McManus, Robert

Millard, Charles E.

English

epublications@Marquette

The Linacre QuarterlyVolume 64 | Number 2 Article 14May 1997The Enigma of Today's PhysicianCharles E. MillardRobert McManusFollow this and additional works at: http://epublications.marquette.edu/lnqRecommended CitationMillard, Charles E. and McManus, Robert (1997) "The Enigma of Today's Physician," The Linacre Quarterly: Vol. 64: No. 2, Article 14.Available at: http://epublications.marquette.edu/lnq/vol64/iss2/14The Enigma of Today's Physician by Rev. Mr. Charles E. Millard, M.D. and Rev. Robert McManus, S.T.D. Dr. Millard is an ordained permanent deacon and Vice Chairman of the Biomedical Ethics Commission of the Diocese of Providence, Rl. Father McManus is Chariman of the Biomedical Ethics Committee, Vicar of Education and Official Theologian of the Diocese of Providence, Rl. The practicing physician today finds himself in a violent maelstrom of rapidly changing situations. He is beseiged on all sides. There are well-meaning citizens sincerely trying to solve the escalating costs of medical care and there are others trying to destroy the present system and take control of it. Unfortunately, there is only one economy in medical practice and that is death. A multiplicity of factors has produced the inexorable increase in medical care costs: rapid advancement in efficacious drug therapy, the discovery of new and expensive medical technology, organ transplantation, surgical procedures unheard of a decade ago, increasing life spans resulting from preventive and improved public health programs and improVed living conditions. On the obverse side of the coin, caring for HIV and Aids-infected individuals and dealing with drug addiction and its related health problems are increasingly expensive. It is little wonder that there has been a marked increase in costs. With the enactment of Medicare and Medicaid the payments to physicians were capped in an attempt to control costs. Other insurers tried various modalities of managed care. As with all insurance programs a bureaucracy evolved of necessity. It is estimated that 10% of the cost of health care in the United States is administrative and a more recent study indicates paper work occupies 33% of the medical professional's time. The milieu of the physician's everyday life is one of interference by case reviewers, insurance company and sundry government employees, hospital personnel and various others in this jungle of a bureaucratic nightmare. The physician's role is adversarial and most of it is unpleasant and not conducive to clear thinking. These extra demands on his time, coupled with such commitments May, 1997 89 that he has to make to the hospital for covering services weekly, attending conferences, serving on staff committees, attending courses of continuing education to retain his hospital staff appointments and to be eligible for medical licensure, are overwhelming. In addition, he must be active in his medical society to try to protect his profession from the constant onslaught of political action threatening his professional and economic security. He also must devote time to his family to avoid a common occupational hazard of the medical profession, namely a failure of his marriage. The Catholic Physician's Problem The Catholic physician also finds himself confronted by the aforementioned problems: The most serious scenario he would suffer from these problems would be a loss of material and earthly goods. Unfortunately, the Catholic physician not only has all of these problems but he must confront the biomedical ethical issues, so prevalent in his profession today, which conflict with his Catholic faith. These problems, abortion, euthanasia, physician-assisted suicide, in vitro fertilization, surrogate motherhood and a myriad of other biomedical ethical issues, are continually developing. These are truly more important than his professional and economic problems because failure to live his faith may result in the loss of his soul and eternal damnation. The many forces operating in society which playa part in the rising cost of medical care are forcing hospitals to merge in order to survive. This has resulted in many of these institutions finding themselves with conflicting moral values. The Catholic staff member, especially the Catholic physician, finds himself with another problem. He must be sure that his moral cooperation here is based on Catholic moral doctrine and is beingjudiciously observed by the Corporation on the campus of the Catholic hospital. The Catholic physician's position would seem untenable: his economic future is threatened, his professional status is being assaulted and his eternal salvation is in jeopardy, his time to participate in extra-medical activities to oppose these forces is sharply curtailed. MOST IMPORTANT OF ALL, BY FAR THE LARGE MAJORITY OF TODA Y'S CATHOLIC PHYSICIANS HAVE NOT A TIENDED CATHOLIC COLLEGES OR CATHOLIC MEDICAL SCHOOLS. CONSEQUENTLY, THEY HAVE NO THEOLOGICAL BASIS TO HELP THEM UNDERSTAND WHAT THE RIGHT ETHICAL DECISION WOULD BE IN SUCH SITUATIONS. THEY ARE ILL-PREPARED TO ARGUE AGAINST THE HUMANIST, SECULARIST POINT OF VIEW, MUCH LESS RESIST ENORMOUS PEER PRESSURE. Unfortunately, there is little help for them in most of the publications they read. These issues are seldom discussed from the pulpit, since the number of physicians in parishes is usually few in number or none at all. It is important that such information be made available to the Catholic medical professional for his salvation and so he can influence the thinking of his Catholic patients on these important biomedical ethical issues. It is therefore imperative that each diocese make 90 Linacre Quarterly an effort to fulfill this need. Theological Principles of Cooperation The moral principle of cooperation in evil derives from the inescapable fact that human beings live in community and will sometimes, willingly or otherwise, share in or contribute to the actions of others that are objectively wrong or immoral. While one might argue that the principle of cooperation is, of necessity, one of the most commonly appealed-to principles in ethical reflection, it is by no means the easiest to comprehend or apply properly. The famous moralist, Henry Davis, once observed that "there is no more difficult question than this in the whole range of moral theology". When a Catholic physician or a Catholic health care institution seeks integration with another medical institution that, from the moral perspective of the Roman Catholic Church, conducts immoral medical procedures, then the moral principle of cooperation in evil is fundamental to any consideration of whether such integration is morally justifiable or not. In the Catholic moral tradition, this principle has been the subject of systematic ethical reflection for over four hundred years. The principle itselfhas two distinct yet related applications. The first application is described as formal cooperation in evil. In formal cooperation in evil, a person (the cooperator) freely agrees with the immoral intention of the wrongdoer. Both the wrongdoer and the cooperator intend to choose the same moral. object of the same immoral action. This type of cooperation is explicity cooperation in evil and can never be morally justified. Materiol cooperation in evil is distinguished from formal cooperation and is a more complex issue. This type of cooperation in the evil action of another takes on several different modalities and nuances. In the case of material cooperation, a person (the cooper?.t0r) does not agree with the evil intention of the person (the wrongdoer) who will perform an immoral action and does not wish to choose the same moral object in performing his or her own action. Nonetheless, the cooperator participates in or contributes to, in some fashion, the performance of the immoral action of the wrongdoer. Under the rather extensive rubric of "material cooperation", there is a distinction to be drawn between "immediate material cooperation" and mediate material cooperation. Immediate material cooperation is virtually beyond moral justification due to the proximity of the cooperator's involvement in the successful performance of the morally wrong action of the wrongdoer and the inability to distinguish the moral object of the cooperator's action from the moral object of the wrongdoer's action. However, if immediate material cooperation is ever to be morally justified, the factor of compulsion or force must be present. Nevertheless, when compulsion or force is absent and when it is impossible to distinguish the cooperator's choice of the moral object from that of the wrongdoer in the performance of this or that morally wrong action, this instance of cooperation in evil is tantamount to implicit formal cooperation and as a species of formal cooperation, it is morally indefensible. There remains yet another distinction to be made concerning mediate material cooperation in evil. That distinction is made between "necessary material May, 1997 91 cooperation" and "contingent material cooperation." If the immoral action of the wrongdoer could not have been successfully performed without the action of the cooperator, then the cooperator's action is termed "necessary material cooperation". If the successful completion of the immoral act of the wrongdoer could have been achieved without the action of the cooperator, then material cooperation of this sort is called "contingent material cooperation. " Mediate material cooperation in evil, be it necessary or contingent, can be morally justified under certain circumstances which can serve to excuse the moral culpability of the cooperator. In all cases of mediate material cooperation, there is never the issue of the cooperator's agreeing with the wrongdoer's choice of a moral object and the proximate participation in support of the action of the wrongdoer. However, the cooperator does in some manner participate in or support the immoral activity of the wrongdoer. While this type of material cooperation is voluntary, the action by which the cooperator participates in the immoral activity of the wrongdoer can be morally justified due to the existence of what moralists call a "proportionate reason." An appreciation of the nature of a proportionate reason is crucial to the proper understanding and morally defensible application of the principle of material cooperation. In many human actions there is a potentiality for the emergence of several effects that will derive from the performance of a single action or a series of actions. Some of these effects can be either good or bad. In some instances where a moral agent is faced with a morally complex and problematic situation, he or she must, to the best of his or her intellectual, emotional and moral ability, think through the network of effects that will derive from the performance of one or more actions. If the intellectual weighing or balancing of good and bad effects results in a preponderence of good effects, there exists a proportionate reason for executing the action under consideration, even if that action has the result of cooperating, to some degree, in the morally wrong action of another. In short, one might say that a proportionate reason is an intellectual construct that is made up of the preponderence of good effects that result from the performance of a given action. One must also remember that the closer the action of the cooperator is to the immoral action of the wrongdoer and the more necessary the action of the cooperator is to the successful completion of the wrongdoer's immoral action, the more serious the proportionate reason must be in order to justify morally the cooperator's action. There is one last element that must be considered in discussing whether mediate material cooperation in evil is morally justifiable or not and that is the reality of scandal. In the Catholic moral tradition, scandal has been defined in strictly moral terms as that which would make evil look good or attractive to another so as to lead another to sin. The Ethical and Religious Directives for Catholic Health Care Services, issued by the National Conference of Catholic Bishops in November, 1994, state, "The possibility of scandal .. . is an important factor that should be considered when applying the principles governing cooperation. Cooperation, which in all other 92 Linacre Quarterly repects is morally appropriate, may be refused because of the scandal that would be caused in the circumstances" (#70). The profile of the institutional provision of health care in the United States is rapidly changing. Catholic health care institutions will not be exempt from the corporate effects of this national restructuring. As a result, Catholic hospitals and other Catholic health care institutions will sometimes find that it will be very difficult for them to stand alone as unaffiliated institutions. In these circumstances there will, no doubt, be cases where Catholic health care institutions will wish to align themselves with non-Catholic institutions. If that alignment is to be morally acceptable, then bishops, religious orders and boards of trustess of Catholic health care institutions and other people responsible for the mission and identity of CatholiC health care institutions will have to reflect on the principle of cooperation and apply it to proposed restructuring models with prudence and pastoral sensitivity. Suggestions For Possible Diocesan Model Local dioceses may wish to undertake one or more of the following measures to assist this vital segment of the population in addressing this enigma. 1. Make tape cassettes available to be lent to interested physicians or medical groups. These tapes could be prepared by recognized theologians approved the Bishop. 2. Place a program on Internet through the Catholic network for those physicians who have computers. 3. Hold seminars led by physicians and theologians. 4. Hold seminars for priests interested in these subjects. 5. Make available information about various sources of information, i.e., Ethics and Medical by the Pope John Paul Center and many other publications. 6. Encourage active . membership in the National Federation of Catholic Physicians' Guild and SUbscription to the Linacre Quarterly, the official Journal of this Federation. May, 1997 93 

The Enigma of Today\u27s Physician

The Linacre QuarterlyVolume 63 | Number 4 Article 10November 1996The Enigma of Today's PhysicianCharles E. MillardRobert McManusFollow this and additional works at: http://epublications.marquette.edu/lnqRecommended CitationMillard, Charles E. and McManus, Robert (1996) "The Enigma of Today's Physician," The Linacre Quarterly: Vol. 63: No. 4, Article 10.Available at: http://epublications.marquette.edu/lnq/vol63/iss4/10The Enigma of Today's Physician by Rev. Mr. Charles E. Millard, M.D. and Rev. Robert McManus, S.T.D. Dr. Millard is an ordained permanent deacon and Vice Chairman of the Biomedical Ethics Commission of the Diocese of Providence, Rl. Father McManus is Chairman of the Biomedical Ethics Committee, Vicar of Education and Official Theologian of the Diocese of Providence, Rl. The practicing physician today finds himself in a violent maelstrom of rapidly changing situations. He is beseiged on aU sides. There are well-meaning citizens sincerely trying to solve the escalating costs of medical care and there are others trying to destroy the present system and take control of it. Unfortunately, there is only one economy in medical practice and that is death. A multiplicity of factors has produced the inexorable increase in medical care costs: rapid advancement in efficacious drug therapy, the discovery of new and expensive medical technology, organ transplantation, surgical procedures unheard of a decade ago, increasing life spans resulting from preventive and improved public health programs and improved living conditions. On the obverse side of the coin, caring for HIV and Aids-infected individuals and dealing with drug addiction and its related health problems are increasingly expensive. It is little wonder that there has been a marked increase in costs. With the enactment of Medicare and Medicaid the payments to physicians were capped in an attempt to control costs. Other insurers tried various modalities of managed care. As with aU insurance programs a bureaucracy evolved of necessity. It is estimated that 10% of the cost of health care in the United States is administrative and a more recent study indicates paper work occupies 33% of the medical professional's time. The milieu of the physician's everyday life is one of interference by case November, 1996 79 reviewers, insurance company and sundry government employees, hospital personnel and various others in this jungle of a bureaucratic nightmare. The physician's role is adversarial and most of it is unpleasant and not conducive to clear thinking. These extra demands on his time, coupled with such commitments that he has to make to the hospital for covering services weekly, attending conferences, serving on staff committees, attending courses of continuing education to retain his hospital staff appointments and to be eligible for medical licensure, are overwhelming. In addition, he must be active in his medical society to try to protect his profession from the constant onslaught of political action threatening his professional and economic security. He also must devote time to his family to avoid a common occupational hazard of the medical profession, namely a failure of his marriage. The Catholic Physician's Problem The Catholic physician also finds himself confronted by the aforementioned problems. The most serious scenario he would suffer from these problems would be a loss of material and earthly goods. Unfortunately, the Catholic physician not only has all of these problems but he must confront the biomedical ethical issues, so prevalent in his profession today, which conflict with his Catholic faith . These problems, abortion, euthanasia, physician-assisted suicide, in vitro fertilization, surrogate motherhood and a myriad of other biomedical ethical issues, are continually developing. These are truly more important than his professional and economic problems because failure to live his faith may result in the loss of his soul and eternal damnation. The many forces operating in society which playa part in the rising cost of medical care are forcing hospitals to merge in order to survive. This has resulted in many of these institutions finding themselves with conflicting moral values. The Catholic staff member, especially the Catholic physician, finds himself with another problem. He must be sure that his moral cooperation here is based on Catholic moral doctrine and is being j udiciously observed by the Corporation on the campus of the Catholic hospital. The Catholic physician's position would seem untenable: his economic future is threatened, his professional status is being assaulted and his eternal salvation is in jeopardy, his time to participate in extra-medical activities to oppose these forces is sharply curtailed. MOST IMPORTANT OF ALL, BY FAR THE LARGE MAJORITY OF TODAY'S CATHOLIC PHYSICIANS HAVE NOT ATTENDED CATHOLIC COLLEGES OR CATHOLIC MEDICAL SCHOOLS. CONSEQUENTLY, THEY HAVE NO THEOLOGICAL BASIS TO HELP THEM UNDERSTAND WHAT THE RIGHT ETHICAL DECISION WOULD BE IN SUCH SITUATIONS. THEY ARE ILL-PREPARED TO ARGUE AGAINST THE HUMANIST, SECULARIST POINT OF VIEW, MUCH LESS RESIST ENORMOUS PEER PRESSURE. Unfortunately, there is little help for them in most of the publications they read. These issues are seldom discussed from the pulpit, since the number of 80 Linacre Quarterly physicians in parishes is usually few in number or none at all. It is important that such information be made available to the Catholic medical professional for his salvation and so he in turn can influence the thinking of his Catholic patients on these important biomedical ethical issues. It is therefore imperative that each diocese make an effort to fulfill this need. Theological Principles of Cooperation The moral principle of cooperation in evil derives from the inescapable fact that human beings live in community and will sometimes, willingly or otherwise, share in or contribute to the actions of others that are objectively wrong or immoral. While one might argue that the principle of cooperation is, of necessity, one of the most commonly appealed-to principles in ethical reflection, it is by no means the easiest to comprehend or apply properly. The famous moralist, Henry Davis, once observed that "there is no more difficult question than this in the whole range of moral theology." When a Catholic physician or a Catholic health care institution seeks integration with another medical institution that, from the moral perspective of the Roman Catholic Church, conducts immoral medical procedures, then the moral principle of cooperation in evil is fundamental to any consideration of whether such integration is morally justifiable or not. In the Catholic moral tradition, this principle has been the subject of systematic ethical reflection for over four hundred years. The principle itself has two distinct yet related applications. The first application is described as formal cooperation in evil. In formal cooperation in evil, a person (the cooperator) freely agrees with the immoral intention of the wrongdoer. Both the wrongdoer and the cooperator intend to choose the same moral object of the same immoral action. This type of cooperation is explicitly formal cooperation in evil and can never be morally justified. Material cooperation in evil is distinguished from formal cooperation and is a more complex issue. This type of cooperation in the evil action of another takes on several different modalities and nuances. In the case of material cooperation, a person (the cooperator) does not agree with the evil intention of the person (the wrongdoer) who will perform an immoral action and does not wish to choose the same moral object in performing his or her own action. Nonetheless, the cooperator participates in or contributes to, in some fashion, the performance of the immoral action of the wrongdoer. Under the rather extensive rubric of "material cooperation", there is a distinction to be drawn between "immediate material cooperation" and mediate material cooperation. Immediate material cooperation is virtually beyond moral justification due to the proximity of the cooperator's involvement in the successful performance of the morally wrong action of the wrongdoer and the inability to distinguish the moral object of the cooperator's action from the moral object of the wrongdoer's action. However, if immediate material cooperation is ever to be morally justified, the factor of compulsion or force must be present. Nevertheless, when compulsion or November, 1996 81 force is absent and when it is impossible to distinguish the cooperator's choice of the moral object from that of the wrongdoer in the performance of this or that morally wrong action, this instance of cooperation in evil is tantamount to implicit formal cooperation and as a species of formal cooperation, it is morally indefensible. There remains yet another distinction to be made concerning mediate material cooperation in evil. That distinction is made between "necessary material cooperation" and "contingent material cooperation." If the immoral action of the wrongdoer could not have been successfully performed without the action of the cooperator, then the cooperator's action is termed "necessary material cooperation". If the successful completion of the immoral act of the wrongdoer could have been achieved without the action of the cooperator, then material cooperation of this sort is called "contingent material cooperation. " Mediate material cooperation in evil, be it necessary or contingent, can be morally justified under certain circumstances which can serve to excuse the moral culpability of the cooperator. In all cases of mediate material cooperation, there is never the issue of the cooperator's agreeing with the wrongdoer's choice of a moral object and the proximate participation in support of the action of the wrongdoer. However, the cooperator does in some manner participate in or support the immoral activity of the wrongdoer. While this type of material cooperation is voluntary, the action by which the cooperator participates in the immoral activity of the wrongdoer can be morally justified due to the existence of what moralists call a "proportionate reason." An appreciation of the nature of a proportionate reason is crucial to the proper understanding and morally defensible application of the principle of material cooperation. In many human actions there is a potentiality for the emergence of several effects that will derive from the performance of a single action or a series of actions. Some of these effects can be either good or bad. In some instances where a moral agent is faced with a morally complex and problematic situation he or she must, to the best of his or her intellectual, emotional and moral ability, think through the network of effects that will derive from the performance of one or more actions. If the intellectual weighing or balancing of good and bad effects results in a preponderance of good effects, there exists a proportionate reason for executing the action under consideration, even if that action has the result of cooperating, to some degree, in the morally wrong action of another. In short, one might say that a proportionate reason is an intellectual construct that is made up of the preponderance of good effects that result from the performance of a given action. One must also remember that the closer the action of the cooperator is to the immoral action of the wrongdoer and the more necessary the action of the cooperator is to the successful completion of the wrongdoer's immoral action, the more serious the proportionate reason must be in order to justify morally the cooperator's action. There is one last element that must be considered in discussing whether mediate material cooperation in evil is morally justifiable or not and that is 82 Linacre Quarterly the reality of scandal. In the Catholic moral tradition, scandal has been defined in strictly moral terms as that which would make evil look good or attractive to another so as to lead another to sin. The Ethical and Religious Directives for Catholic Health Care Services, issued by the National Conference of Catholic Bishops in November, 1994, state, "The possibility of scandal ... is an important factor that should be considered when applying the principles governing cooperation. Cooperation, which in all other respects is morally appropriate, may be refused because ofthe scandal that would be caused in the circumstances. (#70). The profile of the institutional provision of health care in the United States is rapidly changing. Catholic health care institutions will not be exempt from the corporate effects ofthis national restructuring. As a result, Catholic hospitals and other Catholic health care institutions will sometimes find that it will be very difficult for them to stand alone as unaffiliated institutions. In these circumstances there will, no doubt, be cases where Catholic health care institutions will wish to align themselves with non-Catholic institutions. If that alignment is to be morally acceptable, then bishops, religious orders and boards of trustees of Catholic health care institutions and other people responsible for the mission and identity of Catholic health care institutions will have to reflect on the principle of cooperation and apply it to proposed restructuring models with prudence and pastoral sensitivity. Suggestions For Possible Diocesan Model Local dioceses may wish to undertake one or more of the following measures to assist this vital segment of the population in addressing this enigma: 1. Make tape cassettes available to be lent to interested physicians or medical groups. These tapes could be prepared by recognized theologians approved by the Bishop. 2. Place a program on Internet through the Catholic network for those physicians who have computers. 3. Hold seminars led by physicians and theologians. 4. Holid seminars for priests interested in these subjects. 5. Make available information about various sources of information, i.e., Ethics and Medic by the Pope John Paul Center and many other publications. 6. Encourage active membership in the National Federation of Catholic Physicians' Guilds and subscription to the Linacre Quarterly, the official Journal of this Federation. November, 1996 83 

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The Enigma of Today\u27s Physician

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