Dr. Mary Dockter (MD): Father Tad, you’re a priest from the Diocese of Fall River, Massachusetts, and a respected authority in the world of Catholic bioethics. Before you entered seminary in pursuit of the priesthood, you earned a doctorate in neuroscience from Yale and worked as a molecular biologist at Harvard. Were questions of bioethics something you were drawn to from the very beginning and throughout your studies, or did that interest come up later in your career? How did that all come about?
Fr. Tad Pacholczyk (FTad): My interest in bioethics started during graduate school. When I was at Yale for my doctoral studies, I encountered a situation where a nearby laboratory was bringing in fetal parts from abortion clinics. I learned about this in a roundabout way, and it triggered a lot of thoughts and concerns on my part. I didn’t really have any training in bioethics at that time, but I knew that science is so incredibly influential in our society and I felt instinctive concerns about even esteemed scientists heading off in bad directions if they don’t get the ethical lines straight. So that was the genesis of my interest in bioethics.
Subsequently, while still a student at Yale, I also took classes at a nearby seminary part-time, aware that I was going to be a priest in the future. I enrolled in a bioethics course taught by Father Ronald Lawler, and it was, I can honestly say, the best course I’ve ever taken on any topic – and I’ve done a huge amount of coursework in my life as a student! So Fr. Lawler sparked a real interest for me in bioethics. He could take a really challenging bioethical question and probe it from various angles and expose what the key questions really were, and for me to watch his mind work, and the wheels turning live and “on the spot,” was enthralling. He was a remarkable and gifted teacher. At that point, I still didn’t have any idea that I would one day study bioethics myself or end up at the National Catholic Bioethics Center (NCBC) in God’s providence, but Fr. Lawler’s influence was unmistakable. Many years later, when he was dying of cancer, he came to a Fellowship of Catholic Scholars meeting and I had a chance to personally thank him for the significant influence he had on me and my career direction.
MD: As a Catholic university preparing students for careers in health sciences, we teach our students to navigate ethical questions in terms of the principles of Catholic bioethics. Why does Catholic bioethics focus on principles? Why is it important for any Catholic student pursuing a career in the health sciences to be familiar with those principles?
FTad: The world that we’re a part of has a given structure, and that very determinate structure is also reflected in the kind of beings that we are. This has the consequence that there will be certain types of actions, freely chosen, that properly respect the order of our being and others that do not, and will be invariably harmful to our being. The notion of principles arises out of that key insight — that there are objective affirmations that can be made both about reality and about the nature of who we are as human creatures, and in light of those, certain choices will be good while others will be detrimental to us. So principles become important in illuminating our own decision-making processes and assisting us to make more rational and coherent moral decisions.
MD: Could you speak into some of those principles and say a bit about how they apply in real-life scenarios? For instance, one of the most important principles of Catholic bioethics is the principle of double effect. What is it, and how can it serve as a guide for students in real-life situations?
FTad: The principle of double effect is quite an important principle. I remember the former president of the NCBC, Dr. John Haas, once saying something to the effect of, “I didn’t learn about the principle of double effect until I was 26 years old, and my goodness, I’m not even sure how I managed to survive up until that age!” Such a key principle.
The principle of double effect deals with situations where you have an action in front of you that will have both a good and a bad effect. So you find yourself scratching your head, saying, “If I go ahead with this act, something good is going to happen, but something bad will also follow. Would it be reasonable, and allowable, for me to carry out this act?” The principle of double effect provides a set of criteria by which we can answer these sorts of questions.
The first criterion of the principle of double effect is that the action itself must be a good action: you can’t do something that is intrinsically evil or at its core disordered. The second criterion is that the good effect can’t come through the bad effect, which means that the action you’re doing must by itself be responsible for bringing about, directly, the good effect. We may not do evil, that good may accrue. The third criterion is that there has to be a proportion between the good effect and the bad effect. There needs to be some kind of measure that allows you to say that the good effect and the bad effect are concomitant with each other. If the bad effect really outweighs the good effect, you can’t perform the action. The fourth criterion is that your intention has to be upright and directed only towards the good effect. If you also intend the bad effect, the whole action you are choosing becomes problematic. Those four criteria really make up the principle of double effect. Sometimes a fifth requirement is added: that there is no alternative action available that wouldn’t have the bad effect.
A simple example of applying the principle of double effect would be a situation where a woman is pregnant, but unfortunately a tumor is discovered in her uterus. And let’s say that in this case the tumor is so large that chemotherapy is not an option; moreover, it also cannot be surgically resected. Let’s also say that waiting for the baby to reach viability is not an option either, because by that time, the tumor will have spread so much that it will have already killed both the mother and the baby. So the question becomes whether we can perform a hysterectomy. Could we remove that woman’s uterus knowing there's a baby inside? There is clearly a bad effect attached to that action, namely, that the baby will die. Presupposing that all the conditions I mentioned are satisfied, as they sometimes will be in clinical situations, the short answer would be that removal of the gravid, cancerous uterus could be allowable under the principle of double effect.
The principle of double effect can be very helpful in a lot of maternal-fetal cases, and it’s also helpful when we’re considering situations at the end of life. Maybe we’re dealing with the use of morphine and opioids and we realize that in order to combat a patient’s terrible, agonizing pain we’ve had to administer higher and higher doses as their disease progresses. At a certain point, we may face the prospect that the next dose we provide will be so high that it will cut into the patient’s breathing and they could die. The principle of double effect can guide us through and assist us with those ethical questions, and when the clinical requirement of proper titering of pain medications is done, and the other conditions of the principle are satisfied, a strict, very careful use of pain medication in this manner can be allowable, even when it may indirectly result in an individual’s demise.
MD: Father, the example you gave of the woman who is pregnant and has a cancerous uterus is a classic example of the principle of double effect. How important is it that we preserve clear wording and thinking around examples like that? I think some people would say that the procedure you mentioned in your example would be an abortion to save the life of the mother, which is different from saying it’s a hysterectomy with the unintended effect of the loss of life of the unborn child.
FTad: The words here are really important, as are the concepts. You have to make certain distinctions and I think that’s where the power of words comes into play. In this case, a direct attack on the life of the child and an action that indirectly results in the demise of the child are two very different things. By “direct” I mean, for example, a dilation and curettage abortion where the child is basically removed in parts or pieces: that would clearly be a direct attack on the body-person of the child. Even if that were done to save the life of the mother it would still be a morally unacceptable intervention, destroying the life of one individual for the benefit of another. That’s very different from a procedure carried out on the mother’s body (her uterus) that has the second, unintended (but tolerated) effect that the child will subsequently die. So language is critical along with the fundamental concepts, and precision of terminology is needed to specify exactly the type of moral action one is engaging in.
MD: Certainly for those of us at the Saint Gianna School of Health Sciences, named for St. Gianna Beretta Molla, that is an important example we need to keep in mind. Even once health sciences students and healthcare workers begin to understand the principles of Catholic bioethics, they may find themselves in situations in which they are asked to cooperate to varying degrees with procedures and treatments that go against Catholic bioethics. Could you walk us through how Catholics are to understand the varying degrees of cooperation with morally illicit acts?
FTad: The principle of cooperation in evil is rooted in the notion that cooperation implies that we are making some kind of a causal contribution to the evil actions of another person or institution. Let’s say you have a fellow who is going to rob a jewelry store and he goes to the locksmith, and tells him that he plans to rob the store and asks for a master key to get in. It might be the case that the locksmith willingly helps the robber and shares in his intention of committing robbery. Cooperation in which the intention of the principal agent (the robber) is shared is called formal cooperation, and it is always morally unacceptable to cooperate in that way.
Another possibility is that the locksmith does not share the robber’s intention. Instead, he might cooperate because he’s concerned about losing his friendship with the robber, or he's afraid of what the robber might do, or he feels like he owes the robber something for whatever reason. In that case, if the locksmith goes ahead and makes the master key but does not share the intention of the robber, it is called material cooperation because making the master key was materially very important to the commission of the robber’s action. In this case, the action of making the key is so proximate to the robber’s evil act that it should not be performed, but it is not the same as formal cooperation. That action of making and handing over the master key represents an essential contribution by the locksmith to the evil of robbing the store. When you are making an essential contribution, a contribution that is causally very proximate to what the principal agent – in this case, the robber – is doing, it raises fundamental moral concerns and you ought not cooperate in such a scenario.
I’ll also give an example from the healthcare arena because this comes up all the time. If a Catholic healthcare worker recognizes that a procedure or treatment is morally evil and shares the intention of engaging in the procedure or treatment, that would be formal cooperation, which, again is always unacceptable. But let’s say we have a nurse who is working in a hospital system and everything is going fine, and she is requested to scrub in on a procedure at the last minute. When she checks to see what the procedure is, she realizes it will directly end the life of an unborn child. She is being asked to hand instruments to the physician who will do this. That would be an example of providing an essential circumstance to the act. She may be opposed to abortion, but she is also afraid to lose her job and her means of supporting her family. But in this case she would be causally so proximate to the commission of that evil act by handing the physician the very instrument that will be used for the destruction of human life that it would not be morally permissible for her to do so. But what if she is asked to do something less proximate to the evil act? Let’s say that nurse is instead asked to prepare the room the evening before by cleaning up some of the medical instruments. There is less proximity there. So that case would depend on the gravity of the reasons she might have for cooperating, because she won’t be making an essential contribution to the destruction of the human life – she will be assisting in a more remote fashion.
Speaking in the broadest and most general terms, we should avoid cooperation in any evil action to the extent possible – that should always be our desire or default position. But there can be some circumstances in which some instances of material cooperation can be tolerated on a temporary basis, depending in part on the seriousness of the motivating reasons or factors.
So the principle of cooperation with evil provides a helpful set of categories to make some real-world decisions about whether one can cooperate with certain actions or whether one must decline to do so.
MD: That explanation of the cooperation with evil is helpful, but it also seems like it’s the sort of thing that requires prudence and a well-formed conscience. A lot of the time we want cut-and-dried answers that will get us through any situation we might encounter. But it seems like quite a bit of formation has to go into moral reasoning around these questions even after we have learned the principles.
FTad: Yes, it’s a difficult thing. There are variables that need to be prudentially weighed. So with respect to cooperation in evil, we’re attempting to make assessments about the strength of the causal connection between what we’re doing and what the principal agent is doing. We need the virtue of prudence to weigh all the variables and make those assessments realistically and intelligently.
When we speak about moral formation, we need to make sure that we are forming our conscience to be firmly focused on authentic goods. That will include a determination and willingness to make sacrifices on behalf of what we recognize as good and true. We don’t want our consciences to become corrupted faculties that rubber-stamp problematic actions. One of our most notable abilities as humans is our ability to deceive ourselves, so forming our consciences authentically will require working against that tendency all the time. Some people are very good at that sort of pseudo-reasoning, which is not prudence but rather a false rationalizing where you’re negating certain relevant variables for the sake of obtaining particular outcomes. If you practice that sort of approach with regularity you can quickly lock yourself into habits or patterns of wrongdoing that you no longer even recognize as such.
MD: If it’s possible for someone to have a conscience that’s too relaxed, is it possible for someone to have a conscience that’s too scrupulous?
FTad: It certainly is. That’s another danger which can arise in spiritual direction. For those who are intent on seeking God’s will with earnestness, this sort of danger comes up with some frequency. It requires a virtuous sense to avoid getting caught up in a scrupulous mentality that insists the standards are higher than they actually are. Being anchored in fundamental moral principles assists with avoiding either of those two extremes.
MD: I think the question of personal autonomy is related to all of this. A big question in healthcare is that of personal autonomy, which is often couched in terms of being a way of respecting the dignity of the patient. Where does personal autonomy fit into Catholic bioethics, and is there a limit? How do the autonomy and dignity of healthcare workers enter into that consideration?
FTad: There’s definitely autonomy on both the part of the patient and the healthcare professional. I think it’s important to understand medical decision-making within a dialogical approach, where the patient comes to the medical professional seeking their expertise and at the same time, the medical professional has a sense of respect for the autonomy or individualized decision-making capacity of the patient. So this decision-making process is a form of working together where you’re seeking to eliminate medical misunderstandings and helping the patient to understand the options that truly exist for them. While it is for the patient to ultimately decide, the healthcare professional seeks to guide the patient and assist in making good, prudent and well-informed judgments by sharing from their own expertise and medical judgment.
I think sometimes a little bit of lopsidedness takes hold in discussions about autonomy where the patient becomes the supreme boss who walks in, picks out the procedures he wants as if here were at a supermarket, and insists on whatever procedure he declares. In this kind of thinking the healthcare team exists simply to actualize the patient’s desires. Such a mindset vastly oversimplifies personal autonomy. In reality, there needs to be a nuanced interchange between the patient and the healthcare team so that together they can work toward an appropriate exercise of autonomy from both sides or directions.
Healthcare professionals will face situations where an individual patient may request an intervention, putatively made in the name of autonomy, that actually represents autonomy gone-off-the-rails rather than real autonomy. An example of this would be an individual approaching a healthcare team to request that some form of genital mutation be performed in response to a psychological self-perception that he or she is in a wrongly-sexed body. Another example would be an individual requesting a prescription for a lethal dose of a toxin for physician-assisted suicide. Examples like this manifest a misguided sense of autonomy on the part of the patient, an autonomy gone awry. Beyond that, the autonomy of the healthcare professional includes a central concern to do good by the patient and to “first do no harm,” as the famous dictum puts it, which requires them to conscientiously decline any requests to physically harm the patient. The healthcare professional has this responsibility even if the patient’s request is made in a free or apparently-free manner.
In other words, autonomy is always constrained by responsibility toward objective goods. The moment we negate that responsibility or fail to acknowledge the objective goods that are at play, decision-making devolves into little more than a radical exercise of one’s willfulness. In those cases, there is no requirement on the part of the healthcare professional to accede to such requests. So autonomy is real, but it’s not absolute in the sense that it doesn't extend to include any desire whatsoever that a person may express, nor should it function as a lever arm to force others into compliance with morally-problematic requests.
MD: I think healthcare providers can understand all that from a science-based perspective. Healthcare students and professionals know that determination of the best practice is evidence-based, and we would never think to perform procedures that go against established scientific understanding.
FTad: That’s a good point. An individual’s health care team has a unique expertise that comes from their scientific and medical formation, based upon real-world data, so reasonable, evidence-based claims should always stand as the bulwark behind good medical decision-making.
MD: As you’re explaining all of this, a common objection comes to mind. It’s something I hear quite often. The objection says that it’s not the place of a healthcare worker to make judgments about the lifestyles and personal decisions of patients, and that people have a right to basic healing and restorative procedures free of judgment. It seems like we want to train healthcare workers who aren’t making inappropriate judgments about other people but also don’t compromise their own beliefs by participating in procedures that are contrary to their own beliefs.
FTad: I think there is a sense on the part of many healthcare providers that they ought to remain hands-off when it comes to the lifestyle choices of their patients, and that their job is simply to provide evidence-based care to people in a value-free manner. But at the end of the day, that’s not entirely correct. I think of my grandmother who smoked for 50 years straight. Toward the end of her life the effects of that were starting to show, and her doctor told her directly, “You’ve got to stop smoking.” And the next day she stopped smoking. Someone might say that her lifestyle choices weren’t any of her doctor’s business, but I think that’s untrue. Her smoking was his business in the sense that as a healthcare provider he has a broader concern for the whole human person. Physicians are not merely medical functionaries who perform processes and procedures blindly – they interact with other human beings and have an obligation to look at the full set of goods and values that pertain to those individuals and do what they can to assist them in a context of prudence, discretion and confidentiality.
I think this is all becomes exceedingly complicated in a society like ours which has become highly sexually permissive – if not outright promiscuous. Discussions about changes in sexual behavior have become very, very challenging to engage in. Yet sometimes these discussions are really needed in order to avoid clear harms that may accrue. In Catholic settings this often needs to happen in the arena of birth control and direct sterilization. In direct sterilization, for instance, performed to avoid future children, a surgical procedure permanently damages a healthy and properly-functioning organ system for a lifestyle reason. So a person wants to live their life doing certain actions that are meant to lead to pregnancy but doesn’t want that reality to become a part of their life. In this case, the individual is requesting a procedure that will redirect the whole telos, purpose and rationale for which their life-giving sexual faculties were originally created. A Catholic healthcare system cannot concur in that aim by supporting such lifestyle choices and it would be morally problematic if a Catholic healthcare system or Catholic physicians were to participate in that.
MD: To return to the example of your grandmother, it would be different for a physician to refuse to assent to a request to equip her with intravenous nicotine as opposed to refusing to treat lung cancer. Those situations are different, aren’t they?
FTad: Yes, there’s a difference. But even in the case of providing intravenous nicotine, if that were being done as part of a gradual attempt to draw someone out of addiction, like with a nicotine patch, there wouldn’t be per se a moral problem, recognizing also that cigarettes have a whole host of damaging chemicals present in the smoke besides the nicotine, and to the extent that you could minimize some of those bad effects through a nicotine drip, and help conduct someone along a path of renouncing smoking, it could perhaps be a reasonable path forward.
MD: The important thing, though, is that your grandmother be treated with dignity and respect without the healthcare team going out and buying her cigarettes. We can offer care with dignity and respect without actively condoning or participating in choices that go against our values and beliefs.
FTad: Correct, and that would of course include making the full array of treatment options available if it were found, for example, that the patient had lung cancer. We would not impose restrictions on access to good medical care merely because of what might have been prior bad choices made by the patient, even over many years.
MD: Healthcare is ever-evolving, so even those who are well versed in bioethics are bound at some point to run into situations they don’t immediately know how to navigate. That applies to patients and their families, as well. What resources are there for people who find themselves in those situations?
FTad: There is a good deal of information available online through careful searches, including resources we offer at the NCBC. In addition, when families are navigating certain medical decisions and they feel it would be helpful to bounce a few questions off experts, using them as a “sounding board,” the NCBC provides a free consultation service. We do thousands of consultations each year. People can send us an e-mail or call us or even fax us. Our contact information is available on our website at NCBCenter.org. There are other sources of information, as well, such as clergy. Priests and deacons often have received formation and grounding in ethics from seminary training. Although they may not necessarily have medical training or have studied bioethics specifically, they can have a good moral sense honed through seminary training and subsequent experience that enable them to serve as useful guides to those seeking to understand what the Lord intends them to do in complex medical circumstances.
All of this presupposes that there has been a reasonably serious effort to acquire accurate medical information, which would typically be provided by the healthcare team.
MD: Before we conclude, I was wondering if there were any additional principles of bioethics that I haven’t asked about that would help us navigate these challenging times?
FTad: One principle that comes to mind as being important for us to reflect on – and it’s a challenging principle both for Catholics and for non-Catholics – is the principle that life is meant to be engendered in the marital embrace. Our society has moved in the direction of understanding human life almost as a “product,” especially early human life. This likely began with contraception and escalated further with abortion-on-demand. Assisted reproductive technologies have taken that a step further, and we now create life outside of the marital embrace so we can manipulate it, flash freeze it, experiment on it, hand it over to stem cell researchers, and so on.
The principle that life is meant to be engendered in the marital embrace hearkens back to the idea that all human beings need to enter the world within the context of the one-flesh union of marital love, so as to assure an equality in our origins. If you set up situations of inequality in our origins, where some are created in laboratory glassware, while others are not, the consequences become profoundly unfair to some — some are “more equal” than others, with the older and stronger predominating over the younger and the weaker, and human embryos end up being poured down the sink or destroyed outright in facilities that generate them for customers. So the principle is very important in bioethics, touching many related fields of medical practice.
MD: Father, thank you so much for your time today, and for all that you and the NCBC do for our Bioethics program at the Saint Gianna School of Health Sciences.
FTad: We are honored to be involved. It’s been a great partnership, and you are doing tremendous work at the University of Mary.