In light of the recent controversy surrounding Catholic conscience and healthcare, reprinted below is an article by Br. Ignatius Perkins, O.P., a cooperator brother of the Province of St. Joseph.  Br. Ignatius currently serves as the Dean of the School of Nursing at Aquinas College in Nashville, Tennessee.  Before that, he served as professor and chair of the School of Nursing and dean of the College of Health and Natural Sciences of Spalding University in Louisville, Ky.; executive vice president and staff ethicist of the National Catholic Bioethics Center in Boston; and chair of the Department of Nursing at the College of Mount St. Joseph in Cincinnati, Ohio. While at Spalding, Brother Ignatius established the Center for the Study of Human Dignity, Ethics and Caring in Nursing.  This article first appeared on the Catholic Exchange website on October 11, 2008.

Conscience and Catholic Health Care Professionals

“When he listens to his conscience, the prudent man can hear God speaking” (Catechism of the Catholic Church, n.1777)

Brother Ignatius Perkins, O.P., PhD., RN, FAAN, FNYAM October 11, 2008

We live in a culture where health services are driven by moral relativism, commodification of the human person, the technological imperative, profitability in health services, the creep of utilitarian and impersonal ethical paradigms, escalating costs of health care, and increasing numbers of persons who are uninsured or underinsured.  The exercise of a moral conscience both in those who are sick and clinicians who have promised to help and to heal the sick is seriously compromised in this culture.   One of the major effects of the current culture is the violation of human dignity, the diminution of the human person of the clinician, and the disregard for the formation of an informed conscience in providing answers to ethical issues in health care. Further compromising human dignity in health care today is the enactment of legislative mandates that limit or compromise the clinician’s freedom in making decisions and relegates this role to that of a treatment technician.  This growing dilemma, founded on moral relativism and unbridled autonomy, prohibits Catholic clinicians and others of good will from applying the principles of the natural law, the findings of the confluence of faith, science and reason, and the process of moral assessment, analysis and judgment that can inform health care decisions. Within this culture human dignity, freedom and the right and duty to form the moral conscience, both of the sick as well as all those who care for them is removed from the person of the clinician and assumed by the state. What does the Church teach us about the relationship between an informed conscience, the moral teaching of the Church and participating in mandated procedures that are contrary to both the conscience of health care professionals and Church teaching?  While we cannot look to the Church to solve every ethical dilemma, we do know that the Church has a centuries-old teaching authority that can be brought to bear on the threat to the freedom and obligation to act only from an informed conscience of clinicians caring for the sick and vulnerable in our world. Pope John Paul II, in his Encyclical Letter, The Gospel of Life, 1995 (Evangelium Vitae, EV) brings this dilemma to a sharp optic in the obligation of all persons to promote life through every action.  Several of these principles have enormous importance in supporting health care professionals who refuse to participate in mandated treatment protocols that are contrary to Church teaching and the development of an informed moral conscience.  A brief list of key principles, noted in The Gospel of Life, (though not intended to present a thorough exposé), are listed as follows:

1. It is urgent for the future of society and the development of a sound democracy, to re-discover those essential and innate human and moral values which flow from the very truth of the human being and express and safeguard the dignity of the person: values which no individual, no majority and no state can ever create, modify or destroy, but must only acknowledge, respect and promote.
2. In no sphere of life can the civil law take the place of conscience or dictate norms concerning things which are outside its competence.
3. Civil law must ensure that all members of society enjoy respect for certain fundamental rights which innately belong to the person − rights which positive law must recognize and guarantee. First and fundamental among these is the inviolable right to life of every innocent human being.
4. While public authorities can sometimes choose not to put a stop to something which − were it prohibited − would cause more serious harm, it can never presume to legitimize as a right of individuals − even if they are the majority of the members of society − an offence against other persons caused by the disregard of so fundamental a right as the right to life.
5. Any government which refused to recognize human rights or acted in violation of them would not only fail in its duty; its decrees would be wholly lacking in binding force.
6. Authority is a postulate of the moral order and derives from God.  Consequently, laws and decrees enacted in contravention of the moral order, and hence the divine will, can have no binding force in conscience.
7. St. Thomas Aquinas teaches: human law is law inasmuch as it is in conformity with right reason and thus derives from eternal law.  But when law is contrary to reason, it is called an unjust law; but in this case, it ceases to become a law and instead becomes an act of violence. Every law made by man can be called a law insofar as it derives from the natural law. If it is some how opposed to the natural law, then it is not really a law but rather a corruption of the law.

How are Catholic health care professional to act, morally and professionally, in a culture where legislative mandates diminish the exercise of the moral conscience of the clinician and threaten human dignity and freedom?  The following principles are offered to guide moral action of health care professionals when confronted with a decision to disregard mandated unethical legislation in the care of others:

1.  Assuring respect and protection for the dignity and freedom of the person seeking care and in response to the promise of the clinician to help and to heal, no person should be ever be abandoned because of their preferences for treatment which may be contrary to Church teaching or to the moral principles of the clinician.  Explaining to the patient the ethical principles that govern the moral actions of the clinician can help the patient come to a better understanding of the foundation of human dignity that is the foundation of trust and the promise that the clinician has made to the patient in his presence. In this particular clinical encounter the health care professional continues to affirm the intrinsic dignity of the patient without having to agree to engage in treatments or referrals contrary to his conscience or Church teaching.
2. Health care professionals have the obligation as members of society to work to eliminate existing legislative mandates, or to limit the harm done by them, which violate the dignity and freedom of all persons, themselves and especially the sick, the vulnerable, those who care for them and to act according to a properly formed conscience built from the natural law and the moral teaching of the Church.
3. In the cases of intrinsically unjust laws, such as laws, for example, permitting abortion, euthanasia, physician assisted suicide, prescribing medications to terminate pregnancies, use of federal tax dollars for ethical research protocols, it is never licit to obey them, or to take part in a propaganda campaign in favor of such laws, or vote for them.  There is no obligation in conscience to obey such laws; instead, there is a grave and clear obligation to oppose them by conscientious objection. (EV, n. 73).
4. Health care professionals (and all Christians and other people of good will) are called upon under grave obligation of conscience not to cooperate formally in practices which, even if permitted by civil legislation, are contrary to God’s law.  From the moral standpoint, it is never licit to cooperate formally in evil (EV, n. 73).  Such cooperation can never be justified either by invoking respect for the freedom of others or by appealing to the fact that civil law permits it or requires it.
5. Each individual in fact has moral responsibility for the acts which he personally performs; no one can be exempted from this responsibility, and on the basis of it everyone will be judged by God himself (cf. Rom 2:6, 14-17).

In summary, Evangelium Vitae offers these additional principles to health care professionals facing legislatively mandated health care treatment decisions that are contrary to the natural law and the moral teaching of the Church:

To refuse to take part in committing an injustice is not only a moral duty; it is also a basic human right.  Were this not so, the human person would be forced to perform an action immediately incompatible with human dignity, and in this way human freedom itself, the authentic and purpose of which are found in its orientation to the true and the good, would be radically compromised. What is at stake therefore is an essential right that, precisely as such, should be acknowledged and protected by civil law. In this sense, the opportunity to refuse to take part in the phases of consultation, preparation ad execution of these acts against life should be guaranteed to physicians, health care personnel, and directors of hospitals, clinics and convalescent facilities. Those who have recourse to conscientious objection must be protected not only from legal penalties but also from any negative effects on the legal, disciplinary, financial and professional plane (n. 74).

As stated in the Catechism of the Catholic Church, moral conscience, presence at the heart of the person, enjoins him at the appropriate moment to do good and to avoid evil. It also judges particular choices, approving those that are good and denouncing those that are evil. It bears witness to the authority of truth in reference to the supreme Good to which the human person is drawn and it welcomes the commandants.  When he listens to his conscience, the prudent man can hear God speaking. As health care professionals, committed to promoting human dignity and freedom, let us continue our work of listening and then acting on the basis of a well-formed conscience!   Suggested readings: Libreria Editrice Vaticana (1997). Catechism of the Catholic Church.  Washington, DC; United States Catholic Conference of Bishops, Inc. & Libreria Editrice Vaticana. John Paul II  (1995).  Encyclical Letter-TheGospel of Life (Evangelium Vitae).  Boston: Pauline Books and Media. Ratzinger, J. Cardinal. (2007). On Conscience.  San Francisco: The National Catholic Bioethics Center, Ignatius Press. Ratzinger, J Cardinal. (2005). Values in a Time of Upheaval.  San Francisco:  Ignatius Press. United States Conference of Catholic Bishops.  (2007). Forming Consciences for Faithful Citizenship.   Washington: United States Conference of Catholic Bishops.