Health Policy and Ethics: A Catholic Contribution in a Pluralistic Society

Abstract

Health policy generally seeks to improve the overall health of people in society. Since public health policy involves human values, decisions, and actions, it is inescapably ethical. In recent years there has been a growing awareness of the need for a systematic approach to the ethical analysis of public policy. Some government health-policy statements attempt to provide ethical frameworks. In our pluralistic societies, however, these tend to be pragmatic and lack a solid grounding in an adequate understanding of the human person. This could lead to justifying what is popular rather than what is ethical. This article attempts to show how a Catholic moral approach, which provides a solid foundation for ethics, can make a significant contribution to a discussion of health-policy ethics in a pluralistic society.

Introduction

Health policy generally seeks to improve the overall health of people in society by various means, such as immunizations to prevent diseases, and making changes so that people have healthier lifestyles and a healthier environment. Traditional bioethics or health-care ethics has focused on issues such as research, reproductive and genetic issues, end-of-life issues, and allocation of limited resources, with insufficient emphasis on health-policy issues. There is, however, some overlap, such as with the issue of allocation of limited health-care resources.¹ Health policy can have a profound impact on human well-being. Since it involves human values, decisions, and actions, health policy is inescapably ethical. In this article I attempt to show how a Catholic moral approach can contribute to a discussion of health policy in a pluralistic society.²

Consider a recent article, “Unsustainable: Hard Truths About the ‘American Way of Life,’” by well-known bioethicist Daniel Callahan.³ Among other things, he argues that our ever-increasing use of medical technologies and related skyrocketing health-care costs, as well as our wreaking havoc on the environment, are not sustainable. He thinks we are headed for a bleak future unless we make radical changes in our way of life. It seems to me that this highlights the importance of health policy which promotes the health of a population by means such as preventing illness and injuries, and by encouraging people to adopt healthier lifestyles. In line with the old adage “An ounce of prevention is worth a pound of cure,” perhaps such measures will also help us to manage rising health-care costs, help our struggling economy, and contribute to a more sustainable way of life.

While many things are beyond our control, such as an outbreak of a new strain of influenza, ethics deals with what is within our control, our voluntary actions and omissions: for example, how we choose to respond to a pandemic or what is the best way to respond to drug addicts. Mita Giacomini, Nuala Kenny, and Deirdre DeJean state:

Public policy is an inescapably ethical endeavor, especially in the value-laden health sector…. Clarifying the values that underlie policy options is crucial in pluralist societies facing complex questions about limited health resources, the direction of technological innovation, responses to health threats, and the goals of the healthcare system. Value conflicts are inevitable, and ethical frameworks promise a shared language and focus for consensus building.⁴

After analyzing a number of Canadian health-policy statements, however, they conclude that the ethics frameworks found in them

are puzzlingly diverse, and problematically vague in terms of their authority, justification, conceptual clarity, and practical implications. At present, we lack systematic approaches to the rigorous appraisal of ethics frameworks by scholars, critics, and users….

… Ethics frameworks in many cases seem to play a more decorative than developmental or foundational role…. Descriptive information about their genesis, content, and purpose … is currently missing or vague in many frameworks.⁵

They argue that a sound ethics framework should “provide clear and well-supported arguments for the ethics it promulgates.”⁶

The new and emerging area of “health-policy ethics” … literature demonstrates increasing interest in developing a robust health-policy ethic….

Since the 1970s, there has been a growing awareness of the need for a systematic approach to ethical analysis of public policy. Policy creates the shape and scope of ethical dilemmas and conflicts (e.g., whether we fund a program or not, legalize an activity or not, etc.)…. The primary work of policy ethics is to identify and clarify the values and interests that form the basis of common decisions and action.⁷

With regard to health-care ethics and public policy, Benedict Ashley, Jean deBlois, and Kevin O'Rourke note that a number of government commissions in the United States have produced norms which for the most part are useful and protect the rights of all persons. These proposals have been made with our pluralistic society in mind. However, they do not attempt to reflect an appreciation of the true nature of the human person, so their “conclusions are pragmatic and usually balance rights rather than defend them. Proposing ethical guidelines in this manner is dangerous because it may justify whatever is popular at the expense of what is ethical.”⁸

Religious views tend to get pushed to the sidelines in public discussions. Nevertheless, Ashley, deBlois, and O'Rourke argue that

if we are to promote ethical dialogue, it is necessary that all parties, whatever their worldviews and value systems, talk on equal terms…. To assume that secularist views are religiously neutral and objective and hence alone have a right to be heard in the public forum, while other views are subjective, nonrational, and merely “religious,” is a fatal barrier to genuine dialogue among worldviews and value systems, a dialogue necessary in any pluralistic society…. Secular humanism claims not to be a faith, but to be based solely on hardheaded reason, but it is certainly a worldview and value system that places its faith solely in the human potential…. We cannot permit secular humanism to go unchallenged in its claim to be “neutral.”⁹

In line with these conclusions, it can thus be very worthwhile to consider some things that a Catholic view can contribute to a discussion of the ethics of public health policy. First of all, we can note that Catholic ethics is not only based on faith in what God has revealed to us but also on human reason. For example, in Romans 2, the Apostle Paul speaks not only of God's revealed moral law but also of the natural moral law written on the human heart. The Apostle was aware that even without divine revelation it is possible for human beings to understand something about how we ought to live. With regard to our growing in understanding moral truth, whether revealed by God and/or discovered by human reason reflecting on human experience, the Catholic Church has very much appreciated the complementary roles of reason and Christian faith.¹⁰ Therefore one does not need to be a Catholic in order to see the merit in the Catholic view.

In the following sections, we will begin by considering some things that government or professional organizations or other non-religious writings have stated concerning health policy and ethics. We will then consider how a Catholic moral approach provides a solid foundation for ethics and can contribute to a discussion of health-policy ethics in a pluralistic society. Our treatment of these will include looking at some morally relevant human needs, rights, values, goals, means, and principles, as well as the importance of virtue and community.

Human Needs, Rights, and Values

In the document Public Health: Ethical Issues the Nuffield Council on Bioethics in the United Kingdom speaks of various goods related to public health including responding to the needs of members of the population; equity; fairness; knowledge; education of the public; health; trust; public accountability; changing behaviors to healthier lifestyles; and the value of community, fraternity, and solidarity. They speak of the obligation that States have to look after the important needs of individuals and the population as a whole.¹¹ Giacomini, Kenny, and DeJean discuss a number of common ethical elements, values, or principles in health-policy documents published by Canadian government agencies between 1998 and 2005: equity, accountability and transparency, fairness or justice, client-centeredness, collaboration, mutual support, autonomy, evidence from research, efficiency, access, human dignity or worth, social solidarity, public interest, common good, health and wellness, safety, as well as sustainability regarding the needs of both present and future generations. These documents generally do not provide a rationale for why they included these ethical elements.¹²

In a textbook on Nursing Ethics, Leah Curtin and Josephine Flaherty argue that human needs and our response to them provide an objective basis for ethics. They say that we do not have a right to everything that we may want but that each of us has a right to what we need, that is, to survive or be fulfilled. Having a right to what one needs entails responsibilities. People in certain roles have particular responsibilities to provide for the needs of those in their care. For example, many of the responsibilities of parents are related to the needs of their children for food, clothing, shelter, love, education, and so forth. Many of the responsibilities of nurses are related to the nursing needs of their patients or clients.¹³

A number of rights and responsibilities proclaimed by the United Nations Universal Declaration on Human Rights in 1948 correspond to this. For example, with regard to health, article 25, part 1, reads:

Everyone has the right to a standard of living adequate for the health and well-being of himself and of his family, including food, clothing, housing, and medical care and necessary social services, and the right to security in the event of unemployment, sickness, disability, widowhood, old age, or other lack of livelihood in circumstances beyond his control.¹⁴

Note that this does not say that one has a right to a luxurious lifestyle that one may want, but to a standard of living that will provide for what one “needs.” In article 29, this declaration also says in part: “Everyone has duties to the community in which alone the free and full development of his personality is possible.” It relates these responsibilities to “due recognition and respect for the rights and freedoms of others and of meeting the just requirements of morality, public order, and the general welfare in a democratic society.” This Universal Declaration of Human Rights, formulated shortly after the end of the Second World War, was no doubt a response to the many serious violations of human rights during that war including the Holocaust. This declaration was supported by almost all countries at the time and by the major religions. Catholic popes have praised it as a good common basis or starting point for ethics in our pluralistic world.

A workbook related to personal directives by the Calgary Health Region in 2008 states that “Advanced Care Planning: Goals of Care” discussions should include, among other things, “an offer for involvement of regional resources such as the palliative-care program, social work, clinical-ethics consultation, or spiritual care to assist the patient with his/her needs.”¹⁵ This statement shows an appreciation of, not only the responsibility to help others meet their needs, but also an appreciation of different kinds of human needs—physical, social, ethical, and spiritual.

How does a Christian and a more specifically Catholic moral approach compare to these secular statements of values including the value of responding to human needs? First of all, in the Parable of the Last Judgment (see Mt 25:31–46) Jesus emphasizes the importance of our responding to the real concrete needs of our fellow human beings. He says in part that those who respond to the needs of the hungry, thirsty, sick, naked, stranger, and those in prison will receive eternal happiness, whereas those who fail to respond to those in need will be allotted eternal punishment. Jesus' call to meet the basic needs of people is very relevant to health policy today since, among other factors, lack of good food and drinking water results in serious health problems for millions of people in our world today. Concerning this consider what Pope Benedict XVI says in Caritas in veritate: “It is therefore necessary to cultivate a public conscience that considers food and access to water as universal rights of all human beings, without distinction or discrimination.”¹⁶ In another Gospel parable, the Good Samaritan stops and takes care of someone who was beaten by robbers (see Lk 10:25–37). In this story, Jesus illustrates that God's commandment to love one's neighbor as oneself involves responding to the real concrete needs of others, loving and caring for them as we naturally do for ourselves. Christian love is not simply a nice idea or feeling but can involve “rolling up one's sleeves” to serve and help others. In the light of these and some other New Testament teachings, it is clear that Christian morality calls us to try to meet the needs of ourselves and others.

Catholic health-care ethicists Ashley, deBlois, and O'Rourke, following in the tradition of Thomas Aquinas, speak of common, basic, innate human needs as an objective foundation for ethics in our pluralistic society. They speak of various kinds of universal human needs—to survive or be fulfilled—corresponding to the biological, psychological, social, moral, and spiritual dimensions of human beings. Whatever satisfies a human need they consider to be a “value.” Whatever impedes the fulfillment of a human need they consider a “disvalue.”¹⁷ This approach to human needs and values can help us to avoid moral relativism in our pluralistic world, including in public discussions of health policy. Trying to fulfill the needs of oneself and others corresponds not only to the Gospel but also to any truly human ethics.

The great twentieth-century Christian philosopher Dietrich von Hildebrand points out that meeting human needs only matters if human beings have real value. Using a phenomenological approach, he points out that we can discover a number of morally relevant values including the dignity of the person, the sacredness of human life, truth, justice, self-giving love, and fidelity as not made up by us but as givens to our experience. Although we can experience the inherent goodness of such morally relevant values, their worth is not to be equated with our immediate experience of them since that experience varies. While not all human beings (e.g., a racist) properly appreciate one or more of these values, von Hildebrand attributes this to factors such as a faulty upbringing, prejudice, or a kind of moral blindness. Indeed none of us fully appreciates their inherent value—we can and should continue to grow in appreciating them all of our lives. Von Hildebrand points out that we can experience these morally relevant values as ultimately rooted in who God is and who we are. We experience a call to respect these morally relevant values in all situations. If we choose not to respect one or more of these values in a given situation, we will place an impediment in the way of our true communion with God and each other.¹⁸

As a Christian, von Hildebrand notes that such morally relevant values have been experienced and appreciated by human beings of various cultures, and that these are values of the Kingdom of God that Jesus proclaimed. Von Hildebrand also speaks of what he calls the “merely subjectively satisfying,” such as the pleasures of a warm bath, vain thoughts, or sexual relations. Although it is natural to desire such pleasures, the value of the pleasure per se does not transcend one's immediate experience of it. We are called to subordinate our seeking of such pleasures to respecting always morally relevant values such as the dignity of human persons, truth, fairness, and so forth. For example, a husband and wife can properly enjoy sexual relations with each other and respect their dignity as persons at the same time, but a man cannot enjoy sex with a prostitute and respect her and his own dignity as persons at the same time. Von Hildebrand relates subordinating one's desires for those things which are merely subjectively satisfying to one's respecting morally relevant values to Jesus' call to deny oneself for the sake of God's Kingdom and to take up one's cross and follow Jesus. In relation to the discussion of human needs and ethics above, we can note, as does von Hildebrand, that since we human beings do indeed have real intrinsic dignity and value, then meeting human needs is indeed important.¹⁹

From a Christian perspective, one can more fully understand human needs, rights, values, ethics, and all moral issues, including those one encounters in the field of health policy, in the light of an integral vision or holistic theological anthropology.²⁰ Briefly, this begins with God's creation. All created reality, including our physical universe, which science tells us has evolved over billions of years, is inherently good and reflects the infinite goodness of God. Human beings are created in the image of God (cf. Gn 1), and God is “Spirit” (Jn 4:24). Related to this we have wonderfully complex bodies as well as “spiritual” immortal souls. This gives us a special dignity that transcends the value of the rest of the physical universe.²¹ The fact that all human beings—men, women, children, the disabled, and the elderly—are created in the image of God undergirds a number of the values that one typically finds in health-policy statements today, such as the dignity of the person, equity, and fairness. This view also provides a wonderful foundation for respecting the life of all human beings from tiny embryonic human beings to the frail elderly and dying. Genesis 1:26–28 speaks of God giving human beings a responsibility to steward creation with love and wisdom, as God's ambassadors. In the light of this we can appreciate that the capacity of human beings to create and develop various technologies, including medical technologies, is a God-given capacity.

Since God did not create us as unthinking robots but gave us a true but limited freedom, we can not only use created gifts wisely but also misuse and abuse them. Sin in the biblical sense basically means the human failure to love and respect God, oneself, others, and the rest of creation as we were created and called to love. According to biblical and Catholic teaching, we, including our relationships, societies, and cultures, have been deeply wounded by original, personal, and social sin. We can relate the various kinds of alienation that human beings experience to this.

God, who loves each of us immensely, wants to redeem us, to heal us and our relationships. God's plan of redemption includes not only his liberating us from sin and all the negative consequences of sin if we cooperate with his grace. It also includes God offering us the gifts of His eternal love, life, and friendship. This will ultimately include the resurrection of our bodies and a transformed cosmos in the new heaven and earth.²²

In Jesus' teaching on the greatest commandment, he relates all of morality to loving God, oneself, and others properly (see, e.g., Mt 22:36–40). Jesus also calls us to love perfectly as God our Father loves us (see Mt 5:43–48). The new commandment of Jesus is that we love one another as he has loved us (see Jn 13 and 15). Such love is not possible by our own efforts alone, but if we are open to receiving God's Holy Spirit he will help us to grow in better understanding how to love, including how to respond to human needs and to respect morally relevant values (see Jn 16:13). If we receive the Holy Spirit into our hearts, he will empower us to grow in loving as Jesus loves (cf. Rm 5:5). Since none of us loves perfectly, this requires a profound and continuing conversion from sin to God on our part. According to theologian David Bohr, this includes our spiritual, intellectual, affective, and moral dimensions. It involves our cooperating with God's grace to allow him to transform our whole person.²³ Although the biblical call to love perfectly as God, as Jesus, loves may seem unrealistic to some, it is consistent with God's plan for our ultimate destiny. The author of the First Letter of John says that we do not know exactly what the future will be like, but we do know that we will be like God, holy as God is holy (1 Jn 3). Indeed, if heaven is meant to be a state where we will be completely happy with nothing lacking, in complete union and communion with God and each other, this will only be possible if we allow God to transform us, to make us like Jesus and to empower us to love perfectly as he loves us. The Christian vocation to follow Jesus and to love as he loves is, therefore, fully consistent with the Christian vision. This holistic theological anthropology, which explains where we have come from, where we now are, and where we are meant to go, provides the only realistic foundation for ethics, including health-policy ethics.

Goals and Means

In their document Public Health: Ethical Issues, the Nuffield Council on Bioethics develops an ethical framework for public health programs carried out by a stewardship-guided state. With regard to this they say that such public health programs should have certain goals:

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aim to reduce the risks of ill health that people might impose on each other;

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aim to reduce causes of ill health by regulations that ensure environmental conditions that sustain good health, such as the provision of clean air and water, safe food, and decent housing;

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pay special attention to the health of children and other vulnerable people;

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promote health not only by providing information and advice, but also with programs to help people to overcome addictions and other unhealthy behaviors;

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aim to ensure that it is easy for people to lead a healthy life, for example, by providing convenient and safe opportunities for exercise;

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ensure that people have appropriate access to medical services; and

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aim to reduce unfair health inequalities.

This bioethics council also speaks of certain restraints for public health programs, that is, that such programs should:

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not attempt to coerce adults to lead healthy lives;

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minimize interventions that are introduced without the individual consent of those affected, or without procedural justice arrangements (such as democratic decision-making procedures) which provide adequate mandate; and

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seek to minimize interventions that are perceived as unduly intrusive and in conflict with important personal values.²⁴

These restraints can be related to certain means, that is, to certain actions to avoid or pursue to achieve the desired goals. The above goals and means can be related to meeting certain human needs regarding health and to respecting certain values such as fairness, freedom, and the dignity of all human persons including the vulnerable.

In their article, “Ethics Frameworks in Canadian Health Policies,” Giacomini, Kenny, and DeJean say that ethical analysis is typically characterized by a concern for “goals or objectives” and “means and process for achieving the goal.” With regard to the Canadian government health-policy documents that they looked at, however, they say there was “little consistency within or between frameworks in relative attention to these … dimensions.”²⁵ With regard to research involving human subjects in Canada, the tri-council policy statement says such research should include two essential ethical components: “1) the selection and achievement of morally acceptable ends, and 2) the morally acceptable means to those ends.”²⁶ In the next section of this paper we will consider some of their ethical principles related to these.

The question of goals and means is commonly considered not only in health-policy ethics but in ethics generally. How does this relate to the Catholic approach to ethics or morality? Concerning human goals such as seeking to obtain food or clothing, Jesus says in part, “Strive first for the kingdom of God and his righteousness, and all these things will be given to you as well” (Mt 6:25–33).²⁷ Related to this we can say that the ultimate goal in life is to become morally good and loving like God so that we can enjoy perfect happiness with God and others in God's Kingdom forever. Our shorter term goals in this life, including our career and relationship goals, should be conducive to our attaining this ultimate goal. Some ethicists have pointed out that whenever we act deliberately we always act for some end or purpose or goal. Our deliberately chosen actions are thus means to try to achieve some goal or goals (see, e.g., von Hildebrand). Concerning our actions, there are several passages in the New Testament that exhort us to do good and to avoid doing evil. For example, 1 Thessalonians 5:15–22 teaches in part: “Always seek to do good to one another and to all … [and] abstain from every form of evil.”²⁸ A very important question with regard to this is what makes an action good or evil? Related to this the Catechism of the Catholic Church says that the “morality of human actions depends on: the object chosen; the end in view or the intention;” and “the circumstances of the action.”²⁹ Pope John Paul II also explains this approach in depth in his encyclical letter Regarding Certain Fundamental Questions of the Church's Moral Teaching (Veritatis splendor). This official Catholic approach to the morality of human actions is not new. It is rooted in biblical teaching and has been developed by various theologians such as Thomas Aquinas.³⁰

Briefly, the “object” means the kind of act that is the object of choice, that is, its moral meaning or nature. Human actions can be morally good, for example, feeding the hungry; morally evil, for example, murder; or morally neutral, for example, moving one's finger. According to Catholic teaching there are a few kinds of actions that we should never choose because they are always objectively immoral or intrinsically disordered. Some examples related to medicine and health care include direct abortion, euthanasia, and contraception, the deliberate destruction of living human embryos, in vitro fertilization, and non-therapeutic biomedical experimentation on a human being without his or her consent.³¹ That some actions are intrinsically disordered and always wrong to choose is one of the most controversial parts of Catholic moral teaching. However, most people in our society consider at least some kinds of actions, such as rape or pedophilia or murder of innocent persons, as always wrong. The question then is, what makes certain actions intrinsically disordered? The Catholic approach is consistent in that it holds that we should never choose an action that contradicts our proper relationship with God and our rightful path to the Kingdom of God (cf. 1 Jn 3 and Gal 5:19–25). This is because choosing such an action of its very nature violates morally relevant values concerning who God is and who we are—such as the dignity of the person, truth, and the sacredness of human life—and/or directly violates God's purposes—such as his design for marriage and human sexuality, including the latter's inherent procreative and unitive meanings.

The “intention” of an action refers to a person's motive or motives (reasons) for choosing to do or not do something. From a Christian perspective one's motives should all be in line with loving God, oneself, and others properly. Catholic teaching points out that bad motives can corrupt even good actions. Consider, for example, Jesus criticizing those who give alms to the poor or praying publicly to try to look good in other people's eyes rather than to please God (see Mt 6:1–6). Or, consider a health professional promoting a basically good health program not with the intention of helping others but for selfish reasons. Good motives also cannot make an intrinsically disordered action morally good, for example, direct euthanasia as a means to end suffering, or having an abortion to continue one's schooling without interruption.

Regarding “circumstances,” every human action is performed in a certain situation or set of circumstances. The circumstances include the consequences of an action. The important issue here is whether or not any morally relevant values are involved in the circumstances. Certain circumstances can make it irresponsible to do even good kinds of actions because doing the actions in these circumstances involves failing to show proper respect for one or more morally relevant values. An example related to health is that vigorous exercise is normally a good thing but would be irresponsible for a person whose life would be threatened by it because of his or her heart condition. As another example, normally it is a good thing for a husband and wife to have sexual relations with each other and have children. If, however, a pregnancy would seriously endanger the health of the wife or the family, they should try to avoid getting pregnant by using an effective means of natural family planning.³² Related to the circumstances of actions, we can also note here that according to the traditional Christian view, the fact that an action may result in some good consequences does not justify using an evil means (cf. Rm 3:8), doing something that is intrinsically disordered. For example, the fact that some medical research, which violated the rights of some human subjects, resulted in new knowledge does not make that research ethical.³³

With regard to the traditional Christian and official Catholic approach to the morality of human actions, we should note that it is important not only to abstain from every form of evil. We are also called to do good to everyone, to respond to human needs, and to promote morally relevant values such as the dignity of persons, truth, justice, life, and health, according to our talents (cf. the Parable of the Last Judgment, considered above, as well as Jesus' Parable of the Talents), time, and personal vocation. For example, while we should never commit euthanasia, we should also provide the effective pain management and palliative care that is needed by those who are suffering and dying.³⁴

With regard to the above Catholic moral approach let us briefly consider Gardasil, a vaccine which protects against some strains of HPV. It seems to me that giving or receiving Gardasil is not an intrinsically disordered action. For example, who would object to a woman receiving Gardasil if she is about to marry a man carrying a cancer-causing strain the vaccine protects against? The intention to lower the number of women suffering and dying from cervical cancer is certainly a good intention. It remains, however, to consider the circumstances in which this vaccine is or may be used. It is worth noting that the Alberta Catholic bishops have advised that the vaccination of young girls should be a parental decision. They also point out that this decision should be informed and with their daughters' best interest in mind. In addition, Archbishop Michael Miller of Vancouver says, “Parents need to make an informed decision and communicate it in a way that can serve to strengthen their child in the virtue of chastity and reinforce her appreciation of abstinence as the only truly healthy choice.”³⁵

Some Relevant Ethical Principles

Ethical or moral principles or norms generally have been formulated to try to protect and/or promote certain ethically relevant values, and to provide guidance in the meeting of certain human needs. Let us first of all consider some examples of ethical principles in public health policy or health-care documents. The Canadian Medical Association says that its Code of Ethics “is based on the fundamental principles and values of medical ethics, especially compassion, beneficence, non-maleficence, respect for persons, justice and accountability.” This Code of Ethics also contains some more specific principles related to such things as informed consent, conscientious objection, and confidentiality. The latter has certain limits, for example, to prevent “significant risk of substantial harm to others.”³⁶

The tri-council policy statement on Ethical Conduct for Research Involving Humans speaks of respect for human dignity as the “cardinal principle of modern research ethics.” Of interest, it speaks of human dignity as “intrinsic” and says that it is objectionable to treat human persons “solely as means (mere objects or things)” toward “even legitimate ends.”³⁷ This implies a rejection of both moral relativism and utilitarianism. Related to respect for human dignity, this document speaks of a number of “important correlative ethical principles” in research ethics: respect for free and informed consent, respect for vulnerable persons, respect for privacy and confidentiality, respect for justice and inclusiveness, balancing harms and benefits, minimizing harms, and maximizing benefit.³⁸

Related to public health, the Nuffield Council on Bioethics speaks of many of these same principles including the “do not harm principle” and “proportionality” regarding benefits and risks. With regard to curbing the transmission of infectious diseases, depending on the nature of the disease and its transmission, it also speaks, for example, of the need to sometimes limit individual freedom by means such as quarantine, isolation, and public distancing in order to prevent serious harm to others. A lot of what this council says concerning the stewardship role of the state with regard to public health, the respective roles of medical institutions, charities, businesses, and schools,³⁹ as well as individual responsibility for health, can be related to the principle of subsidiarity that is an important part of Catholic social teaching.

In her book What's Fair: Ethical Decision Making in an Aging Society, Nuala Kenny relates her principles of meaningful autonomy and responsible citizenship to subsidiarity.⁴⁰ She also relates her protection of the vulnerable principle to the option of the poor, another principle found in Catholic teaching. Although Nuala Kenny is a Catholic nun, she does not explicitly express her Catholic faith in this book published by the Canadian Policy Research Network. It is not difficult to see, however, many parallels with Catholic social teaching in what she says in this book, including her treatment of the principles of justice, sustainability, solidarity, and respect for persons of all ages, as well as her saying that these principles provide no magic answers but help us to frame and focus our deliberations.

The University of Toronto's Joint Bioethics Committee concludes that the directly intended killing or causing of death of a suffering person is immoral, whereas the use of pain control intended to relieve suffering is moral even when this results in the foreseen but unintended hastening of death of the person. In support of this distinction with regard to intention it refers to the doctrine of double effect, which it notes is widely accepted in law.⁴¹ This “principle” of double effect is another well-known Catholic moral principle.

Since Western society was a predominantly Christian society for several centuries, even today in our highly pluralistic and secular society our public morality and legal systems retain some principles that have roots in the Judeo-Christian vision. This faith vision provides a good grounding for these principles, including respect for human persons, justice, double effect, subsidiarity, and solidarity. For example, as we considered above in relation to a holistic theological anthropology, human beings are created in the image of God. Related to this, the Compendium of the Social Doctrine of the Church says that we have a capacity for “self-knowledge, self-possession, and of freely giving [ourselves] and entering into communion with other persons” (n. 108). We have the spiritual faculties of reason and free will and are created by God with the capacity to enter into a personal relationship with God so as to find true life and fulfillment. This compendium also speaks of justice as giving God and one's neighbor what is due to them. It points out that justice is not simply a social convention or determined exclusively by criteria of utility and ownership. Justice “acquires a fuller and more authentic meaning in Christian anthropology” (n. 203); what is just is determined “by the profound identity of the human being” created in the image of God (n. 202). By itself justice is not enough; it “must find its fulfillment in” love, which has its source in God, who is love.⁴² This teaching on the great and equal dignity of human beings, justice, and love, is relevant to health-policy ethics, for example, in how we distribute a vaccine when the demand exceeds the supply, such as was the case with the H1N1 vaccine when it first became available. Many would consider, for example, giving priority to the rich to violate these principles but giving priority to those who are most at risk to be in line with these principles.

According to the principle of double effect, as this has developed in the Catholic moral tradition, when a human action is foreseen to have both good and bad effects, the action is moral if four conditions are all met. The Catholic Health Association of Canada's Health Ethics Guide explains these conditions as 1) “the directly intended object of the act must not be intrinsically evil, i.e., contrary to one's fundamental commitment to God, neighbor or oneself; 2) “the intention of the agent must be to achieve the beneficial effects and to avoid the harmful effects as far as possible (i.e., the harmful effects should not be wanted, but only allowed)”; 3) “the foreseen beneficial effects are not achieved by means of the foreseen harmful effects; rather, the beneficial effects are inextricably and unavoidably linked to the harmful effects”; and 4) “the foreseen beneficial effects must be equal to or greater than the foreseen harmful effects.”⁴³ While some non-Catholic medical and legal documents refer to the principle of double effect, the Christian vision provides a foundation for its conditions in the call to love and will as God does.⁴⁴ God never acts in an intrinsically evil way, nor does God ever directly intend evil. Neither should we. On the other hand, to avoid causing a greater evil, God tolerates a lot of evil and sin, and so should we. The principle of double effect can help us to appreciate the important moral differences between such things as direct euthanasia and refusing disproportionate life-prolonging treatments, and direct abortion and treating a pathology of a pregnant woman which indirectly results in harm to her unborn child.⁴⁵ It can also provide some guidance in approaching some health-policy issues such as the fluoridation of drinking water and distributing a vaccine to a population when these are expected to benefit many people but also pose some risks of harm.

The principle of legitimate cooperation, another Catholic moral principle, applies the principle of double effect to situations where one is asked to assist or cooperate in another's actions. In brief, while we can be called to help others to do good and we should want other people to do good, we should never formally cooperate in someone else's sin, that is, directly intend that another person act immorally, for example, have a direct abortion or sexual relations outside marriage. At times, however, it can be moral to cooperate materially with an immoral action of someone else provided that “one does not intend the evil effects, but only the good effects, when only in this way can a greater harm be prevented.”⁴⁶ Among other things, this principle provides some guidance with regard to what public policies including health policies we should support, promote, tolerate, or oppose. In line with this, for example, both the Catholic Medical Association and the Catholic bishops of the United States support making health care affordable and accessible to all people in the United States but “insist that health-care reform excludes abortion coverage or any other provisions that threaten the sanctity of life.”⁴⁷

The Compendium of the Social Doctrine of the Church speaks of a number of interconnected principles that relate to the organizational foundations of life in society: the common good, the universal destination of goods, subsidiarity, participation, and solidarity. These social principles are founded in the dignity of the person created in the image of God and are born of the encounter of the Gospel message with its demands of “love of God and neighbor in justice with the problems emanating from the life of society” (n. 160). In order for a society to serve the human being it needs to have as its primary goal the common good, “the good of all people and of the whole person” (n. 165). Promoting the common good demands a commitment to peace,

a sound juridical system, protection of the environment, and the provision of essential services to all, some of which are at the same time human rights: food, housing, work, education and access to culture, transportation, basic health care, the freedom of communication and expression, and the protection of religious freedom. (n. 166, emphasis added)

A proper understanding of the common good includes appreciating its transcendent dimension, that “every reality, including human society,” ultimately finds its fulfillment in its Supreme Good, God (n. 170). The principle of the universal destination of goods means that God gave the earth and all its resources to the whole human race, without excluding or favoring anyone, to satisfy human needs. The call to share goods fairly includes a “preferential option for the poor,” embracing “the immense multitudes of the hungry, the needy, the homeless, those without health care and, above all, those without hope of a better future.”⁴⁸

Related to these principles, for example, the Catholic bishops of the United States call for health-care reform and policy that recognizes that “decent health care is not a privilege but a right.” They say that, “All people need and should have access to comprehensive, quality health care that they can afford, and it should not depend on their stage of life, where or whether they or their parents work, how much they earn, where they live, or where they were born.” Health care, they say, is not just another issue for the Church but is “a fundamental issue of human life and dignity” and a “critical component of the Catholic Church's ministry.”⁴⁹

According to the principle of subsidiarity, as explained by Pope Pius XI, it is “wrong to take from individuals what they can accomplish by their own initiative and industry and give it to the community” or to assign to a “higher association what lesser and subordinate organizations can do. For every social activity ought of its very nature to furnish help to the members of the body social, and never destroy and absorb them” (n. 186). This principle “protects people from abuses by higher-level social authority and calls on these same authorities to help individuals and intermediate groups to fulfill their duties…. Every person, family and intermediate group has something original to offer to the community” (n. 187). All citizens have a duty to participate in, to cooperate with, and to contribute to building the life of the community with a view to the common good. Overcoming obstacles to such participation calls for education and encouraging “participation above all of the most disadvantaged” (n. 189).⁵⁰

With regard to these principles and health-care reform in the United States, for example, the Catholic Medical Association says, “We must ensure that well-intentioned efforts to bring about ‘change’ are not exploited to create a federally controlled system that promises health care for all, but creates an oppressive bureaucracy hostile to human life and to the integrity of the patient-physician relationship.” While the Catholic Medical Association supports universal access to quality health care, it criticizes some recently passed bills in the United States as violating the principle of subsidiarity because they “empower a small group of unelected government bureaucrats and committees to determine the composition and cost of health insurance policies, the reimbursement of providers, the approval of treatments, etc.” Among other things, the Catholic Medical Association calls for a more participatory process and legislation which makes “it possible for individuals and families to purchase health insurance that meets their needs and also respects their values.”⁵¹

According to the Compendium of the Social Doctrine of the Church, the principle of solidarity highlights the intrinsic social nature and equality of human persons, as well as “the common path of individuals and peoples towards an ever more committed unity.” With the expansion of the means of communication there is a greater awareness today of the “bond of interdependence between individuals and peoples.” Solidarity requires that “various forms of exploitation, oppression and corruption…. ‘Structures of sin’ that dominate relationships between individuals and peoples must be overcome … purified and transformed into structures of solidarity.” Solidarity requires each of us to commit ourselves “to the good of all and of each individual,” to serve rather than to oppress others (nn. 192–193). Solidarity requires us to realize our indebtedness to the legacy of past generations and to share culture, knowledge, material, and immaterial goods with present and future generations. Jesus, “the living sign of that measureless and transcendent love of God-with-us, who takes on the infirmities of his people, walks with them, saves them and makes them one,” invites us “to ever higher and more involved forms of sharing” (n. 196).⁵²

Since there is clear evidence linking low socio-economic status to poorer health,⁵³ solidarity is very relevant to health policy. With regard to this consider the Catechism of the Catholic Church teaching that

socio-economic problems can be resolved only with the help of all the forms of solidarity: solidarity of the poor among themselves, between rich and poor, of workers among themselves, between employers and employees in a business, solidarity among nations and peoples. International solidarity is a requirement of the moral order; world peace depends in part upon this.⁵⁴

In concluding this section, I would like to note that the Catholic Health Association of Canada outlines the above Catholic ethical and social principles in the introduction of its Health Ethics Guide. These principles serve as the foundation for their treatment of more specific issues of health care and health policy in the rest of the guide.⁵⁵ Indeed these principles are very important to keep in mind with regard to developing health care and health policy that truly benefit all human beings.

In the article “Bridging the Gap: Catholic Health Care Organizations Need Concrete Ways to Connect Social Principles to Practice,” Bill Brinkmann et al. point out that Catholic social tradition, which has developed over many centuries, “gives a clarity of vision and breadth of perspective that most current analyses of social and organizational issues lack.” They also say that this tradition historically has focused on overarching themes rather than on behavior specifics. This is related to the view that specifics are better left to people on the spot.⁵⁶

The Importance of Virtue

The Nuffield Council on Bioethics says that a common theme in health policy is behavior change, since personal behavior can have a significant effect on health. Among other things, it speaks of social marketing campaigns including promoting people to use condoms. Of interest it does not promote sexual abstinence outside of marriage as a way to reduce the transmission of sexually transmitted infections. It does, however, promote healthier living and appropriate behavior changes as part of the solution to reduce the harms of obesity, tobacco, and alcohol.⁵⁷ With regard to behavior change we can note here that education programs in public health in general are related to leading people to live healthier lives and/or to behave voluntarily in ways that do not harm others.

Educating people to behave in good ways can be related to virtue ethics, which has been promoted in the past by great philosophers such as Aristotle and great Christian theologians such as Thomas Aquinas. In recent times, the resurgence of interest in virtue ethics is also apparent in the field of health care. The word “virtue” is not always used in contemporary approaches to public health policy. Nevertheless, encouraging positive behavior changes implies the need for virtue.

From a Christian perspective Jesus is seen as the best model of all the virtues, which are good character traits or habits. Just as all morality is related to a properly ordered love of God, others, and oneself from a Christian perspective, so are all the virtues. For example, related to the virtues of temperance and chastity, the self control related to eating, drinking, and how we express ourselves sexually is not arbitrary. It simply involves no more and no less than what loving God and human persons properly involves in these areas of our lives. This includes respecting God's purposes, respecting morally relevant values such as the dignity of persons, life, health, truth, justice, self-giving love, and fidelity, and subordinating human desires and wants to the fulfillment of human needs.

Concerning human sexuality, for example, Pope Benedict XVI says in his encyclical Caritas in veritate:

The Church, in her concern for man's authentic development, urges him to have full respect for human values in the exercise of his sexuality. It cannot be reduced merely to pleasure or entertainment, nor can sex education be reduced to technical instruction aimed solely at protecting the interested parties from possible disease or the “risk” of procreation. This would be to impoverish and disregard the deeper meaning of sexuality, a meaning which needs to be acknowledged and responsibly appropriated not only by individuals but also by the community.⁵⁸

More specifically concerning the problem of AIDS, on a flight to Africa the pope said,

The scourge cannot be resolved by distributing condoms; quite the contrary, we risk worsening the problem. The solution can only come through a twofold commitment: firstly, the humanization of sexuality, in other words a spiritual and human renewal bringing a new way of behaving towards one another; and secondly, true friendship, above all with those who are suffering, a readiness—even through personal sacrifice—to be present with those who suffer.

While many in the West criticized the pope for these comments, Dr. Edward Green, director of the AIDS Prevention Research Project at the Harvard Center for Population and Development Studies, said:

The best evidence we have supports the pope's comments…. There is … a consistent association shown by our best studies, including the U.S.-funded “Demographic Health Surveys,” between greater availability and use of condoms and higher (not lower) HIV-infection rates. This may be due in part to a phenomenon known as risk compensation, meaning that when one uses a risk-reduction “technology” such as condoms, one often loses the benefit (reduction in risk) by “compensating” or taking greater chances than one would take without the risk-reduction technology…. The largely medical solutions funded by major donors have had little impact in Africa, the continent hardest hit by AIDS. Instead, relatively simple, low-cost behavioral change programs—stressing increased monogamy and delayed sexual activity for young people—have made the greatest headway in fighting or preventing the disease's spread.⁵⁹

Related to our topic, Catholic authors Ashley, deBlois, and O'Rourke think that virtue theory will surely play an important role in the development of bioethics,

because professional codes cannot keep pace with the rapid advance of medical technologies. Hence the application of bioethics to actual medical practice is more and more in the hands of professionals who alone are acquainted with the complexities of these new situations. If they lack moral integrity such applications will be seriously at fault. Furthermore, in preventative medicine, as individuals take more and more responsibility for their own health care, their need for virtue in making these decisions will also increase.⁶⁰

The Importance of Community

With regard to public health ethics the Nuffield Council on Bioethics speaks of the value of community, solidarity, and fraternity, the value of belonging to a community in which each person's welfare and the welfare of the community matter to everyone. It notes that public health often depends on universal programs which need to be collectively endorsed to be effective.⁶¹

With regard to public health policy, Nuala Kenny speaks of the importance of relationships. She says, “The ethic of care” is an approach which

holds that moral/ethical decision making [involves] finding solutions that reduce conflict by fostering human dignity and the good of the entire community/society. This ethic does not see people as individual, autonomous and unconnected but rather as rooted within relationships—for instance, family relationships, social relationships, work relationships, and political relationships. The ethic of care says that every time decisions are made, there needs to be consideration of what kind of relationship the decision comes from and what kind of relationship is at stake.

With regard to sharing health-care resources, she also says that this approach sees people not in competition but as interconnected.⁶²

Community is vital to a Christian approach to ethics first of all because according to the Christian view God is a Trinity, a “community” of three divine persons in reciprocal relationships of love and unity. Our being created in the image of God can be related not only to our special dignity and stewardship responsibilities as God's ambassadors. It also relates to our social or relational nature and our need for community. Many Christian authors speak of our interdependence. None of us is completely self-sufficient. At times we are completely dependent on others, such as in early childhood and in the frail elderly stage of our lives with its generally increasing weakness and disabilities that often precede death. From a Christian perspective the communion of persons—in mutual self-giving and receiving love and unity—in our Triune God is the highest model for human relationships. Our God, who is a mystery of love (1 Jn 4:8), is the source of the grace and love that we need to grow in properly loving and respecting each other. Cooperating with God's grace enables us to have better relationships and to build a truly human community. The Christian vocation to grow in loving as Jesus loves (see Jn 13 and 15) and in all the virtues relates not only to our individual responsibilities. It also relates to our responsibility to help each other to grow, to develop genuine community and a true communion of persons.

Good pastoral care involves not only helping people understand what is moral and what is not. It also involves helping people to overcome any concrete obstacles to living good moral lives that they experience. Good pastoral care and the Church, that is, the Christian community, can be wonderful resources to help us all to live moral and healthier lives.⁶³ With regard to this, consider, for example, not only telling a woman faced with a crisis pregnancy that direct abortion is immoral but also providing her with all the support she needs to carry through with her pregnancy and to decide and act in the best interests of the child.

Conclusion

In its Health Ethics Guide the Catholic Health Association of Canada says, “The ultimate goal of all ethical reflection… by all those involved in these ethical processes is to bring the healing, compassion and reconciliation of Jesus to all who form the health and social service communities.”⁶⁴ Although this is said with regard to the context of Catholic healthcare institutions, we can also apply this to Catholics and other Christians working within other professional or secular contexts.⁶⁵ Wherever we are we can bring the love, grace, wisdom, and healing of Christ into these situations as “sacraments” of Christ, even if we do not explicitly talk about this. If someone, however, asks us the reason for our hope (cf. 1 Pt 3:15), we can share our views in appropriate ways.

References

Cf. Nuffield Council on Bioethics, Public Health: Ethical Issues (2007), http://www.health-policy-systems.com/content/3/1/3/ref. Note: The Nuffield Council on Bioethics includes clinicians, lawyers, scientists, philosophers, and theologians. Among its funders is the Medical Research Council of the United Kingdom. This independent council has achieved an international reputation for providing advice to assist policy making, to address public concerns, and to stimulate debate in bioethics.

I presented a talk on this topic for a conference sponsored by the Calgary Catholic Medical Association on health policy and ethics, Calgary, Alberta, Canada, May, 15, 2010. This article has been developed and expanded from that talk. Besides many other references, both the original talk and this expanded article include a number of sources relevant to the Canadian context. I have left these in this article since I think that these sources are also relevant to other contexts such as that of the United States of America. I would like as well to express my appreciation here to the reviewers of an earlier draft of this article, as well as the editor of The Linacre Quarterly, for their helpful comments and suggestions.

Callahan

Daniel

“Unsustainable: Hard Truths About the ‘American Way of Life,’”

Commonweal 135.12 (June 20, 2008): 12–14.

Giacomini

Mita

, Kenny

Nuala

, and DeJean

Deirdre

“Ethics Frameworks in Canadian Health Policies: Foundation, Scaffolding, or Window Dressing?”

Health Policy 89 (2009): 66.

The quotes are from Health Policy, 66 and 68, respectively.

The quotes are from Health Policy, 68.

The quotes are from Health Policy, 67.

Ashley

Benedict

, deBlois

Jean

, and O'Rourke

Kevin

Health Care Ethics: A Catholic Theological Analysis, 5th ed. (Washington, D.C.: Georgetown University Press, 2006), 226.

Health Care Ethics: A Catholic Theological Analysis, 20–21. Cf. Jonathan Chaplin, Talking God: The Legitimacy of Religious Public Reasoning (London: Theos, 2008).

10.

Cf. Pope John Paul II, encyclical letter Veritatis splendor (Regarding Certain Fundamental Questions of the Church's Moral Teaching) (Ottawa: Canadian Conference of Catholic Bishops, 1993), nn. 46-50; United States Conference of Catholic Bishops, Ethical and Religious Directives for Catholic Health Care Services, 4th ed. (Washington, D.C.: United States Conference of Catholic Bishops, Inc., 2001), preamble; William E. May, Catholic Bioethics and the Gift of Human Life (Huntington, IN: Our Sunday Visitor, Inc., 2000), 55-63; and Ashley, deBlois, and O'Rourke, Health Care Ethics, 19-30.

11.

Nuffield Council on Bioethics, Public Health, 2.41.

12.

Giacomini , Kenny , and DeJean “Ethics Frameworks in Canadian Health Policies.”

13.

See Curtin

Leah

, and Josephine Flaherty

Nursing Ethics: Theories and Pragmatics (Bowie, MD: Brady Communications Co., Inc., 1982), chs. 1-2.

14.

United Nations General Assembly, The Universal Declaration of Human Rights (1948), http://www.un.org/en/documents/udhr/.

15.

Calgary Health Region Programs, “My Voice (Standard Form): A Workbook and Personal Directive for Advanced Care Planning” (2008), 3.3, http://www.calgaryhealthregion.ca/programs/advancecareplanning/acp_docs/103284_workbook_standard.pdf.

16.

Pope Benedict XVI, encyclical letter Caritas in veritate (2009), n. 27, original emphasis, http://www.zenit.org/article-26386?l=english.

17.

See Ashley , deBlois , and O'Rourke Health Care Ethics, ch. 2.

18.

Von Hildebrand

Dietrich

Ethics (Chicago: Franciscan Herald Press, 1972).

19.

Von Hildebrand

Dietrich

Ethics (Chicago: Franciscan Herald Press, 1972).

20.

Cf. Pope John Paul II, Man and Woman He Created Them: A Theology of the Body, trans. Michael Waldstein (Boston: Pauline Books and Media, 2006).

21.

Cf. John Paul

Pope

II , “Message to Pontifical Academy of Sciences on Evolution,” Origins: CNS Documentary Service 26 (1996): 414–416.

22.

Catechism of the Catholic Church (Toronto: Doubleday, 1997), nn. 385-1060; and United States Conference of Catholic Bishops, Ethical and Religious Directives, general intro.

23.

Bohr

David

Catholic Moral Tradition, rev. ed. (Huntington: Our Sunday Visitor, Inc., 1999), ch. 4.

24.

Nuffield Council on Bioethics, Public Health, 2.44.

25.

Giacomini , Kenny , and DeJean “Ethics Frameworks in Canadian Health Policies,” 4.

26.

Medical Research Council of Canada, Natural Sciences and Engineering Research Council of Canada, and Social Sciences and Humanities Research Council of Canada, tri-council policy statement, Ethical Conduct for Research Involving Humans (Ottawa: Medical Research Council of Canada, 1998), i.4. Note: this document provides ethical guidelines and principles for the Medical Research Council of Canada, the Natural Sciences and Engineering Research Council of Canada, and the Social Sciences and Humanities Research Council of Canada.

27.

All scripture quotations in this article are from The Holy Bible: Containing the Old and New Testaments with the Apocryphal / Deuterocanonical Books: New Revised Standard Version (Toronto: Collins Publishers, 1989).

28.

Cf., e.g., Mt 25: 31-46; Rm 2: 5-11 and 3: 8.

29.

Catechism of the Catholic Church, n. 1750; see also nn. 1749-1761.

30.

See Paul

John

II , Veritatis splendor, nn. 71-83; and cf., e.g., Ashley, deBlois, and O'Rourke, Health Care Ethics, 50-54; and Bohr, Catholic Moral Tradition, 224-226.

31.

See, e.g., United States Conference of Catholic Bishops, Ethical and Religious Directives.

32.

Cf. Ethical and Religious Directives., dir. 52.

33.

Some of this section is adapted from Flaman

Paul

, “Moral Discernment and Culpability,” Linacre Quarterly 71 (2004): 34–46.

34.

Cf. United States Conference of Catholic Bishops, Ethical and Religious Directives, dirs. 60–61.

35.

From McMahon

Laureen

, “Gardasil Vaccine Needs Parental Consent,” Western Catholic Reporter (Edmonton), October 19, 2009, 5. See also Alberta Catholic Bishops, “A Message of the Alberta Catholic Bishops to Parents, Trustees, Superintendents of Catholic Education of Catholic School Boards, and to the Catholic Education Community” (June 23,2008), http://www.edmontoncatholic-church.com/lorlinks/HPVmessage.PDF.

36.

The quotes are from the Canadian Medical Association, “CMA Code of Ethics” (2004), first paragraph and n. 35 respectively, http://policybase.cma.ca/PolicyPDF/PD04-06.pdf.

37.

Medical Research Council of Canada, et al., Ethical Conduct for Research Involving Humans, i.4.

38.

Ethical Conduct for Research Involving Humans., i.5–i.6.

39.

See Nuffield Council on Bioethics, Public Health, chs. 4 and 2.46.

40.

Kenny

Nuala

What's Fair: Ethical Decision Making in an Aging Society (Ottawa: Canadian Policy Research Network, 2004), 19.

41.

University of Toronto, Joint Centre for Bioethics, news release, “New Guidelines for MDs Draw Line Between Relief of Suffering and Euthanasia” (September 16, 2002), http://www.jointcentreforbioethics.ca/rss/news/news_euthanasia.shtml.

42.

Pontifical Council for Justice and Peace, Compendium of the Social Doctrine of the Church (Ottawa: Canadian Conference of Catholic Bishops, 2005), 50-52 and 89-92. Cf. 1 Jn 4: 7-12.

43.

Catholic Health Association of Canada, Health Ethics Guide (Ottawa: Catholic Health Association of Canada, 2000), 13. Cf. Catechism of the Catholic Church, n. 2263; Bohr, Catholic Moral Tradition, 226-227; and Ashley, deBlois, and O'Rourke, Health Care Ethics, 54-55.

44.

See, e.g., Mt 5: 48; Jn 15: 9-15; Rm 3: 8; 1 Th 5: 15-22; and 1 Jn 3: 2-3.

45.

Cf. Congregation for the Doctrine of the Faith, Declaration on Euthanasia (1980), http://www.vatican.va/roman_curia/congregations/cfaith/documents/rc_con_cfaith_doc_19800505_euthanasia_en.html; United States Conference of Catholic Bishops, Ethical and Religious Directives, dirs. 56-57, 60-61, and 45-51; and Catholic Health Association of Canada, Health Ethics Guide, 39 and 42.

46.

Catholic Health Association of Canada, Health Ethics Guide, 13–14; cf. United States Conference of Catholic Bishops, Ethical and Religious Directives, part 6.

47.

The quote is from Zenit, “US Bishops Support Universal Health Care,” July 21, 2009, http://www.zenit.org/article-26511?l=english. See also Catholic Medical Association, Health Care in America: A Catholic Proposal for Renewal (September 2004), http://www.cathmed.org/assets/files/CMA%20Healthcare%20Task%20Force%20Statement%209.04%20Website.pdf; and idem, “Open Letter to Catholics and Catholic Organizations” (September 21, 2009), http://www.cathmed.org/assets/files/Open%20Letter%20to%20Catholics%20and%20Catholic%20Organizations%20FINAL%203.pdf.

48.

Pontifical Council for Justice and Peace, Compendium of the Social Doctrine of the Church, 71–79, emphasis added.

49.

Zenit “US Bishops Support Universal Health Care.”

50.

Pontifical Council for Justice and Peace, Compendium of the Social Doctrine of the Church, 81–84.

51.

Catholic Medical Association, “Open Letter to Catholics and Catholic Organizations.” Cf. idem, Health Care in America.

52.

Pontifical Council for Justice and Peace, Compendium of the Social Doctrine of the Church, 84–87.

53.

Cf. Nuffield Council on Bioethics, Public Health, 3.24.

54.

Catechism of the Catholic Church, n. 1941.

55.

See Catholic Health Association of Canada, Health Ethics Guide; cf. United States Conference of Catholic Bishops, Ethical and Religious Directives.

56.

Brinkmann

Bill

“Bridging the Gap: Catholic Health Care Organizations Need Concrete Ways to Connect Social Principles to Practice,”

Health Progress 87.6 (November–December 2006).

57.

See Nuffield Council on Bioethics, Public Health, chs. 3.35, 3.26, 5, and 6.

58.

Benedict XVI, Caritas in veritate, n. 44.

59.

Westen

John-Henry

“Harvard AIDS Expert Says Pope Is Correct on Condom Distribution Making AIDS Worse,” LifeSiteNews.com, March 19, 2009, http://www.lifesitenews.com/ldn/2009/mar/09031906.html. Cf. Edward C. Green and Norman Hearst, “Was the Pope Wrong?” Lancet 373 (2009): 1603. For a fuller treatment of Catholic teaching on the virtue of chastity, see the Catechism of the Catholic Church, nn. 2337-2400. For a fuller Christian theological treatment of the virtues in the context of the whole Christian life, see, e.g., Jordan Aumann, Spiritual Theology (Manila: University of Santo Tomas, 1989).

60.

Ashley , deBlois , and O'Rourke Health Care Ethics, 16.

61.

Nuffield Council on Bioethics, Public Health, 2. 33–34.

62.

Kenny What's Fair, vii.

63.

Cf. United States Conference of Catholic Bishops, Ethical and Religious Directives, part 2.

64.

Catholic Health Association of Canada, Health Ethics Guide, 78.

65.

Cf. United States Conference of Catholic Bishops, Ethical and Religious Directives, preamble and general intro.