THE DIGNITY of the HUMAN PERSON in HEALTH CARE: PATIENTS as AGENTS

We often use the word “patient” when speaking of men and women who are receiving medical care without giving much thought to what that word means. That is not necessarily a problem. The word “patient” is a helpful signifier in the context of health care. Everyone knows who is being referred to. Nevertheless, it is good for us to examine the meaning of this word and what it might imply about the human persons to whom it is applied.

The word “patient” comes from a Latin word (pati, patior) that means, “to permit, undergo, or suffer,” the same word that is the root of the English word “passive.” To be a patient, according to the original meaning of the word, is to be a passive recipient of someone else’s action. In this sense, being a patient is the opposite of being an agent. An agent is one who acts. A patient is one who is acted upon.

It is easy to see why the word “patient” came to designate a person who receives medical care. Such a person is a passive recipient of the actions of medical professionals. Doctors, nurses, and technicians act; patients are acted upon. Medical professionals give medical care; patients receive it.

All of that is well and good. A problem arises, however, when we identify the person with the role he or she plays in the exchange of medical care. A man may be a passive recipient of a surgical procedure. In that instance, the surgeon acts and the man is acted upon. He is a patient. But what cannot be forgotten is that he is also a man. To put it another way, the man, as a patient, is the object of the surgeon’s action. The man, however, cannot be reduced to a mere object. He is also a subject of his own actions and must be treated with the dignity of a human subject. He is a patient. What must not be forgotten, however, is that he is also an agent.

The fact that patients are also agents has, in some ways, gained greater recognition in contemporary medical practice. This development is reflected in things like patient’s bills of rights, patient advocates, laws and policies protecting patient privacy, and various forms of advanced directives seeking to insure that patients’ wishes are respected. Medical ethicists have also emphasized the right of patients to be agents of decision making for their own medical care. The principle of autonomy is often invoked in advocating for this right.

Despite these positive developments, however, there are other ways in which contemporary medical practice militates against the recognition of patients as human subjects. It does this, I would suggest, by making it more difficult for medical professionals to know their patients as human beings.

Contemporary medical practice has become increasingly specialized and increasingly corporate. Specialization means that patients are more likely to have multiple doctors and doctors are more likely to be responsible for only part of a patient’s care. Specialized medicine certainly has great benefits. It allows doctors to have greater knowledge and competency in their areas of specialty. Nevertheless, specialized medicine makes it less likely that doctors will have comprehensive knowledge of their patients’ overall medical condition. Not knowing their patient’s whole medical picture, doctors are less likely to know their patients as whole persons. Specialization also means spending less time with more patients, making it more difficult for doctors to appreciate the human dignity of every person in their care.

The increasingly corporate nature of medical practice is evidenced by the increasing number of physicians working in hospitals and hospital-owned practices. The shift toward practicing medicine in larger institutions means that doctors and other medical professionals are more likely to be caring for patients who come from greater distances and less likely to care for patients they see frequently and know personally. The growing influence of corporate structures, insurance companies, and government mandates also mean that policies and priorities governing medical practice are more and more being determined by people who are not directly involved in caring for the health of patients. Excessive interest in bottom lines, time spent in computerized charting, and concern for efficiency can make it more difficult for clinicians to know and treat their patients as agents: human subjects with personal dignity.

When doctors and other health care professionals do not know their patients as human beings, they are less inclined to think of their patients as human beings and less disposed toward treating their patients as human beings. It is therefore imperative that they deliberately counteract the factors in contemporary medical practice that militate against knowing patients as human subjects. Health care professionals need to be reminded, and to remind themselves, that the human persons in their care are agents as well as patients, subjects as well as objects, and deserve to be treated with the respect and dignity that is rightly theirs.

HEALTH CARE and HOPE

According to J.R.R. Tolkien, author of The Hobbit and The Lord of the Rings, there are two kinds of hope. These two kinds of hope are expressed by two different words in an Elvish language Tolkien invented. The words are amdir and estel. Both words can be translated by the English word ‘hope’ but they have different meanings. Tolkien defines amdir as “an expectation of good, which, though uncertain, has some foundation in what is known.” Amdir is akin to optimism, expecting good things based on evidence or experience. When, in a time of drought, a man calls the appearance of dark clouds “a hopeful sign,” he is expressing amdir, an expectation of good based on what he has observed. Estel is more like trust. As one of Tolkien’s characters expresses it, estel “is not defeated by the ways of the world, for it does not come from experience, but from our nature and first being ... [as] the Children of the One.”  Estel is hope in God. For some of Tolkien’s characters, it is an explicit hope in the divine creator. For others, it is an implicit trust that good will ultimately prevail. Unlike amdir, estel is not based on experience of the world. It is based on who God is and who we are as God’s children. Thus, even when amdir is lost, when all worldly experience points toward evil, estel need not be defeated. For it is based on something deeper that worldly experience: our identity as God’s children.

Tolkien’s distinction between amdir and estel can help us understand what it means for us to have hope, especially when we or our loved ones suffer illness or injury. One of our goals as health care providers and ministers to the sick and dying is to bring hope. We want to encourage our patients and lift the spirits of those who suffer. Tolkien’s distinction between amdir and estel can help us to recognize the different ways we can do that.

One way we can inspire hope in the sick and suffering is by showing them that good things are possible. Doctors do this when they emphasize the positive outcomes that can result from treatments or procedures. They also inspire hope by their own competency. Having a reputation for excellence and high rates of success gives patients confidence. Other caretakers inspire hope by encouraging the sick person to focus on the positive or providing examples of successful outcomes.

I count myself blessed to be able to encourage people in this way. I am a survivor of brain cancer and sometimes, in the course of my ministry, find it helpful to share my story with patients I visit. Very often, they find in my story a new reason to hope. Seeing that I have made a successful recovery, they are encouraged in the belief that they can too.

The sick can also find hope in the healing works that God has wrought in ways that defy our understanding. The Lord Jesus accomplished countless miracles of healing. By doing this, he inspired great hope and more people came to him to be healed. Many more healing miracles have been performed by the power of the Holy Spirit that is constantly at work in his Church. The sick rightly see these works of healing as a reason to hope. Through their prayers and the prayers of their loved ones, and through the intercession of the Blessed Virgin Mary and the saints, God can and often does accomplish mighty works of healing.

This kind of hope is what Tolkien’s elves would call amdir. It is the expectation of good results based on human experience. This kind of hope is very important for the effective care of the sick. It is important for the emotional well-being of patients and their loved ones. It is also important for bringing about good outcomes. When a patient has hope, the patient will be more likely to positively cooperate in her own care.

Amdir is good and important and we do well to cultivate this hope in ourselves and seek to inspire it in others. But this kind of hope can be false. A person has false hope when he is deceived, mistaken, or in denial about the possibility of his recovery or healing. A person has false hope when she presumptuously expects a miracle. Amdir can also be lost. When death becomes immanent or when treatment options are exhausted, it may no longer seem sensible to hope for recovery.

Estel cannot be false and cannot be lost. This hope is both similar to and different from amdir. In both senses, to hope is to anticipate good things to come. The differences are about what those good things are and on what basis they they are to be anticipated.

The basis for estel is the faithfulness of God. Hoping in God means trusting that God will faithfully fulfill His promises. We expect good things from God because God is good and God has been good to us in the past. We therefore trust that God will also be good to us in the future. In particular, we trust that God will be good to us in the ways that He has promised. God’s promises are given to us most especially in Sacred Scripture. In Scripture, God has promised to answer our prayers, to give the Holy Spirit to anyone who asks, to give eternal life to those who believe in his only begotten Son and to make all things work for the good for those who love Him. We hope to receive all those things because God has promised them and we can trust God to be faithful to His promises.

The good things for which we hope, in the estel sense of the word, are the good things God has promised us. These are the best things of all. But they do not include many of the good things we rightly desire in this life. God does not promise us good health and long life, success and prosperity, freedom from suffering and deprivation. These things are indeed good and we can hope for them and even hope to obtain such things from God. But this hope is amdir. It is hope based on our experience of the world for the good things that seem possible. God has blessed people with health and prosperity and deliverance. Based on that knowledge, we can hope that God might bless us and our loved ones in those ways. But God has not promised those blessings and some people do not receive them. Estel is about what God has promised.

In caring for the sick and the dying, how can we encourage patients and their loved ones to hope in this way? One answer is that we can pray for them. This is something that everyone can do. We can pray for the sick and the dying and we can pray particularly that they will be strengthened in hope. Serious illness can lead to despair. The sick and the dying face the challenging task of persevering in hope despite the possibility, perhaps even the certainty, of a future with bad medical outcomes. It is not easy to see beyond that future to the future that God has promised. We need to help such people with our prayers.

Another way we can encourage the sick to hope in God is by building them up with assurances of faith. When Jesus encountered Martha after her brother had died, He assured her of the truth that “I am the resurrection and the life.” Family members and visitors to the sick and the dying can encourage their loved ones to hope by reminding them of God’s promises and the assurance that God will be faithful to his promises. Chaplains and ministers to the sick are especially called to give this kind of encouragement.

Many heath care providers cannot offer this kind of encouragement in an explicit way. Professional standards may prevent clinicians from overtly witnessing to their Christian faith in God’s promises and God’s trustworthiness. Nevertheless, they can inspire this kind of hope through the way that they care for the sick. When a clinician demonstrates her respect for the dignity of the people in her care, she is a witness to hope. When a clinician says by her actions, “This person, no matter how ill and debilitated, no matter the prognosis or quality of life, is a being of inestimable dignity,” she is sending a message of hope. She is inviting the patient and the patient’s loved ones to look beyond the apparent hopelessness of their situation and recognize the source of their dignity in God.

Whenever we recognize the dignity of a human person, we implicitly acknowledge that that person is a child of God. And understanding ourselves as children of God is the ground of our greatest hope. We belong to God, who can be trusted to take care of his children. To believe that is to have a hope that cannot be proven false or taken away.

 

SADNESS, HOPE, and REVERSAL of FORTUNE

There are great joys that people in health care get to experience. Patients get well, receive favorable diagnoses, overcome difficult bouts of illness, and emerge from sickness with deepened gratitude and fresh perspective. Those who care for those patients feel that joy too, along with the satisfaction of having helped bring it about. But there is also a lot of sadness. As a priest working in health care ministry, I encounter that sadness quite a lot. When I am called to see a patient, it is often because he or she is dying or has died. Naturally, people who are dying and their loved ones experience great sadness. Very often, they also have deep faith and lively hope. I find it rewarding to nurture that faith and hope and to provide comfort through my presence and the sacraments I administer. But the sadness remains.

Jesus said that the sad are blessed. One of the beatitudes of Jesus recorded in the Gospel of Matthew is: “Blessed are they who mourn, for they will be comforted” (Matt 5:5). In the Gospel of Luke, Jesus says, “Blessed are you who are now weeping, for you will laugh” (Luke 6:21). Jesus calls the sorrowful blessed (some English translations say ‘happy’) because they can expect good things in the future – comfort, laughter – that will far outweigh the sadness they feel in the present.

This confident anticipation of future blessing is what Christians call ‘Hope’. Hope is the virtue by which the Christian believer faithfully clings to the blessed future that God has promised. The New Testament is filled with expressions of that promise. We have mentioned Jesus’ beatitudes. Consider a few more examples:

Come, you who are blessed by my Father. Inherit the kingdom prepared for you from the foundation of the world.
— Matthew 25:34
Whoever eats my flesh and drinks my blood has eternal life, and I will raise him on the last day.
— John 6:54
I am the resurrection and the life; whoever believes in me, even if he dies, will live, and anyone who lives and believes in me will never die.
— John 11:25-26
Behold, God’s dwelling is with the human race. . .. God himself will be with them. He will wipe away every tear from their eyes.
— Revelation 21:3-4

Promises like these are the content of Christian hope. God will save us, end our suffering, give us eternal life, and welcome us into His kingdom. This is the confident hope of all Christians. However, to those who suffer in especially egregious ways – whose deprivation, loss, or affliction plunge them into deep sadness – God promises particular blessing. Because God’s purpose is not only salvation for His people, but salvation for His afflicted and suffering people. We might call this God’s promise to reverse the fortunes of his afflicted people. And the Bible is filled with it. For example:

The Lord . . . raises the needy from the dust; from the ash heap lifts up the poor.
— 1 Samuel 2:8
God . . . changed the desert into pools of water . . . and settled the hungry there.
— Psalm 107:35
[The Lord] has cast down the mighty from their thrones, and has lifted up the lowly.
— Luke 1:52
The last will be first, and the first will be last.
— Matthew 20:16

Jesus came to us as “a man of sorrows, acquainted with infirmity” (Is 58:3). He “was tested through what he suffered” (Heb 1:18). When his friends wept, “Jesus wept” (John 11:35). In his identification with human sorrow, he emptied himself “unto death, even death on a cross” (Phil 2:8). And it was “because of this” that “God greatly exalted him” (Phil 2:9).

Jesus Christ was exalted because of his self-emptying solidarity with suffering and sorrowful human beings. Christian disciples who hope to be exalted with Jesus must share Jesus’ compassion for the afflicted and show love for Jesus in the afflicted. “Come, you who are blessed of my Father . . . For I was ill and you cared for me” (Matt 25:34,36). God’s saving promise, it turns out, is given especially to the sorrowful and to those who, with Jesus and for Jesus, give comfort and help to those who are sad.

The ETHICAL PERSPECTIVE

We are accustomed to evaluating people according to professional standards. “She’s a good doctor.” “He’s a good accountant.” “Their second baseman is terrible!” These kinds of statements are familiar to us. We understand what they mean because we understand that there are particular sets of standards to which people doing particular kinds of work must measure up. These standards, whether or not they are explicitly codified, are generally recognized by anyone familiar with the profession. A doctor should have a thorough knowledge of the human body, familiarity with various kinds of injury and disease, and skill in diagnosis and prescription of treatment. An accountant should understand financial record-keeping standards and have skill in the management of money. A second baseman should have a good on-base percentage, good range in the field, and be able to throw with accuracy. According to standards like these, we measure the quality of a person in his or her professional role. We judge that he or she is good or bad as a doctor, as an accountant, or as a second baseman. How, though, are we to measure the quality of a person as a person?

To be sure, we often hear it said that “he’s a good man,” or “she’s a good woman.” These statements, however, are less often associated with a clear set of standards. How can we tell whether someone really is a good person? How can statements like that be verified? The answers to these questions tend to be limited and vague. Someone might say that a good person is someone who hasn’t done anything really bad. Anyone who hasn’t committed murder or isn’t a serial adulterer or persistently spiteful, we may be told, is “basically a good person.” A good person, one might think, is someone who is, in some vague sense, “nice” or “kind” or “cool.” Beyond these very minimal considerations, there does not seem to be much widespread agreement about the standards to which human beings must measure up in order to be recognized as good.

The standards for determining the quality of a person as a person, it turns out, are much more difficult to identify than the standards for determining the quality of a person as a second baseman. There are many reasons why this is so. Being a human person is far more complicated than being a second baseman. A second baseman is a role that was invented as part of the game of baseball; a person is not a role that any human being invented or created. A second baseman has a well-defined purpose – to help his team score more runs than the opposing team; the purpose of being a human person is far more difficult to grasp. Moreover, the person who plays second base could be expected to provide a more thorough account of what makes a second baseman good than someone who has never played that position. But everyone has the shared experience of being a person and most people could not give a thorough account of what it is that makes a person good.

Added to the difficulty of determining what makes a person a good person is the fact that, for many people, the question just doesn’t come up. It’s too fundamental. It’s like asking why something exists instead of nothing – a question only a philosopher or a madman would think of asking. Everyone who sets out to become a doctor will, in some way, ask the question, “What must I do to become a good doctor?” But not everyone who embarks upon living the life of a human person asks the question, “What must I do to become a good person?” When the question does come up, it is often dismissed as impossible to answer or not worth answering.

Ethics is the kind of thinking that seeks to answer this question. To think from an ethical perspective is to see oneself and one’s fellow human beings not only as having professional capacities and social roles, but as being persons first and foremost. To think from an ethical perspective is to consider that being good and acting well apply not just to what one does as a doctor or lawyer or mother or father or violinist or chess player, but to who one is as a person. As human beings, we take on all sorts of roles, jobs, and functions. Often a single person will “wear many hats” as the saying goes. I am a Dominican friar, a Catholic priest, a U.S. citizen, and a Mets fan. All of those are good things (or so I would contend). They are good for me, however, only insofar as they contribute to making me a good person. For I am a person first of all. And if I am truly to be good, I must be good as a person.

So what is it that makes a person good? What standards must one measure up to in order to be good as a person? These are big questions, and we cannot even begin to answer them here. Still, by asking the right questions, we have taken the first step toward finding the right answers.

By adopting the ethical perspective, we have begun to consider ourselves and our actions according to the standards that measure who we really are: not just professionals or functionaries or role players, but human persons.

VIATICUM: the LAST SACRAMENT of the CHRISTIAN

The sacrament of Anointing of the Sick, when administered to the dying, is called by the Catechism of the Catholic Church, “sacramentum exeuntium (the sacrament of those departing)” (CCC 1523). Nevertheless, it is not the sacrament of Anointing, but the Eucharist as 'viaticum', that the Catechism calls, “The last sacrament of the Christian” (CCC 1524). It explains,

Communion in the body and blood of Christ, received at this moment of “passing over” to the Father, has a particular significance and importance. It is the seed of eternal life and the power of resurrection, according to the words of the Lord: “He who eats my flesh and drinks my blood has eternal life, and I will raise him on the last day” (John 6:54). The sacrament of Christ once dead and now risen, the Eucharist is here the sacrament of passing over from death to life, from this world to the Father.
— CCC 1524

Most of the time, when I visit dying patients in the hospitals we serve, they are, regrettably, not able to receive the Eucharist as viaticum. Sometimes they have tubes in their mouths or throats; sometimes they are unconscious or otherwise unable to receive food by mouth. Other times, however, dying patients can receive the Eucharist as viaticum. This is frequently the case when patients have exhausted their treatment options and are preparing to receive hospice care. Administering the Eucharist as viaticum to such patients and explaining to them the meaning of that sacrament is one of the most rewarding experiences I have in my health care ministry.

To explain the meaning of the Eucharist as viaticum, I typically tell patients about the meaning of that word. ‘Viaticum’ is a Latin word that comes from ‘via’, which means ‘road’ or ‘way’. ‘Viaticum’ refers to the provisions that one brings on the way. The Eucharist as viaticum is, first and foremost, the Eucharist. It is the body, blood, soul, and divinity of Jesus Christ really present in the sacrament Jesus instituted at the Last Supper. Whenever we receive the Eucharist in Holy Communion, Jesus is really present with us and in us. When we receive the Eucharist as viaticum, Jesus is present with us and in us to guide us on our way to eternal life. Jesus is our food for the journey heaven.

The Eucharist is our Communion with Jesus in the sacrament of his body and blood. It is our Communion in who Jesus is and what Jesus did. At the Last Supper, Jesus took bread, blessed it, broke it, and give to his disciples, saying, “This is my body, which will be given for you” (Luke 22:19). Eucharist is a noun – it is Jesus – and it is a verb – it is Jesus’ self-giving on the cross. The reality of Jesus in the Eucharist cannot be separated from his saving work – his Passion, Death, and Resurrection that were his passing over from this world to the Father.

When a person receives the Eucharist as viaticum, she is united with Jesus and, in a special way, she is united with Jesus’ “passing over from death to life, from this world to the Father.” In the Eucharist as viaticum, Jesus is the food for her journey. Jesus guides her on the way that he himself has trodden: the road from death to life.

People who are facing the prospect of dying are frequently scared and confused. They have a hard time making sense of what is happening and don’t know what to do. When I talk to such people about the Eucharist as viaticum and administer that sacrament to them, I often find that they experience a wonderful peace of heart and clarity of mind. They know Jesus is with them and is leading them along his way. One man told me, “Father, I was filled with fear and now I have serenity.”

The Eucharist as viaticum is “the last sacrament of the Christian.” But it is not isolated from the other “last sacraments” of the Church. When I administer the Eucharist as viaticum to a person preparing for death, it is almost always right after celebrating the sacraments of Reconciliation (aka ‘Confession’ or ‘Penance’) and the Anointing of the Sick. As the Catechism says:

Penance, the Anointing of the Sick, and the Eucharist as viaticum constitute at the end of the Christian life ‘the sacraments that prepare for our heavenly homeland’ or the sacraments that complete our earthly pilgrimage.
— CCC 1525

"GOD'S REMEDY": the STORY of RAPHAEL the ARCHANGEL

I am writing this on September 29, the feast day of the archangels Michael, Gabriel, and Raphael. They are the three angels who are named in the Bible, whom God sent to his people for specific purposes. Those purposes are revealed in the meaning of their names: Michael means “Who is like God”; Gabriel means “The Strength of God”; and Raphael means “God’s Remedy.” As his name suggests, the archangel Raphael is sent by God to heal. In the Bible, the story that exemplifies Raphael’s healing mission is told in the Book of Tobit.

The Book of Tobit begins by introducing its title character, a faithful Israelite living in captivity in Nineveh. It tells how Tobit was afflicted with blindness and the mockery of his neighbors. Meanwhile, in the distant land of Media, a young kinswoman of Tobit named Sarah was afflicted by a demon who had killed all seven of the men she had married. Both Tobit and Sarah prayed for death. Their prayers were both faith-filled and desperate. Tobit prayed, “You are righteous, Lord, and all your deeds are just . . . command that I be release from such anguish . . . for it is better for me to die than to endure so much misery” (Tobit 3:2,6). Sarah prayed, “Blessed are you, merciful God! . . . Bid me to depart from the earth . . . But if it does not please you, Lord, to take my life, look favorably upon me and have pity on me” (Tobit 3:11,13,15).

It did not please the Lord to take either of their lives. Rather, God sent the angel Raphael to heal them. Raphael presented himself to Tobit in the guise of a kinsman and accompanied Tobit’s son Tobiah on a journey to Media to claim a sum of money that Tobit had deposited. On the journey, Tobiah caught a large fish whose organs possessed healing properties. When they arrived in Media, Raphael led Tobiah to the family home of Sarah, who, Raphael informed him, Tobiah had the right to marry. Tobiah did marry Sarah and, as Raphael had instructed, he burned the liver and heart of the fish he had caught and thereby cast out the demon who had afflicted his new bride. Soon afterward, they all returned to Nineveh. Upon greeting his father, Tobiah, again at the instruction of Raphael, used to gall of the fish to anoint Tobit’s eyes and thus removed the scales that had blinded him.

Raphael then revealed his identity, saying, “I am Raphael, one of the seven angels who stand and serve before the Glory of the Lord” (Tobit 12:15). He explained to Tobit, “When you, Tobit, and Sarah prayed, it was I who presented the record of your prayer before the Glory of the Lord” (Tobit 12:12) and “God sent me to heal you and your daughter-in-law Sarah” (Tobit 12:14).

Like Tobit and Sarah, countless people in the present time experience severe affliction and cry out to God in ways that are both faith-filled and desperate. Like Tobit and Sarah, some go so far as to pray for death. Many of them are sick and suffering people in our own neighborhoods. The story of Tobit and Sarah and the archangel Raphael reminds us that God hears those prayers and that God has a remedy.

God’s remedy includes the angels and the human beings God sends to heal. Raphael, patron saints like Saint Luke, Saint Peregrine, and Saint Catherine of Siena, as well as doctors, nurses, and other “angelic” practitioners of health care all share in that mission. God’s remedy also includes medicines and treatments that are derived from the natural world God created. Modern day equivalents of Tobiah’s fish gall are healing remedies that God provides.

The story of the Book of Tobit also shows us that it’s okay to pray to God in desperation and honestly tell God what we want and how we feel. The prayers of Tobit and Sarah demonstrate profound faith in God’s goodness and, at the same time, do not hesitate to express raw feelings about their afflictions. God heard those prayers and showed mercy. We have every reason to trust that God will hear our prayers and look favorably on us as He looked favorably on the prayers of Tobit and Sarah.

Finally, the healing wrought by Raphael in the Book of Tobit shows us God’s remedy, but it does not reveal God’s greatest remedy. That is revealed in the Incarnation, Passion, and Resurrection of Jesus Christ, in whom God prescribed a remedy, not only for sickness and suffering, but for sin and death as well.

ANOINTING of the SICK: a SACRAMENT for the SICK and the DYING

The Anointing of the Sick is a sacrament that is frequently misunderstood. When I receive emergency calls asking me to come to a hospital to minister to a dying patient, the requests are usually for “last rites.” When, during more routine visits, I offer to administer the sacrament of Anointing of the Sick, people often react as though I had suggested the patient were dying. The use of the term “last rites” and the association of Anointing of this Sick with impending death are based on a misunderstanding of the nature of this sacrament and its administration in the contemporary Church.

The nature of the sacrament of Anointing of the Sick was clarified in the Vatican II Constitution on the Sacred Liturgy more than fifty years ago. It states (SSC 73): 

[Anointing of the Sick] is not a sacrament for those only who are at the point of death. Hence, as soon as any one of the faithful begins to be in danger of death from sickness or old age, the fitting time for him to receive this sacrament has certainly already arrived.

This teaching was put into practice through the 1972 instruction of Pope Pius VI, who declared, “The sacrament of the anointing of the sick is administered to those who are dangerously ill” (Sacram Unctione Infirmorum). So, for many decades now, the teaching of the Church has been clear: Anointing of the Sick is for the seriously sick and not just for the imminently dying.

This renewed understanding of the sacrament of Anointing of the Sick, while correcting one misunderstanding – that it only for the dying – has given rise to another – that is not for the dying at all, but for anyone who is sick. This misunderstanding is reflected in some celebrations of Anointing within Mass (sometimes called ‘Healing Masses’) at which Anointing of the Sick is administered to everyone indiscriminately. It is also expressed by some who suggest that, since Anointing is for the sick, the Church’s ministry to the dying need not include this sacrament, but should be confined to prayers and blessings that do not require the presence of a priest.

An authentic understanding of the sacrament of Anointing of the Sick can be found in the Catechism of the Catholic Church. There the truth is presented unambiguously: Anointing of the Sick is for the sick and also, in a particular way, for the dying.

The Catechism enumerates four effects of the sacrament of Anointing of the Sick. The first three are of equal benefit to the sick person who hopes to be restored to health and the sick person who is preparing to die. The first effect listed in the Catechism is “a particular gift of the Holy Spirit” by which the sick person receives “strengthening, peace and courage to overcome the difficulties that go with the condition of serious illness or the frailty of old age” (CCC 1520). This gift of the Spirt intends a two-fold healing: “to lead the sick person to healing of the soul, but also of the body if such is God’s will.” The second and third effects have to do with the sick person’s union with the suffering Christ as a member of his body the Church. The sick person “is consecrated to bear fruit by configuration to the Savior’s redemptive Passion” (CCC 1521) and thereby “contributes to the sanctification of the Church and to the good of all” (CCC 1522)

The fourth effect of the sacrament of Anointing of the Sick concerns the sick person’s “preparation for the final journey” (CCC 1523). The Catechism teaches, “The Anointing of the Sick completes our conformity to Christ, just as Baptism began it.” For this reason, its concludes:

If the sacrament of Anointing of the Sick is given to all who suffer from serious illness and infirmity, even more rightly is it given to those at the point of departing this life; so it is also called sacramentum exeuntium (the sacrament of those departing).

When our loved ones are seriously sick and, especially, when they are nearing the point of death, we should call for a priest. That is, we should heed the instruction we find in the Letter of Saint James: “Are their people sick among you? Let them send for the priests of the Church and let the priests pray over them, anointing them with oil in the name of the Lord.” (James 5:14)

CONTEMPORARY HEALTH CARE and the CHOICE for LIFE

I have set before you life and death . . . choose life!
— Deuteronomy 30:19

The choice that Moses set before the Israelites as they prepared to pass into the Promised Land is a choice that is set before us today in a variety of ways. The exhortation to choose life applies to the decisions we make to serve the Lord of life and treat others with the justice that human dignity demands. It applies to the choices we make in political life to secure the rights of the needy and defend the unborn, aged, infirmed, and disabled. We are called to choose life. We are to protect, nurture, and sustain our own lives and the lives of others, acting as faithful stewards of God, who is the Lord and giver of life.

We are not, however, to sustain bodily life at all costs. Consider the Passion of Christ and the death of the martyrs. Jesus and his faithful witnesses gave up their lives willingly, not by choosing to cause their own deaths, but by choosing that which is greater that bodily life: faithfulness, truth, the salvation of the world, eternal life in God’s kingdom. For Christians, suicide and martyrdom are opposites. Suicide is the choice to cause one’s own death. Martyrdom is the choice to allow one’s death to be caused by others for the sake of greater life.

Most of us will not have the opportunity to die as martyrs. Many of us will, however, confront challenging circumstances that require us to distinguish between choosing to cause death and choosing to allow death to occur naturally for the sake of a greater good.

This dilemma occurs frequently in the world of contemporary health care. Medical technology has given us better methods for both preserving and destroying human life. People with terminal diseases have more ways of keeping themselves alive and more ways of hastening their deaths. Pregnant women have greater means at their disposal both to save the lives of their unborn children and to end them. How can these people know when allowing death is morally right? How can they distinguish between permitting of death as an unfortunate side effect and choosing death in an act of killing?

The Catholic Church has the resources with which to answer these questions. The Church’s moral tradition distinguishes between ordinary and extraordinary means of preserving life. It identifies the conditions according to which an evil result can be permitted as a side-effect of a good action. Often these principles can be applied easily and straightforwardly to the situation at hand. Sometimes applying such principles correctly is difficult and complicated. In every case, however, arriving at the right answer begins with asking the right question.

The right question is not the question of life or death: Should I live or should I die? Is life worth living or not? Does that person’s life have any value? These are questions we have already answered in responding to the exhortation of Moses. We choose life! We choose to value, uphold and defend the dignity of all human life. We reject the choice to cause death. God is the master or life and death. We are not. Our task is to protect, nurture and sustain our lives as long as God’s providence permits.

The question that is ours to ask and answer is not whether life is worthwhile; it is whether or this or that procedure, treatment, or intervention is worthwhile. We know that life is always good. Our question is whether this or that lifesaving measure is good or whether it is evil, overly burdensome, or otherwise unreasonable. It is to this question, not the question of life or death, that we apply the resources of the Church’s moral tradition.

We start by choosing life, affirming its value and God-given dignity. We choose to protect, nurture and sustain life and never to make death our aim. If we are firm in this life-affirming choice and rely on the guidance of Catholic teaching we can be confident that, even when we decide to allow the natural process of death to occur and entrust our loved ones to mercy of God, we remain faithful to the exhortation of Moses:

I have set before you life and death . . . choose life!

REPRODUCTIVE TECHNOLOGIES and the RIGHTS of PARENTS and CHILDREN

Our society generally uses the term “reproductive rights” to refer to the options that should be made available to a woman insofar as she is a potential (or sometimes actual) mother. The Catholic Church teaches that mothers and fathers and children all have rights regarding the manner of their reproduction. According to the Catechism of the Catholic Church, a husband and wife have the “right to become a father and a mother only through each other” (CCC 2376). In the same paragraph, the Catechism refers to “the child’s right to be born of a father and mother known to him and bound to each other by marriage.” Both the rights of the parents and the rights of the child, according to CCC 2376, can be violated by the use of reproductive technologies. Here is the full paragraph, which quotes from the Congregation of the Doctrine of the Faith’s document, Donum Vitae:

Technologies that entail the dissociation of husband and wife, by the intrusion of a person other than the couple (donation of sperm or ovum, surrogate uterus), are gravely immoral. These techniques infringe upon the child’s right to be born of a father and mother known to him and bound to each other by marriage. They betray the spouses’ “right to become a father and a mother only through each other.

In what follows, I will expound upon this teaching by commenting upon the rights of the child and the spouses that are referred to in the Catechism.

The Rights of the Child

“The child’s right to be born of a father and a mother known to him and bound to each other by marriage” touches the heart of the Church’s teaching on marriage and human sexuality. The stable and exclusive union between husband and wife is the proper place for sexual activity largely because it is the proper setting for the rearing of children. The kind or reproductive technologies referred to in CCC 2376 intrude upon the exclusivity of the marital union. A child conceived by an anonymous biological father or born to a surrogate mother is deprived of the unambiguous identity of being the child of one father and one mother in the security of one family. A child has a right to a family in which he or she is the fruit of the love of a husband and wife who become a mother and a father in the expression of their exclusive union. The right on the part of the child implies a corresponding obligation on the part of the parents. They are morally obliged to conceive children only through their shared acts of conjugal love and free from intrusive technologies or third parties.

The Rights of the Parents

The rights of spouses “to become a father and mother only through the other” are implicit in the vows they make at their wedding. Fidelity to those vows requires that their sexual relationship be exclusive. Even if they were to agree to do otherwise, their conduct would betray the vows they made to each other before God. Fidelity also requires that their child bearing be the fruit of that exclusive relationship. Even if they were to agree to bring in a third party to effect the fertilization or gestation of their child, it would be a violation of their vows and an intrusion into the exclusive relationship that is proper to husband and wife. A husband and wife have mutual rights and obligations that are definitive of their marriage. Among them are the right and obligation of both to become father and mother only through each other.

Husbands and wives have the right and obligation to give and receive the exclusive conjugal love by which a child might be conceived. They do not, however, have the right to conceive a child. Husbands and wives are right to want to have children. That is a natural and praiseworthy desire. But the desire that is praiseworthy is the desire to receive a child as a gift – a gift from God received through the mutual giving of husband and wife – not the desire to receive a child as an entitlement. Sadly, by asserting this false right to a child, potential parents can be inclined to make use of reproductive technologies in ways that violate the true rights of both parents and children to be gift and family only through each other.

TOWARD a SPIRITUALITY of HEALTH CARE

Christian revelation tells us that seeking what is truly good — and seeking the one who is Truth and Goodness — is not just something we do, but something God does in us. It is only by the power of God’s grace, with which we must freely cooperate, that we are made able to attain the goal for which we were created, which is God Himself.      

This means that ethics in general, and medical ethics in particular, is closely related to what we might call “Christian spirituality.” Studying what is good for us to do, it turns out, has everything to do with how God is acting in our lives and leading us more deeply into relationship with Himself. For Christians, doing what is good is always about cooperating with God’s grace. We recognize that in our weak and fallen state we cannot direct ourselves toward God through our own feeble efforts. We need the transforming power of God’s grace in order to do the good that will lead to true happiness. Infused with God’s grace, our good deeds transcend the limits of our natural capabilities. Our actions are no longer limited to what we can do on our own, but are elevated by what God can do in us. In the light of Christ, ethics opens out into spirituality; human action is infused with the Spirit of God.

St. Thomas Aquinas gives us an illuminating way of understanding this dynamic when he says that charity is the form of all the virtues. Now charity, for St. Thomas, “is the friendship of man for God” (Summa Theologiae II-II q. 23 a. 1). It is “the movement of love whereby we love God” (ST II-II 23.2). Charity is the love that God creates in us, which elevates our ability to love and so makes us capable of loving God truly. It is therefore charity above all that makes us able to attain our ultimate goal, which is God Himself. In St. Thomas’ words, “The ultimate and principal good of man is the enjoyment of God . . . and to this good man is ordered by charity” (ST II-II 23.7). This means that charity is not only the greatest of the virtues, since it directs us to our greatest good. It is also the form of all the other virtues, because “it is charity which directs the acts of all other virtues to the last end” (ST II-II 23.8).

What this means for us is that every good action we perform can be an act of love for God. When our souls are enlivened with charity, all our virtuous deeds are informed by our friendship with God and contribute to the attainment of that perfect enjoyment of God that is our principal good and ultimate end. This is not to say that our good actions are any less ours. What God does in us by his grace does not cancel or diminish the freedom God has given us as integral to our human nature. Rather, the grace of God elevates and perfects our God-given freedom, making it capable of the love for which God made it.

In addition, to say that charity is the form of all the other virtues is not to say that those virtues lose their distinctiveness or their distinctive importance. The diverse virtues that order different human actions toward their common goal remain diverse. The virtue of chastity, for example, by which we do what is good in matters of sexuality, is not less important for being informed by charity, but more important. We would be wrong to think, “It doesn’t matter so much if I’m chaste as long as I love God.” The correct conclusion is rather, “Chastity matters more to me because being chase is one way I can live in friendship with God.”

Applying this to the practice of health care, we can conclude that our daily activities matter much more that we might have thought. When those actions are right and good, we don’t just serve our patients well, we also render to God acts of supernatural love and advance toward our ultimate purpose. Conversely, when our actions are unjust, unkind, or poorly considered, we fail not just to be good clinicians, but to love God and to advance on our way toward Him. By the grace of God, we have the opportunity each day to care for others in a way that can have eternal importance both for them and for us. This should motivate us to come to the practice of health care with both generous hearts and ethically informed minds. For when we care for the health of others in a way that is truly good – caring, competent, and ethical – our seemingly mundane actions can be elevated by the infusion of divine love to become deeds of supernatural consequence. When we allow God to work in us and through us, ethically informed practice becomes a spirituality of health care. When we do what is good in our everyday actions and decisions, we can recognize with eyes of faith the presence of the Spirit of God, who elevates our human actions beyond the limits of human achievement and transforms them into expressions of divine friendship.

The EUCHARIST, the CHURCH, and the HOSPITAL

"The Church draws her life from the Eucharist.” With these words, Pope Saint John Paul II began his 2003 encyclical Ecclesia de Eucharistia. He continues, 

In a variety of ways, she [the Church] joyfully experiences the constant fulfillment of the promise: ‘Lo, I am with you always, to the close of the age’ (Matt 28:20), but in the Holy Eucharist, through the changing of bread and wine into the body and blood of the Lord, she rejoices in this presence with unique intensity

The Pope goes on to explain how the communion we share in receiving the Eucharist builds up the communion of the Church. “The Eucharist thus appears as the culmination of all the sacraments in perfecting our communion with God the Father by the identification with his only-begotten Son through the working of the Holy Spirit” (EE 34). He calls the Eucharist “the supreme sacramental manifestation of communion in the Church” (EE 38) and says, “The Eucharist creates communion and fosters communion” (EE 40).

The Eucharist gives life to the Church by uniting Christians more perfectly with Christ and with one another. When we celebrate the Eucharistic sacrifice, receive the Eucharist in Holy Communion, or adore the Eucharistic presence of Christ in prayer, we are made the body of Christ by the body of Christ; we are constituted as the Church by our common participation in the Eucharist. The Eucharist creates communion. It brings us into communion with the whole Church and not only with those assembled. Pope Saint John Paul II writes,

Given the very nature of ecclesial communion and its relation to the sacrament of the Eucharist, it must be recalled that ‘the Eucharistic Sacrifice, while always offered in a particular community, is never the celebration of that community alone. In fact, the community, in receiving the Eucharistic presence of the Lord, receives the entire gift of salvation and shows . . . that it is the image and true presence of the one, holy, catholic and apostolic Church.

When we bring Holy Communion to the sick, we extend to the sick persons the communion of our local churches. When a sick person who is confined in her home or in a hospital receives the Eucharist that is consecrated and offered in the worship of a local community, she is united to that church and shares in that assembly. But the Eucharist is never the celebration of one local community alone. Through Communion in our Eucharistic Lord, we receive Jesus’ presence completely and are perfected in our communion with the universal Church that is one, holy, catholic and apostolic. When our sick brothers and sisters receive Holy Communion, they are made one with Jesus, with the communion of Jesus’ believers in a particular church, and the Church universal that is Jesus’ body.

“The Church draws her life from the Eucharist” and the sick person draws her life from the Eucharist by which she shares in the communion of Christ and his Church. When ministers of Holy Communion bring that Blessed Sacraments to sick and suffering men and women confined in homes or in hospitals, we give them the Eucharist; but at the same time we give them the Church. Those sick persons are separated physically from the local community in which the Eucharistic sacrifice is celebrated. Nevertheless, by receiving the Eucharist, whether physically or spiritually, the sick person is brought into communion with the worship of the assembly and the communion of the Church universal. Though that sharing in the Eucharist and the communion it creates, the sick person in the hospital truly is  “the image and true presence of the one, holy, catholic and apostolic Church”

The RIGHT to LIFE: the RIGHT of a CHILD; not the RIGHT to a CHILD

That illnesses can now be diagnosed and treated when a child is still in the womb represents a significant advance in modern medicine. Some diagnoses can be achieved by testing the genetic make-up of an unborn child either in utero (in the womb) or in vitro (in a test tube). Pre-natal diagnosis and treatment are, as I say, significant medical advances. However, they also raise significant ethical questions.

In vitro diagnoses frequently accompany in vitro fertilization (IVF), which itself presents ethical problems that we will not consider here. When IVF is accompanied by prenatal genetic testing, additional ethical problems can occur. An embryo that is found genetically undesirable is likely to be destroyed precisely for that reason. In such a case, the injustice of discrimination is added to the injustice of killing. Moreover, the attempt to identify and implant a genetically desirable embryo is likely to lead to the fertilization and destruction of increased numbers of newly conceived human beings.

Prenatal genetic diagnoses during pregnancy are not so ethically problematic. Genetic diagnostic testing is commonly administered as a standard aspect of prenatal care. It can be of help to parents in preparing to cope with the challenges of raising children with genetic disorders such as Down syndrome. In some cases, prenatal genetic testing can even lead to the diagnosis of disorders that can be successfully treated by gene therapy.  In these cases, prenatal genetic diagnoses can be morally good. Difficulties arise when prenatal genetic diagnoses are made for the purpose of aborting unborn children that are found genetically undesirable. As in cases of genetic testing in vitro, this use of genetic testing in utero compounds the evil of killing the innocent with the evil of unjust discrimination. It also leads to the proliferation of abortions.

The ethical problems presented by prenatal genetic diagnosis seem to be rooted in a kind of mindset that people can have about bearing children. Many people, especially married couples, want very much to have children. This desire is natural and good. Having children is something to which we are naturally inclined. Having children is also a task given us by God, whose first words to the human beings He created were, “Be fruitful and multiply” (Gen 1: 28). So when couples find themselves unable to have children it can be a source of great sorrow. Married couples faced with this situation deserve compassion and can often profit from the assistance of natural methods and medical specialists to achieve pregnancy through their acts of conjugal love.

The desire to have children is good. It becomes ethically problematic when their desire for a child leads a couple to suppose they have a right to a child. When a couple thinks they have a right to a child, they necessarily think of the child they might conceive in a false way. In their minds, their potential child is no longer someone they might receive as a gift from God, but someone they might produce with the assistance of technicians. The child is then thought of not as a human subject possessing rights of his own, but as an object that his parents have the right to possess. As Donum Vitae puts it, 

A true and proper right to a child would be contrary to the child’s dignity and nature. The child is not an object to which one has a right, nor can he be considered an object of ownership: rather, a child is a gift, ‘the supreme gift’ and the most gratuitous gift of marriage, and is a living testimony of the mutual giving of his parents
— CDF, Donum Vitae II, 8

This kind of mindset becomes even more troublesome when people imagine they not only have a right to a child, but a right to the child they want: the perfect child. Coupled with the practice of prenatal genetic testing, this way of thinking can lead to tragic results. If a couple imagines they have a right to a genetically flawless child, they can use genetic testing as a means of producing such a child. The tragedy is that to produce the “right” child, it is often found necessary to destroy the “wrong” child, if not multiple “wrong” or “unnecessary” children. This misuse of prenatal genetic testing can, in turn, reinforce the troublesome mentality. Insuring the genetic wellbeing of one’s children is a desirable thing. Now that this desire can be fulfilled through prenatal testing, it becomes tempting to fulfill this desire at all costs, even the cost of unborn human lives.

The right to life is the right of every human being, including unborn children. It is the right to have own life valued and respected. It is not the right of one human being to the life of another. Human beings should be valued for who they are themselves, not for the fulfillment they bring to others. Human beings are subjects to be loved, not objects to be used. Human life is not a commodity. Having children is not like picking apples. We can’t just keep the one’s we want and throw out the ones we don’t.