Although I am a theologian and not a bioethicist, I do have some extensive experience in pastoral ministry. Before I became a Catholic, some four years ago, I had been a Lutheran pastor for ten years, serving in a wide range of parish settings both in Australia and abroad. It is a particularly special and sometimes demanding dimension of pastoral ministry to be closely involved in people's lives at those very momentous occasions: birth, baptism, confirmation, marriage, sickness, and death. Six years of my ministry was in a central urban parish within close walking distance of three big hospitals. In six years I got to know those hospitals very well. What I witnessed and experienced in them changed my life for the better in many crucial ways. It is a very humbling thing to be drawn alongside patients and their families in those critical times of sickness, vulnerability, dying, and death. Although people would look to me to pray, to offer counsel, to help, these were often the times when I felt most helpless, with nothing to offer except the consoling and life-giving ministry of the gospel and sacraments. Of course, what more could a pastor want to give? What more do people need? Yet always I was conscious that in such moments, I was standing on holy ground, the weak among the weak, and I rarely left a hospital visit without a deeper sense of my own mortality, and my absolute dependence on divine grace.
Strangely enough, I had something of a similar experience reading this book. Far from offering a series of dry mathematical analyses of clinical case histories, this second volume of Nicholas Tonti-Filippini's About Bioethics series represents a deeply pastoral approach to the sensitive and sometimes excruciating problems that present themselves at the extremities of human living.
The book unfolds in five chapters: Chapter 1 on caring relationships, Chapter 2 on care until the end, Chapter 3 on representation and disability, Chapter 4 on ethics and mental illness, and finally Chapter 5 on being a patient. It is not that the author has tried to be pastoral or practical. It is pastoral, and it is practical, but these qualities seem to arise more from Tonti-Filippini's own experience and way of communicating than they do from any strategy. In these pages we are introduced not only to a vast number of difficult personal and family situations, sensitively and sympathetically conveyed, but we meet an author who himself knows firsthand his many vulnerabilities and fears, and has accepted them, and indeed, I would venture to say, has discovered in, with, and through them a remarkable capacity to feel and communicate empathy, to discern the truth, and to embrace love. Perhaps a number of examples will help to illustrate.
In Chapter 2, the author recounts the highly publicized cases in Australia and New Zealand of Christian Rossiter, who had recently suffered quadriplegia and needed artificial nutrition and hydration, and Margaret Page who had suffered a cerebral hemorrhage twenty years before but could take food and water in the normal way. While each was in unimaginably difficult circumstances, neither was terminally ill, neither was dying. Yet each wanted to die by refusing nutrition and hydration. Their cases went to the courts, which decided respectively in favour of their right to refuse food and water. Mr. Rossiter did not exercise this court-given right, and ultimately died of pneumonia. Mrs. Page did exercise that right, and died of starvation.
Now there are many complex aspects to these two cases, which I know get examined and debated at length in the author's bioethics classes at the John Paul II Institute. In recounting the story, however, he draws our attention to several gaps in the public discussion of these cases. Whether or not the two patients concerned were expressing suicidal intentions, Tonti-Filippini maintains the view that a Catholic hospital should never refuse to care for a patient, even if that patient's refusal of care were thought to be suicidal. In other words, the ethical principles which guide the practice of Catholic hospitals do not exclude, but rather mandate, the provision of the best medical care and support for patients whose own ethical principles or moral choices may be skewed or ill-informed. Permit me to quote at length:
I am of the view that a Catholic facility should do its best to persuade a person, who is refusing nutrition and hydration in order to die, to change his or her mind. It should call upon the best of its counselling and other services to that end, but the facility should not act coercively and neither should it withdraw other forms of care. It has a duty of care to do the best by the patient and that includes seeking to persuade them of the right course of action…. There are some who seem concerned that a course of action in which a hospital continues to care for persons refusing nutrition and hydration could be seen as cooperating with the evil of suicide by omission. In my view, a hospital and its staff are restrained by a person's refusal …. This view is supported by Pope Pius XII: “The rights and duties of the doctor are correlative to those of the patient. The doctor, in fact, has no separate or independent right where the patient is concerned. In general he can take action only if the patient explicitly or implicitly, directly or indirectly gives him permission.” (87)
A second example arises a little earlier on in the same chapter. Here, in the context of discussing the ethics of decisions relating to burdensome treatment and, in particular, to the issue of tube feeding, Professor Tonti-Filippini highlights one dimension of the issue which is often overlooked in more abstract ethical discussions, namely,
The importance that feeding someone has in our relationship to them. The process of cooking and providing a meal for someone is usually an act of love and expressive of the relationship between people.
One need only think of Karen Blixen's remarkable film Babette's Feast, and its study of the way in which an extravagant love can establish a holy communion transcending the limits of the petty and parochial, to get a sense of what the author is referring to here. He goes on:
Tube feeding still has that significance of an act of love…. My experience of the circumstances when a decision was made to cease feeding, was that often the relatives received the decision emotionally as giving up, and sometimes they stopped or reduced their visiting on this point. It was as though the decision not to feed meant that their relative might as well be dead, because he or she would be so very soon. Loss of feeding can thus mean loss of supportive relationships. (83)
The message coming through here and in similar passages is that we are essentially relational beings, and that moral acts cannot be properly weighed and judged in isolation from the web of relational, emotional, and symbolic networks within which we live. Something as simple and apparently extrinsic as a plastic tube into or out of my body can in fact communicate and dramatically symbolise a whole range of relational and dispositional meanings.
One final example from the book underscores this multi-levelled dimension of the bioethical situation yet again. In the last chapter on being a patient, the author relates a personal experience of a critical medical emergency he suffered in which he recalls the confronting presence of two very strong desires. “One was to be free of the burden of pain. The other was to be able to reach out to Mary [the author's wife] to both reassure her and to receive the comfort of her nearness and support.” Reflecting on this experience, Professor Tonti-Filippini wonders why it was that “despite being confident intellectually in [his] relationship with God, despite [his] prayer life and the great gift of prayer, in that moment it was to Mary [his wife], rather than to God that [he] turned” (165).
The theological reflections that follow this expression of puzzlement reveal a number of valuable speculative suggestions concerning the mysterious and wonderful character of the human situation and, in particular, of human marriage. We human beings are created not simply in the image of God generically considered, but in the image of the holy Trinity, the one true God eternally existing in a tri-personal communion of love. It is similarly the case that marriage between a man and a woman is a communion of love, so much so that marriage itself can be called an image of the Trinity. In the words of John Paul II, “the divine ‘We’ is the eternal pattern of the human ‘we,’ especially of that ‘we’ formed by the man and the woman created in the divine image and likeness” (166).
Tonti-Filippini goes on to apply this insight to the two-fold experience in his medical crisis of wanting to escape the pain on the one hand and to reach out to his wife on the other. Why didn't he reach out to God? For me, his comments at this point were among the most insightful moments of the whole book:
As spouses … we are helpless to prevent the end of our relationships through death. Dying separates us. The relationship between spouses is thus not a substitute for a relationship with God. But the gift that God gave to Adam and Eve was the gift of love, a gift that humanly introduces God's love to them. In the person of one's spouse is the nearness and intimacy of God and the capacity for a communion of persons which is ultimately our vocation. Our spousal love leads us to God by giving us the opportunity for love that ultimately is love for God, and in empathy we can be united to the other in the way in which we hope ultimately to be united with God. (170)
Woven into these and other chapters are numerous anecdotes and stories drawn from Nicholas's experiences as a husband, father, student, son, hospital ethicist, teacher, scholar, and consultant. These personal accounts serve constantly to connect the more technical ethical analyses with real people and real situations.
Clearly this is no ordinary Bioethics class textbook. Not only does it embody a more autobiographical and narrative style, but it is quite explicit in its witness to the way Christian faith contributes to the author's analyses and judgements. This of course is an approach that leaves the door wide open to criticism: doesn't the author risk the charge of exploiting his experience of illness to silence rigorous ethical debate? Who can argue with a dying man? Probably more to the point, it is one of the inviolable sacred principles of the secularist agenda that religion and faith should be given no place in the formation of public policy. Even Catholics have sometimes adopted a similar view, that we should argue our moral convictions by reason alone, and leave God, faith, scripture, and revelation for more domestic settings. But in company with an increasingly prominent and influential body of Catholic thinkers today, including Pope Benedict XVI, Prof. Tonti-Filippini recognizes that there is no such thing as “pure reason”: reason is always influenced by our beliefs, our habits, our choices, for good or for ill. By gently but openly acknowledging the role that his Christian faith and spiritual convictions play in his processes of reasoning, Tonti-Filippini has not only been honest but, he has also given his book the character of personal testimony which no critic worth his salt can simply dismiss. To me, his approach seems a not unfitting response to that ancient admonition: “Always be prepared to give an answer to everyone who asks you to give the reason for the hope that you have. But do this with gentleness and respect, keeping a clear conscience, so that those who speak maliciously against your good behaviour in Christ may be ashamed of their slander” (1 Pet 3:16).
This book is not without its faults: in particular, a number of minor typographical errors and the like mar its otherwise attractive form. But outweighing these we can array the following virtues: carefully researched; philosophically and ethically weighty; drawing on a long professional career with direct experience in the field; pastoral; practical; personal; affordable; and an extensive 22-page index. Volume two of Prof. Tonti-Filippini's About Bioethics is sure to make its mark on the Australian and international scene, and promises much for the greatly-awaited volumes yet to come.