Bio Ethics PHi 324

PHI 324 – Module 2 Guiding Assignment

Complete Steps 1 and 2 below. Refer to the Assignment Guidelines document in the Course Home menu for further information regarding critical thinking standards and grading.

Submit this assignment to the Dropbox no later than Sunday 11:59 PM EST/EDT. (This Dropbox basket is linked to Turnitin.)

Step 1: Answer all of the questions below.

1. How does Devettere define virtue and prudence? List and define both the moral and intellectual virtues.

2. What features did Aquinas link to prudence? What does the Devettere text describe as a proper notion of prudence?

3. What did Aristotle understand by Eudaimonia? What does the Devettere text describe as a proper notion of happiness?

4. Compare and contrast Devettere’s treatment of the role of religion in moral decision making with that of David Kelly in Chapter 1 of Contemporary Catholic Health Care Ethics.

5. According to Chapter 2 of A Primer for Health Care Ethics, there are a number of approaches or methods people use when making ethical decisions. List, and in your own words describe, each. Include an example of how you may have used each method at one time or another. What approach does O’Rourke advocate and how does it compare with Devettere’s approach?

Step 2: After answering the questions, conclude with the following process:

1. Summarize the main points made in the reading or readings as concisely, but as completely, as you can. What went on in these texts (whether in print or online)? Feel free to provide brief illustrative quotations from the texts (with page numbers in parentheses after the quotations) to help make your point. Where there are many readings assigned, their main points generally overlap; therefore, do your best to succinctly present what’s most crucial.

2. State what you thought was most interesting about what you read. Your aim should be to personalize (that is, say what these readings taught you, what you found interesting or of value), rather than to summarize (as you did in the first part). Use phrases like the following: “From these readings, I learned…” or “I didn’t used to understand…but now I do because…,” or “What I found interesting was…,” and so on.

Chapters for this assignment

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· Practical Decision Making in Health Care Ethics: Cases and Concepts, Chapter 2

 

· A Primer for Health Care Ethics: Essays for a Pluralistic Society, Chapter 2
 

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Contemporary Catholic Health Care Ethics, Chapters 1, 2,

 

· National Catholic Bioethics Center, Moral Teaching Serves the Human Person( web search

THIS CHAPTER INTRODUCES the virtue-based ethics that Aristotle first developed in the fourth century B.C.E. and Aquinas retrieved in the thirteenth century. It will explain the starting point and then the three primary ideas of this ethics: happiness, moral virtue, and prudence. The starting point is the deeply rooted desire of human beings to achieve what is truly good for themselves; selves; the best good is happiness, the best chance of achieving personal happiness is developing authentic moral virtue, and the best way to decide what will develop moral virtue is prudence. This chapter develops these four topics. Before we begin we need to make a preliminary remark about terminology. In this book the terms “ethics” and “ethical” will be used interchangeably with “morality” and “moral.” Some authors distinguish ethics and morality, but we will not make that distinction. Both words share a common etymology: What the Greek language called “ethics,” the Latin language tended to call “morals,” and both roots now appear in our English language. Also, it will be helpful to note that what the Greek language called the “character excellences,” the Latin language called the “moral virtues,” thus showing how the moral virtues pertain to what we often refer to as character integrity or good character. In addition to the moral virtues philosophers writing in both Greek and Latin identified an “intellectual excellence” or a “cognitive virtue” that also plays a major role in virtue ethics. THE GOOD WE SEEK Ethics begins, according to the ancient Greeks, when a person wonders how her life should be lived. How should we be living? What should we be trying to achieve? What should we be aiming for in our lives? These questions are the existential and practical questions almost every thoughtful person inevitably asks. Aristotle’s answer begins with the opening sentence of his Nicomachean Ethics: “Every skill and every investigation, and likewise every activity and choice, seem to aim at some good; hence the good has been well described as what all things aim at.” No reasons can be given to explain why “every activity and choice seem to aim at some good.” That they do is simply, for Aristotle, a given of our experience. Although the immediate aim of our actions and choices is a particular good, we can also think of aiming at an overall good for our lives as a whole. This overall goal is the subject matter of ethics. Ethics clarifies this overall goal and then shows what feelings and behaviors are likely to achieve it in our particular lives. And what is the overall goal we desire above all for our lives? It it nothing less than making our lives, as a whole, good lives. We do not simply desire life-we desire a good life. We do not simply want to live-we want to live well. We do not simply want to be-we want to flourish. Recognizing that the best good we can aim at is making our life as a whole a good life is the starting point of this virtue-based ethics. Aristotle called this starting point the first principle of ethics. Be careful of the word “principle” here. It does not mean what the word “principle” means in modern ethics, in which principles are understood as action-guides deduced from a moral theory or induced from a line of previous moral judgments in similar cases. The first principle in the ethics of the good is the absolute beginning, the foundation whence all else is derived. We cannot prove this first principle; nor can we give any reasons for it. There are no proofs or reasons for first principles. The word “principle” (principium in Latin and arche in Greek) means beginning, and no reasons can be given to establish the “beginning.” If there were reasons for a beginning, the reasons would come logically before the beginning, and then the beginning would then no longer really be the beginning. Both Aristotle and Aquinas agreed that first principles of reasoning are not provable but self-evident. They are self-evident because we soon realize we cannot reason if we do not accept them. Aristotle was the first philosopher to develop first principles in both theoretical reasoning (the reasoning in what he called science-physics, mathematics, and theology) and practical reasoning (the reasoning we use when we are making or doing something). The best known first principle of theoretical reasoning is the principle of noncontradiction: You cannot think something both is and is not at the same time. You cannot, for example, think something is both a square and not a square; that is, you cannot think

something is a square circle. The principle of noncontradiction is so powerful that Christian theologians did not hesitate to say it restricts God. The God of Christian theology is all-powerful, but He cannot create a square circle or a circular square. The first principle of any practical reasoning is the principle of the good-our choices aim at something we perceive as good. The first principle of the practical reasoning known as ethics is that our choices aim at whatever is good for our lives, whatever helps us flourish as human beings. This ethical good is intensely personal. The “good” Aristotle and Aquinas are talking about in ethics is your good and my good. Aristotle and Aquinas are trying to show their audiences what makes their lives good lives. Hence, if you join their audience, it is your good, your living well, that is meant when they speak of “the good.” It is also a shared good, the common good, because both philosophers considered human beings not only personal beings but essentially social beings as well. People do, of course, disagree on what above all makes a life good. Some say the overall good in life is money and property, others say it is pleasure, some say it is power, and still others say it is honors and recognition. Certainly money, property, pleasure, power, honors, and recognition are good, but are they the best goods we can aim at or desire for our lives as a whole? To answer that question ask yourself whether a person could achieve these goods and still not be living a life you would consider good overall. Certainly money, pleasure, power, honors, and recognition are desirable goods, but they are at least arguably not the most desirable goods achievable able in a human life. The first moral philosophers thought that the most desirable overall good was something else, and, despite variations in their accounts, they generally agreed on what it was. They called the best good we can desire for our lives eudaimonia. The word has no exact equivalent in English-literally literally it means something like “good fate,” but “happiness,” or perhaps “flourishing,” is probably the best translation. The Greek ethicists began with the idea that the overall good any thoughtful person would desire for his life is his happiness. A human life is successful if it is a happy life. HAPPINESS Happiness, of course, is a very general and vague term that can be understood in many different ways. Hence the challenge now is to explain what is meant by happiness. And the challenge is a demanding one for two reasons. First, human life is complex and supports many different ways of achieving happiness. And second, happiness is somewhat paradoxical in this sense: We achieve happiness not by aiming at it directly as if it were a concrete objective but by pursuing the concrete feelings, behaviors, and habits that make a life happy. We begin our explanation ofhappiness by saying what it is not. What Happiness Is Not First, we do not equate happiness with feelings of pleasure and the absence of pain. Pleasure may well accompany happiness, but this is not necessary, and as is well known pleasure can mislead us about what is truly good and thus undermine our happiness. And the presence of pain, although unpleasant, does not necessarily indicate that we are doing something bad. The identification of happiness with feeling pleasure and avoiding pain has a long history going back at least to Epicurus (342?-27o B.C.E.) and his famous cloistered garden outside the walls of Athens. In modern times Thomas Hobbes and Jeremy Bentham, both important political philosophers, were leading proponents of reviving this notion. But feelings of pleasure cannot be equated with happiness understood as what is truly good for ourselves, because pleasure often distracts us and sometimes leads us toward what is not truly good. Second, we do not equate happiness with the satisfaction of whatever desires a person might have. Happiness is not getting what we happen to want at the moment but achieving a good life. Sometimes a particular thing we want is not good for us, and getting it will not bring us happiness despite our thinking that it will. Third, we do not equate happiness with whatever a particular person believes it to be. A person might believe happiness is living promiscuously and so live this way, but his belief that he is happy does not provide the happiness of which we speak because such a life is not truly good for human beings. The word happiness designates what is truly good for a person, not what the person believes is good or brings happiness. In an ethics of happiness, the simple fact that someone declares he is happy is not enough for us to say he has achieved happiness; it must also be shown that he has achieved what will truly bring happiness-that is, a good life. It is always possible for people to think that they are living fulfilling lives when in fact they are not. People afflicted with Down syndrome, for example, often seem more happy and content in life than many other people, but no Greek moralist would have said such a life was a good life, something any rational person would deliberately seek. Happiness Is Agent-Centered Making personal happiness the starting point and goal of ethics could easily suggest something close to narcissism, egoism, individualism, or a crass “looking out for number one,” but it should not. Any understanding of personal happiness implying selfishness is incompatible with a credible morality. Sensitivity to this threat of egoism or selfishness is at least partly the reason why many modern moral philosophers and theologians have proposed something other than personal happiness ness as the foundation of ethics-perhaps rights, or principles, or an altruistic Christian life of self-sacrifice. sacrifice. These modern theories are so influential that many people have forgotten the blunt appeal to personal happiness in earlier philosophical and religious ethics. Although the ethics of Aristotle is typical and perhaps the best-known ancient morality grounded in personal happiness, his understanding of ethics was not unique in the earlier centuries. Just about every philosopher and religious leader of the time proposed personal happiness as the goal of morality. Consider two examples, one from Plato (427?-347 B.C.E.) and one from the Christian tian scriptures (ca. 6o-ca. ioo). In the beginning of Plato’s The Republic, a man named Thrasymachus insists that there is no good reason for being ethical or just: “The just man is always a loser, my naive Socrates. He always loses out to the unjust” (343D).

human being she was before the others were removed. Since human existence is a coexistence, if the existences of others are undermined, so is mine. Human being is social being; my being is a being-with-others. Once we understand ourselves not as discrete atomic entities related to others by some kind of social contract we decide to embrace, but as existentially interconnected with others in the very being we call human being, then the tendency to understand an ethics advocating personal fulfillment ment and happiness as selfishness is derailed. If my life is always a life-with-others, then my happiness and flourishing is always entwined with the happiness and flourishing of others. If my existence is a coexistence, then it is impossible for me to flourish at the expense of others. Treating them unjustly or insensitively undermines my good as well as their good. Understood in the framework of its origination, where human beings were thought of as essentially social beings, an ethics of personal happiness is anything but an ethics of selfishness. The happiness of any human being is the happiness of a social being, not of a discrete individual. This is why, for Aristotle, the study of ethics-how I go about making moral decisions-is only a phase in a larger study, a study he called politics. This can be difficult for the modern mind to understand because the modern approach (whether influenced by the liberal political philosophies extolling individual rights and liberty but neglecting community or by the more conservative political philosophies extolling family and communitarian munitarian values but neglecting the important modern values of liberty and self-determination) assumes the dichotomy of self and others, of individual and community, and then opts for one over the other. But it is anachronistic to place the ethics of personal happiness developed by Aquinas or Aristotle in the modern conceptual framework that dichotomizes the individual and her societies and then to criticize it. The familiar dichotomies of egoism and altruism and of self and community were, in the forms we experience them, unknown to earlier moralists. They never hesitated to claim that acting for the sake of virtue was acting in our own best interest. Nor did they hesitate to claim that acting for the good of others was also acting in our own best interest. They simply assumed that human beings are political beings, that human existence is always a coexistence with others in communities. Hence an ethics of the good retrieved from Aristotle and Aquinas is not an ethics of the liberal self striving primarily for his happiness, nor is it an ethics of the communitarian self striving primarily for the common good; it is both. Living well has both individual and communal dimensions. sions. Speaking of my good is also speaking of the common good; speaking of my happiness is also speaking of the happiness of others; speaking of my flourishing is also speaking of the flourishing of my communities. Happiness Is a Collective Term We have said that the happiness we speak of in ethics is not simply pleasure, nor is it the satisfaction tion of whatever desire we happen to have, nor is it whatever we happen to think it is, nor is it anything selfish. What, then, is this personal happiness? What can we say about it? We can begin by saying that happiness in ethics is a collective term describing the right balance and coordination of all the important goods in a person’s life. That is why it was described by Aristotle as the “complete” good. An analogy may help us to understand how a collective term is used. A rope is composed of, let us say, a thousand strands twisted together. The rope is not something added to the strands. We do not have a thousand and one things-the thousand strands and one rope-but the strands themselves constitute the rope. In a similar way, our happiness is not some additional good that comes as the result of achieving other good things in life. It is, rather, the life we call good because it combines successfully all the important elements and strands that constitute the human good. Happiness is not the reward gained after a life has been lived well but the good life itself. The good things in our lives come from two sources: luck and choice. Under luck we include any good thing we receive apart from our own effort. Some people prefer to speak of “blessings” instead of luck. By luck or blessings we may have inherited good health or happen to live in peaceful times with an abundance of friends and wealth, for example. Good luck and many blessings ings will certainly contribute to our personal happiness, but they are not the crucial factors. Luck will not by

itself bring us the personal happiness envisioned in ethics, and its absence will not preclude this happiness. Something else is much more important. The second and more important source of our happiness is the particular goods we choose to pursue as we live our lives. Aristotle noted but never organized, at least in the texts we have, the various good elements composing a happy life. Some later commentators did attempt some organization, however, and their schema is helpful. They identified three categories of goods according to the importance of their contribution to happiness. The categories are clear enough, although translating the ancient terms into English is somewhat awkward. The categories of goods constituting happiness, beginning with the most valuable, are these: •Noble goods •Potential goods •Useful goods Noble Goods These are the essential feelings, behaviors, and habits creating a happy life. By “behaviors” we mean actions as well as omissions (things you could do but choose not to do). By “behaviors” we also mean both private actions and omissions as well as a whole range of social actions and omissions sions with other people, interactions ranging from intimate love and friendship to all forms of social, political, and commercial relationships. Finally, by “habits” we mean acquired dispositions for feeling and behaving in certain ways. We develop these habits through constant repetition of the feelings and behaviors. The feelings, behaviors, and habits called the noble goods are the principal ingredients of happiness. We choose them for the sake of our happiness and, since they are also valuable in themselves, for their own sake as well. The Greeks called these feelings, behaviors, andhabits “excellent.” The subsequent Latin word for them was virtutes, the etymological origin of the English word “virtues.” The essential noble goods are the virtues. The ethics of happiness is a virtue ethics. Potential Goods These are goods providing us with opportunities to pursue the all-important virtues. They were called potential goods because they have the potential for contributing to the virtues and to happiness. ness. Some examples of potential goods are health, financial resources, pleasure, religion, art, music, science, charitable work, and almost any legitimate occupation. These are all goods that foster opportunities for virtue and happiness. These potential goods share one similarity with the virtues-we tues-we seek them for their own sake as well as for the sake of higher goods. They differ from the noble goods or virtues because, according to Aristotle, you need all the virtues for happiness but you do not need all the potential goods. Useful Goods These are goods sought not for their own sake but only for the sake of other goods, either the noble goods (the virtues) or the potential goods. An example of a useful good is an antibiotic: We do not take an antibiotic for its own sake but for the sake of a more valuable good-our health. Tools are another example: We do not buy a lawn mower for its own sake but for the sake of cutting grass. Useful goods are like tools that we need to accomplish something valuable. We do not seek them for their intrinsic value but for some other good we desire. Once we distinguish the major kinds of good, we can see how happiness, the most desirable good in a human life, is actually composed of several different categories of goods. Of these the most important are the noble goods (the virtues); then come the potential goods and finally the useful goods. The virtues play the major role in our happiness, but they need support from some potential and useful goods. Today the word “goods” seems a little awkward for the ideas just presented. It might make things more clear if we use the word “value” and recast the schema in terms of a hierarchy of values. The goal of life is happiness-making our lives truly good lives. The highest values are the virtues, and they are valuable both because they are the principal elements in happiness and because they have intrinsic value as well. Next in line after the virtues are things humans value for their potential to contribute to happiness and virtue as well as for their intrinsic value. Finally, at the lowest level, are the utilitarian values valuable only for their contribution to the higher values. Ancient commentators on this schema of goods and values all agreed that the best good we could pursue in a

itself bring us the personal happiness envisioned in ethics, and its absence will not preclude this happiness. Something else is much more important. The second and more important source of our happiness is the particular goods we choose to pursue as we live our lives. Aristotle noted but never organized, at least in the texts we have, the various good elements composing a happy life. Some later commentators did attempt some organization, however, and their schema is helpful. They identified three categories of goods according to the importance of their contribution to happiness. The categories are clear enough, although translating the ancient terms into English is somewhat awkward. The categories of goods constituting happiness, beginning with the most valuable, are these: •Noble goods •Potential goods •Useful goods Noble Goods These are the essential feelings, behaviors, and habits creating a happy life. By “behaviors” we mean actions as well as omissions (things you could do but choose not to do). By “behaviors” we also mean both private actions and omissions as well as a whole range of social actions and omissions sions with other people, interactions ranging from intimate love and friendship to all forms of social, political, and commercial relationships. Finally, by “habits” we mean acquired dispositions for feeling and behaving in certain ways. We develop these habits through constant repetition of the feelings and behaviors. The feelings, behaviors, and habits called the noble goods are the principal ingredients of happiness. We choose them for the sake of our happiness and, since they are also valuable in themselves, for their own sake as well. The Greeks called these feelings, behaviors, andhabits “excellent.” The subsequent Latin word for them was virtutes, the etymological origin of the English word “virtues.” The essential noble goods are the virtues. The ethics of happiness is a virtue ethics. Potential Goods These are goods providing us with opportunities to pursue the all-important virtues. They were called potential goods because they have the potential for contributing to the virtues and to happiness. ness. Some examples of potential goods are health, financial resources, pleasure, religion, art, music, science, charitable work, and almost any legitimate occupation. These are all goods that foster opportunities for virtue and happiness. These potential goods share one similarity with the virtues-we tues-we seek them for their own sake as well as for the sake of higher goods. They differ from the noble goods or virtues because, according to Aristotle, you need all the virtues for happiness but you do not need all the potential goods. Useful Goods These are goods sought not for their own sake but only for the sake of other goods, either the noble goods (the virtues) or the potential goods. An example of a useful good is an antibiotic: We do not take an antibiotic for its own sake but for the sake of a more valuable good-our health. Tools are another example: We do not buy a lawn mower for its own sake but for the sake of cutting grass. Useful goods are like tools that we need to accomplish something valuable. We do not seek them for their intrinsic value but for some other good we desire. Once we distinguish the major kinds of good, we can see how happiness, the most desirable good in a human life, is actually composed of several different categories of goods. Of these the most important are the noble goods (the virtues); then come the potential goods and finally the useful goods. The virtues play the major role in our happiness, but they need support from some potential and useful goods. Today the word “goods” seems a little awkward for the ideas just presented. It might make things more clear if we use the word “value” and recast the schema in terms of a hierarchy of values. The goal of life is happiness-making our lives truly good lives. The highest values are the virtues, and they are valuable both because they are the principal elements in happiness and because they have intrinsic value as well. Next in line after the virtues are things humans value for their potential to contribute to happiness and virtue as well as for their intrinsic value. Finally, at the lowest level, are the utilitarian values valuable only for their contribution to the higher values. Ancient commentators on this schema of goods and values all agreed that the best good we could pursue in a

virtue and intellectual virtue. The inclusion of an intellectual virtue in virtue ethics is absolutely crucial; in fact it is the intellectual virtue, what Aristotle called phronesis and Aquinas called prudentia, that is the action-guiding norm in virtue ethics. We cannot stress the intellectual decision-making virtue in virtue ethics enough because many contemporary accounts of virtue ethics either ignore the intellectual virtue or reduce it to a secondary role. Although we will explain them separately, they always work together in practice. A degree of moral virtue is necessary for the relevant intellectual virtue, prudence, to function well, and a degree of prudence is necessary for morally virtuous decision making in each particular situation. Every moral virtue presupposes prudential reasoning, and sound prudential reasoning presupposes the person has already developed some level of

The moral virtues are the excellences of a person’s character-the feelings, behaviors, and habits that contribute to character integrity and thus contribute to his living well, living a good life. As previously noted, “moral virtue” is synonymous with “character virtue” or “character excellence.” This section will explain five moral virtues that play a major role in traditional virtue ethics: temperance, ance, courage, justice, love, and pride. The section that follows it will explain the intellectual virtue that plays the normative role in virtue ethics: prudence. Emergence of the Moral Virtues The different moral virtues originate in various natural inclinations or tendencies that have evolved in human beings over time. We will live well by embracing these natural inclinations and cultivating vating them so that they will enrich rather than impoverish our lives. In other words the different moral virtues are nothing more than our natural inclinations shaped by intelligence so they will likely enhance rather than undermine our happiness. Aristotle’s writings suggest five major natural inclinations in human life and give a name to the moral virtue appropriate for each: •Our inclinations to satisfy our appetites for eating, drinking, and sex •Our inclinations to act despite fears and risks •Our inclinations to seek close personal relationships •Our inclinations to seek working relationships with others •Our inclinations to seek honors and recognition First, we have natural inclinations to seek food and fluids when we are hungry and thirsty. We may also seek mood-enhancing substances such as alcohol, nicotine, and so forth. And we seek some form of sexual gratification. Second, we have a natural inclination to engage in activities despite the fears that accompany them. Sensing that we could never live a rich and fulfilled life unless we are willing to take some risks, we are inclined to take them. Third, we have a natural inclination to bond closely with others. We were born into a network work of relationships, some kind of family. And as we mature we naturally pursue personal relationships tionships as we come to realize a life lived without intimate connections is a life not well lived. Fourth, we also have a natural inclination to encounter others in less personal ways. We relate to other people every day, sometimes for the first and last time, sometimes over extended periods of time. All human lives are interwoven with various social, political, commercial, and professional encounters. Finally, we have a natural inclination for honors and praise, especially when we do well or bear up well under great challenges, adversity, sickness, or tragedy. We naturally seek recognition for our achievements. We want our success to be recognized and acknowledged. You can easily see how these major natural inclinations can hurt as well as help us live well. We know that not all eating, drinking, and sex; not all risky behaviors; not all relationships; and not all honors and praise contribute to our living well and flourishing as human beings. Of course, other natural inclinations exist as well-inclinations to anger and to aggression, for example-and these too can hurt as well as help us live well. When these natural inclinations spontaneously give rise to good feelings and behaviors-those those contributing to a good life-Aristotle called them natural virtues. We often see natural virtues in children when they share cookies or perform an act of kindness or carefully try something risky. Moral training can shape and strengthen these natural virtues. Spontaneous natural virtue and early moral training provide an orientation toward living well, but they are woefully inadequate for the complexities of adult life. For a mature moral life we need more than natural virtues and moral training-we need what Aristotle called the authentic moral virtues. Whereas natural virtues arise spontaneously and are shaped by training, the authentic moral virtues arise from intelligent choices guided by prudence. Whenever we deliberately and intelligently guide the feelings and behaviors arising from our natural inclinations, we are forming authentic moral virtues. Looking at the five major domains of life we singled out earlier, we can name five major authentic moral virtues: •Good management of eating, drinking, and sex is temperance. •Good management of risk taking is courage. •Good management of personal relationships is love or •Good management of general encounters with others is justice. •Good management of honors and recognition is pride. Aristotle’s claim is that developing the authentic moral virtues gives us the best chance of achieving happiness in life. You probably recognize the first four moral virtues-temperance, courage, love, and justice-and have some idea of what they are. However, you are probably not familiar with the fifth moral virtue, pride. Yet Aristotle actually considered pride to be the most important moral virtue. Since his views on pride have often been neglected in the virtue theory tradition, we need to say something about it. Pride-The Forgotten Virtueintelligently our natural inclination to seek honor and recognition nition for our accomplishments in life. It is natural to want our achievements to be honored and recognized. But honor and recognition bestowed by others can be tricky. They may not recognize our achievements or they may misunderstand them or find them politically unattractive. Hence we cannot reliably depend on others to satisfy our natural desires for honor and the recognition of our achievements. The greatest accomplishment in life is to make the choices that will form our characters in an excellent way and thus be living a good and noble life. If we are making significant progress toward this goal, we would do well to recognize it and be proud of it and to accept recognition given by others if they honor us properly for our moral nobility. Actually truthful self-recognition is more accurate than recognition by others for two reasons. First, the bestowal of honors by others is unreliable-people bestow honors on others for many reasons other than honest evaluation of significant achievement. Second, those truly deserving of honor and recognition are often neglected because they lack political connections or clever public relations. The Greek word we are translating here as pride is megalopsychia, which literally means “greatness of soul.” There is no exact English equivalent. Magnanimity is also a literal translation but does not tell us much. Some translate megalopsychia as dignity, which is fairly accurate. In any event, Aristotle tells us that this virtue is the capstone of a life well lived and that the person living a noble life should recognize the achievement because it is difficult to do and not many people actually succeed in living morally noble lives. A person with virtuous pride so esteems herself that she will not compromise her character for other goods no matter how enticing they may be. Pride is the virtuous self-respect and self-esteem that has been earned over time and tested by adversity and temptation. A person with this virtue has great moral dignity. Making pride a virtue is somewhat unsettling for many in the Christian tradition. This tradition, after all, suggested that pride was the first of the seven capital sins and encouraged people to seek the virtue of humility. But Aristotle’s idea is this. If people have work to do-painting a picture, building a house, practicing as a nurse or a physician, writing a term paper, or whatever-experience experience suggests that they will do a better job if they take pride in what they do. Now the most important work in life according to traditional virtue ethics is becoming a noble human being, and we will do a better job at succeeding in this if we take pride in how we live our lives. Aquinas seems to have recognized the value of Aristotle’s virtue in his Commentary on the Nicomachean Ethics, for he declined to oppose megalopsychia to humility and suggested that Christians could legitimately take pride in their moral achievement as long as they acknowledge God’s help. Lists of Moral Virtues No canonical list of the moral virtues exists. The traditional moral virtues of temperance, courage, love, and justice appear in some form on just about every ancient list of moral virtues, but other virtues are often mentioned as well. Lists often vary with the same author. Aristotle, for example, gives various lists. His Rhetoric names seven moral virtues: justice, courage, temperance, magnificence, cence, dignity, generosity, and gentleness. The moral virtue of love is noticeably absent here, but he does define and discuss it at some length in book II of the same work. The Eudemian Ethics lists the seven moral virtues of the Rhetoric and adds love, respect for self and others, righteous indignation, truthfulness, solemnity, and patience. The Nicomachean Ethics also lists the seven moral virtues of the Rhetoric and adds love, truthfulness, and several other virtues for which Aristotle totle says there are no names. The lack of a definitive list of moral virtues is not a problem because the moral virtues in a morality of happiness do not play the role moral principles play in the various moralities of obligation. tion. Unlike action-guiding principles and rules, the moral virtues are not a stock of maxims that we apply to particular situations to determine what we ought to do. They are simply the ways of feeling and behaving that make up a good life, that is, a life of personal happiness. Any feeling, behavior, or habit contributing to a truly good life is an ethical virtue. In the health care field caring, empathy, sympathy, kindness, and so forth are important moral virtues. According to Aristotle, philosophical reflection shows that a life will likely be happy if it is composed of feelings, behaviors, and habits known as temperance, courage, love, justice, dignity, and so forth. In other words, the moral virtues give us the best chance of flourishing as human beings. You may disagree with Aristotle, but if you do, you will need to show that the chances of living a good and happy life will be better if a person feels and behaves in nonvirtuous ways. You will need to show how happiness will be more likely in a life lived without the moral virtues of temperance, courage, love, justice, and dignity. It is not easy to find intelligent arguments that support the position that a good life is a life constituted by the lack of moral virtue or by the vices contrary to them. The notion of authentic moral virtue is now beginning to emerge. Authentic moral virtue is rooted in our good management of our natural inclinations. Our natural dispositions become morally ally virtuous when we go beyond the formation we received in our youth and from our secular and religious culture and begin to deliberate personally about what we might do to live well and then choose this course. Only when we choose our behavior-choose to be

kind, just, loving, courageous, geous, and so forth-for the sake of virtue and not simply because it is a duty or obligation are we achieving authentic moral virtue and living a truly good human life. These chosen actions of virtue gradually build up our moral character, and the stronger our moral character, the more easily and often we will continue to choose truly virtuous behaviors. A reciprocal dynamic occurs whereby our good choices and our virtuous character mutually reinforce each other. Unfortunately the converse is also true: The more we choose contrary to virtue the more our character becomes bad, and the worse our character becomes the more we tend to make bad choices. Making good choices-choices that make our lives good and happy lives-about the feelings and behaviors arising from our natural inclinations is accomplished by the other virtue that we mentioned: prudence. This indispensable intellectual virtue guides every decision that results in authentic moral virtue. Prudence plays the crucial management role in traditional virtue-based ethics, and without the personal practice of prudential reasoning, there is no authentic moral virtue. As Aquinas puts it: “And thus the whole matter of the moral virtues falls under the single reasoning of prudence.” PRUDENCE Two kinds of intelligence play major roles in the philosophy of Aristotle and Aquinas: theoretical intelligence and practical intelligence. Theoretical intelligence strives to know about the realities that exist independently of us. These independent realities comprise two domains. One domain embraces the beings our senses encounter, and the other embraces the beings our senses cannot encounter, such as human souls and the God or gods functioning as sources of motion. Knowledge about the sensible beings is of two kinds; it is either physics (natural philosophy) or, if it focuses only on the quantitative aspect of sensible beings, mathematics. (The Aristotelian separation of physics and mathematics lasted until Isaac Newton, building on the work of Copernicus, Kepler, and Galileo, showed in his revolutionary book of 1687, The Mathematical of Natural Philosophy, that physics is actually mathematical.) Knowledge about the nonsensible beings-souls and gods-Aristotle called first philosophy and theology; others later termed it metaphysics. The ideal of theoretical knowledge-the knowledge of given realities-exhibits several important characteristics. It is consistent-its major first principle is the principle of noncontradiction. tion. It is deductive-once its general principles are discovered by induction or set forth in theory, we can understand all the particulars covered by the principles and rules. It is universal-its truths hold everywhere and always. And it is necessary-if achieved, it allows its possessors to claim the certitude that comes only with knowing their truth is necessarily so. Practical intelligence, on the other hand, is not ultimately about realities that exist independently dently of us. It is about knowing what voluntary human activities will work in the world. These voluntary activities fall into two domains: We make things and we do things. Building a good structure or writing a good play calls for practical intelligence in making things, whereas directing a military operation well or treating a patient well calls for practical intelligence in doing things. The most important thing we can do is to make our lives good lives, and the practical intelligence for doing this is the intelligence we need in what Aristotle and Aquinas call ethics. This practical knowledge does not, indeed cannot, reflect the rigidity of theoretical knowledge. edge. The knowledge for knowing how to make and do successful things is not the same as knowledge edge about what is already made and done. Since ongoing situations are always changing and developing, practical knowledge is not so much consistent, deductive, necessary, and universal as it is variable, experiential, provisional, and situation specific. The moral virtues are the chief elements of a good and happy life, but they alone are not capable of directing us in ever-changing circumstances. They require on-the-spot intelligent management. agement. Aristotle called this intellectual aspect of every moral virtue phronesis, Cicero and Aquinas called it prudentia, and we are translating it as prudence. Prudence is the intellectual virtue that clarifies the overall good we are aiming at for our lives, and it manages our feelings, behaviors, and habits in each situation so that we will likely achieve a measure of this happiness. For many reasons that we cannot go into here, later modern European languages lost the ability to express the rich notion of phronesis and prudentia that we find in the ethics of Aristotle and Aquinas. The words prudence in English and French, and klugheit in German, simply do not convey what phronesis and prudentia meant in the older ethics. In fact the “prudent” person today is often not the morally noble person characterized by the phronesis and prudentia of the earlier ethics but rather an overly careful person bent on avoiding difficulties in his life. Such prudence, however, may in fact be unethical. In health care for example, some physicians, possibly influenced by legal counsel, think it prudent to avoid any behavior that might result in litigation. They never see that such prudence could be highly immoral in some circumstances-when it leads to medically unnecessary tests, for example. Modern authors discussing Aristotle’s phronesis and Aquinas’s prudentia therefore shy away from using the misleading English word “prudence.” They employ instead phrases such as “practical tical wisdom,” “practical reason,” “practical rationality,” “moral insight,” “intelligence,” and “non-scientific scientific deliberation.”There are good reasons for using these phrases, but there are also drawbacks. One drawback is the confusion caused by the use of different English words to translate one Greek or one Latin word with a very definite meaning in ethics. Another is the fact that, in his Ethics, Aristotle takes great care to show that phronesis is not associated with wisdom, and thus the frequent translation of phronesis as “practical wisdom” is misleading. Moreover, Greek has common words for practical and wisdom (pratike and sophia), and this suggests that we should translate phronesis by another English word. Despite the problems associated with the word prudence in English, we will use the word to translate what Aristotle called phronesis and Aquinas called prudentia. The complex and rich meaning these authors gave prudence will, I hope, emerge in what follows. Prudence or prudential reasoning is, quite simply, how we figure out what choices are most likely conducive to our goal in any given situation. In ethics prudence is the deliberation we use to determine what will give us the best chance to achieve happiness (that is, to determine what is ethical or morally good). It tells us what to do in order to achieve a good life. What Prudence Is Not We begin by saying what prudence is not. It is not, as we explained earlier, a moral judgment deduced from general norms such as principles, rules, or rights. Prudence never reasons this way. It is much more imaginative, narrative, and creative. This does not mean, however, that any of the conclusions deduced from principles and rules are necessarily wrong or incompatible with those of prudence. In many cases the conclusions deduced from the ethics of principles and rights are compatible with those generated by an ethics of prudence. But the contrast we are making here between prudential reasoning and principle-based based reasoning centers not on conclusions but on the process of arriving at conclusions. Prudence does not make general principles or rights central and then proceed by deductive logic to a particular judgment. Recognizing this may leave some people uncomfortable because the logical certitude available with deductive reasoning is not available. Prudence simply does not provide vide us with the logical comfort we expect in deductive geometry, or in science, or with religious dogma. An ethics of prudence accepts this discomfort and, with Aristotle and Aquinas, acknowledges edges that in matters of concrete human behavior our knowledge is, at best, valid “only for the most part.” Morality is simply not science. Galileo and Newton taught us how to measure physical bodies and how to predict a high tide or an eclipse or a sunrise a thousand years from now, but no historian or psychologist or sociologist or ethicist can measure human choice and predict future human action with such precision. What should make us uneasy in ethics is not that we do not have the certitude we think we have in modern science or thought we had in ancient metaphysics and theology but that so many people think we have, or should have, such certitude in the field of deliberate and free human conduct. This does not mean prudence is some form of guessing or little more than a matter of personal beliefs and opinions. We can certainly guess or sincerely believe or have a strong opinion that something is good or bad, and our guess, belief, or opinion might well be correct, but this is not prudence. The judgments of prudence are always supported by reasons. Feelings play an important tant role, as we shall see, but they do not replace the need for reasons. What we always have to show in an ethics of prudence is why we think something will indeed contribute to what is truly good. This is why, in the second part of this book in which we consider concrete ethical issues, we will always insist on reasons to support the ethical judgments we suggest. And the reasons are valid when they show that an action or omission truly contributes to living well. Adopting an ethics of the good employing prudence as the reasoning that directs our conduct means that we can never say a behavior is morally good or morally bad “because I believe it with all my heart” or “because that is the way I was brought up” or “because this is what civil or religious authorities say.” Prudence, the intellectual virtue at the heart of morality, always supports its judgments ments with reasons why the behavior in question will, or will not, actually contribute to my human good. Aristotle and Aquinas always insisted that acting prudently is, in the last analysis, acting not according to mere beliefs, nor according to how I was brought up, nor according to the dictates of authority, but “according to right reason.” Finally, we should not confuse prudence with a purely instrumental kind of reasoning, a reasoning concerned exclusively with the means needed to achieve a goal and not with the goal itself. In instrumental reasoning the end and the means are distinguished. Vacationing in the Caribbean is one thing; buying the ticket weeks ahead of time is quite another. The distinction between ends and means in instrumental reasoning becomes very clear when we have a good end and a bad means-we desire money, so we steal it. In prudence there is no sharp distinction between means and end. The behavior is not simply the means to happiness but happiness itself. The end, happiness, is embedded in the means. Happiness piness is not distinct from the virtuous activity that achieves it; happiness is living virtuously. Prudence is therefore a reasoning about the end as well as about the means. Prudence grasps the complete good of human life as well as the means to achieve it. We totally misunderstand Aristotle and Aquinas if we think their ethics is an instrumental reasoning wherein “the end justifies any means.” In every case, prudence must grasp the end-living well-and show how the means will promote it. What Prudence Is Prudence is the deliberation and reasoning in any particular situation that determines what feelings and behaviors will truly promote my good or at least avoid the worse bad. But how does prudence determine what behavior is virtuous and reasonable? How do I decide what behavior makes my life a good life? Outside of tragic situations and excluding situations in which what I am contemplating is clearly contrary to a good life by definition (murder, for example), Aristotle suggests that prudence begins by recognizing that a good life is enhanced by striking a balance between feelings and behaviors

that are neither excessive nor deficient. Some behaviors, for example, contribute in a significant way to the biological aspects of the human good. The primary examples are eating, drinking, exercise, and sex. But if we eat too much or too little, we undermine living well. Just how much and what to eat will vary from person to person and from circumstance to circumstance, and prudence is needed to determine how much we should eat in any given situation. I know too much is not good for me, and obviously too little is not good. I also know circumstances play a role-I should not eat anything before major surgery. So I cannot simply say eating is good for me. What is good for me is eating reasonably, that is, eating well or virtuously. Eating is reasonable able when, given the circumstances, it is neither too much nor too little for me. The knowledge I need to figure out how much I should eat is primarily practical, not scientific, and it is circumstantial. tial. This example of practical knowledge in the matter of eating-which Aristotle and Aquinas considered a matter of the moral virtue known as temperance-gives us a preliminary idea of how prudence works. Prudence, recognizing that good behavior is undermined by excess or by defect, endeavors to determine just where on the spectrum between those extremes the behavior promoting moting my good will fall in the particular circumstances facing me at any given time. Prudence not only determines what achieves my good, it is also decisive. It directs me to behave in a certain way. This is what distinguishes prudence from what we called judgment. The processes of reasoning in prudence and in judgment are similar, but unlike judgment, prudence directs the person doing the reasoning to do, or not to do, something. The controlling role of prudence is clearly seen when it overrides what would normally be morally virtuous. Consider the following situation adapted from an ancient example in virtue ethics. A person borrowed a friend’s rifle last week and promised to return it today. The friend comes to the house to retrieve his gun. Justice and promise keeping indicate the borrower should return it as promised. But now think of this. The owner is going after someone who has wronged him. You know he can be violent and may use the gun to threaten or even shoot at the other person, so you hesitate to return his gun. But he reminds you that the gun is his property and that you promised to return it today. He argues that keeping his property without his consent violates the moral principle of justice. He also points out that the great moralist Immanuel Kant insisted that everybody is bound by a strict moral duty never to break a promise. Obviously you cannot simply think of justice and promise keeping in this situation and then return his property. What more do you need to do? You need to figure out what would really be a good choice for you in these circumstances. Once you realize that giving a weapon to someone on the way to threaten and maybe shoot at another person is not the kind of action that is likely to make your life a good life, you know what decision is intelligent-the decision to keep his property without his consent despite your promise. By so doing you reveal how prudential reasoning is the controlling factor in virtuous decision making. The actual practice of prudential reasoning can be difficult at first. There is no clear methodology ology similar to the deductive method of deducing particular moral judgments from ethical principles. ples. Indeed some think that method is the enemy of the prudential reasoning needed in ethics. Fortunately, the person practicing prudence in any moral situation does not start from scratch. Before trying to determine what is right in a particular case, she has the benefit of three things. First, every person has a preliminary natural orientation toward a good life. Living things, including human beings, strive not only to live but to live well. Second, she has received some moral education from parents, from schools, from society, and frequently from religious organizations. tions. This moral education provides a preliminary apprehension of how to go about living a good life. Third, if she is reasonably mature, she has complemented her natural orientation and moral education toward a good life with a personal awareness that living well is the overall goal of life. When the practitioner of prudence is faced with a challenging concrete situation, these three background features have already provided a preliminary orientation. Now she must determine what behavior will achieve her personal happiness in the situation. Prudence will provide the answer to the extent it can be provided, so we must examine its features more closely. The Features of Prudence Aquinas lists eight features of prudence and three additional secondary virtues associated with it. His list is a compilation of features drawn mostly from Aristotle but from others as well. It is not intended to be exhaustive. It is a convenient way to organize the chief characteristics of prudence, as long as we do not mistake the list for any kind of highly organized methodology or for any kind of sequence such as we find in manuals telling us how to operate equipment or build something. Prudence is not like that. It is a way of thinking that cannot be considered a science, or a craft, or a technique, but only as a unique and somewhat disorganized process. The list that follows is, therefore, not to be taken as steps of a method to be followed every time we make a moral decision. It is simply a compilation of features embedded in prudence and largely unnoticed by the prudent person in the process of exercising prudence. Only through analytical lytical reflection on prudential activity does the list emerge. Not every feature on the list is of equal importance. Some features are rather obvious and simple, whereas others will require some explanation. And some features are debatable. With these remarks in mind, we now take up the eight features of prudence and the three secondary intellectual virtues associated with it. Memory We learn from experience, sometimes the hard way, what contributes to our fulfillment and what does not. What happened to us in the past can serve as plausible grounds or “quasiarguments,” as Aquinas calls them, for figuring out what we should do in the present. Understanding This term requires some comment for a correct appreciation of its meaning. “Apprehension” might be a better translation of the Greek nous and the Latin intellectus but, since “understanding” is so often used, we will retain it. We shall have to be careful, however, how we understand this word, understanding. It is a highly technical term with a precise meaning for Aristotle and Aquinas. It refers to the ability to know something directly (that is, without a reasoning process). Aquinas says things known this way are “known per se.” They are self-evident and obvious. They need no proof, no arguments, no reasons. Aristotle and Aquinas thought this understanding of the self-evident was the way we came to know two kinds of things: (r) the first principle of theoretical reasoning (the principle of noncontradiction) and the first principle of practical reasoning (our choices always seek what is thought to be good) and (2) the moral issues in the concrete situations we face in the course of a life. We have already seen how this

possible in the life after death. But Aristotle did not believe in life after death. What, then, can be said about an ethics of seeking our good when none of the available choices promotes a good life? Does the ethics of the good go on a holiday when this tragic situation arises? Suppose, for example, a person is dying of widespread and painful cancer. Realistically, these are his choices: (i) he may choose to remain alert as long as possible and thus experience great pain; (2) he may choose heavy pain medication and thus spend his last days so drugged that he loses all meaningful contact with reality; or (3) he may choose euthanasia or suicide and thus give up his life. None of these options leads to happiness. Living in pain or in a drugged state is not living a good life, nor is euthanasia or suicide, for that ends life. What, then, could an ethics of the good and personal happiness offer in tragic situations when achieving a good life and happiness is noThe answer to this question in Aristotle is important. In tragic situations where no choice will lead to happiness, an ethics of the good acknowledges an important corollary: When we can no longer achieve a good life, the best we can do is avoid what is contrary to a good life. In other words when none of our choices will promote our happiness, when all options are undesirable and unwanted, then we are reduced to choosing the less worse option. The ethical aim of our life is to live well and be happy; if living well and happiness are not possible, then all we can do is reduce the bad features in the situation as far as possible. Not choosing the less worse is immoral because it undermines an ethics of the good by promoting more bad than is necessary. The ethics of the good, then, is understood this way: Behavior is moral when we choose what promotes living well or, in tragic situations where living well is no longer possible, when we choose the less worse. Thus Aristotle, inlaws, principles, and rights. What constitutes a good life determines what the laws, principles, and rights will be and when they will be relevant; the laws, principles, and rights derived from moral theories or from a common morality, no matter how important, do not determine a priori what constitutes a good life. Happiness and Virtue A key notion in any ethics of the good is virtue. Virtue meant “excellence” in ancient Greek, and the word was used for both living and nonliving things: A machine can be excellent, or a horse, or a human being. Something is excellent when it is well formed and performs well. A machine is excellent if it is well made and works well; a horse is excellent if it is well formed and functions well. A flutist is excellent if she is an outstanding flutist and actually plays exceptionally well. A flutist is not excellent if she has mastered the instrument but does not play; nor is she excellent if she has not mastered the instrument but happens to play well in a particular concert. In the Iliad Homer called a soldier excellent only when the man was a courageous fighter and actually did fight courageously. A courageous soldier who does not fight is not excellent; nor is a cowardly soldier excellent who fights courageously only when stimulated by the wine he drank out of fear. From these examples we can see that excellence is related to a goal. If a thing is so formed and so functions that the goal is achieved, then it is an excellent thing. If the machine, the horse, and the flutist are so formed and so function as to achieve the goals appropriate to that machine, horses, and flutists, we call them and their performances excellent. The goal is the norm for excellence. lence. Only when we know what the machine, horse, and flutist are expected to accomplish can we judge whether their structures and functions are excellent. As we have explained, the goal of any human life considered as a whole is personal happiness. We say “considered as a whole” because the subsidiary goals are not those that concern us here. These are many and worthwhile and include, for example, graduation from school, earning a good living, developing loving relationships, having a family, being a good clinician, and so forth. But in ethics it is the overall goal of every human life that concerns us, and this, as we saw in the last section, is personal happiness. We can now define an excellent or virtuous human being as a person so formed and so functioning as to achieve personal happiness. Simply put, whenever our habits, feelings, and behavior are in fact achieving personal happiness, we call them excellent or virtuous. The virtues are those human qualities that promote personal happiness. Virtues are the feelings, habits, and behaviors constitutive of living well. Two kinds of virtue play major roles in the morality of happiness: moral

the first principle of practical reasoning, but now we need to note the second area where we have to rely on this direct apprehension called understanding-the immediate grasping of moral issues, what is significantly good or bad, in each concrete situation that we face in life. Understanding grasps directly the particular situation with its salient moral features. Prudential reasoning thus begins with two starting points grasped by understanding: the first principle (people seek their good) and the moral nuances embedded in the unique particular situation facing us. Learning from the Prudent In The Republic Plato advanced a famous theory: our communities should be run by philosopher-kings kings who master philosophy and ethics and then direct the moral lives of the citizens. The philosopher-kings opher-kings were the ethical experts. In some religious traditions a similar theory exists: the community munity should be run by theologian-authorities who master theology and ethics and then direct the moral lives of the believers. Aristotle and Aquinas proposed a fundamental revision to this model. They still embraced the idea that a special group provided moral direction, but membership in the group is not confined to philosopher-kings or theologian-authorities. Rather, the group is composed of experienced people who have actually achieved a high degree of moral success in their personal lives. The group comprises people who are in fact prudent or were prudent when they were alive. They are the people who actually live, or did live, good lives. These people are the ethically successful people; we recognize them as noble human beings. Aristotle called these people the phronimoi, the people who had mastered phronesis; Aquinas called them the “experts,” the “elders,” and the “prudent.” We have all met these people in life. They are the people we recognize as being of high moral integrity; they are good, decent, and noble people. Some are rich, but many are poor; some are powerful, but many are weak or even exploited. Some are political or religious leaders, but many are not. We trust and admire these people of high moral integrity, and both Aristotle and Aquinas insisted we should learn from them. And how do they teach us? Not in a scientific or theoretical way and not by statements backed by whatever authority they might have. They do not give us principles, rules, laws, and regulations to follow. Nor are the particular behaviors they chose in their lives necessarily the model for what we should choose in our lives. We do not simply imitate their lives and do what they did. Rather, we learn from their ability to deliberate prudently. In the different situations of their lives they were able to figure out the behavior constitutive of a good life. They did this by prudence. So we want to learn from their example, from how they practiced prudence and went about perceiving the right thing to do in their lives. These good and noble people do not tell me what behavior is right in my situation; they teach me how to perceive the moral dimensions in particular situations and how to figure out what behavior is best suited to achieve happiness. The prudent people who serve as role models do not dictate what is the right thing to do; they offer advice and show us how to figure out for ourselves what is the right thing for us. They serve as examples. We want to study how they made virtuous choices in their concrete situations so we can make them in our own. Shrewdness This is the ability to grasp very quickly what is the right thing to do. The shrewd person has the ability to hit the mark, to get right to the point, to cut through all the irrelevant factors and see, while on the spot, what is really necessary to achieve the end. Shrewdness quickly grasps what we should start doing now, in this situation, to achieve our goal-a good life. Reasoning Reasoning consists of showing how certain feelings and behavior will truly achieve my good in the particular situation. My reasons will, or should, show how the behavior is better suited to my good than the other options available in the circumstances. And if my action causes bad things to happen to me or to others, then I must produce convincing reasons for the bad I cause. Consideration of Consequences We can call this foresight. Aquinas calls it “providence” because it is a foreseeing or seeing ahead. We know our actions have consequences, and so we look to these consequences and try to discern how they fit into our personal happiness. Prudence acknowledges that we must always consider the consequences of our actions and whether they will bring good things or bad things for ourselves and others. Consideration of Circumstances Prudence is about individual actions in particular situations, and hence many circumstantial factors are involved. Some of the circumstances are morally significant and should be a part of prudential consideration. Circumstances can sometimes make all the difference in the world. Something considered sidered good in one situation might not be good in other circumstances. Thus, to use Aquinas’s example, it is good to treat another person kindly-unless she happens to be a suspicious and cynical person, for then the kindness may very well make her more suspicious and eventually disturb and upset her. The ethical person not only does the good thing but does it in the right way and at the right time. Virtue is living well and doing well, and this depends in large measure on circumstances. We have to look at all the circumstances to make a good moral decision because the virtuous mean always depends on the circumstances in which the moral agent finds herself. The major circumstantial factors affecting morality were well known in Greek, Roman, and medieval ethics. They revolve around who is performing the action, what kind of action it is, where it is being done, by what means it is being done, why it is being done, how it is being done, and when it is being done. Cicero and the medieval moralists often summarized these factors as follows: “who, what, where, by what means, why, how, when.” Except for the “what,” which refers to the action itself, and the “why,” which refers to intention and purpose, all these factors are circumstances. Caution Moral situations are often not clear-cut.

possible counter moves to these moves, then its possible moves after these counter moves, and so on. After comparing thousands sands of alternatives, it picks the best move. This artificial intelligence is so powerful that good computer programs can now beat the best chess players. The beginning chess player, by the way, also relies on rational choice strategy. He compares the advantages and disadvantages of possible moves to find the best one. Of course his ability to compare moves and counter moves is far less than that of a computer. The expert player, on the other hand, relies chiefly on a recognition-primed decision approach. He perceives key patterns on the board, considers them rather briefly, and then makes his moves. He has neither the time nor the cognitive ability to calculate the huge number of possibilities implied by each move he could make. The computer, of course, can do all the calculations tions quickly, and that is why computers can now beat the best human players. You might think that this shows that a rational choice strategy is better than a recognition-primed primed approach for making decisions, but this is not so for at least three reasons. First, although computers with rational choice software can now beat chess experts, players using rational choice strategy cannot beat them. An expert chess player will inevitably defeat any human player using rational choice strategy. A rational choice strategy gains the advantage only when coupled with the incredible calculating power of computers. No human brain, not even the brains of expert chess players, can compare the advantages and disadvantages of the available moves as quickly and as accurately as the computer. When human chess players try to imitate the decision-making strategies gies of machines, they actually degrade their decision-making ability. Second, rational choice strategy works well when the environment is rule governed, as it is with games. When preexisting rules determine what moves can and cannot be made, a comparative analysis of options is feasible even when the options are numerous as they are in chess. But preexisting isting rules do not ultimately determine human choices in life. Humans make the rules as they go along, and important areas of life-relationships of love, for example-are never well managed by rules. Third, rational choice strategy is rather detached and unemotional. The comparisons tend toward calculation and quantification, and personal feelings do not play a major role. Making ethical decisions, however, is a very personal and often emotional affair, and the practical reasoning that we need to make them well is not primarily that of rational calculations. The recognition-primed decision model of recent naturalistic decision theory is very similar to prudence. Aristotle insisted that prudence only works well when the decision maker has already developed some level of expertise in the moral virtues. Virtuous habits provide the moral expertise that permits a person confronting a new situation to recognize the morally salient features and then to perceive rather quickly an appropriate response. A virtuous person seldom compares all the alternatives with each other and then calculates their relative advantages and disadvantages. Rather, she recognizes the morally significant features in the situation and then perceives a move likely to achieve her overall goal in life-happiness. Only beginners in ethics rely on a rational choice strategy. Without the expertise to size up a situation and readily see a promising course of action, beginners have to rely on comparing the advantages and disadvantages of all the alternatives. As people develop virtue in ethics, however, they rely less on comparative analysis and more on recognizing patterns and perceiving directly the choices in any developing situations likely to accomplish their overall aim in life-happiness. Modern psychological research thus suggests that Aristotle was on the right track centuries ago when he distinguished practical reason from rule-based deductive reason and insisted that practical reasoning is what we need for human affairs such as ethics, politics, military tactics, medical practice, and so forth. Practical decision making in ethics is prudence-a naturalistic decision-making sion-making process distinctly different from rational choice strategies. Prudence and Deliberation Aquinas makes a distinction between prudence and another virtue closely allied to it, deliberation. The difference seems to be this. A person well advanced in having acquired the moral virtues generally makes moral decisions more by experience, insight, and intuition than by deliberation, as we have just noted. However, when faced with the radically new situations that we so often encounter in bioethics today, even the person with a high level of moral virtue and decision-making expertise needs to deliberate carefully and dialogue widely. Strictly speaking, however, prudence is not deliberate; but deliberation is a virtue closely allied to it. Prudence and Formal Reasoning Understanding prudence as a natural decision-making process requiring virtue and practical expertise tise does not do away with all formal reasoning in ethical decision making. Prudence is not science or geometry, nor is it calculating the advantages and disadvantages of as many options as possible, but it often benefits from some formal reasoning. Usually this formal reasoning occurs after the decision maker has identified a tentative decision. To show how this is so, it will be helpful to note how formal reasoning plays a role in another form of practical reasoning-legal reasoning. Imagine a civil dispute for which both sides present documentation and testimony to the court. As the judge reads the evidence and listens to the testimony, her intelligence probably begins to formulate a decision in her mind. Her developing decision is shaped by her experience with the law and her expertise with cases as well as by her consideration of the evidence and testimony. Gradually a tentative decision takes shape. Only then does she begin formally gathering the legal reasons to support it from relevant legislation, regulations, and previous court decisions. When the judge writes her decision, however, she will cite these legal reasons as premises leading to her conclusion. Logically, this is correct. Existing laws, regulations, and precedents are important reasons that support judicial decisions. In actuality, however, the judge finally organized her legal reasons for the decision only after she made it. Her perception and reflection on the case, along with her experience with the law, first led to her decision. The formal legal premises appearing in her written decision as steps that led to her decision were actually developed formally only after she had reached a decision. In some cases the judge may formulate a decision and then be unable to support it with adequate legal reasons. If this occurs, she will reconsider the case, revise her conclusion, and then look for legal reasons in support of her revised decision. More probably, however, her experience and review of the testimony in the case will have led her to a conclusion supported by legal reasons, and she will write her decision accordingly. It is somewhat the same in ethical reasoning in difficult and complex situations. We perceive the situation in its complexity and see a good response. Only then, if we have the time, might we explicitly formulate the reasons for our decision. When we explain the decision, we undoubtedly present the reasons as coming before the conclusion, although in fact we developed them after it. Does this make the formal reasoning in prudence no more than rationalization? Are we simply making up reasons to give a veneer of respectability to our preferences? Not really, if the prudential reasoning is authentic. The reasons we develop after we make a tentative decision do play a role. Formulating the reasons serves as a check. When we are able to develop good reasons that show that our decision is likely to help achieve what we are aiming at above all-a good and happy life-we can go forward with added confidence. On the other hand when we are not able to develop good reasons for our decisions, we can abandon our conclusion and take another long look at the situation so that we can make a more reasonable choice. Prudence and Bad Moral Decisions Most people tend to call a bad decision one that results in a bad outcome and, conversely, a good decision one thatThe good is often mixed with the bad. Therefore, we have to be very careful as we make our way through the jungle of moral dilemmas. Caution rules out any kind of dogmatic or fundamentalist approach in ethics. Prudence always tiptoes along, for it recognizes the complexity and contradictory nature of many situations and knows that no simple answer is possible in difficult and complex cases. Listing these eight factors characterizing the intellectual virtue of prudence helps us to understand the virtue better. Prudence is a complex intellectual virtue embracing memory, understanding standing the first principle and concrete situations, learning from the truly prudent, shrewdness, reasoning ability, the consideration both of consequences and of circumstances, and an element of caution. Prudence and Feelings It has been noted with some reason that Aquinas’s description of prudence is overly intellectual and neglects an important aspect of good prudential decision making-feeling. Traditional wisdom has long warned us about letting emotions and feelings disrupt our thinking. What we now realize more and more, however, is the disruption in moral reasoning that occurs when emotions and feelings are not part of thinking, especially thinking about living well and how to achieve it. Studies in psychology have shown how some people with normal cognitive abilities but who lack emotions because of brain damage consistently fail to make good decisions about living. Undoubtedly emotions and feelings can inhibit or overwhelm thinking and lead to poor decisions. But the lack of emotion also leads to poor decisions. Emotions and feelings can lead us in the right direction as surely as they can lead us astray, and they can help us create a happy life as surely as they can create unhappiness. Living without emotion and feeling is not living well, and choices without emotion and feeling are not morally mature. Emotion plays a major role in figuring out what it takes to live life well. Our longing for happiness-our primary goal-is primarily emotional although rational reflection certainly clarifies this goal. Emotions shape our deliberations and choices chiefly by conveying more rapidly than unemotional, detached reasoning the good and bad features of a situation. In some situations emotions and feelings give immediate and clear moral direction. If you see a child tormenting an animal for example, the unpleasant feeling you experience at seeing the animal being tortured will be the major factor prompting you to stop the child’s cruel behavior. Emotions enable us to respond correctly to some situations without the slower processes of deliberation. ation. Emotions and feelings often apprehend the ethical features in a situation more quickly and sometimes more accurately than deliberation. Emotions and feelings obviously play a larger role in some areas of life than they do in others. They are significant features of decision making in matters of love, friendship, courage, and being unjustly victimized, for example, but they are less significant when it comes to matters of what we owe in justice. A major emotional attitude of great importance to prudence is caring. Caring about a person or a project is feeling a concern for that person or project to flourish and be successful. In the virtue-based based morality of personal happiness outlined here, we care for ourselves by helping ourselves grow toward a good and flourishing life. We care for other people-lovers, family, friends, communities, and so forth-and for projects by helping them flourish. And we care for animals and the environment ment by helping them flourish. Caring plays a major role in living well. If we care about ourselves, we will choose what is good for ourselves; if we care about our work, we will do it well; if we care about others, we will treat them well; and if we care about our political and social institutions, we will help make them good. Care is truly an integral component of prudential reasoning. Feelings, then, are an integral part of prudence. They shape its cognitive descriptions and evaluations and in turn are shaped by them. Prudence, as Aristotle observed, can be thought of either as desiring reason or as reasoning desire. Next we turn to the final stage of prudence-making and implementing a decision to feel or behave in a certain way. Prudential Decision Making Prudence not only perceives our moral goal (happiness) and the feelings and behaviors likely to achieve it but actually directs our feelings and behaviors. Prudence culminates in decisions to do whatever will likely make our lives truly good lives. Practical decision making has been the object of intense study in recent decades. Two major paradigms have emerged: one is generally known as rational choice, and the other is often described as naturalistic decision making. Rational choice strategies emerged from psychological studies of problem solving in controlled laboratory situations. Naturalistic decision making, on the other hand, emerged from observations of how experienced people actually make good decisions in real-life life situations. The defining feature of the rational choice strategy is that it is a comparative strategy-it lays out as many alternatives as possible and then compares the favorable and unfavorable consequences quences of each. Some authors suggest laying out all the alternatives together in what they call a decisional balance sheet. Others suggest that we compare only two alternatives at a time, pick the better one, and then compare that one with a third, pick the better one, continuing until the best alternative is found. Do these comparative rational choice strategies work? To a point, yes. Comparing alternatives tives can play an important role in some decisions, especially when the decision maker wants or needs to justify the decision to others or when he is expected to seek maximization in his decision making, that is, the best that can possibly be achieved. But is rational choice strategy the best way to make practical decisions in ambiguous moral situations? Probably not. Naturalistic decision making is more promising and supports Aristotle’s ancient idea of prudence dence and choice. When researchers watched experienced people make decisions in real life rather than as subjects of controlled research in problem solving, they realized that they did not compare the many possible alternatives with each other to identify the best one. Rather, after assessing the overall situation, they perceived a possible solution and decided to try it. Instead of laying out all the alternatives and comparing them by weighing the advantages and disadvantages of each, they recognized key patterns as well as anomalies in the unfolding situation, imagined a solution compatible patible with their goal, and then evaluated it as they implemented it. They developed a situation awareness highlighting both familiar and novel features and then saw a promising response they could pursue. Instead of comparing the advantages and disadvantages of many alternatives with each other, they considered only one or a few options in light of their goal and then recognized what would likely achieve that goal. How do experienced people size up a situation and perceive a promising response so readily? They do so by what researchers call expertise. What happens is this: Experience provides the rise that primes the decision-making process by enabling the experienced decision maker to recognize nize quickly what is going on and what to do about it. Hence, one important version of naturalistic decision making is aptly called the decision model. This model emerged from decades of studying how people actually made good decisions in their area of expertise. As researchers watched firefighters, nurses, pilots, engineers, nuclear plant operators, and military commanders make good decisions and then discussed with them how they did this, they found that experienced people arrived at their decisions not by rational choice strategies but by a recognition-primed tion-primed decision strategy. Only beginners with little or no experience, or people whose decisions sions would be carefully analyzed by others, employed the laborious comparative analysis suggested by rational choice theory. One way to grasp the difference between a rational choice strategy and a recognition-primed decision strategy is to think of how a computer plays a game of chess. The computer uses a rational choice strategy. It considers all the possible moves, then the opponent’s

out well for us. And some good decisions may have bad outcomes; for example, we may make a decision consistent with temperance or courage and actually things may not work out well for us. A truly good decision might bring tragedy, and a truly bad decision might not. There are no guarantees. All we can say is that over the long run, moral decisions made with intelligence and prudence are more likely to contribute to our happiness and living well than decisions not so made. What then is a bad practical decision? It is not one that happens to have a poor outcome but one that was poorly made. And what is a poorly made decision? In the practical decision making guided by prudence, a poorly made decision is one made by someone who lacks situational awareness ness and the virtuous experience needed to cope well with the situation. In other words the major causes of a poorly made practical decision are not, as rational choice theorists suggest, faulty comparative parative analysis of all the alternatives or psychological biases preventing us from thinking clearly. The major causes of bad ethical decisions are an inadequate awareness of what is going on and insufficient experience to handle it well so that the decision maker can achieve what he desires most-a good life. Prudence and Religion Religion is a complex and difficult topic. It is complex because so many religions exist in the world, and most of them encompass internal factions ranging from “fundamentalist” to “liberal.” Also it is a difficult topic because many believers consider matters of religious faith to be inappropriate subjects for rational discussion and critical thinking. Moreover, the religions that trace their roots back to the God of Christianity, and Islam-present a unique challenge to the ethics of happiness and prudential reasoning. These religions teach that morality originates with God and obligates the religious faithful to obeythe divine law as presented and interpreted by religious authorities. A conflict thus exists between these religious ethics and the virtue-based ethics pioneered by Aristotle. A religious believer will be torn between two fundamental questions: Does ethics originate nate from his religion or from his humanity? Does the guide for living well come ultimately from divine law or from human intelligence? Does religious faith or human reason provide the primary insights about how one should live one’s life? Religious believers do not agree on how to answer these questions. Some believers say that religious faith provides the norm for moral decision making. Others say that religious faith is important but does not provide the norm for moral decision making. Still others say that religious faith and virtue combine in complementary ways and together provide the norms for making moral decisions. Often, however, proponents of this last view tend not to consider religion and reason truly complementary-in controversial issues of human behavior, they give the last word to religious gious faith, not reason. The debate over whether morality and ethics ultimately come “from above” in some kind of religious revelation of commandments presented and interpreted by religious authorities or “from below” in some kind of rational or intelligent modification of the desires and inclinations inherent in our nature has existed for centuries and will likely continue for a long time to come. We cannot hope to solve it here. However, one way to look at the relation of the virtue-based ethics and religious faith is to encourage each person to ask whether religious faith is valuable in achieving his aim of living a good life. If he finds that religious faith is valuable for living virtuously, then it is one of the potential goods, which are, you may remember, goods that are valuable in themselves and valuable also because of their contributions to the virtues. Might religious faith be more than a potential good? Might it be what the virtue-based tradition called a noble good, that is, a moral virtue? Probably not. The moral virtues are the necessary components of a morally good life. If religious faith is a moral virtue, we would have to say it is necessary for a morally good life, which seems clearly false because it is not hard to find people who live truly virtuous lives without embracing any organized faith or religion. If religious faith is considered a virtue, and some theologians do so consider it, then it is best thought of as a theological virtue granted as a gift from God and not a moral virtue gained by intentionally and repeatedly choosing morally virtuous feelings and behaviors for their own sake and for the sake of personal happiness in life. This was the general position Aquinas adopted. He argued in the Summa Theologiae (I II QQ 62) that the theological virtues (faith, hope, and charity) are specifically distinct from the moral and intellectual virtues for three reasons: They have a superhuman human aim (God); they come as gifts from God (and not from our decisions and behavior); and knowledge of them comes from biblical revelation (not human reason). In evaluating whether and to what extent religious faith might be a value that contributes to living well, it is important to remember that religion is much more than a moral code. Religions point to something sacred; provide rituals of celebration, mourning, conversion, and forgiveness; offer faith in something transcendent, hope in times of despair, and love in the midst of obligations. Religions also preserve important traditions and practices and provide communities where morality is taken seriously and endlessly debated. All these religious elements may help people achieve their primary aim-living a good and happy life. To the extent that they do, it makes sense in a virtue-based based ethics to embrace them. In other words, the virtue-based morality of happiness can, but need not, include religion as a potential good in a well-lived life. It is not without interest to note that Aristotle, the architect of the morality of happiness presented here, acknowledged the importance of religion for good living. This is somewhat surprising prising because in his theoretical philosophy he described God as an unmoved mover who neither knew of nor cared about humanity. On the political level, however, he felt it important to acknowledge edge recognition of Greek religion. Apparently he thought that religious practices conducted by the priests contributed something valuable to the social and political well-being of the community. Aristotle also spoke of “the divine element” in us as the ultimate source of our desire for happiness and of our natural tendencies to seek the goods that compose it. Finally, he claimed that contemplation of “god” is the best of human activities and thus an integral part of human happiness. ness. The exact

meaning of these remarks at the end of the Nicomachean Ethics is a matter of much dispute, so it would not be wise to make too much of them. Still, the passages exist and are suggestive. It is important to note, however, that Aristotle never felt that the divine element in us or the god we contemplate would tell us how to live a good life. That is the job of prudence rooted in moral virtue. This concludes our sketch of prudential decision making in the virtue-based ethics of happiness ness initiated by Aristotle and retrieved by Aquinas. The cases in this book will bring you as close to prudential reasoning and ethical decision making as possible by examining dilemmas in health care from the various perspectives of the moral agents involved-the people who had to decide to do something, or to do nothing. Only after their perspectives have been considered will a general ethical reflection be introduced. The purpose is not to judge others but to consider what they faced so we can better make the practical decisions in our lives that will likely make our lives good lives and bring us the happiness we desire. Before looking at particular cases, however, we need to consider some preliminary notions. The next chapter looks at the language we use and often misuse in health care ethics. SUGGESTED READINGS For a splendid account of the beginning of the moralities of happiness in ancient Greece, see Julia Annas, 1993, The Morality of Happiness, New York: Oxford University Press. Helpful comments on this book by noted Aristotelian scholars Nancy Sherman, John Cooper, and Richard Kraut, with a response by Annas, appear as a symposium on the book in Philosophy and Phenomenological Research 1995, .fS 909-37- Although the assumption that happiness is the overriding good in life was widespread in ancient Greece, it was not universal. A notable exception was the Cyrenaic school. Influenced by Aristippus, one of Socrates’ followers, its members claimed our ultimate good was pleasure, and if we seek happiness, it is only because it gives us pleasure. Unlike the Epicureans, who claimed happiness is pleasure, the Cyrenaics naics taught that happiness is a means to pleasure. See Terence Irwin, “Aristippus against Happiness,” Monist 1991, 74, 55-82. We rely on Aristotle and Aquinas for the development of personal good or happiness as the central theme of ethics. The classical texts are Aristotle’s Nicomachean Ethics, especially books i and 10; the Eudemian Ethics, books i and z; the Rhetoric, book 1, chapters 6 and 7; and the Topics, book 3, chapters i and 2. In the past decade a major movement in psychology inaugurated by Martin Seligman and known as positive psychology has reintroduced the ancient notions of eudaimonia and a set of virtues or “strengths of character” that enable people to achieve this happiness in their lives. Positive psychology’s focus on happiness (rather than mental illness)

Name of book and author (A Primer for Health Care Ethics) Author O’Rourke Kevin

(Link for book is right below,

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primer for health care: essays for a pluralistic society, chapter 2

CHAPTER 1 RELIGION AND HEALTH CARE Introduction IN THE UNITED STATES in the late 1960s a new development occurred in a longstanding area of inquiry. What had been the largely intrareligious study of the morality or ethics of medical practice became “bioethics.”1 Displaying perhaps a combination of arrogance and ignorance, American bioethicists often claim, or at least imply, that this field of study was created brand new by the philosophers who coined the term. Without question what happened in the last four decades of the twentieth century was a major development, essential to the emergence of what the discipline has become. Secular philosophers (those who speak from no religious tradition) began in the 1960s to show interest in a field they had for a long time ignored, and this interest and excitement made bioethics a far more influential endeavor than it had previously been. New research centers and professional groups were established. Governmental oversight bodies were appointed. Scores of new journals appeared. And the religion-based approaches that had preceded this new development have been influenced and to some extent eclipsed by it. It is nonetheless entirely inaccurate to suggest that the new American bioethics of the late twentieth century owes little to its religious forebears. As the second and third parts of this book make clear, much of what bioethicists claim, many of the judgments they make, are based on conclusions reached by religion-based approaches to medical ethics.2 From the American perspective—indeed, from the perspective of the West in general—the Roman Catholic tradition has been most influential. Catholics developed over many centuries a highly specified approach to medical ethics. The Jewish tradition also created a detailed and centuries-long tradition of medical ethics, but it had less influence largely because Catholic immigrants to the United States outnumbered Jews and because, as discussed in detail in part II, Catholics adopted a natural law approach to morality, claiming that moral judgments were based on reason and, hence, applicable to all humans, whereas Jewish scholars were less apt to insist on this, basing moral claims at least in significant measure on rabbinic interpretations of scripture (Mackler 2000, 2–12). In any case, religion has been of major significance in shaping health care ethics as we know it today. Religion develops an understanding of the human person on which an ethic of health care can be based. Thus, the first part of this book is directly theological. Readers who work on health care ethics from a religious perspective will find this part especially useful and perhaps in some sense normative. But even readers who do not find religious anthropology persuasive may want to discover what Christianity has to say on these issues. Bioethics, after all, even in its secular garb, deals with patients and health care providers who are religious and whose faith affects their approach to health care. It is clear that American bioethicists need at least a decent knowledge of the Catholic and Jewish traditions if they are to practice well. Bioethics has emerged from religious roots and cannot be understood apart from them. Nor is it true, as is often stated by those who reject the role of religion in public bioethics discourse, that religions are not helpful because they disagree with one another. It is true that they do often disagree. But so do secular thinkers and secular approaches. Somehow it is thought valid to ask both liberals and conservatives about stem cell research despite the fact that they usually disagree, but it is invalid to ask both Catholics and Jews because they may also disagree. The richness of religious language often adds an essential dimension otherwise missing from the discussion. Religion is concerned with the meaning of human life in its ultimate dimensions. Religious faith is the human person’s response to God’s revelation as God discloses to us who we are in the divine plan. Theology is our search for a greater understanding of this revelation and of our response to it. Thus, religion, revelation, faith, and theology are all centrally interested in the meaning of human life. Why do we exist? When and how do we live at our human best? What kind of respect do we owe our own human lives and those of others? Sometimes religion has tended to understand human life from an overly spiritualized or angelicized perspective. This has occurred from time to time in certain movements in Christian and Catholic theology. When this occurs, religion tends to reject the importance of the body, of human health, and of the processes of health care. These aspects of human life are then considered irrelevant to spiritual growth or are even seen as hindrances to it. The human person is turned into a kind of inferior angel whose true home is the world of the spirit. Religion is reduced to the otherworldly. More often religion has included in its searching and its theologizing these essential aspects of human living. Human health and health care have been of central importance to much of Christian theology and Christian practice. Religious women and men, clergy and laity alike, have dedicated their lives to human healing, both of the body and of the spirit. Theologians and health care professionals have worked together in developing theologies and anthropologies of health care and of health care ethics. Health care and religion have something to offer one another. The aim of part I is to explore the idea of a theological basis for health care and health care ethics. What can Christian theology bring to our understanding of human health, of human health care, and of bioethics? We explore the topic in several stages. The first chapter is an overview of the history of the relationship of religion and medicine, suggesting some of the main lines in the Christian theology of health care. The second and longest chapter develops the theological basis for human dignity, exploring the theological themes that serve as the fundamental basis for health care. The third chapter speaks of the integrity of the human person and explores both dualistic and holistic approaches to Christian anthropology. Here we also try to deepen our understanding of how God works through human actions, of the relationship of divine and human (natural) causality in health care. Chapter 4 speaks of the sanctity and quality of life, two concepts often seen in opposition to one another as principles for health care ethics, and also discusses the problems of individualism and corporatism in health care. Finally, chapter 5 is a methodological analysis of how theological principles have worked and ought to work in the actual practice of health care ethics. It deals especially with divine sovereignty over human life and with the meaning of human suffering as principles in medical ethics. The scope of these first five chapters includes themes common to all religions, but the focus is on Christian theology generally and on the Roman Catholic tradition specifically. This focus reflects the historical influence of Catholic medical ethics. Religion and Health Care Until the last forty years or so, Roman Catholic theologians and philosophers, together with Jewish scholars, were virtually alone in the field of medical ethics. Although other philosophers and theologians studied ethics and moral theology in general, and although they applied moral principles to sexual and social issues, they never developed in depth the science and art of health care ethics. Professional associations of physicians such as the American Medical Association did promulgate and interpret codes of medical ethics, but these were more likely to be codes of etiquette for members of the profession intended to enhance the prestige of physicians than they were actual moral analysis of health care procedures and structures. As has already been noted, this situation has changed radically in recent decades as bioethics has become a rapidly growing field of study for philosophers, health care professionals, lawyers, historians, sociologists, theologians, and religionists of various backgrounds and religious affiliations.3 The fact that, until recently, only Catholics and Jews developed detailed studies of health care ethics does not mean that only they were interested in the larger relationships of religion and medicine. Even though the Roman Catholic tradition was the most detailed and the most influential, and even though only this tradition produced a truly systematic and extensive literature in health care ethics, the relationship of medicine and religion is significant within the larger Christian tradition and generally in the religions of our world. Religion deals with the core questions of human existence and is thus interested in issues of healing. The human person is an embodied spirit, an animated body, and so human health involves spiritual and physical aspects in inseparable interaction. Although one or the other of these may rightly be emphasized for certain purposes, the complete separation

of the human person into spiritual and physical parts is detrimental. Until the Enlightenment of the eighteenth century, the radical separation of medicine from religion was not attempted, and religions generally included physical healing in their ministry to whole people. A number of world cultures have combined the two arts of healing in the same person. Egyptians and other Near Eastern peoples, Asians, and some of the Celtic and Germanic tribes did this. The “holy man” was the physical healer as well as the religious leader. What we know today as modern medicine, of course, was not available, and these healers combined a trial-and-error approach (empirical medicine) with religious practices of a supernatural or magical kind. Westerners are starting to find out that, although some of what “primitive” peoples do and did to heal themselves is ineffective, many of their techniques do work, and we are adding this “alternative and complementary medicine” to our own medical repertory (Callahan 1999). Perhaps more important, we are discovering anew what “primitives” were never tempted to forget, that healing concerns whole people and is most effective and most ethical when it addresses the needs of whole people. Physicians who forget this and see only parts of a body, and clergy who forget it and see only angels or souls, run the risk of doing a great deal of harm (Kelly 1979, 47; Agnew 1967, 581–82; Pompey 1968, 14). Historians often refer to the Greek physician Hippocrates of the fifth century BC as the founder of scientific or rational medicine. He introduced a rational approach to medicine, insisting on the process of diagnostic analysis. For Greek medicine—and for Roman medicine, which followed it—this replaced the previous combination of “empiricism” (trial and error) and magic (Kelly 1979, 47; Entralgo 1969, 15; Agnew 1967, 582; Pompey 1968, 15). But it did not separate religion and medicine. Hippocrates saw medicine not as something secular but as a part of his religion. The changes he introduced were as much religious as medical. Nature was sacred, not secular, and to study it and heal it was to act religiously. For Hippocrates, disease and health followed laws of “natural” causality, but these laws were nonetheless sacred, not secular (Kelly 1979, 48; Entralgo 1969, 42–44). Following the time of Hippocrates, most Greek and Roman doctors were not official religious leaders, and this practice continued during the first centuries of Christian Rome. Physicians of the time recognized, however, that their vocation was of religious significance. They were to serve as Christ had served, to heal as he had healed, even to save as he had saved. The Christian concept of agape (love or charity to others in imitation of Christ’s love of humankind) entered their understanding of the Christian medical vocation, and with it came an insistence that doctors must treat the poor for free, must care even for incurable patients, and must consider spiritual as well as physical needs. Patients were more than objects to be treated if curable and otherwise ignored (Kelly 1979, 49; Entralgo 1969, 54). As the structures of the Roman Empire collapsed, so did the approach to medicine the Romans had inherited from the Greeks. But in accord with the importance Christianity gave to healing and to caring for the poor and the suffering, specifically religious Christian institutions began to take up the work of the “lay” doctors. Monks in their monasteries cared for the sick, and some bishops built hospices for travelers and indigents. Thus, priests and religious women and men began to take over the work of the physician (Kelly 1979, 49–50; Entralgo 1969, 56–57, 60–62; Pompey 1968, 17–20). It is interesting to note that the results were at best mixed. At first, these monks and nuns studied and followed the medical practices of the best of the Greek and Roman doctors, and they added to this what they discovered in their missionary wanderings among the pagan tribes of Europe. Gradually this learning was rejected, and the same combination of trial-and-error with specifically religious remedies that we noted in pre-Hippocratic medicine replaced it. It seems as if there was little interest in exploring how to be a better doctor or in trying to understand disease and its cure (Kelly 1979, 50; Entralgo 1969, 65–70; Pompey 1968, 18–19). For the monks, medicine was not so much an art to be studied and wondered about as it was an added responsibility. Their primary desire was to be monks, not physicians. In this context, and in the general social disintegration of the time, medical care diminished in quality. But once again the Christian religion and its institutions had given evidence of the importance of health and health care to religion. In the High Middle Ages of the twelfth and subsequent centuries, medicine again came alive as a discipline in its own right. Educational centers appeared in the great cities of Europe, and these universities began to teach medicine to interested students. Fewer and fewer physicians now were priests or monks (Kelly 1979, 50–51; Entralgo 1969, 62, 74). In fact, church synods and councils began to forbid the clergy to practice medicine, probably because they did not want them to earn their living at it and thus fail to carry out their religious duties, and because the primitive state of medicine at the time often meant that physicians would be involved in useless or harmful procedures that could bring notoriety and even criminal charges (Kelly 1979, 51; Pompey 1968, 23, 25–26). Of more lasting importance in the reemergence of medicine was scholastic theology, especially that of Thomas Aquinas and his followers, which rediscovered the philosophy of Aristotle with its insistence on nature and on natural laws. Medicine could emerge again as an art to be studied and explored. But in this revival medicine was still religious. The intellectual context of the time was theocentric, and the study of medicine was perceived to be a part of the study of God’s creation as God willed it to be (Entralgo 1969, 78–79, 83–90). For many of the lay doctors of the Middle Ages, and of the Renaissance and Baroque eras that followed, the care of the sick was a specifically Christian vocation (Entralgo 1969, 91–100; Pompey 1968, 30). Sir Thomas Browne’s 1642 book is a classic example of how one physician viewed his vocation (Browne [1642] 1963). This started to change in the eighteenth century, when European intellectual patterns came to be dominated more and more by the Enlightenment. Enlightenment philosophers such as Voltaire, Kant, Newton, Locke, and Hume began to stress the importance of human reason and of scientific analysis for human progress in isolation from and even in opposition to religion (Kelly 1979, 61–62). They saw that the preceding centuries had often been engulfed in interreligious disputes that had caused turmoil and considerable suffering for the people. They thought that a freedom from this kind of darkness would release humanity from the shackles that kept it bound to reactionary authoritarianism. They thus rejected much of religious authority, especially when they perceived it as hindering human development, which they tended to identify with scientific and technological progress. Human reason could achieve a better society. Religion was accepted only, or at least primarily, for its utilitarian function of teaching people how to behave morally for the establishment of a better society. In this intellectual environment, medicine tended for the first time to separate itself ideologically from religion. In the previous centuries, most doctors had been lay Christians, not priests and religious. But they had seen their vocation as quite clearly a part of their Christian religion and of its worldview. Now medicine was to become secular, unreligious, and sometimes even antireligious (Pompey 1968, 8–11). It was in the eighteenth century that Christian theologians began to develop a specific field of study and body of literature to explore the interface of religion and medicine. What had previously been sporadic or had been incorporated into larger treatises of systematic or moral theology now found its own expression and a beginning of cohesion in a subdiscipline of pastoral theology known as pastoral medicine. Theologians and some Christian physicians recognized that the complete separation of medicine from religion was harmful to both disciplines, and pastoral medicine emerged as an attempt to correct this. The term “pastoral medicine” is generally unfamiliar today, especially in the United States, but it was the primary prediscipline to the Catholic medical ethics of the twentieth century. As pastoral medicine arose in the eighteenth century, and as it continued into the nineteenth and twentieth centuries, it tried to bridge the gap between religion and secularized medicine by including all aspects of the interface of these two disciplines (Kelly 1979, 62; Fleckenstein 1963, 160). Pastoral medicine thus developed two emphases, one medical and the other theological. The first emphasis was to teach the theologians and the parish clergy what they needed to know about medicine. Theologians would need this knowledge in their study of Christian anthropology in order to understand better the meaning of human persons

as God created us and intends us to live, the way in which human beings act and react, the theological questions of body–soul interaction and of grace and human freedom, and in order to develop a moral theology of medical practice. The parish clergy would need medical knowledge in their parish ministry as counselors and confessors, and to enable them to provide first aid and basic medical advice to parishioners where doctors were lacking (the tendency of medical personnel to gravitate to the big cities is not new, and rural sections of Europe in the eighteenth century were often without physicians). The second emphasis of pastoral medicine was theological and ethical. Doctors could learn from theologians about the spiritual dimensions of the person and about the application of moral–theological principles to medical practice (Kelly 1979, 60–61). As pastoral medicine developed, it emphasized first one, then another of the various aspects it included. During the eighteenth century, under the influence of the Enlightenment, much of it was limited to manuals of first aid for rural priests and ministers. Religion was to be useful in some measurable way, and physical healing and hygiene to prevent disease were ways to achieve this goal (Kelly 1979, 63–64; Niedermeyer 1955, 1:15–19, 53–54; Fleckenstein 1963, 160–61; Pompey 1968, 8–12, 33–117, 295–96). In fact, some of the early literature quite clearly argued that this was to be the clergy’s primary task. It transformed the clergy into doctors. At the other extreme were works of pastoral medicine that altogether rejected the Enlightenment search for better medical science and argued for a supernaturalist approach that would change doctors into clergy (Niedermeyer 1955, 1:55–57). In the nineteenth and twentieth centuries pastoral medicine moved more and more in the direction of moral theology or medical ethics, and some books were really medical ethics texts. Yet despite these shifts in emphasis and tendencies to limit the field to one or another aspect, pastoral medicine maintained a dialogue between medicine and religion. The years since the 1960s have seen a new revival of the study of medicine and religion and of medicine and ethics. Medical ethics, long a Roman Catholic discipline, is now quite ecumenical. Nurses, physicians, lawyers, and other professionals involved in health care and in health care institutions are studying with philosophers and theologians to develop better approaches to the complex individual and structural questions that beset the health care system. Medicine no longer considers itself separate from the wider concerns of the meaning of human existence, traditionally the subject matter for theologians and philosophers. There are many reasons for this. Some are obvious to all who are involved in health care in any way: the rapid growth in medical technology with its tendency to dominate medical care to the exclusion of personal interaction and personal choice; the rise in health care costs; the availability of instant communication techniques in the media, which bring public attention to the advances and the failures of the health care delivery system; and new problems connected with transplants, allocation of resources, genetic engineering, and so on. Beneath these readily apparent reasons are more subtle ones. Theology has long been a source of ethical reflection. As early as the fifteenth century, physicians were singled out for analysis in the moral manuals of the Catholic tradition along with judges, clergy, and politicians. Over the centuries, only health care providers have received detailed attention, an attention due to the special nature of health care itself. It is because medicine is of its very nature a relational profession that it has such an intrinsic moral component. In the practice of medicine, in the provision of health care, professionals put their knowledge and skills to use in dealing with nonprofessionals at exceptionally intimate and vulnerable moments. Patients are by definition those who undergo, those who suffer. The patient, who undergoes, is vulnerable. Thus, sociologists note that professionals have a “guilty knowledge,” a knowledge of things dangerous to know. It is this combination of vulnerability and guilty knowledge in the clinical life-and-death context of medical practice that sets health care apart as a particularly moral enterprise. There is an even deeper reason for the long relationship of medicine and religion, one especially apparent in recent decades. Medicine, particularly when it is in a period of rapid change, tests our understanding of the very meaning and importance of human life. Biotechnology, genetic engineering, and similar contemporary pursuits emphasize this. And it is a religious question. Religion and medicine are both concerned with the existential center of the human person, with sickness, sin, health, and salvation. Both deal with limit situations, with moments and events and questions in our lives that put our very selves to the test of meaning. A theological basis of health care and of health care ethics will have to deal with this, with questions of Christian anthropology, with questions about what it means to be human. Notes 1. The term “bioethics” was coined by Van Rensselaer Potter, who wrote Bioethics: Bridge to the Future in 1971 (see chapter 30 in this volume). The term was then adopted by others to imply a shift in emphasis from the “medical ethics” that had preceded it, adding to the previous emphasis on the doctor-patient-treatment context an emphasis on biological research and biomedical techniques. 2. Throughout its history, various terms have been used to designate the field. In this book we will use “bioethics,” “biomedical ethics,” “medical ethics,” and “health care ethics” more or less interchangeably, though in some cases historical context will suggest the use of one or another of them. For a detailed analysis of the various names used, see Kelly 1979, 106–8, 219–21, 407–8. 3. The first influential modern work written by a Protestant was Joseph Fletcher’s Morals and Medicine (1960).

CATHOLIC MORAL THEOLOGY has traditionally argued that ethics (what we ought to do) must be based on anthropology (who we are). Contemporary theologians have drawn from both the tradition of Catholic theology and the developments of modern philosophy to explore anew the meaning of human life as God intends it. This chapter suggests a theological basis for the dignity of the human person. Health care and health care ethics presuppose at their very core that the human person is of special worth, and the Christian understanding of the human person supports this concept of human dignity. Catholic theology has traditionally argued for the dignity of the human person from two theological bases: creation and redemption. It was God’s original purpose to create the human person with a special status within creation. But sin tainted the original goodness of humankind, and, though we never entirely lost our position as specially valued images of God, we were found to need a savior, a redeemer to restore us to God’s grace and favor. Thus God decided to send Jesus as savior, to return to us the capacity of life according to God’s original design. This approach to the theological foundation of human dignity is of value, and its emphases on creation and redemption are essential to the Christian story of God’s loving care for human beings. But contemporary theologians are apt to point out that this approach suggests too much that Jesus Christ is an afterthought in God’s plan for human destiny. The God who creates is the same God as the God who saves from sin, say such theologians as Karl Rahner and Edward Schillebeeckx, and it was God’s will from the beginning that all of humankind should share in the divine life in and through Jesus Christ. God did not “decide to send Jesus” only as an answer to sin. The tradition of the felix culpa (“happy fault”), for all its beauty, is inadequate. It was not sin that caused the incarnation of God in Jesus Christ; it was God’s original creation of human dignity and destiny that laid the basis for the divine communication of God’s self to humankind in the God-Man Jesus Christ. For Schillebeeckx, “ ‘Christology’ is concentrated creation: belief in creation as God wills it to be. It is not a new divine plan for a creation which has gone wrong…. Belief in creation is essentially bound up with belief in the person of Jesus as God’s definitive salvation for men and women” (Schillebeeckx 1982, 118). Human dignity, created by God and revealed in Jesus, the human face of God, is at the center of the Christian message. It serves as a basis for the theological anthropology that grounds health care and health care ethics. Christian theology has often referred to our human dignity as an “alien dignity” (Thielicke 1975, 231). Sometimes this implies that it is not really we who are special but rather that our dignity is only borrowed temporarily from God, as if God might at any moment decide to eliminate it. In this scenario God becomes something of an uncaring experimenter. God grants us a temporary set of attributes to see what we might do with them, to see if we will jump the hurdles. God may be intrigued but does not ultimately care. The entire Christian message of the incarnation rejects this interpretation of alien dignity. Alien dignity means something quite different. Having freely chosen to create human beings, God has also freely chosen to involve God’s very self with us, with our plans and our sufferings, our virtues and our sinfulness. That is what the cross and resurrection of Jesus mean. Our dignity is indeed “alien.” Properly understood, however, the alien nature of human dignity means not that human dignity is a fiction, nor that it is extrinsic to ourselves, but that it is established by God. That God keeps us in existence does not reduce who we are but ennobles us. Alien dignity means that our worth is not found in any mere usefulness granted us by other women and men. We are of worth. That worth is from God, not from the individual or social agreement of other humans. We are of more than utilitarian value. Our worth remains even when sin-filled persons or sin-filled structures ignore it. It is alien because it transcends us and our possibilities of rejecting it. It is this approach to human dignity that best serves as foundation for health care and health care ethics. The Christian message, when properly understood, adds a theological, religious dimension that reinforces the basis for health care and health care ethics. Humans are inintrinsically worthy. God has said yes to human life. The concept of human dignity as developed in Christian theology can be explored through various themes. Following the outline of John F. O’Grady, in Christian Anthropology: A Meaning for Human Life (1975), this chapter treats four such themes: the human person as image of God, chosen by God, ordered to God in grace, and alienated from God by sin.1 The Human Person as the Image of God The Christian understanding of the human person considers men and women to be the pinnacle of God’s creation. We are made in the image of God (O’Grady 1975, 10–11). The very beginning of the Bible makes this clear. The Jewish and the Christian understanding of the meaning of human personhood as created by God in the beginning is one of total goodness and of almost divine stature. In the stylized poem of the first chapter of Genesis, the author waits until the sixth and last day of God’s creative activity to create the land animals and man and woman. God has prepared for this moment. First came light; then land and water; then the plants; then the sun, moon, and stars; and, on the fifth day, the fish and the birds. These last receive a blessing to go forth and multiply. At the end of each day, “God saw that it was good” (Gn 1:1–25). Finally, on day six, “God said ‘Let us make humankind in our image and likeness.’ … God created humankind in God’s image. In the divine image God created it. Male and female God created them” (Gn 1:26–27). Men and women receive the same blessing as the other animals to go forth and multiply, but to them is also given “dominion” or authority over the rest of creation. At the end of the sixth day, God saw that what had been created was “very good.” Two of the key words here are the Hebrew words “selem” and “demuth,” usually translated “image” and “likeness,” respectively. The first word suggests an actual physical resemblance. People look like God. The second word corrects that impression while adding to the impact by repeating that God creates us to be of almost divine stature. We are not photocopies of God, but in a very concrete way we resemble God and are God-like (O’Grady 1975, 10–11). Much of the tradition of Christian theology, influenced by Greek philosophy, has tended to interpret this theological theme of creation in God’s image in a very spiritualized and dehumanized way. Since much of Catholic theology has depicted God as pure and perfect spirit, unchanging, and completely indivisible, theologians have tended to emphasize only the spirits, souls, or minds of women and men in the context of our created imaging of God. Only our souls are created in God’s image, according to this approach, not our bodies. But a human soul is not a human person. The book of Genesis tells us that humankind is created in God’s image. There is no implication in most of the Hebrew Scriptures that men and women are split into two parts. That is, there is little or no anthropological dualism. Nor is there an “original dualism” (O’Grady 1975, 11). Unlike some other religions contemporaneous to Jahwism, the Hebrews rejected the idea of two creative forces or gods—one good creating spirit and light, the other evil creating matter, darkness, and sin. It was not just a part of the human person that was created in the image of the one God. Rather, the human being, the body–soul complex, the existing person is like God. Why? What is it about the human person that makes her or him like God? The answer is complex, but it is at least partly because humans, like God, have dominion over the rest of creation (O’Grady 1975, 11–14). We exercise authority in God’s name over the earth and the animals. Adam names the animals, a sign of authority over them. Unlike the rest of creation, in the language of contemporary theology we can be said to transcend who we are. We are open to self-creation in and through history. We can hope for a future and act to bring it about. Alone in creation—at least the creation we have so far come to know—women and men can reflect on who they are, can be aware of what they are not, and can decide, within the limitations of created finitude, to change themselves and their society. The very enterprise of health care depends on this kind of understanding of the human person, even if the understanding is not explicitly theological. Scientific knowledge requires both a faith in the ongoing coherence of nature and the possibility of making leaps into the unknown, of hypothesizing about the future, and of making that future real. Thus, the biblical teaching on the human being as created in God’s image, or a secular equivalent of it, is in some ways essential to the ongoing task of health care. In biblical times, this notion that human beings were the image of God was very different from the idea of humanity prevalent in some other religions. In many of these, humans were subservient to the forces of nature. Humans were to worship these forces and in some cases actually sacrificed themselves or their conquered enemies to them. For the Hebrews, in contrast, human beings were not set below the rest of creation, but above it. Nature was not divine. It was created, like humans, by God. This was the natural order of things: God the creator in dominion over all of creation, including human beings, and humans acting for the Lord in dominion over the rest of creation, constituted the original harmony desired by God (O’Grady 1975, 12). This emphasis on the created goodness of human persons and on our almost divine stature does not require a literalist belief in the details of the Genesis story as if this work were scientifically or historically “accurate.” If time travelers could go back with video cameras, they would see something quite different from the idyllic garden pictured in the book of Genesis. The goodness of God’s creation is not that of a created infinity, of a created perfection, were such a thing logically possible. We are not God. This is symbolized for us even before the fall in the fact that God gave a command that separated humanity from Godhood. Humankind was not to eat of the fruit of the tree that only God could digest. This has important implications for an anthropology that proposes to found a health care ethic. It means, first, that human beings are created in a dignity that makes them both creatures and cocreators with God. We are not merely equal to the rest of creation. We are to some extent cocreators, or at least coagents with God in bringing God’s plan for creation to fulfillment. Yet we are not God; we are creatures. Our creative powers are limited, both by our creaturely finitude and by sin. Not only can we make mistakes but we can also sinfully break up the fabric of God’s creation and of our own society. I will return to the ethical implications of this theological principle of creaturely cocreator in chapter 5. The understanding that Genesis is not meant to present a historically accurate idyllic picture of a perfect garden is important for a second reason as well. It is important to know that there never was a time when creation was not finite. Sometimes we get the idea from certain interpretations of Genesis that in the beginning life was totally without struggle, without work—indeed, without growth and maturation. Education was instant, love easy, healing unnecessary. This approach can lead us to see our life and work mostly as the unfortunate consequences of that “original sin.” Had there been no sin, there would have been no work, no reading, no art, no struggle to create, no medicine, no progress or regress, no tripping and falling. Admittedly, it is very difficult to distinguish, in this real world of ours, between sin, which God did not want, and human finitude, which was part of the divine plan. But a more nuanced understanding of the theology of creation at least tries to grasp more adequately the built-in finitude of our creation, understanding it not essentially as a sin-caused obstacle but as the very possibility of creation in the first place. God never intended to make us God. What God did was create a “good creation.” And in that creation, the creature ha adam—humankind—was of very special worth. This more nuanced approach to the notion of creation in God’s image is also helpful in understanding and responding to some recent criticisms of Christian anthropology that have emphasized its potential dangers. Some have argued that it is precisely because we think we have dominion over the earth that we have caused such human and ecological havoc. Those who take this view argue for an anthropology that sees the human being as merely one more kind of animal, more complex, perhaps, but differing only in degree and not in quality from the beasts. They charge Christianity with “humanocentrism,” or with “speciesism,” with forgetting the rest of nature in its rush to depict men and women as God-like. Although there is much truth to these charges, at least in their practical ethical implications, it is unhelpful to reduce the stature of the human person to that of nonhuman nature. The human person, as created by God, experiences herself or himself as transcendent. This is a phenomenon of human life. It is not evil humanocentrism to recognize and make theologically explicit the vast difference in freedom and dignity between human beings and the other creatures with which we are familiar. To fail to do so is perhaps to hate oneself by rejecting one’s own nature. But this does not give us a license to run roughshod over the rest of creation. God’s universe is good in itself, even prior to the arrival of our species. God’s purpose in creating cannot be restricted to what is good for humanity. The Jewish and Christian notion of human dominion over creation is not intended to be absolute. It is a created and limited dominion. There are two reasons why this is so. The first requires no real theological sophistication and can be supported simply from human self-interest. An absolute dominion would lead to devastating results for the human species itself were we to act on it in an unlimited fashion. Human beings are part of the ecosystem and depend on it. Our selftranscendence does not change this. The second reason is theological. Humankind is called to exercise its authority in creation not as God but as cocreative creature. Though we are created with special dignity and preeminence, and with special authority and “dominion,” we are nonetheless created along with the rest of God’s work. God’s will is not that we undo what God presents for both divine and human honor and glory but that we transform creation and ourselves as caretakers of what God has made. People are called to exercise stewardship, not total domination.

The theme of the human person as the image of God continues in a particular way when Christian theology proposes Christ as the perfect image of God. If all women and men are created in God’s image, Christ is the perfect image of the Father. For the rest of us, the image is tarnished, but not for Jesus. Thus, Paul tells us that “Christ is the likeness of God” (2 Cor 4:4) and “the image of the invisible God” (Col 1:15). Jesus exercises his dominion as God does, and as God wants us to exercise it. What women and men are called to be in creation is realized in Jesus. The Human Person Chosen by God The theme of the human being as image of God is one of the core creational themes of Christian anthropology. As we turn now to the theme of divine election, and when we later discuss the theme of the ordering of humanity to God in grace, we should remember that these are not added to the first theme in any separable way. That is, God’s election and the gift of God’s grace are not decisions added later or superimposed by God as afterthoughts. Rather, they reflect from different theological perspectives the very same intrinsic dignity of human life that we have already discovered. God created human beings with a destiny to be chosen. The best of Christian theology does not see that destiny, and its actual achievement in grace, as another layer added to ungraced, undestined natural humanity. The human person is special, according to Christian theology, because we are created at the start with a graced destiny of self-transcendence. That human beings have a destiny in God’s original creating will can properly be called a kind of “predestination” (O’Grady 1975, 25). Human dignity arises in large measure from the fact that God has created us with this predestiny to transcend ourselves, to move beyond our own horizons and that of our surroundings to share God’s life. Even those of us who do not accept this belief in its specifically Christian form experience the phenomenon of human freedom with its call to move beyond who we are, to seek the infinite, to share in the spirit of God. The term “predestination” has, of course, another meaning as well—a meaning that, in its more extreme and simplistic forms, contradicts and undermines the very possibility of true self-transcendence and thus destroys in large measure the theological basis for human dignity. This second meaning is unfortunately the more common one. Here predestination means not the creating will of God that all humans be ordered to God through grace, but a kind of arbitrary divine decision whereby only some are given the real possibility of salvation, while others, comprising most of humankind, are left inevitably without God’s power and life, condemned to endless death. God decides ahead of time who will be saved and who will be damned. Human freedom has little or nothing to do with it. God’s grace, when it is offered, overwhelms freedom totally; the saved have no choice, since this kind of grace cannot be rejected. Nordo the damned, since God withholds grace from them and leaves them to the power of sin and death. The theological problems of the relationship of grace and freedom, or of “nature and grace,” are complex, and even such theologians as Karl Rahner have not “solved” them. The divine–human relationship is a mystery.2 But it is at least clear that God’s creating desire and plan for human beings includes a destiny that respects the human freedom and capacity for transcendence that God has given men and women. Thus, it is in this more theologically precise sense that the term “predestination” is best used. God has planned, in creation, that human persons should live full human lives with God in Christ. God has predestined all women and men to live with God’s own self (O’Grady 1975, 24–25). The Jewish and the Christian teachings on election make more specific certain historical and symbolic events through which God is seen to work the divine salvific plan. Christians specify three principal events or stages in the unfolding of God’s plan for human salvation: creation, election, and incarnation. We have already discussed at some length the first principal stage, the creation of men and women in the image of God with a special blessing and a special task. Humans are to share in God’s work of transforming the world and themselves in accordance with God’s plan. This creative alliance is continued in an ongoing covenant between God and all humanity, a covenant symbolized in events that the Bible narrates as having preceded the more important covenant with the people of Israel that would follow later. Two examples here can give us an indication of how God continues this creating alliance with all people. The first occurs after Cain kills Abel in the fourth chapter of Genesis. God punishes Cain for this act of murder, but even here God agrees to give Cain a token that will be a sign to others who might harm him that God still holds Cain in his favor and protection. This event is a symbol of God’s ongoing relationship to created humanity. The second example is better known, and it, too, symbolizes the universality of God’s covenant with the human person. The eighth and ninth chapters of Genesis narrate the story of Noah and his family, saved by God from the flood. After the flood ends, God repeats to Noah and his family the same blessing given to Adam and Eve at the moment of their creation. God adds a covenant with them, an alliance with all of humanity that pledges God’s fidelity and sets in the sky a token of that pledge: the rainbow, a sign that God would never again in wrath destroy the world by water. All of humankind is special to God. The second principal stage in the unfolding of the history of salvation is, of course, the election of the chosen people of Israel. This event is seen first in the call to Abraham and is then repeated over and over again throughout the Old Testament. God calls Abraham out of his own land to a new land that God will give him. Abraham will be the father of a new and special people. God symbolizes the degreeof commitment to Abraham and to the people of Israel by agreeing that if God should ever reject the people, which will never happen, it will be right for God to be destroyed. The oath ritual in Genesis 15 is a kind of early and solemn “cross my heart and hope to die.” The ritual was used to solemnize treaties between persons or peoples. The parties to the treaty would kill a number of animals, cut them in half, and then walk between the pieces. The idea was that if they violated the treaty, they would deserve death and dismemberment. Here it is God (a fiery oven) who walks between the pieces of the animals. God is committed to the chosen people. “You will be my people and I will be your God.” The election enters a new and advanced stage with Moses, when God leads the people out of Egypt, symbolizing a release from bondage and oppression. God gives them the law, which they receive not as a new burden of impossible tasks but as a gift from God establishing anew the covenant God continues to make with the specially chosen people. The alliance is again renewed through the kings, who will rule the people in God’s name. The covenant does not always work out well. The prophets constantly remonstrate with the people about their failure to fulfill their responsibilities. The people are unfaithful to God. They oppress the poor and the powerless. They refuse to accept their task of transforming self and society in accordance with the divine plan for their destiny. Sin alienates them from the God who has chosen them. Yet the dignity of their lives re

remains. God’s fidelity to the election remains. God punishes and calls them to repentance, and when they repent, God again accepts them and the alliance is renewed and repaired (O’Grady 1975, 29–31). The third stage in the working out of God’s plan for human destiny, as this is seen by Christians, is the incarnation. When the time was right, God came as a human being to reveal God’s own self to women and men. The predestination of humanity is accomplished in the enfleshment of God in Jesus, and through the cross and the resurrection. Here is the new election, the new covenant, the transformation of humanity from the order of Adam to the order of Christ. God gives God’s very self to created humanity in a self-communication. The life, teaching, and death of Jesus reveal how important humans are to God. God is involved in the actual living of a human life and in the actual dying of a human death. The Christian scriptures leave no opening for an idea that has sometimes invaded our theology and our piety: that Jesus was not really human but only a kind of extraterrestrial visitor from a spiritual world. That heresy has been with Christianity throughout much of its history. Perhaps it is because we are unable to accept the idea that, for God, we are worth the incarnation, the humanization of divinity. Perhaps it is because when we reject the possibility of God’s forgiveness we need some kind of excuse to distance ourselves from the challenge Jesus gives us to live life as fully and as lovingly as he did. So we say that the reason he could live that way was because he was God, and not really human. Whatever the reason, the docetic heresy, the idea that Jesus merely appeared to be human, that he was a kind of visiting deity masquerading as one of us, undermines the central Christian basis for the dignity of the human person. If God could become a human being, the dignity of humankind is indeed demonstrated in a new and exciting way. Christians believe that Jesus establishes a covenant, a new development in the alliance of God with the chosen people. Christians are called to make this covenant manifest, to be its sacrament, to sign forth the alliance by their lives and their actions and their very beings. The first letter of Peter states: “You are a chosen race, a royal priesthood, a holy nation, a purchased people; that you may proclaim the perfections of him who has called you out of darkness into his marvelous light” (1 Pt 2:9). Christians have a task to make manifest what has been revealed to them about God’s plan for humankind. They are to strive for peace and justice, for the transformation of self and world in accordance with the dignity and the cocreative challenge given them by God in creation, in election, and in incarnation. Like Israel, Christendom has failed to live up to the covenant. Christians oppress the poor. They violate their own dignity. They are unfaithful to the God who has chosen them and who has shown them the way in Jesus. Yet, as with the people of Israel, God calls them to repentance and is faithful to the alliance (O’Grady 1975, 32).The Human Person Ordered to God by Grace The dignity of the human person as created by God and as destined to divine life is oriented or ordered to this life through grace. We have already noted the complexities of any theological attempt to spell out the relationship of grace and human nature with any precision when treating of the two meanings of predestination. Christian theology has tried, not always successfully, to maintain a balance between the created freedom and dignity of the human person and the gratuitous grace of God. Contemporary theologians, especially Karl Rahner, have furthered this attempt in an important direction by refusing to allow any easy separations between “nature” and “grace.” Though not identical, the natural and supernatural orders in the human person cannot be separated. And while the exact relationship is mysterious, the mystery reflects the complexity of the human person actually existing in the world and is not so much a problem to be solved by theological analysis as a disclosing and unfolding of what it means to be a human being (O’Grady 1975, 52–56; Rahner [1954] 1961; 1963, 3–44; [1959] 1965). All of this, which seems sometimes so abstract, is essential to any attempt at establishing a theological basis for health care and health care ethics. Health care providers develop sensitivity to their patients. Those who approach their work from a specifically Christian perspective will find that this sensitivity is affected by their theology of the human person. In chapters 3, 4, and 5, we deal more specifically with the problems of dualism, with the relationship of divine and natural causality, and with the use of theological principles specifically in health care ethics. But all of this depends on an adequate theology of the meaning of human life. For Christians, this must of necessity include the issues of nature and grace. If these two aspects of human life are seen as antagonistic to one another, so that human “nature” is somehow unworthy of care, then health care can never be a truly Christian vocation. Only grace and the supernatural life of the soul have importance. The mystery of graced nature remains a mystery, but it is important to grasp that in humankind God’s gift of grace does not mean that human “nature” is less worthy but that it is more worthy. That the human person is ordered to God by grace is one further dimension of the dignity of the totality of human life, not a reason for splitting people into matter and spirit and limiting our ministry to the spirit. It is the whole person who is graced. For Catholic theology, at least in its better moments, grace does not overwhelm human freedom, nor is the human being so radically depraved as to be without reception for, or a natural affinity to, grace. Grace reaffirms and enhances the dignity and the nobility of human life (O’Grady 1975, 58–59). Grace is experienced. If it is true that God, in creation, has destined us to share divine life in Jesus, then that divine life ought somehow to be experienced. The actual experience of God’s life through grace has been the subject of analysis by theologians and psychologists

and of poetry and expressive prayer and narration by those we call mystics. For some, the experience of grace, or the religious experience, is a feeling of total dependency on God, or a blind leap into God’s void. Rudolf Otto, in his classic work The Idea of the Holy (Otto [1923] 1950), suggests that true religious experience is the experience in human life of the fascinating and scary mystery who is God. The mystics have tried through narration and symbol to describe their encounters with God’s presence in their lives, but these attempts never capture adequately the experience itself. The fact is that “grace,” or the experience of God’s life in our human lives, can never be adequately defined. There are two reasons for this. The first is the more commonly recognized. Since grace is of God, grace is of its own nature mysterious. It transcends our comprehension. The second is less obvious but perhaps of greater importance for health care. If grace is not something separable from our own humanity, if—although not identical to human nature—grace can never be separated from our humanity or analyzed apart from it, then the mystery of human nature itself, the transcendence of the human person in our actual lived experience, imposes its own mystery on the mystery of grace. Grace, in other words, is mysterious not only because it is supernatural, thus going beyond our comprehension; it is also mysterious because it is human. Human persons, in our unfathomable humanness, are the ones who are graced. Grace does not exist on its own, out there somewhere in a large reservoir waiting for people to turn on the tap. It is human beings who are graced, and grace thus shares in the human mystery. In the scriptures, grace is really any and all gifts of God to women and men. Grace is a free gift. It is not something contractually owed. God does not owe us creation, nor does God owe us salvation or our human destiny—though having created us, God owes us the respect due to his own handiwork. Grace is any and all communication of God to us. It is the process whereby God tells us about herself, calls us closer to divine life. Various theologians in the development of Christian theology have given different emphases to grace and have seen the relationship of grace and human nature differently (Getz 1982). For Augustine, in the fifth century, grace was primarily a medicine that healed a humanity corrupted by original sin. His purpose was to heal; Augustine was no hater of humanity. Yet there is in Augustine a kind of pessimism about human nature, especially in its bodily and sexual aspects. Augustine emphasized the power of grace, and although he usually tried to maintain the tension between this divine power and human freedom (Augustine 1887b, 5–10), there are places in his theology where he lets go of that tension and almost eliminates freedom from the balance. He sometimes argues for the more simplistic forms of predestination where humanity becomes God’s plaything, and the vast majority of humankind is condemned (Augustine 1887f; 1887e; 1887b, 41–46). Nonetheless,

Augustine maintains the biblical notion that God created humankind good, and that God intended men and women to share divine life in Jesus Christ. For Augustine, humankind’s purpose from the very beginning was to share in God’s life. Thomas Aquinas, in the thirteenth century, was considerably more positive about the worth of human nature. Even without grace, human nature in its “pure” state and in its fallen state retains its natural tendency toward God, its desire to see God, its affinity for God’s grace. If Augustine’s starting point was original sin and the need for healing grace, Thomas emphasizes the goodness of human nature as created by God and sees grace as elevating that nature to a new, added, supernatural level with its own new purpose (Thomas Aquinas 1945, II, 997, Summa theologica Ia Ilae, q. 110 in corp., also ST, IIa IIae, q. 171, ad 3). In this way, Thomas better expresses the continued worthiness of the human person and better maintains the dialectic between freedom and grace. Grace builds on nature; it does not oppose it. Grace opposes sin. This was true for Augustine, too, but since for him human nature had been thoroughly and radically depraved by sin, there was little or nothing good left in it for grace to build on. Thus, for Augustine, grace opposed (sinful) human nature, whereas for Thomas, human nature, in its freedom and capacity to receive grace, could work more harmoniously with it. But Thomistic theology, especially as it developed in theologians who followed after Thomas, tended to split nature and grace too much. Grace built on nature, true. But grace was something added to nature, as if nature could exist without it. Thus the danger came of a new kind of dualism, one that split the human person into the merely natural and the newly supernatural. This distorted the mysterious interaction in human life, the dialogue of the divine and the human. In some theologies it also led to the reification of grace. If grace was separated from the human mystery, perhaps “it” could be comprehended as a thing on its own. The various distinctions among kinds of grace, and the tendency to think about amounts of grace earned and lost and kept somewhere in escrow till the next confession, came from this separation. Paradoxically, as grace became more and more supernatural, separated from the human, it became more and more definable and comprehensible. It could become a thing added to human nature, rather than an integral aspect of the alien dignity of human life in its mysterious richness. Contemporary theologians, particularly Karl Rahner, have tried to overcome the dualism inherent in some earlier concepts of grace. Rahner’s approach has been called “transcendental Thomism” because he tries to build on Thomas’s notion that human nature has a built-in capacity for or affinity with grace while he changes the tendency in some older theologies to separate nature and grace. Rahner talks about a “supernatural existential” (Rahner 1963, [1954] 1961). Human beings, as we exist in this world, participate in the supernatural order and are never totally
separate from it. Even those who reject God’s grace are, as human beings, related toward it even in its absence. This “supernatural existential” means that saving grace is not limited to those who are explicit believers in Christ. Grace is not added to human nature as an extra. There is only one order of human existence, and it includes our supernatural destiny as God intended in our creation. For Rahner, grace is God’s self-communication to women and men. And it is we, as humans, who are the primary communicators, the sacraments of God’s revelation. We humans are the symbols through whom God’s revelation comes. Among us humans, Jesus Christ is the perfect symbol, the most complete communication, the definitive grace. A definition from another time and context can summarize our brief survey of the dignity of human life as ordered to God in grace. The Council of Trent in the sixteenth century declared that grace is God’s love for us as that love is in us and changes us. God’s gift of grace to human persons is an integral part of the dignity of human life. The Human Person Alienated from God by Sin In exploring the biblical and the theological notion of the dignity of the human person, we have already mentioned the reality of sin. This final brief section on sin in the human condition comes last among the themes for good reason, because for the Christian, the dynamic of sin, important as it is, is secondary to the dynamic of creation-election-grace. God’s plan from the beginning was and is for the supernatural human destiny of all men and women. Human sin opposes that plan, but in God’s power and love sin never really threatens to destroy it. The supernatural existential in God’s graced creation is not just an equal antagonist holding its own against the powers of sin and death. Rather, the order of grace has achieved the ultimate victory over sin. This is the good news of the gospel (O’Grady 1975, 62–92; Mahoney 2003, 724–26). Nonetheless, sin remains an important and often devastating dynamic in human life. Those who are involved in health care know this from experience. First, and more obviously, there are the ethical issues connected with health care—the issues that comprise “medical ethics”—and these issues have to do with right and wrong, with human choice, and often with greed, sloth, deceit, lust, envy, hubris, violence, and waste—in a word, with sin. These dynamics exert their influence not only in the individual acts of sinful people, including both healers (health care providers) and patients (health care recipients), but also in the very structures of the way health care is delivered. Some of these issues are relatively simple; many more are excruciatingly complex. It is not always easy to know precisely where the “sin” is or what the morally right solution is. Yet despite this, we sense the reality of sin, of brokenness, and of the injustice and cruelty that we people do to one another. Second, and less obviously, there is a deeper dynamism of sinfulness inherent in the human condition that can appear in times of sickness. Here distinctions between sinfulness and created human finitude blur. Not all limitations are sin or sin’s results. It is sometimes hard to know what is sin or the effect of sin, what is truly evil, and what is merely part of the necessary processes of growth and decay inherent in creation. We have seen that among the species we know, humans alone are aware of their future and can hope for a true transcendence beyond their present limitations. Yet this very capacity brings with it a loneliness, an anxiety, a recognition of limits, a human confrontation with death. Sensitive health care professionals are aware that the medical enterprise, with its vulnerability and “guilty knowledge” in combination with what is often a life-and-death context, brings out these human encounters at their deepest and most significant level. This can be terrifying. It can also be faith-filled, trusting, and consoling. The Christian belief that God in Jesus Christ has triumphed over sin and death adds a hope and a faith that human life is ultimately meaningful. This does not remove the pain of confronting sin and the ultimate limits of creation. It does not easily answer the challenge that comes to us from the experienced absurdities and evils that plague human living. But it does offer a faith and a hope that God’s plan will be brought to fruition despite the power of sin and alienation. God’s destiny for humankind is prior to and greater than the sin and death that would deny it. The question of how evil can exist in a world created by a good and loving God yields no easy answers. Yet some approaches are more adequate than others, especially in the context of health care and health care ethics. For some Christian theologies and pieties, all human limitation is the result of personal sin. Disease is a sign the sick person has sinned. Natural calamities like droughts and floods are signs of God’s wrath on sinners. The Bible itself often connects calamity and misfortune with the sins of Israel. Often such a connection does indeed exist. Sickness can be the result of abuse or violence. “Natural” calamities can be the result of environmental exploitation or of unjust economic and political systems. But the facile identification of all limitation, of all sickness and suffering and decay, with sin and its results is inadequate and even harmful, especially in the context of health care. More adequate Christian theologies and pieties recognize that God could not create a second God. God could only create something created, and creation has within itself, seemingly of necessity, characteristics of finiteness, characteristics of limitation, characteristics of growth and decay, even characteristics of violence. The alternative to this may not be perfection; it may be nothingness. Then, too, there is human freedom. The human person, in his or her freedom, is given the possibility of rejecting for himself or herself the realization of God’s plan. Contemporary moral theology is far less apt to identify specific ways in which this is done (mortal

sins) than was the moral theology of prior times. But Catholic theology has traditionally upheld the possibility of such a rejection. True freedom, of course, is not the freedom to sin; it is the freedom not to sin that comes with grace. But God gives us grace in a way consonant with our own human freedom. God does not overwhelm our freedom but invites it to an acceptance of the eternal plan for humankind. Thus, in a paradoxical way, human freedom requires the possibility of sin. If it is to have the possibility of saying yes, which is truly freeing, it must also have the possibility of saying no. This is the heart of what many of today’s Catholic moral theologians mean by the term “fundamental option.” The idea is often misunderstood to mean a kind of laxism or even subjectivism. But “fundamental option” does not do away with the possibility of mortal sin, the possibility of choosing death instead of life. Nor does it imply that real sinning is only internal, that those who may cut themselves off from God and from neighbor must do so by some kind of deep introspective decision that has no direct connection with others in the real world. It is true that the Bible, and all of moral theology, is clear that sin is ultimately a violation of God’s holiness. But the same Jewish and Christian tradition proclaims loudly that sins of injustice, greed, and lust against other persons are equally sins against the holiness of God, precisely because God has created humanity in God’s own image and likeness, has predestined it to share divine life, and has established that destiny through grace. A fundamental option for evil, like a fundamental option for good, is symbolized, established, and confirmed through human choices and human acts. The reality of sin in our human world is both individual and structural. There has been a direction lately in Catholic moral theology toward a reemphasis of structural and systematic sin. Structural sin was never really forgotten in the Catholic moral tradition, though it was often underemphasized. Ethicists now recognize the interdependence of structures and individual actions. When structures are unjust, and to the extent that they are sin-filled, their oppressive tyranny often surpasses the evil of individual sinful actions. And individuals who find themselves within such structures are less free to say yes to God’s plan. The reemphasis on structures and systems within Catholic moral theology in general has had important results in health care ethics. Prior to the 1960s, Catholic medical ethics was concerned almost exclusively with topics of immediate concern to medical professionals in their daily practice (Kelly 1979, 221–27). Most of the larger issues of pastoral medicine were ignored. Little attention was paid to the nature and biases of medicine itself, or to the social and economic factors so essential to health care. Topics concentrated on the individual medical actions of physician, nurse, and patient. Many concerned reproduction. The methodology of Catholic medical ethics, the way it analyzed issues of health care, was especially apt for these kinds of topics and stressed specific distinctions of actions in their precise physical or biological components. Chapters 10 through 12 examine this in detail. This has now changed. Many Catholic moralists are interested in the more complex issues concerning structural sin in the health care system (Kelly 1979, 407–16). Unfortunately, as we will see in chapters 28 and 29, there is sometimes a tendency to think that easy answers are available, a tendency similar to the past idea that individual medical procedures were open to simple moral analysis. Some approach structural issues in medicine with the same kind of facile condemnation they now reject when it is applied to individual procedures. Despite these dangers, however, the shift in emphasis toward recognition of the importance of structural sin is beneficial to health care ethics. The dynamic of sin is an important and fundamental dimension of human life. But more important from the Christian perspective than the order and dynamic of sin is the order and dynamic of grace. Sin is not dominant. For the Christian, sin is seen in the context of the prior and more fundamental order of graced creation with its God-given destiny. Sin is relativized by the forgiveness and reconciliation that God offers in Jesus. The alien dignity of the human person is established by God and thus worthy of human respect. Notes 1. Jack Mahoney approaches this using the four doctrinal pillars of Christian faith: creation, sin, salvation, and fulfillment (Mahoney 2003, 721–27). 2. For a typology of the ways in which divinity and humanity are understood to interact, see Getz 1982.