone’s finger with his little dying for him. Around dawn little They found a new doctor and a hands. His parents fed him little Thomas died as he slept between different Catholic hospital, and drops on the end of a finger. his parents in the hospital. We that place proved a refuge for Grandparents, uncles and aunts, gathered again, his parents and them and their little baby. gathered from various parts of the grandparents, this time to pray the gg

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praised the God of Israel.”3 Just as Jesus’ healing miracles at once expressed the healing compassion of God and provided signs and foretastes of the coming of God’s kingdom, so Catholic healthcare providers and professionals “see their ministry not only as an effort to restore and preserve health, but also as a spiritual service and a sign of that final healing which will one day bring about the new creation that is the ultimate fruit of Jesus’ ministry and God’s love for us”.4 Even in the best secular tradition medicine and nursing are about far more than just technical excellence or the fulfilment of market demand. All the more so must Catholic healthcare testify to beliefs about a loving, provident God, about creation and human nature, about sickness and death, the communion of saints, the forgiveness of sins, the resurrection of the body, prayers for the dead and to pray ly technical achievement or market and life ever-lasting...5 Our faith for those who grieve them. Every- product; between a consequent means we see the person as much thing possible had been done for view of healthworkers as profes- more than a special kind of intelli- him by his parents, extended fam- sionals and saints-in-the-making gent animal or machine deter- ily and friends, by his health pro- and a view of them as mere techni- mined to get its own way, able to fessionals and chaplains. Together cians or service–providers; and be- attain to certain technically im- they gave the most powerful testi- tween a view of individual health- pressive achievements, or produc- mony to the Gospel of Life, to the care practices and choices as activ- ing and consuming goods and ser- preciousness of human life; to- ities with their own proper goals vices: the human person is the im- gether they demonstrated the no- and subject to common morality age of God and the human com- bility that even so great a tragedy and a view of those practices and munity is the image of the Trinity. can call forth from the spirits of choices as bound only by the limits We are, indeed, brothers and sis- ordinary people; together they of the possible. It is these three ters in the Lord and we are our wrote a love song with their frontiers that I wish now to ex- brothers’ and sisters’ keepers; fa- lives...1 plore. milial love, reverence, wonder, In this conference speakers what St Thomas called dulia,6 this have drawn our attention to the 2.1 On the frontier between attitude should mark our relating. enormous range of new possibili- “healthcare as a vocation” Embracing the whole person – ties in healthcare in the new cen- and “healthcare as a body, mind and spirit – with com- tury, of new questions which these technical achievement passion and love, Catholic health- technological possibilities pose, or market product”2 care says to people, “As Christ and of new answers which might would reach out to touch and heal be given. All of these present When God came among us in you, so too do we.”7 enormous challenges to Catholic Jesus Christ he redeemed human- How that will pan out in day-to- healthcare institutions and profes- ity not only by his saving death, day healthcare in our new century sionals, and thus to the Church not by preaching his saving word, by is not easy to predict: perhaps in just as the provider of healthcare absolving sins, by gathering us in- the courtesy and compassion, the services, but as pastoral carer for to a new people of God, but also patience and perseverance, the both patients and healthworkers. by curing people. Matthew tells vigilance and hopefulness, the us, “Great crowds came to him, willingness to engage in apparent bringing with them the lame, the inefficiencies such as standing by 2. Healthcare today: maimed, the blind, the mute, and and listening, a reverential lan- on three frontiers many others. They put them at his guage and touch and awe not un- feet, and he cured them, so that like that with which we treat the Healthcare and chaplaincy today the crowd was amazed when they holy things. And words like ‘vo- find themselves on three frontiers: saw the mute speaking, the cation’, ‘mission’ and ‘aposto- between a view of healthcare as a maimed whole, the lame walking, late’, which roll so easily – too vocation and a view of it as a mere- and the blind seeing. And they easily – off the Christian tongue, gg

DOLENTIUM HOMINUM N. 46/1-2001 87 must mean more than ‘job’ or to any genuinely Catholic form of hand, conceived of as a mere even ‘profession’ here: they must healthcare. And there need to be technician, a service provider, bespeak a kind of priestly min- regular opportunities for commu- even a hired gun. ‘Profession’ is istry of mediating and praising the nal prayer and worship, both for properly an ethical notion entail- God who is the lover of life and patients and staff. Obviously such ing much more than does the idea health.8 spiritual care, like the rest of of a job, a trade or an art: a con- If Catholic healthcare is con- healthcare, will have to be tailored viction on the part of members ceived as a religious vocation, to the particular needs of patients about the importance of a particu- those charged with it must be and staff: non-Christians, non- lar service of others and their wary of secularization, accommo- Catholics and non-practising ‘calling’ to it as ‘full-time’ occu- dation and compromise to the log- Catholics, for instance, will have pation with enduring expecta- ic of the merely technical achieve- very different needs to more ‘reg- tions; immersion by those mem- ment or market demand,9 and ular’ Catholics. None the less bers in the particular practice, wary too when medicine exceeds even non-Catholics come to our with its particular knowledge, its legitimate sphere, colonizing institutions as patients or staff ex- skills and ethos, which calls forth the whole of reality, promising to pecting a distinctively ‘spiritual’, and requires from them devotion alleviate people of the human unembarrassedly Christian, ap- of life and character and life; condition, offering them false proach, and we ought not to be some kind of public profession of hopes of earthly immortality, en- afraid that ‘showing our Catholic a ‘service orientation’ and public gaging in therapeutic overkill, petticoats’ will offend outsiders. responsibility by the members; pretending health is salvation. In addition to the sacraments, some parallel act(s) of public Worshippers of true religion must pastoral care to the sick “encom- recognition by the community always be ready critics of health- passes the full range of spiritual that this practice is an expression care messianism, therapeutic ob- services, including a listening of its core values and that these stinacy and idolatry of life and presence, help in dealing with people are suitable practitioners; health.10 Health is not our highest powerlessness, pain and alien- continuing (self)regulation by the good and healthcare is not our re- ation, and assistance in recogniz- members of the profession ac- ligion. ing and responding to God’s will cording to the internal ends of the Jesus healed whole persons, with greater joy and peace”.14 The practice and the best traditions of body and soul. When he cured the goal here is to confirm brothers ethics. paralytic he first forgave him his and sisters in the Lord so that they The call to be saints, which is sins.11 The links between physical might live, suffer and die well. the call of every Christian health and spiritual sickness, and physi- Seeking to humanize and Chris- professional, is a call not in con- cal and spiritual healing, have tianize sickness, dying and health- flict with the demands of profes- long been appreciated by Chris- care technology itself, and offer- sionalism but rather to be more tians and other believers. As the ing cause for hope even when than a tradesman, more even than US Bishops have observed, medicine can do no more, are cru- a professional: it is a call to a “without health of the spirit, high cial ways in which pastoral care Christic kind of self-giving told so technology focused strictly on the complements clinical care.15 In the wonderfully in our tradition in the body offers limited hope for heal- case of Clare and Tom, pastoral image of Christ the physician, in ing the whole person. Directed to care and the support of family and the story of the Good Samaritan, spiritual needs that are often ap- friends were crucial supports in and happily in many saintly health preciated more deeply during their heroism: without these I do professionals we have known. To times of illness, pastoral care is an not know how they could have attain to such heights is not beyond integral part of Catholic health- made the journey to their child’s the grasp of ordinary healthwork- care.”12 Catholic pastoral care to birth. ers: on the contrary it is their very the sick is different from social calling. But it does require a spiri- work, counselling, other human 2.2 On the frontier between tuality of the healthcare vocation supports, even if it includes ele- “healthworkers as and a genuine effort to cultivate a ments of these things: it is first professionals and certain kind of character marked and foremost about the sacra- saints-in-the-making” by respectfulness, pietas, compas- ments.13 But this presents particu- and “healthworkers sion, understanding, benevolence, lar challenges today. The shortage as technicians spontaneity, honesty, fidelity, thor- of priests, lay chaplaincy teams and service providers” oughness, patience, moderation, including people of various back- humility.16 grounds and perhaps some in- Parallel to the frontier between Leaders and staff of Catholic terns, a mixed bunch of patients, healthcare as a vocation and hospitals should therefore be es- shorter stays: all this presents new healthcare as a mere technical pecially wary of the institutional- opportunities but it can also lead achievement or market product is ization of vices such as cavalier to a de-sacramentalisation of that the frontier between two different disrespect for human life and dig- ministry. Yet the sacraments of conceptions of the healthworker: nity, blindness or indifference to anointing of the sick, confession, on the one hand, conceived of as effects of policy on particular peo- communion and viaticum for the professional and indeed a saint in ple, avarice and ageism, the tech- dying – these must remain central the making; and, on the other nological imperative, and so on. gg

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They must resist the sacrifice of als at the Mercy Hospital in my trust; love of neighbour and of the persons for the sake of efficiency, home city of Melbourne, where common good, including a pas- progress or profitability, and pro- he emphasized that healthcare is sion to ensure universal access to mote a certain asceticism in re- first and foremost “a very valu- a reasonable level of care and the sponse to the drive to medical able service to life” but also “a just allocation of resources; re- maximisation, and a certain conform of Christian witness”.20 We spect for the nuptial significance templativeness in response to the are challenged today to renew our of the body; a desire to humanize busyness of the average hospital. appreciation of healthcare as heir medical practice; and a preferen- Associations of Catholic health to a particular tradition – the noble tial option for the disadvantaged.22 professionals, moribund in many wisdom of Hippocratic medicine This runs quite contrary to the countries for the past two decades, – with its own internal ends and view of healthcare practices and might usefully be refounded with logic, and subject like all human choices as activities bound only a clearer focus on ethical and spir- activities to the norms of common by the technically and politically itual formation and support for morality;21 to renew also our sense possible. healthworkers possibly little cate- of Catholic healthcare as heir also Catholic healthcare is prophetic chised or facing external pres- to a revealed tradition, articulated the more consistently and lumi- sures to conform to the values of nously it exemplifies these Christ- ‘this world’ rather than those of ian values and norms; it obscures God’s kingdom. and ultimately abandons its raison d’être, the muter and more com- 2.3 On the frontier between promised is its moral witness. In healthcare practices as recent years Church leaders have “activities with their own repeatedly recommitted the proper goals and subject Church to healthcare, but also in- to common morality” sisted that this must be in accord and as “activities as bound with sound morality as articulated only by the possible” by the best of the Hippocratic tradition purified by the Gospel and In his programmatic reading the Church’s Magisterium.23 In- from the prophet Isaiah at the be- creasingly in the ‘post-Christian’ ginning of his ministry, Luke’s Je- Western world, at least, Catholic sus declares himself anointed by healthcare should offer a stark al- the Holy Spirit both to preach the ternative of a training and style of Gospel to the poor and unfree, and care in accord with our particular to bring healing to the blind.17 “Je- tradition and ethos. We should not sus,” we are told by Matthew, shy away from this, for fear of los- “went about Galilee, teaching in ing funding or respectability. In- the synagogues, preaching the deed, I suspect that it is precisely gospel of the kingdom, and heal- in Scriptures such as that of the as a high-quality alternative to the ing every disease and infirmity Good Samaritan, and clarified in a run-of-the-mill that Catholic among the people.”18 Sometimes tradition including such priceless healthcare will best be able to jus- the healings preceded and evoked works as Evangelium vitæ and the tify continued tolerance and sup- faith; at other times the cure was a Charter, and applied through the port of funders, regulators and response to faith. Thus Jesus’ charisms of particular founder professions in the future. prophetic work of preaching was congregations and their lay col- Unashamedly Catholic codes of intimately related to his work of laborators. ethics and practice, ethics com- healing. The linking of these two In recent decades there have mittees, staff education pro- ministries is extended to his disci- been enormous ethical challenges grammes etc. will not only help ples: “As you go,” he tells them, for those committed to continuing ensure that Catholic health ser- “proclaim the good news that the the healing ministry of Jesus, not vices fulfil their primary mission kingdom of heaven is at hand. least the pressures of secularism, of providing sound care but also Heal the sick, raise the dead, bureaucracy and the market, and offer them a ‘market niche’. This cleanse lepers, cast out demons.”19 the perennial temptation to ‘jump will have its attractions not only Whether for Jesus or for his disci- into bed with the zeitgeist’. We for many patients but also for ples, healing and preaching are, as must therefore be crystal clear many staff: for it is already the it were, two sides of the same re- what our central commitments case in some parts of the world demptive coin. are: respect for the dignity of that trainees and practitioners in Catholic healthcare, then, must every human person as made in certain specialties such as obstet- be prophetic, a lived proclamation the image of God, redeemed by rics-gynæcology, family plan- of the Gospel. The very first foot- Christ and made to enjoy the eter- ning, genetics, pædiatrics, geron- note in the Charter for Health nal joy of the Trinity and the tology and intensive care, are Care Workers, I am pleased to saints in heaven; reverence for pressured to conform to immoral say, refers us to Pope John Paul every instance of human life from practices and even refused posi- II’s address to health profession- conception to death as a sacred tions if they will not. Without gen- gg

DOLENTIUM HOMINUM N. 46/1-2001 89 uinely Catholic healthcare institu- option’ for the unborn and the cause they or their spouse or their tions in which to train and work, newborn. That has plenty of sup- child or their yet-unborn or yet- some healthworkers might either port in our theological tradition, unconceived children have a ge- compromise their consciences dating to the psalmist’s rejoicing netic predisposition to some ad- and objective morality, or have to in the child knit together in his verse condition. Personal prefer- quit their specialty. And without a mother’s womb, and Jesus’ de- ence and social pressures on par- clear sense of the boundaries – the light in having little children ents to produce the perfect child frontier – between healthcare brought to him. And medicine to- and abort any imperfect ones are practices seen as activities with day can do much that is life-af- already there, and they are likely their own proper internal logic firming with respect to early hu- to grow. A couple who choose not and subject to common morality man life. But newly conceived to have a test for, or not to abort a and healthcare practices seen as and newly born human life is not child with, say, Downs Syndrome, activities as bound only by the universally welcomed and in the may well be regarded as back- technically, politically and finan- future we will have more and ward, superstitious, selfish, socially possible, such perseverance more to decide whether to give cially irresponsible, even crimi- in the pursuit of the good will be sanctuary for such little ones. nal. What, we might wonder, will impossible. Consider the new genetics.24 We become of those who escape the naturally rejoice in the extraordi- genetic screening net and are born nary achievement of the human with genetic defects in such a 3. The future of healthcare: genome project and other activi- world: far from being welcomed on three more frontiers ties which have contributed so and given every opportunity by a very much to our understanding sympathetic human family, these We are witnesses to a biotech- of the genetic basis of the human children may come to be regarded nological revolution probably condition and which are so preg- and treated as parasites, a drain on more significant than industrial- nant with therapeutic possibilities. limited resources and sympathy. ization, the atomic age, computer- Prudent therapeutic interventions Who decides which genetic ization. Recent advances in biolo- aimed at correcting genetic dis- qualities warrant death, before or gy and medicine mean we are eases and preventing their occur- after birth? On what basis? And in rapidly acquiring the power to rence or onset are in principle whose interests? Eugenics, far modify and control when and how good uses of genetic science and from being a Nazi German or Chi- we come to be, when and how we healthcare – even if there is cause nese monopoly, affects the think- die, and our very natures, capaci- for caution with respect to experi- ing of many ‘enlightened’ and ap- ties and activities in the mean- mentation, privacy, equity of ac- parently good willed people, and time. Healthcare will in the future cess, ‘germ line therapy’ and ‘ge- is told in the high and growing find itself increasingly on three netic enhancement’. The big rate of genetic search and destroy new frontiers in addition to the problem is: now and for the fore- missions (called ‘prenatal screen- three I have already outlined: the seeable future the principal use of ing and genetic termination’). Be- frontier between life and death in this technology will not be thera- hind this, the Pope suggests, lies the womb; the frontier between peutic at all. It will be used for “an exclusivist mentality that respect for the dignity of the per- testing unborn children. And would deny solidarity with those son and the commodification of where the child is diagnosed as who are different to ourselves or persons; and the frontier between carrying some major disease, the who call forth from us some de- natural death and medicide. It is mother is likely to choose or in- gree of self-sacrifice”. The view these three frontiers that I wish to deed to be steered – ‘non-direc- that the handicapped are better off explore in what time is left to me tively’ of course – by doctors, never born, never existing, is cer- this evening. counsellors, family and friends to- tainly very much at odds with the wards a genetic termination of Gospel which values every hu- 3.1 On the frontier between life pregnancy. My friends Tom and man being as a sister or brother, and death in the womb Clare suffered acutely from these relativizes all handicap, and em- pressures from various ‘enlight- phasizes the power of the weak to At both ends of life the Christ- ened’ and ‘well-meaning’ people. minister to the strong; it is also ian vision of respect for every hu- In a moving article about his contrary to the principle of justice, man being however vulnerable or daughter Domenica who has shared by many people of all reli- strong, however wanted or un- Downs Syndrome, Nigel Lawson gions and none, of equal respect wanted, however suffering or wrote about the complicity of ge- for the dignity and life of every well, is especially under pressure netic technology in the current human being, especially the vul- today and will continue to be so in search and destroy against nerable and powerless.25 the foreseeable future. Catholic Down’s babies. Cystic fibrosis, Until recently the targets of ge- health institutions and profession- spina bifida, Downs, predisposi- netic search and destroy have als are world leaders in the care of tion to heart attack: where will it been those with severe handicaps little ones, the tiniest, most vul- stop? The US National Academy who could easily be identified in nerable, of human beings, and of of Sciences has reported that al- utero. But the list of those handi- course their mothers. We have ready people are losing their jobs caps is growing, partly as a result taken something of a ‘preferential and health and life insurance be- of increased technical capacity to gg

90 HEALTH CARE AND SOCIETY identify more and more of them, 50% chance of growing up killing on the same day: one, a more and more accurately; and obese.28 Fat baby tests may well Milwaukee man who had shot his partly as a result of the line mov- be on the market within the cat to death because it hissed at ing as to which handicaps are re- decade. The target group for ge- him, was sentenced to 21 years in garded as incompatible with netic screening and destruction is prison; the other, a New Yorker worthwhile existence. growing all the time... who had illegally performed I was once consulted regarding There are lots of things which abortions on two babies already a case of a dwarf couple who pre- can and should be said about the mature enough to survive perfect- sented at a hospital pregnant and genetic revolution which is ahead ly well outside the womb, was requesting genetic screening. On of us: the dangers of the all-too- given no prison sentence at all, being told their child was perfect- common reduction of people to only a five year period of proba- ly normal they declared that they their genes; the pressure which tion. In many Western countries a wanted an abortion. The clinical the very availability of these tests third or more of women now have staff were aghast: despite long ex- puts upon parents and health pro- an abortion in their lifetime; in perience of abortion on demand, fessionals to use them and then to countries such as Russia most they had never before faced a case join the genetic abortion treadmill women by far do so. This makes where a child was to be aborted for all the talk of reproductive lib- abortion the most common surgi- specifically because she or he was erty; the power of the technological procedure in the world, and normal! The case raised for them cal imperative to sweep people ensures that the emotional, ideo- all sorts of questions about the na- along in its path and become an logical and financial investment ture of health and handicap, and overarching ideology for medi- of many in the justification and whether individual parents, cine; the informative natural re- continuation of this particular va- medicos or societies are entitled vulsion of ordinary people to- riety of homicide is very great – to decide which conditions war- wards some extremes of contem- even as more and more women rant the death of a child, whether porary genetic science. But my are terribly damaged by it. The in the child’s best interests or the main point here is that here we outgoing US President supports interests of others.26 have a technological revolution even ‘partial-birth’ abortions, a The cover-feature of the April already under way which, for all practice so grotesque it has shak- 1998 number of Life magazine its much vaunted therapeutic po- en the collective conscience of confidently included the following tential, will in the foreseeable fu- even the AMA. Where America qualities among those entirely or ture contribute more to death in will go on this issue in the months largely genetically determined: the womb than to therapy and and years ahead will I think be eye, hair and skin colour; sex; health there. crucially symbolic of where our body shape and athletic prowess; Meanwhile a whole new gener- civilisation at its present cross- intelligence of various kinds; in- ation of ‘morning after pills’, roads is going to turn. somnia, blood pressure, migraines, ‘emergency contraceptives’ and As a result of all this Christian depression and psychosis; shyness abortifacient drugs is being and and other pro-life doctors, nurses and aggressiveness, risk aversion will be developed, further blur- and pharmacists can expect to be and thrill-seeking, optimism, ex- ring the line between contracep- pressured to compromise their po- troversion and alienation, leader- tion and abortion. And embryos sition or be increasingly marginal- ship and career choice; æsthetic galore are being created in labora- ized. They will stand on the fron- sensibility, sexual orientation, tories and will probably be creat- tier between life and death in the tastes and addictions; and, I was ed in increasing numbers by womb and it may be a fairly lone- interested to learn, religiosity.27 cloning and other techniques in ly place. For the Church this pre- Nor are such claims the preserve the future, then experimented up- sents an enormous evangelical of pop magazines: David Rosh- on or exploited for body parts or and pastoral challenge: how are land, the one-time editor of the disposed of, without any serious we better to support pro-life prestigious journal Science, even outcry from populations system- health professionals living on this attributed homelessness and un- atically desensitized to the evil of frontier? How are we better to employment to genetic defects! killing early human life.29 preach our Gospel of Life, better If genetic factors are indeed The result: we now have abor- to convert and reconcile those identified as contributing to many tion on an unthinkable scale, who have acted contra-life, and of these qualities, children who do more devastating in sheer number better to support those who might not measure up to parental and so- of fatalities than the great world be tempted to act against life in cial expectations may be targeted wars, the great plagues and the womb or the laboratory? How for destruction. I am far from con- famines, the great natural disas- do we make a world in which the fident that talk of multi-factorial ters – killing millions and mil- little Thomas Walters will be causation, the importance of envi- lions of children every year till we ‘welcome at the inn’, rather than ronment, the ambiguity of test re- are so used to it we are all desen- the victims of ‘early induction’, sults, and so on, will do much to sitised to the daily death-toll. And and where distressed mothers-to- stop that. One recent study found wherever abortion is so common- be are supported through their that three-quarters of young ly and publicly practised, it tends pregnancy and beyond, rather Americans polled would choose to be trivialised. Last year two than press-ganged into abortion abortion if told their fœtus had a Americans were convicted for by a cop-out society?30 gg

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3.2 On the frontier between come from people other than preferences of the me-generation, “respect for the dignity those who actually want the child. and disposed of when they fail to of the person” and “the Those involved may or may not do so by the throw-away society? commodification of persons” be related to the child or to each In my own country a Federal other; they may be married, un- Court recently ruled that single Wherever people aspire to married, homosexual or solo; they women and lesbians have a right small or no families, wherever may be paid or unpaid, alive or to state funded artificial insemina- ‘sex education’ means in practice dead, comatose or even aborted tion and in vitro fertilisation, that acquiescing in unchaste sexual ac- and never born. Cryopreservation it is discriminatory to restrict such tivities and seeking only ‘harm allows twins to be born at differ- services to married or even de fac- minimisation’ strategies, wherev- ent times and to different parents, to married heterosexual couples. er individualism and moral sub- even many years after their genet- The thought seemed to be that the jectivism are rampant, both sexual ic parents’ deaths, and even to be wherewithal for child-making, activity and contraceptive rates go born into different generations. and by implication children them- up, and so too, inevitably, do Through genetic manipulation, selves, are good and services to pregnancy and abortion rates. Per- parthenogenesis, cloning and in- which all should have access haps the area where twentieth duced chimeras, people in the fu- whatever their circumstances. No century medicine wrought the ture may have only one or many one spoke for the children in this most extraordinary changes was genetic parents, and possibly case except the Catholic Church – not in surgery or even vaccina- many twins, and these children the silence on that score from gov- tions, but in ‘family planning’: might be designed so as to have ernment, courts and civil rights agencies was deafening. In an age where the consumer society and the autonomy obsession have in- vaded the cradle and even the genome, the tendency is increasingly to regard parenting not as a trust received so much as a project chosen, not as receiving a gift so much as going shopping. Leon Kass describes the difference this way: when a couple chooses to procreate, they come together to give or to risk giving existence to another being who is formed, exactly as they were, by what they are: living, bodily, mortal, imperfect, passionate beings. through the provision of devices, certain preferred human or non- They say yes to the emergence of drugs and surgical procedures, human characteristics, or to be a new life in all its novelty, how- biotechnology has promised sexu- cannibalised for genomic material ever that child turns out. Embrac- al activity on demand supposedly for sick adults or for body parts ing the future by procreating without the ‘threat’ of unwanted for their families. Depending up- means relinquishing some of our pregnancy and children.31 on market demand, post- grip. For our children are not our The search for the perfect con- menopausal women, surrogate children, they are not our posses- traceptive and abortion will con- mothers, men, animals and ma- sions, not our projects. They are tinue into the future, and the per- chines can carry children; chil- sprung from the past, but they sonal, social and cultural ramifi- dren can be created in memory of take an uncharted course into the cations continue to be colossal, deceased lovers; and much else future. In genetically controlled but I will not dwell on them here. which we have not yet even imag- conceptions, on the other hand, Apart from stopping babies, med- ined will soon be achieved. “we give existence to a being not icine has also advanced in en- What about the children? In an by what we are but by what we in- abling them: artificial reproduc- age when the right of adults to tend and design. As with any tive technologies have produced have whatever they want – hous- product of our making, no matter hundreds of thousands of live- es, cars, videos, whatever – on de- how excellent, the artificer stands born children and destroyed mil- mand, in whatever colour and above it, not as an equal but as a lions of unborn, embryonic chil- model they desire, to use at will superior, transcending it by his dren in the process.32 People can and discard when unwanted, is will and creative prowess.”33 now commission others to pro- being extended to everything, are The new genetics is morally vide those requisites of child- children becoming the ultimate problematical, therefore, not only bearing which they cannot or do commodity, the last consumer because it stands on the frontier not provide themselves. Eggs, good for the person who has between life and death in the sperm, embryos, womb, techno- everything? Will they increasing- womb, but also because it tends to logical wherewithal, all may ly be manufactured to satisfy the commodify even those children gg

92 HEALTH CARE AND SOCIETY whose lives are not threatened by who runs London’s thriving ‘Cos- ‘consciousness-expanding’, eu- it. It can so easily represent yet an- metic Surgery Network’, made phoriant and hallucinogenic phar- other grave imposition by parents headlines by writing up her nine macology. The future promises of of their preferences upon children years, 37 operations and hundreds memory-enhancing pills, mood and a further rejection of the tradi- of thousands of pounds spent on controlling pills, pleasure-induc- tional notion that “children should having herself surgically remade ing pills and like. Hyperactive and be accepted by their parents as a as close as possible to the ‘Barbie’ troublesome children, old people divine gift to be loved for what doll. Surgeons turned Cindy’s lips in nursing homes, and emotional they uniquely are and not merely inside out and padded them with people in mid-life are increasingly because they conform to the par- fat from her bottom. They tranquillized; anabolic steroids ents’ hopes and expectations”.34 widened her eyes, broke and reset and various other performance- Procreation becomes mere repro- her jaw-bone, sawed her chin enhancing drugs marred the reduction, replacing being begotten down to size and implanted her cent Olympics in my homeland; with being made, making children cheeks with silicon. They der- recreational drug-taking is com- into quality-controllable com- mabrased her face, did two nose monplace and most of it terribly modities, and pregnant mothers jobs on her, as well as cosmetic harmful; and the pharmaceutical into test drivers. And genetic dentistry and a hair transplant. industry, both licit and illicit, is screening has the power to detach They liposuctioned her hips and constantly creating new products, us (both figuratively and literally) thighs, and enlarged her breasts. new markets, and new dependen- from our children, making every She has had three facelifts and an- cies. In all this children, adoles- pregnancy ‘tentative’ and requir- nual ones are projected hereafter. cents and adults, like unborn chil- ing of mothers a certain distance Many women have since hired dren before them, risk being treat- until all is judged well and good. Cindy’s surgeon to follow the ed not as subjects of care so much Of course biotechnology is not same blueprints and make them as objects of manipulation, just about life and death dealing into Cindy ‘clones’. Much more whether or not with their sup- measures. As I was writing this in the way of body engineering posed consent. Rather than the paper I was struck with renal col- will be possible in the future. proper loci of reverence, love and ic. It is a terrible affliction and The big field for the future in care, they become loci of hedonic there is no comfort in being told mid-life biotechnology will, how- preference fulfilment, consumer that childbirth is just as bad! Yet ever, be in controlling human ca- satisfactions, or technical ma- the experience highlighted for me noeuvres. the wonders of modern pain re- As a result of all this Christian lief, diagnostic x-rays, keyhole health professionals can again ex- surgery, laser treatment and pect to be pressured and marginal- lithotripsy. Biotechnological ad- ized – as well as admired and vances have allowed more people praised – as they stand on a new to live healthier lives and for frontier: the frontier between re- longer, to be cured of various dis- spect for the dignity of the person eases and various unpleasant and the commodification of per- symptoms, and to have their suf- sons. Once more it could become fering alleviated in various ways. a fairly lonely place. And once And much of this is a very great more it presents the Church with a benefit.35 Yet it all comes with its great pastoral and evangelical own moral dilemmas, such as the challenge: how are we better to appropriate distribution of health support health professionals liv- resources.36 ing on this frontier? How are we Even more troubling are the us- better to preach the dignity of es of these technologies which every human person, and better to seem to treat the body as if it were convert and reconcile those who a mere thing rather than the con- treat human beings as mere com- crete expression of a unique per- modities? son.37 The instrumentalisation of pacities such as strength, agility, the corpse, and even of the body reflexes, emotions, memory, 3.3 On the frontier between of the consenting live donor, is an imagination, desire, libido, ag- “natural death” aspect of organ harvesting which gression, thought, choice, speech and “medicide”40 is yet to receive sufficient theo- and action.39 These techniques are logical reflection.38 Another ex- in a rather primitive state at the The notion that death can be ample is the application of drugs, moment, but already we have a ‘tamed’ is a potent one in ancient hormones and surgery not to cor- battery of surgical techniques mythology and in modern sci- rect defects but merely to eradi- such as sex-changes and elaborate ence. Developments such as or- cate the signs of perfectly normal cosmetic and other reconstructive gan transplantation, xenotrans- ageing or to change body shape, surgery, and drug techniques, es- plantation, artificial organs, ge- colour or sex according to person- pecially use of tranquillisers and netic engineering and other real preference. Cindy Jackson, stimulants, uppers and downers, search into slowing or stopping gg

DOLENTIUM HOMINUM N. 46/1-2001 93 ageing – all very promising in ill, all dressed up as respect for one direction we see healthcare as themselves – hold forth the rights, mercy for those who cannot a merely technical achievement or promise of increasing not just the be cured, and efficient use of re- market product, provided by mere average age, so that most people sources. And it is all the more dif- technicians, ‘service–providers’ achieve an ordinary life-span, but ficult to hold the line when even or ‘hired guns’, and limited only also the maximum life expectan- theologians and health profession- by the technically and politically cy. According to some estimates it als of good will disagree about possible: this is, of course, health- may soon be possible to add twen- such fundamental issues as care in ‘the culture of death’ and it ty to forty years to the human life- whether we should feed and hy- is ultimately amount neither span: the death in August 1998 of drate unconscious patients.43 health nor care. If we look the oth- the 122-year-old Frenchwoman, I need not spell out here why er way on our frontier, however, Jeanne Calment, may one day be this matters so much to us. Suffice we see healthcare as a vocation, unremarkable. The World Health it to say that essential to respect engaged in by people who are Organisation predicts that the for the precept against killing and professionals and saints-in-the- number of centenarians in France to the killing-letting die distinc- making, and whose activities with will rise from the 200 there were tion of classical and Christian their own proper goals and are in 1950 to around 150,000 by medical ethics is a high view of subject to common morality: this 2050.41 This raises all sorts of human dignity and equality, and is genuine healthcare, part of the questions about when to apply of our moral responsibilities in building up of ‘the civilisation of and when to withhold life-sustain- acting and forbearing to act with life and love’. Tom and Clare and ing treatments, how long to ex- respect to it. This brings the Chris- their little baby and their carers tend life or perhaps prolong dy- tian health professional into direct stood on that frontier. Likewise ing, including of course the added conflict with the values of a cul- they stood on the three new fron- burden on our aged care system. ture which says happiness is about tiers between life and death in the But my main point here is that, as contentment and control; that says womb, between respect for the with the efforts at cosmetic people matter for how much they dignity of the person and the com- surgery to remove all signs of age- produce or consume or contribute modification of persons, between ing, there is a doubly vain notion in some other way; that says natural death and medicide. They that eternal life and youth can be choice is king and each may had some hard choices to make. had here on earth. The fact is that choose how he lives and dies. And their story is paralleled thou- even baby faced young priests get Standing on the frontier between sands of times a day around the kidney stones: we are all going to natural death and medicide, world in Christian healthcare in- die and death, our last enemy, can- Christian health professionals stitutions and in the work of not be tamed. may in yet another respect find Christian health professionals. The other way to ‘tame’ death, themselves pressured and desert- Thomas Walter Ryan was born on of course, is to make it part of the ed. Once again this challenges us 18 December 1996 and died soon medical armoury. In one part of pastorally and evangelically: how after. But his story, and the story my own country voluntary eu- are we better to preach the dignity of his family, goes on. In the same thanasia was briefly legal in the of elderly, frail and dying people, hospital, exactly one year later, on 1990s and the campaign in many and better to convert and recon- the very same day but in 1997, parts of the world for the regulari- cile those who think comfort and with some of the very same carers sation of that practice continues. self-determination must trump all in attendance, his brother Isaac Christian care for the elderly and else and that medical killing can Peter Ryan was born. Isaac is the dying is under considerable thus be justified? How are to sup- alive and well... pressure at present and is likely to port those life-affirming health be under even more pressure in the professionals living on this fron- Rev Prof ANTHONY FISHER OP future.42 Even from the cross tier – in their understanding, their Vice-President of John Paul II Christ showed his care for a dying conviction, their resolve, their Pontifical Institute for Marriage thief; and as Christ himself died perseverance in morally sensitive and the Family, Melbourne Episcopal Vicar his own mother and beloved disci- care despite hostility from some for Health Care, ple stood by him. The task of quarters? Archdiocese of Melbourne Christian healthcare is to care even when it cannot cure. Chris- tians have been at the forefront of 4. Conclusion the hospice movement, in special- ized care for the dying, including I began my lecture this evening but not limited to the increasingly with the story of Clare and Tom effective science of palliative care. and their little baby Thomas Notes But the task of caring well for the doomed to death so soon after terminally ill is especially chal- birth. That story I think very 1 The Ryan family’s story is told more ful- lenging in a world increasingly in- poignantly brings home the sever- ly in: “Thomas Walter Joseph Ryan: celebration of a life,” Bioethics Outlook 8(2) (June clined to discrimination, abandon- al frontiers on which health pro- 1997), 1-3. ment, even medicide – medical fessionals and their patients find 2 On the vocation of healthcare see Pontif- homicide – towards the terminally themselves today. If we look in ical Council for Pastoral Assistance to Healthcare Workers, Charter for Healthcare gg

94 HEALTH CARE AND SOCIETY

Workers (1995), 1-10. I explore some of of souls and bodies, and following the exam- ties.... Newly born infants in danger of death, these issues at greater length in: “Is there a ple of their respective foundresses... [they] including those miscarried, should be bap- distinctive rôle for the Catholic hospital in a should persevere in their witness of love to- tized if this is possible... When a Catholic pluralist society?” in Luke Gormally (ed), Is- wards the sick, devoting themselves to them who has been baptized but not yet confirmed sues for a Catholic Bioethic (London: with profound understanding and compas- is in danger of death, any priest may confirm Linacre Centre, 1999), 200-230. sion. They should give a special place in the person. (Directives 12-18). Likewise 3 Mt 15:30-31. their ministry to the poorest and most aban- Charter §§108-113. 4 National Conference of Catholic Bish- doned of the sick, such as the elderly, and 14 US Bishops 1994. ops (USA), Ethical and Religious Directives those who are handicapped, marginalized, or 15 Cf. Honings 1996. STANLEY HAUERWAS, for Catholic Healthcare Services (1994). terminally ill, and to the victims of drug Suffering Presence: Theological Reflections 5 Cf. JOHN PAUL II, Salvifici doloris: Apos- abuse and the new contagious diseases.” on Medicine, the Mentally Handicapped and tolic Letter on the Christian Meaning of Hu- 8 Wisdom 11: 26. See Charter §3; and the Church (Notre Dame IN: University of man Suffering (1984). BONIFACIO HONINGS, “The Charter for Notre Dame Press, 1986), 81 observed: “No New Jersey Bishops, “The rationale of Healthcare Workers: A synthesis of Hippo- matter how powerful [medicine] becomes, it Catholic healthcare,” Origins 25(27) (Dec cratic ethics and Christian morality,” Dolen- cannot in principle rule out the necessity of 21 1995), 449-452, at 451: “We are a com- tium hominum 31 (1996): 48-52. prayer. For prayer is not a supplement to the munity of faith and worship and fraternal 9 The literature on the ‘Catholic identity’ insufficiency of our medical knowledge and love and care, who know who we are and be- of healthcare institutions is now consider- practice; nor is it some divine insurance pol- come who we are through the life, death and able. See, for instance: JOHN R AMOS et al, icy that our medical skill will work; rather, resurrection of Jesus... [In him we recognize] The Search for Identity: Canonical Sponsor- our prayer is the means that we have to make the God who suffered along with us... In his ship of Catholic Healthcare (St Louis: God present whether our medical skill is suc- resurrection we acknowledge not only the Catholic Health Association, 1993); BENE- cessful or not. So understood, the issue is not power of God, but also the new life given by DICT ASHLEY OP, “The documents of whether medical care and prayer are antithet- God... God dwells with us and within us Catholic identity,” in R. E. SMITH (ed), The ical, but how medical care can ever be sus- through the power of the Holy Spirit and that Gospel of Life and the Vision of Health tained without continued prayer.” makes us really and truly different... We who Care: Proceedings of the 15th Workshop for 16 Cf. AUGUSTINE DI NOIA OP, The virtues have been touched and saved and changed Bishops (Braintree: Pope John Center, of the Good Samaritan: healthcare ethics in by God must make all this visible not only by 1996), 10-16; JOHN BEAL, “Catholic hospi- the perspective of a renewed moral theolo- our grateful faith-filled praise of God, but al- tals: how Catholic will they be?” Concilium gy,” Dolentium hominum 31 (1996), 211- so by our loving presence with each other 1994-5: Catholic Identity (London: SCM, 214; ALASDAIR MACINTYRE, Dependent Ra- and our compassionate care for one another. 1995) 81-90; JOSEPH BERNARDIN, “Cross- tional Animals: Why Human Beings Need Catholic healthcare exists as a practical sign roads for the Church’s health care ministry,” the Virtues (London: Duckworth, 1999) (and of living faith; it exists ‘to be Jesus’ love for Origins 22(24) (Nov 26 1992), 409-411; his many previous works); GILBERT the other in the healthcare setting’.” Catholic Health Association (USA), “How MEILAENDER, “Are there virtues inherent in a US Bishops 1994: “For the Christian, our to approach Catholic identity in changing profession?” in EDMUND PELLEGRINO et al encounter with suffering and death can take times,” Health Progress (Apr 1994), 23-29; (eds), Ethics, Trust and Professions (Wash- on a positive and distinctive meaning JOHN E CURLEY, “Catholic identity, Catholic ington DC: Georgetown UP, 1991), 139-55; through the redemptive power of Jesus’ suf- integrity. Health Progress (Oct 1991), 56- EDMUND PELLEGRINO, “Toward a virtue- fering and death. As St. Paul says, we are 69; RICHARD MCCORMICK, “The Catholic based normative ethics for the health profes- “always carrying about in the body the dying hospital: mission impossible?” Origins sions,” Kennnedy Institute of Ethics Journal of Jesus, so that the life of Jesus may also be 24(39) (Mar 16 1995), 648-653; THOMAS 5 (1995): 253-277 (and his many other manifested in our body” (2 Cor. 4: 10). This MURPHY, “What is the bottom line in works on virtue). truth does not lessen the pain and fear, but Catholic healthcare?” Origins 26(4) (Jun 13 17 Lk 4:18. gives confidence and grace for bearing suf- 1996), 56-60; JOHN O’CONNOR, “The temp- 18 Mt 4:23; 9:35. fering rather than being overwhelmed by it. tation to become just another industry: 19 Mt 10:7-8. Catholic healthcare ministry bears witness to healthcare,” Origins 25(27) (Dec 21 1995), 20 JOHN PAUL II, “Address to healthwork- the truth that, for those who are in Christ, 452-454; ers at the Mercy Maternity Hospital, Mel- suffering and death are the birth pangs of the 10 The anathemas against witch-doctors in bourne, 28 November, 1986,” Insegnameni new creation. “God himself will always be the Old Testament (Lev 20:27; Dt 18:10-14; IX/2 (1986), 1734. with them. He will wipe every tear from their 1 Chr 10:13-14; cf. Acts 13:6-12) and against 21 Cf. DIEGO GUILLEN, “The Hippocratic eyes and there shall be no more death or the pharmacists (farmakoiV) in the New Oath in the development of medicine,” Do- mourning, wailing or pain, for the old order (Rev 21:8; 22:15) draw our attention to the lentium hominum 31 (1996): 22-28. has passed away” (Rev. 21: 3-4). dangers of ‘medicine’ become ‘magic’. cf. 22 Cf. JOHN PAUL II, Evangelium Vitæ: Cf. Juliana Casey, Food for the Journey: STANLEY HAUERWAS, “Salvation and health: Encyclical on the Value and Inviolability of Theological Foundations of the Catholic why medicine needs the Church,” in EARL Human Life (1995) and innumerable speech- Healthcare Ministry (St Louis: Catholic SHELP (ed), Theology and Bioethics: Explor- es on healthcare issues. Amongst the contri- Health Association, 1991); Alasdair MacIn- ing the Foundations and Frontiers (Dor- butions from the Congregation for the Doc- tyre, “Can medicine dispense with a theolog- drecht: Reidel, 1985), 205-224; and GILBERT trine of the Faith are Quæstio de abortu: De- ical perspective on human nature?” In D. MEILAENDER, Body, Soul, and Bioethics claration on Procured Abortion (1974), Callahan and H. T. Engelhardt (eds), The (Notre Dame: University of Notre Dame Haec sacra congregatio: Declaration on Roots of Ethics (New York: Plenum, 1981), Press, 1995). Sterilization in Catholic Hospitals (1975), 119-138. 11 Lk 5:17-26; cf. Mk 2:1-12. Declaration on Certain Questions concern- 6 Summa theologiæ IIa IIæ 25, I; 103-109; 12 US Bishops 1994; cf. Charter §3. ing Sexual Ethics (1976), Jura et Bona: De- IIIia 25,ii. 13 Charter §§ 108-113. cf. US Bishops claration on Euthanasia (1980), Donum vitæ: 7 US Bishops (1997). Administrative 1994 direct that “for Catholic patients or res- Instruction on Respect for Human Life in its Committee of the National Conference of idents, provision for the sacraments is an es- Origin and on the Dignity of Procreation Catholic Bishops (USA), The Bishops’ Pas- pecially important part of Catholic health- (1986) and, most recently, the interventions toral Rôle in Catholic Healthcare Ministry care ministry. Every effort should be made to with respect to abortion counselling and in- (1997) in Origins 26(43) (Apr 17), 700-704 have priests assigned to hospitals and health- jecting rooms in Germany and Australia re- at 704. care institutions to celebrate the Eucharist spectively. Some of these and other magiste- In Vita Consecrata: Apostolic Exhorta- and provide the sacraments to patients and rial documents are collected in: KEVIN tion on the Consecrated Life and its Mission staff... Particular care should be taken to pro- O’ROURKE AND PHILIP BOYLE (eds), Medical in the Church and in the World (1996: §83), vide and to publicize opportunities for pa- Ethics: Sources of Catholic Teachings (2nd John Paul II describes the diakonia of nurs- tients or residents to receive the sacrament of ed,. Washington DC: Georgetown Universi- ing religious in terms which might be ap- penance... Responsive to a patient’s desires ty Press, 1993). plied more generally to all those who share and condition, all involved in pastoral care 23 Cf. BRUNO ZANOBIO, “The ethical di- in the Catholic healthcare apostolate: “The should facilitate the availability of priests to mension of Hippocratic medicine and its Church looks with admiration and gratitude provide the sacrament of anointing of the specific relationship to Christian morality,” upon... [those] who, by caring for the sick sick, recognizing that through this sacrament Dolentium hominum 31 (1996): 29-32. and the suffering, contribute in a significant Christ provides grace and support to those 24 I give a fuller account of some of these way to her mission. They carry on the min- who are seriously ill or weakened by ad- matters in: “Adult science and adolescent istry of mercy of Christ, who ‘went about do- vanced age.... All Catholics who are capable ethics: A response to John Henley,” in HI- ing good and healing all [who were op- of receiving communion should receive vi- LARY REGAN et al (eds), Beyond Mere pressed by the devil]’ (Acts 10.38). In the aticum when they are in danger of death, Health: Theology and Health Care in a Sec- footsteps of the Divine Samaritan, physician while still in full possession of their facul- ular Society (Melbourne: Australian Theo- gg

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logical Forum, 1996), 145-168; “The brave University of Tasmania, 1997), 13-26; and new world of genetic screening: ethical is- the forthcoming The Allocation of Health- sues,” in JOHN FLADER (ed), Death or Dis- care: An Ethical Framework for Policy (with ability? Proceedings of a Seminar at the Luke Gormally and others, London: Linacre University of Tasmania (Hobart: University Centre, for the British Bishops). of Tasmania, 1996), 16-34; and “The human 37 See Charter §§ 38-41. genome project: hopes and fears,” Philip- 38 See some of my questions in “Contrast- piniana Sacra 30(90) (Sept-Dec 1995), 483- ing ethical approaches to organ transplanta- 498. tion and xenotransplantation,” in FAUSTO See also: Charter §§ 12-14. GOMEZ OP AND ANNIELA YU-SOLIVEN (eds), 25 See Hauerwas 1986 and MacIntyre Love and Life-Making, Confidentiality, 1999, ch. 1. Xenotransplants and Aging (Manila: UST 26 For fuller details of this case see: AN- Department of Bioethics, 2000), 75-110. THONY FISHER OP, “Ethical issues in genetic 39 On these matters see: LEON KASS, To- screening,” Bioethics Outlook 8(4) (Dec ward a More Natural Science: Biology and 1997), 1-12. Human Affairs (New York: Free Press, 27 GEORGE COLT, “Were you born that 1985); Charter §§ 92-107. way?” Life (April 1998): 38-50. 40 See Charter §§ 114-124, 130-138, 147- 28 Colt 1998. 150. I give a fuller exposition of some of 29 On these matters see: Charter §§ 35-36, these ideas in: “Theological aspects of eu- 42-46, 139-146. thanasia,” in JOHN KEOWN (ed.), Examining 30 For heart-rending accounts of this terri- Euthanasia: Legal, Ethical and Clinical Per- ble process and its after-effects, see Melinda spectives. Cambridge: Cambridge Universi- Tankard Reist’s excellent book, Giving Sor- mans,” The New Republic 216(22) (2 June ty Press, 1995, pp. 315-332; and “Why the row Words: Women’s Stories of Grief After 1997), 17-26 at 20-24. Lords rejected euthanasia,” Human Life Re- Abortion (Sydney: Duffy & Snellgrive, 34 BENEDICT ASHLEY OP AND KEVIN view, 22(3) (Summer 1996), 15-23. 2000). O’ROURKE, Healthcare Ethics: A Theologi- 41 World Health Organisation Annual 31 On these matters see also Charter §§ cal Perspective (4th ed, Washington DC: Health Report, 11.05.97. 15-20. Georgetown UP), 317; cf. CDF 1986. 42 Cf. O’Connor 1995. 32 I give a fuller account of some of these 35 See also: Charter §§ 56-58, 62-71. 43 I give fuller accounts of this dilemma in matters in: “The brave new world of repro- 36 I give a fuller account of some of the “On not starving the unconscious,” New ductive technologies,” Philippiniana Sacra dilemmas in this area in: “Accountant, Poll- Blackfriars, 74 (Mar 1993), 130-145; and 30(89) (May-Aug 1995), 277-292. See also: ster, Samaritan: three models of justice in “Should we starve the unconscious?” Aus- Charter §§ 21-34. health care resource allocation,” in JOHN tralasian Catholic Record, 74(3) (July 33 Cf. LEON KASS, “The wisdom of repug- FLADER (ed), Health Care in the Balance: 1997), 315-329. nance: why we should ban the cloning of hu- Ethical Issues in Medical Funding (Hobart:

TOMÁS BARRIENTOS FORTES IV: The Teaching of the Future Professionals of the World of Health and Health Care

The training of medical profes- in a formal way in the way it was epoch in physiology, biochem- sionals has always been one of the imparted. With the advent of istry, histology, and the study of first activities of universities. This anaesthetics and the modern theo- infectious diseases. has been the case ever since their ries of asepsis and antisepsis the At the beginning of the twenti- creation. Together with theology techniques of surgery began to be eth century Flexner, in North and the humanistic sciences, med- included in the therapeutic battle. America, with the financial sup- ical instruction occupied an im- This lay behind the fact that med- port provided by the Carnegie portant place in the activity of icine had to be taught not only in a Foundation, carried out a detailed universities. theoretical and individual way study of the realities of medical During the nineteenth century, through a tutor, as until that mo- instruction as they obtained at the at the time of the industrial revo- ment had usually happened, but at beginning of the first decade of lution and social modernisation, the same time required the student the century. Flexner was surprised medical instruction began to un- to be in contact with the basic by the great variety of teaching dergo a transformation. It began medical sciences, which had been programmes which, given their to involve scientific methodology enriched by the discoveries of the very heterogeneous range of con- gg

96 HEALTH CARE AND SOCIETY cerns, encountered notable diffi- of the human body, represented to stimuli, whether of an external or culty in the provision of a medical begin with by simple radiography, an internal origin. instruction which could be homo- were the pillars on which Flexner With the discoveries of the bio- geneous in a qualitative sense. At decided to base the reorganisation chemistry of genetic mechanisms that time the idea of the establish- of the systems of teaching of the the path was opened up to the ment of universal standards of medical schools of his time. complete ability to analyse the de- quality in medicine was seen as a Gradually, the influence of North velopment of the cells, the tissues, goal to be aimed for, and it was American medicine spread and the organs of the human body. thought that it was necessary to throughout the world. This expan- The perfect way in which our prevent the medical schools from sion was supported by the events Creator had codified us in order to training medical doctors of differ- which followed the Second World develop our bodies and our life ent levels of quality. It was diffi- War, when the world economy functions in a process of adapta- cult to graduate them and subse- was built up again under the tion to this world thus begun to be quently achieve a safe and effi- strong influence of North Ameri- understood. cient practice of medicine. ca. During the growth and devel- The decisive role of the images The impact of Flexner in estab- opment of medicine during the produced by electronic micro- scopes, together with the opportunities offered by molecular mark- ing through the use of histochem- istry, and the techniques of ra- dioimmunoanalysis, allowed us to locate in a physical sense the specific sites where the fundamental reactions of cellular biology take place in the various cells of the human body and its or- ganelles, and in the micro-organ- isms with which we come into contact. The techniques of ultrafiltration and spectrophotometric analysis led contemporary biology to acquire a striking and impressive diversity. The quantity of expression molecules in the different cells of the corporeal economy is very great, and the most beautiful aspect of this is that every particular molecule is responsible for an original and specific biochemical action which determines the pro- gression of a normal physiological sequence. At the present time, in the ma- lishing the configurations of the second part of the twentieth cen- jority of cases of pathology the programmes of medical instruc- tury, the advance of medical tech- concept of physical illness has to tion was of the very greatest im- nology in both the fields of diag- be explained at the level of the portance. But during the epoch nosis and that of treatment and molecular sphere, given that treat- when he was alive half of the therapy was very impressive. ment will also be directed toward medical schools of the United Forms of microtechnology, correcting this cellular alteration States of America had to close be- pushed forward by scientific ad- through the application of forms cause of the low standards of their vance and progress (the fruit of of medicine of a very specific teaching curriculums. Flexer laid the space era and the beginning of kind and type of activity to the stress on the involvement of dis- the electronic and computer era), cellulars or the receptor sites ciplines of basic science at the be- were the principal engines behind within the human organism. This ginning of the career of the med- this change. same specific character of the ap- ical doctor. Subsequently, it was The ability to explore the inside proach has meant that present-day necessary to include the teaching of the human body at a molecular medicines are more effective, of the clinical sciences, and there level revolutionised both our powerful and safe because their had to be a constant emphasis on knowledge of the body itself in secondary effects are reduced to a the physiopathology of the noso- terms of its architecture and its minimum by the very specific logical pictures in the basic sci- functions and our knowledge of character of their action. ences. The inclusion of the clini- the physiopathological reactions However, medical technology cal laboratory and basic imaging of the human body to damaging has grown and developed under a gg

DOLENTIUM HOMINUM N. 46/1-2001 97 terrible economic stimulus. The human relationship than on the in- practice of medicine. cost of the development of both struments and techniques they This injustice in the distribution diagnostic and therapeutic forms employ to provide treatment. of the world’s resources is accen- of technology has reached record There can be no doubt that in the tuated when one examines the levels and has made them exces- field of health and health care hu- particularities of each of the coun- sively expensive for the popula- manism continues to prevail in tries which make up the world tion in general. the use of curative methods and concert of nations. For this rea- The population of the world has techniques, whether of a scientific son, we must always recognise also undergone a major growth. or an alternative character. the advances in medical knowl- According to data furnished by In the light of what has just edge and health care resources at the United Nations, over six mil- been outlined, it is indispensable a world level, without confusing liard human beings populate the to redirect medical instruction in them and mixing them up with planet. However, despite the fact the rational use of, and the correct their availability at a local level, that we already have the techno- cost/benefit approach to, the med- with particularities which belong logical resources which allow us ical-diagnostic and therapeutic re- to, and are characteristic of, each to achieve an effective identifica- sources which are now available country of our planet. We should tion of, and to engage in preven- to medical science. not despise the cultural and social tive action in relation to, nearly all This instruction should not be values of each community of the illnesses, we cannot utilise them confined exclusively to the train- world but try to incorporate the to the benefit of the world’s popu- ing of new medical doctors. It benefits of medical progress with- lation considered as a whole. should also involve on-going out dehumanising the individual, What has just been observed medical instruction for medical his family, or society as a whole. has its roots in part in the bad dis- doctors who have already gradu- The globalisation of medical in- tribution of the global economic ated and are engaged in the daily struction and practice must not in- income, and in part in the practice of clinical medicine. volve contempt for this element socio-cultural realities of the vari- It is difficult to imagine what which is so relevant for the devel- ous regions of our planet. At the should today be the profile of opment and growth of humanity. present time, despite the fact that medical doctors. However, for the The diversity of climatic and so- we have very sophisticated drugs medical profession to survive in cio-economic contexts will estab- and medicines and very advanced modern times the primary goal of lish barriers to the worldwide ap- instruments for the creation of di- medicine should not be lost from plication of medical principles of agnostic and therapeutic images, sight – that of taking care of the a particular character. We must over half of the medical consulta- health of mankind and seeing the not contaminate local medical in- tions which take place in North human being as an end and not as struction through a universalisa- America involve alternative med- a means. In this way humanism tion of those particular features icine. Hydrology, magnetic medi- will always be the basis of the which do not correspond to all the cine, naturism, acupuncture, medical structure and will ensure realities of the world. In Mexico homeopathy, herbalism, and other that the individual is never rele- we often use a term which exem- non-scientific medical practices, gated to second place. In this way plifies what I have just said, that is instead of diminishing in impor- it will act as a guide in relation to to say ‘to tropicalise’ (tropi- tance seem to be engaged in a the daily ethics of medical prac- calizar). This refers to the appli- self-confident ascent. In large part tice. This is a reality which must cation of universal medical this is due to the lack of regulation be shared day after day by each knowledge at the level of its by health care governmental au- and every medical doctor who is a processes rather than in terms of thorities which is present in all the part of that world community its fundamental universal bases. countries of the world. We should which is made up of those who The history of humanity has not forget that most people in serve health. demonstrated for over two thou- government are not medical doc- However, the environment sand years that universal princi- tors and do not know about the which surrounds us has changed a ples are constantly redefined and importance of these non-scientific great deal. These changes are to that an adherence to the dogmas branches of alternative medicine. be found in an increased popula- of scientific or non-scientific On the other hand, because they tion, an improved management of medical practice often leads to are ‘not very remunerative’ and information, better technology their obsolescence over time. ‘involve little risk’, such practices and a higher quality of life. Un- One of the missions which we have not gained the attention of fortunately, this reality is the pre- as a Church have in the field of people in government with a view rogative of only a narrow number health and health care is that of to regulating them as has hitherto of people and has not reached a favouring and promoting access been the case with scientific med- majority of the world population. to better forms of health service icine, which belongs to the sphere Social injustice in economic dis- for all the populations of the of concern with looking after the tribution continues to be the ele- world. Our Lord left to us the world’s health. Equally, we ment which hinders mankind in apostolic mission of going out in- should not deny that those who the promotion of the most ad- to the world to take care of the practise alternative medicine of- vanced and up-to-date forms of sick in their suffering and where ten place greater emphasis on the progress in the knowledge and possible to cure their illnesses, to gg

98 HEALTH CARE AND SOCIETY help them along the lines taught mental and spiritual well-being of should engage in the communica- us by the Good Samaritan, to be the individual, and, when we refer tion between different specialists moved by solidarity in our con- to community health, of his or her of medical information through duct and behaviour to convert this community as well. telepresence medical pro- mandate into reality, to be com- In this way, to medical doctors grammes. In this way we can mitted to our brothers and sisters as well it will be taught that the shorten the distance between pa- and to give them the best of what promotion of health is an under- tients and their medical doctors we have for their care and treat- taking which involves the partici- and achieve a better distribution ment. But at the same time we pation of the whole of the com- of abilities and make them avail- must see ourselves as one large munity, at both a local and world- able to distant and remote places. family, we must see that we are all wide level. For this reason, such In communicating in this way brothers and sisters in Christ, activity cannot be carried out by with the world one can promote from whom we obtain the re- the individual alone. Hence the care amongst all the populations sources and the inspiration to de- imperative that medical schools of the universe. feat illness. We must also oppose should promote communication Only by creating teams of med- illness and find in Christ and with, and the active participation ical doctors who know about through Christ all those resources of, their students, to their benefit medical science and are active in which are needed to deal with out and that of their communities, their communities, and by devel- human condition, preparing our- teaching them to work in a team, oping programmes which pro- selves at the same time for eternal both as collaborators and as lead- mote individual, family and col- life. ers in relation to their own collective health in specific commu- Today, with the phenomenon of leagues. This approach of leader- nities, will we be sure to go on globalisation, we have broken the ship must be promoted beginning implementing this great mandate barriers of non-communication, with a Catholic vision of service which we received from our Lord and we are the living witnesses of strongly based on the social doc- Jesus Christ two thousand years worldwide human suffering. The trine of the Church. At the same ago. In this way, his kingdom of Church must, therefore, act in line time the medical doctor must be peace and justice will be ad- with these times that we are now educated to use those instruments vanced and built so that, through living, both at a universal level, of communication which enable the corporeal and community through the Pontifical Council for him or her to keep in contact with health which we enjoy in this life, Health Pastoral Care, and through his or her own patients, his or her we can obtain eternal life with her bishops in their local dioceses own community, and the rest of him in his glory and eternity. and through the religious and sec- the medical profession in an ef- ular organisations rooted in the fective and up-to-date way, taking Dr. TOMÁS BARRIENTOS principles of Christianity which advantage of the opportunities FORTES, are produced by civil society and which God provides us with day Director of the School of Medicine, which are committed apostolical- after day to the benefit of our pa- the University of Anáhuac, ly to their brothers and sisters tients. At the same time, we Mexico. within the Church in the building up of health care initiatives and services of both a local and a universal character. Catholic medical schools must not abandon the task of training medical doctors who know at a fundamental level the workings and the structure of the human being, created in the image and likeness of his Creator. They should also be committed to look for the best routes and paths by which their neighbour can maintain his or her health, and recover that health which has been lost. One must begin with the teaching of the concept of health as defined by the World Health Organ- isation and which the Holy Father brought to completion when he added what in reality is its most important aspect, that is to say spiritual well-being. This should be done so that it is understood that health is the physical, social, gg

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saturday 18 RUDESINDO DELGADO PÉREZ november V: The Training of Chaplains

Introduction future work and initiatives in this ic-care institutions which are be- field of formation. coming more complex and expen- I would like to divide the analysis 3. In this paper I have chosen to sive and through which, sooner or of the subject which has been en- centre the discussion around actual later, pass all citizens. They must trusted to me into three sections: practice, although such a discussion be known about for a good service first of all I will make certain obser- is clearly based upon theoretical re- to be provided. Good will is not vations, then I will provide some flection on, and illumination of, the enough. reasons for upholding the need and question in hand. 2. Hospitals are a key place for urgent importance of the training of 4. The sources on which this pa- the new evangelisation. The Church chaplains and I will describe the per is based are the documents of has the challenge and the opportu- ends and the fundamental contents the Magisterium of the Church on nity to illuminate with the values of of such training, indicating some of the training of presbyters, the re- the Gospel and her rich tradition the its characteristics and pointing out flections and experiences in relation meaning of the fundamental events some of its stages and instruments, to the subject of the Church over re- of the existence of those who live in and finally I will present certain cent years, and my experience as a hospitals, and to contribute to a policies designed to bring about the chaplain and Director of the De- clarification of the serious human, implementation of such training. partment of Pastoral Care in Health social and ethical problems which of the Spanish Bishops’ Confer- arise within hospitals. A world of ence. this kind requires today better wit- 1. Observations nesses and masters or teachers. 3. Pastoral work in modern hos- First of all, I would like to make 2. The Evident Need for, pitals is not an easy task. It is tiring certain observations in order to con- and Urgent Importance of, and can wear out or stress people. textualise and locate this subject, the Training of Chaplains The secularised and technologised discern its importance, and under- environment which reigns within stand its failings. In the Church, above all begin- them, religious indifference, the 1. I will focus on the training of ning with Vatican Council II, train- rapid coming and going of sick peo- chaplains, that is to say the training ing has been a constant and repeat- ple and the constant changeover of of presbyters to whom has been ened element present in all fields and patients to be treated and care for, trusted the pastoral care of the faith- sectors. There has been a clear the excessive burden of work for ful in hospitals. I will not dwell up- awareness of the fact that training the staff and chaplains, the daily on the training of those who, with- and constant up-dating are a need contact with people who suffer etc., out being priests, provide religious and requirement when it comes to all require training, commitment, assistance as members of the pas- all those who exercise a profession, realism, dedication and care. toral service of the Church, al- have a position, or engage in work, 4. Training today is even more though what I will say is in large in order to be effective and necessary and urgent because a no- part applicable to them as well. This up-to-date. In the case of the priest, table number of chaplains were not training without doubt deserves pri- training is required of him and it is in their time prepared for, and made ority attention because one is deal- an expression of the faithfulness of capable of, working in the world of ing here with an essential route by his ministry, his love for Christ, and pastoral care in hospitals. which to achieve the renewal of the a duty of justice in relation to the 5. Only good training will allow pastoral services provided by the People of God who have the right to chaplains to acquire the necessary Church. service to the Word, the sacraments, ability to co-operate in centres with 2. I have observed the chaplains and charity (PVD, 72). people and services which take care of that part of the first world where With respect to chaplains, the of sick people. Latin culture prevails, although I do need for their training is a reality for not have tried and tested evidence the further following reasons: on the training of chaplains of An- 1. The chaplain carries out his 3. The Goals and Contents glo-Saxon culture or in the third mission in an institution which has of the Training of Chaplains world. This is an important limit undergone great changes. Today, which I hope will be a stimulus for hospitals are secularised, scientif- John Paul II has said that ‘the gg

100 HEALTH CARE AND SOCIETY profound meaning of training is that whose actions they co-ordinate by and Christian possibilities of ill- of helping priests to be and to carry being a bond of unity.4 ness; the human and Christian value out their functions in the spirit and Training must help chaplains: 1. of the giving of blood and organs; in the style of Jesus the Good Shep- To feel that they are ministers of Je- the human and Christian experience herd’ (PDV, 73). The training of sus Christ, the sacrament of the love of old age; and the human and chaplains has as its goal not that of of God for man, every time that Christian sense of dying.6 defining their role but of helping they are mediators and alive instru- them to grow and to mature in a hu- ments of the grace of God towards 3.2. Visiting and Accompanying man and Christian way, to define men (PDV, 73). 2. To mature an the Sick Person and his or her their own identity, and to enable awareness of the fact that their min- Family in the Process of his them to carry forward in an effec- istry is radically ordered to sum- or her Illness, Treatment tive way their mission’.1 moning the family of God as a and Care, and or Death brotherhood which is animated by The sick person, and his or her a. Helping to Grow and Mature charity and to bring it to the Father family, is the privileged centre of in a Human and Christian Way through Christ in the Holy Spirit the attention, care and pastoral con- (PDV, 74). 3. To grow and develop cerns of chaplains. Visiting and ac- The first objective of training is within themselves an awareness of companying the sick person must the very person of the chaplain. their own participation in the salvif- be based upon the same approach as Training must help chaplains to ic mission of the Church (PDV, 75). Jesus and offer to the sick person know their own internal world and The careful contemplation of Je- the help that he or she needs in or- their own therapeutic resources, to sus, of his life, of his words and his der to live out the various stages of meet their difficulties and their af- actions, his way of addressing him- his or her illness in a good way in flictions, and to reconcile them- self to suffering and death, his way order struggle in a worthy way for selves with their own death. of acting and his relationships with his or her health and where this oc- Training must favour within people, and especially with sick curs to draw near to death with chaplains the growth of mature per- people, will help chaplains to define hope. sonal feelings. This is because love their own identity as pastors and Training must help chaplains to for God is especially communicat- their style of presence next to the know in profundity the interior ed through the witness and the ex- sick person and to faithfully carry world of the sick person, his or her pression of one’s own life. out their mission in the name of the needs, and particularly his or her Amongst the qualities which Lord as friends and servants of life.5 spiritual and religious needs. It chaplains must cultivate the following may be listed: deep respect for 3. Supporting and Completing other people, readiness to help, un- Chaplains so that in an Effective derstanding, knowledge of one’s Way they can Carry own gifts and limitations, an ability out their Missions to establish a person to person relationship, flexibility, discretion, and Training does not end with itself a readiness to co-operate and work – it has a practical goal. This is to in a team.2 prepare chaplains for the effective carrying out of their mission. So, b. Defining the Identity what is their mission and what are of Chaplains their functions?

‘The presbyter, through his pres- 3.1 To evangelise life and health, ence at the side of the sick person, is illness and care, suffering and a sign of the presence of Christ, not death, as well as assistance. only as a minister of the sacraments Training must enable chaplains but also as a special servant of his to enter into deep dialogue with the peace and his consolation’.3 culture of the world of health and As a servant of the Word, chap- health care and offer the meaning lains proclaim the truth of the which the Gospel, theology and the Gospel, applying it to the concrete Magisterium give to such important circumstances of life in hospitals. subjects as: the defence of and care must in addition help them in rela- As a servant of the sacraments, for life; the human contents of a re- tion to the pastoral help which has chaplains preside over the Eucharist al quality of life; health as a respon- as its objectives: and celebrate repentance and the sible endeavour directed towards – To better understand the needs anointing of the sick (PO, 6). As the overall growth of the person; the of the sick person, take on board his pastors, sent by their bishops to the ecological meaning of health un- or her questions, understand those hospitals, they have the mission of derstood as harmony with the envi- questions which are not expressed, exhorting Christian brotherhood ronment in which life develops and and share his or her hopes, trials and amongst all those who work in hos- grows; the Christian vision of the joys. pitals or pass through them, and of physical dimension of man and the – To learn the art of listening and creating a pastoral group or team, government of the body; the human communication. gg

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– To know how to begin, deepen, which are raised in the exercise of even more to realise that the stay of and conclude pastoral encounters. their profession. Where health care sick people in such a centre will be – To teach us to walk with the workers are members of religious increasingly short in duration. sick person, and to follow and re- orders, chaplains must dedicate Training will help chaplains to dis- spect his or her rhythms. special attention, seeing their pres- cover this need and to break this – To know the resources of Chris- ence in positive terms as a gift and isolation, which brings benefits to tian faith on order to live out illness relying on their co-operation in the nobody at all.11 and death. activities of pastoral service.8 Some sick people must have pri- 3.8. To Construct the ority for chaplains: the terminally 3.5. The Offering of Ethical Christian Community ill, the mentally ill, those suffering Consultation to Sick People, within the Hospital from AIDS, the elderly, sick people their Family Relatives, Chaplains have the task of build- belonging to other denominations the Staff, and the Services ing up and presiding over the Chris- or faiths, patients far from home, of the Centre when they tian community within hospitals. It and non-believers. Training must are asked to do so is the helping body of Christ within prepare chaplains in relation to spe- In hospitals, every day, the great which every member of that com- cialised pastoral care for these sick questions of science are raised, and munity develops their own charism people. ethical problems concerning sick and places it at the service of their people, their relatives, health care mission – evangelisation. Training 3.3. Celebrating Life in the workers, and the various depart- must make chaplains able to pass Sacraments of the Sick: ments and services, present them- from pastoral work where they al- Reconciliation, Communion, selves. Training will help chaplains most alone are the protagonists to Anointing and the Viaticum to make a contribution to their un- pastoral activity effected in com- The celebration of the sacraments derstanding and their clarification, munion with, and with the co-re- occupies a privileged place in the taking part in the training of health sponsibility of, the members of the mission of chaplains. Training must care workers and offering that ethi- pastoral service, the Christians who help them to understand the theo- cal consultation which is asked for, work in hospitals, and voluntary logical meaning of each sacrament, as well as actively taking part in workers as well. In the same way, to organise their celebration with those committees of ethical assis- training must prepare chaplains to real zeal, to discern the motivations tance which are now growing up organise the pastoral care which has of the sick person at a pastoral lev- and spreading in hospitals.9 been planned, carried out and as- el, to seek out the right moment at sessed within a group where all par- which to bring about the active par- 3.6. Co-operating in the ticipants, respecting their own ticipation of the sick person, to ex- Progressive Humanisation charisms, should work to overcome plain to him or her the expressive of Health Care individualistic tendencies and wealth of each sacrament, to en- The humanisation of health care temptations.12 courage where possible celebration is one of the great concerns today in in community form, and above all the hospital world. Training must else to stimulate the nearness of be- prepare chaplains so that they can 4. The Characteristics lievers, family relatives, workers co-operate through: the provision of of Training and volunteer workers who are near the humanising force of the Gospel to sick people and thereby values (compassion, respect, mutu- Each form of training has charac- ‘sacralise’ with their service and al help, solidarity, free self-giving, teristics which differentiate it from work the presence of the healing reconciliation...), the human and other forms. Those characteristics and saving Christ.7 competent discharge of their own which make the achievement of its functions, care for those who must goals and objectives must be cho- 3.4. The Pastoral Care suffer the effects of dehumanisa- sen. Taking this reality into account, of the Staff of the Centre tion, and participation in and sup- the specific and on-going training Pastoral care directed towards port for actions which are promoted of chaplains must have the follow- health care workers, and particular- in hospitals to obtain more human ing characteristics. Such training ly Catholic health care workers, is treatment, etc.10 must be: an obligation of primary impor- Overall and integral: it must in- tance which, however, chaplains at 3.7. The Promotion of a more volve all the dimensions of training times neglect. Training must make Intense and Fecund and act to support authentic spiritu- them able to look after such health Relationship with Parishes ality, careful human and theological care workers with regard to their The Christian community which grounding, and effective technical spiritual and religious needs. In ad- is present in a hospital centre, ability in communication and or- dition it should help them to discov- which receives and cares for sick ganisation. Something which begins er in a better way the meaning of people, does so as an extension of with life (the exercise of the min- their work and the Christian con- the community from which they istry), illuminates life and returns to tents of their healing service; sup- come and to which they return. It is life. port their efforts to further human- thus necessary to achieve a more in- Theoretical-practical: it must ise assistance to the sick and share tense relationship and greater link action and knowing because in with them the serious problems co-operation between both, and acting we express what we learn gg

102 HEALTH CARE AND SOCIETY and in our action we can constantly are present in certain subjects such America, Canada, the countries of learn. as Holy Scripture, Christology, the central and northern Europe, the Active and personalised: it must sacraments and liturgy, anthropolo- Philippines etc.) specific training is involve the subject of the formative gy, philosophical and moral ethics, a requirement in order to practice as process who is really its protago- and pastoral care. a chaplain and has characteristics nist. In practice some seminaries offer which derive from the socio-cultur- Participated in and shared: it a basic initial training through con- al climate, from ecumenical sensi- must be gained through personal versations, encounters, and short tivity, and from a pragmatic spirit. study and reflection carried out courses, and promote pastoral expe- These countries place greater em- within a group. riences in the field of the sick – vis- phasis on the Word, on pastoral dia- Transforming: it must involve iting them, bringing the commu- logue, on an apprenticeship based help being a factor in the growth of nion to them, taking part in fields of upon experience, on the profession- the person and the identity of the work or voluntary work during hol- alisation of the chaplain, on open- chaplain, his attitudes, his knowl- iday periods... ness to interdisciplinary co-opera- edge, and his weaknesses. Every summer in Spain since tion, and the organisation of pas- Contextualised: it must be some- 1995 a theoretical-practical course toral service. They use the training thing adapted to concrete situations, on pastoral care in health has been model called CPE (‘Clinical Pas- the health care context in which held. This has been very well re- toral Education’) which sees train- chaplains work, and to the needs of ceived by the candidates involved ing as a constant process of growth the recipients of the ministry. who have also given a very positive in three domains: the personal do- Gradual: it must be a process assessment of it. The initial train- main, being oneself, growing in an which favours and fosters a harmo- ing of seminarists in this pastoral awareness of the weak and strong nious growth, which respects the field can be a nursery for future aspects of one’s own personality rhythms of people and which does chaplains, something which is in- and with a gradual filling in of the not seek to do things too quickly. creasingly necessary if we take into ‘dark zones’; the professional do- It must have Christ as a model, account the average age of chap- main, knowing how to do good the Spirit as a guide, and sick peo- lains today, which indeed is ad- well; and the theological domain, ple as teachers. vanced. reflecting theologically on one’s own experience and discovering the 5.2. The Specific Training spiritual needs of people, trying to 5. Levels or Stages of Chaplains see with them the signs of the pres- of this Training It is right to recognise that over ence of God in human events.14 recent years initiatives and activity In countries with a Latin culture Training in pastoral care in health of a training character have in- (of the European-Mediterranean involves various levels which then creased in number. This is the result area and those in Latin America) unfold during the subsequent stages of greater awareness and greater specific training is not an obligatory of that training. commitment on the part of chap- requirement in order to be appoint- lains, to the impetus given to trained a chaplain but it is a need to 5.1. The Initial Training ing by the various bodies of pastoral which an answer should be given. of Seminarists care in health and the associations The training model is not that of This has two principal objectives: of chaplains, to the institutions Clinical Pastoral Education, al- 1. To sensitise seminarists in rela- which are being created to provide though some of its characteristics in tion to pastoral care in health and to training in this pastoral field, and to adapted form are now being incor- make them suited when they be- the training requirements of our porated. come presbyters to carrying out the hospital centres. In the Spanish Church we have mission which the Church has en- It is also true, however, that often made a great effort over recent trusted to them – that of ‘looking af- priests are sent to hospitals without years to increase the awareness and ter the sick and the dying with care suitable training, and in some case facilitate the training of chaplains. and concern’ (PO, 8). 2. To take ad- without a vocation, and that they After a survey in which the training vantage of the opportunities offered are left to look after themselves. requirements were set out, a train- by contact with sick people to clari- This has a negative effect both upon ing plan was drawn up which in- fy, assess, strengthen or modify a the evangelising presence of the cluded a programme of subjects, life choice, that is to say their voca- Church in hospitals and upon the the holding of one or two annual tion. ‘the training of pastoral care in priests themselves who experience courses at a national level to reflect health’, John Paul II writes, ‘is for being immersed in an unknown upon those subjects, and the distrib- the candidates to the priesthood an world which for them is at the least ution of information material to ex- authentic school of life and a secure foreign and at times hostile where amine these subjects through per- means by which to achieve person- they have to engage in activity for sonal study and reflection in meet- al growth because it is directly which they do not feel prepared. It ings and in diocesan meetings. This based upon the example of Christ is self-evident that this situation is a was begun in 1983 and beginning the Physician’.13 serious one and that it is necessary with the third year the courses were In the study plans pastoral care in to find a remedy to it. opened to members of religious or- health does not appear as a specific In countries with an Anglo-Sax- ders working in health care and to subject but its themes and elements on culture (the United States of members of the laity who were be- gg

DOLENTIUM HOMINUM N. 46/1-2001 103 ginning to work in the services of local Churches. It confers academic of pastoral service, and the provi- pastoral care. The development of titles (diplomas and doctorates in sion of support to them in the carry- each subject begins with an analysis the theology of pastoral care in ing out of their mission. of the reality followed by biblical health) and with its various activi- 5. Support for the establishment and theological illumination of it, ties it has helped to give rise to a of schools, training centres in pas- and ends with a pastoral answer. new culture of life in order to make toral care in health, and other initia- The methodology employed links the field of health and health care a tives directed towards the training the exposition of doctrine with ac- privileged place of evangelisation. of chaplains and other people en- tive personal and group work. In This is the first and so far the only gaged in providing pastoral care. 1987 the bishops of the Episcopal higher theological institute of its 6. The permanent stimulation of Pastoral Commission published a kind which has been established. theological-pastoral reflection in re- report entitled ‘pastoral directions lation to the fundamental events ex- in religious assistance in hospitals’ perienced in the world of health and which contains a favourable assess- health care – health, illness, suffer- ment of the development of hospital ing, death, assistance, forms of pastoral care. treatment and care, questions of justice etc., involving bible experts, 5.3. The Permanent Training theologians, catechists, and special- of Chaplains ists in pastoral work, in addition to Permanent training has amongst secular health care workers, associ- other goals the following specific ations for sick people, and other ex- objectives: 1. To offer mutual help perts in this whole field. through the communication of 7. The decisive promotion of in- one’s own experiences and reflec- tegrated pastoral services for tions. 2. To face up to the risks priests, members of religious or- which pastoral work in hospitals ders, and members of the laity who runs – routine, inner tiredness, ex- work in a team, with the provision aggerated activism etc. 3. To ac- of the wealth and the complemen- quire up-dating on aspects and sub- tary advantages and benefits of jects of training so as to be more ef- their respective charisms. fective. Permanent training is ef- 8. The establishment of an inter- fected through personal study and national association of chaplains. by taking part in periodic meetings, 6. Some Proposals I hope and wish that these pro- study-days, seminars or courses, posals will soon become a happy experiences undergone together, The training of chaplains is the reality as a result of the efforts and spiritual exercises, activity directed task and the responsibility of chap- co-operation of everybody, so that towards the permanent training of lains, as it is of the bodies of the pastoral services in hospitals are members of the clergy, and so forth. Church which deal with pastoral qualified and ecclesial services At the present time various in- care in health in the dioceses, in the which are co-ordinated with the struments are utilised. They are: bishops’ conferences, and in the other services which are provided Specialised reviews or journals Holy See. I would like to present, and with the pastoral work of the such as Dolentium Hominum, after the above observations, a Church as a whole. Aumôniers d’Hôpitaux, Insieme number of practical proposals. I would like to finish with the per Servire, Labor Hospitalaria, They are as follows: words of a priest who is a friend of Camillianum, Horizonte Médico, 1. The carrying out of an in-depth mine. These words were provoked Selare, etc. study of the present-day situation in by the death of a sick woman whom relation to the training of chaplains. he looked after in a pastoral sense: 5.4. The Training of Trainers 2. The creation of a service which ‘Yesterday, when I greeted you... The growing demand for training stimulates co-operation and co-or- do you remember? I held your and the improvement of its quality dination between the various insti- hands in mine. I said to you: “they require specialists who are well tutions connected with the training are very cold”. And you answered: trained in matters relating to pas- of those engaged in pastoral care in “You always have warm hands. You toral care in health. Today there ex- health, and which gives an impulse are the pastor”. Without knowing it, ist suitable institutions for such re- to, and stimulates, the exchange of you gave me one of the most beau- quirements. Amongst these there training experiences, programmes, tiful definitions of priesthood. To be stand out the International Institute documents, and other elements con- a priest means ‘to always have of Health Care Pastoral Theology nected with training. warm hands’. It means, in a selfish “Camillianum”. This is a centre of 3. The giving of greater relevance and egotistical world, to bring the Camillian fathers which was ap- in seminary training programmes to warmth to very many people who proved by the Holy See in 1997 and the theoretical and practical con- die of cold because they do not re- which provides theological training tents of pastoral care in health. ceive love. You yourself died thank- and pastoral practice for the world 4. To ask for and facilitate the ini- ing God for the fact that you felt of health and health care. Its results tial and permanent training of chap- surrounded, until the end, by the have already been observed in our lains and all the personnel and staff love of your dear ones. gg

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In taking your leave of me I said 2 Comisión Episcopal de Pastoral, op. cit., n. JOHN PAUL II, the apostolic exhortation Pas- 179. tores Dabo Vobis, on the training of priests in to you “goodbye”. And you an- 3 Ritual de la Unción y de la Pastoral de En- the present-day context. swered me: “goodbye until the next fermos, Orientaciones dcotrinales y pastorales Pontificio Consiglio per la Pastorale della life!” And to my surprise and del episcopado espaZol, n. 147. Salute, Carta degli Operatori Sanitari (Vatican 4 Comisión Episcopal de Pastoral, op. cit., n. City, 1995). amazement you raised your right 147. Pontificio Consiglio per la Pastorale della hand, made three signs of the cross 5 For the basic questions of the study-week Salute, Formazione sacerdotale e pastorale in the air and gave me your bless- on ‘the Catholic chaplain in pastoral care and sanitaria (Vatican City, 1990). health on the threshold of the third millennium’ The Pontifical Council for Health Pastoral ing. I left your home with my eyes organised by the Pontifical Council for Health Care, seminar on ‘the identity of the Catholic swollen with tears. I will never be Pastoral Care and held on 22-23 November chaplain in pastoral health in care and health able to forget that blessing which 1999, see Dolentium Hominum, n. 44, 2000/2. care on the threshold of the third millennium’, 6 Departamento de Pastoral de la Salud, in Dolentium Hominum n. 44, 2000. was as surprising as it was unex- Congreso Iglesia y Salud (Edice, Madrid, Comisión Episcopal del Clero (Conferencia pected. I will always carry it in my 1995), n. 175. Episcopal EspaZola), Congreso Espiritualidad heart as a valuable relic because this 7 Departamento de Pastoral de la Salud, op. Sacerdotale (Edice, Madrid, 1989). cit., n. 165. Comisión Episcopal de Pastoral, La asisten- blessing will remind me that my of- 8 Departamento de Pastoral de la Salud, op. cia religiosa en al hospital. Orientaciones pas- fice as a priest is to bless everyone, cit., n. 166. torales (Edice, Madrid, 1987). to forgive, to serve, to work for oth- 9 Comisión Episcopal de Pastoral, op. cit., Departamento de Pastoral de la Salud, Con- nn. 120ss. greso Iglesia y Salud (Edice, Madrid, 1995). ers... and will carry in my hands the 10 Comisión Episcopal de Pastoral, op. cit., Consulta Nazionale della Cei per la Pas- ever alight flame of a sincere and nn. 135-136. torale della Sanità, La Pastorale della Salute selfless love’. 11 Departamento de Pastoral de la Salud, op. nella Chiesa Italiana (EDB, Bologna, 1989). cit., n. 167. F.ALVAREZ, ‘Pastoral de la salud, un reto a la 12 Departamento de Pastoral de la Salud, op. formaci\n’, in Dolentium Hominum, n. 32, Rev. RUDESINDO. cit., n. 164. 1996. DELGADO PÉREZ, 13 JOHN PAUL II, ‘Speech to the Plenary As- A. BRUSCO AND L.SANDRIN, Il cappellano National Ecclesiastical Consultant sembly of the Pontifical Council for Pastoral d’ospedale. Disagi e nuove opportunità (Edi- Assistance to Health Care workers’, Rome, 9 zioni Camilliane, 1993). of the Association of Health Care Workers, February 1990. A. BRUSCO, La humanización de la asisten- PROSAC, 14. A. Pangrazzi, Girasoles junto a sauces cia al enfermo (Sal Terrae, Santander, 1999). Spain. (Sal Terrae, Santander, 1999), pp. 61-62. Instituto Internacional de Teologia a Distan- cia, Plan de formación sistemática. Pastoral de la Salud (Madrid, 1996). H.J.M. NOUWEN, Un ministero creativo Bibliography (PPC, Madrid, 1998). A. PANGRAZZI, Girasoles junto a sauces (Sal Vatican Council II, Presbyterorum Ordinis, Terrae, Santander, 1999). Notes Decree on the ministry and the life of pres- A. PANGRAZZI, ‘El cappelán, la asistencia re- byters; Optatam totius, on training for priests. ligiosa y la cappellanía’, in Dolentium 1 Comisión Episcopal de Pastoral, La asis- The rite of the anointing of the sick and pas- Hominum, 33, 1996. tencia religiosa en el hospital (Edice, Madrid, toral care for the sick. The directives and notes AAVV, Dizionario di teologia pastorale 1987), n. 178. of the Spanish Episcopate. sanitaria (Ed. Camilliane, Turin, 1997).