The Human Person, the Physician, and the Physician’s Ethics

First published in The Linacre Quarterly 62:1 (74-82)

February 1, 1995

Editor’s note: This year marks the 100th anniversary of the birth of Edmund Pellegrino, MD. It’s safe to say that few people have matched him in the breadth and depth of his contributions to medical ethics in both the secular and the religious spheres. I can think of no better introduction to the topic of this issue than this address of his.

Introduction

My invitation to address you was very specific. Dr. Murrell said that the truth about the human person was to be the unifying theme of this conference. Within that context, he asked me to address the question of how the truth of the human person defines the physician’s vocation.

I approach this assignment with a sense of diffidence for several reasons: First, the topic is complex and not easily reduced to the dimensions of a luncheon talk. Second, you have already heard from Fr. Benedict Groeschel and Sister Prudence Allen, who have explored the theological and philosophical reaches of this subject. Finally, the other speakers will have shown how central the idea of personhood is to our understanding of the family, marriage, and child development.

At the risk of repeating what has been said, and with less eloquence, I shall try to connect some selected aspects of the Catholic, Christian notion of person to the vocation and ethics of the physician, to the relationship with patients, and the moral choices physicians are called upon to make in the relationship.

I apologize particularly for the necessarily sketchy and inadequate rendition I shall give of Christian anthropology and personalism, especially its philosophically subtle construal in the work of His Holiness, Pope John Paul II, which I take to be especially significant for my topic.

In these days of high technology, it is ever more difficult to remember that medicine is essentially a relationship of persons. Yet, this is what makes it a moral enterprise. This is why medical ethics is unavoidably grounded in some concept of personhood. Ultimately, both the ethics of the patient-physician relationship and the making of ethical decisions depend on our conception of the human person. Despite this, most of bioethics today avoids or trivializes the question of personhood.

But personhood is a question that cannot be avoided. Implicit in every theory and decision of medical ethics is some notion of what it is to be human, of the purposes, ends, and goods of human existence. In secular bioethics, there is an implicit, yet dominant, concept of personhood. Personhood is defined in terms of freedom, liberty, self-expression, and self-generated or socially constructed norms of good and evil. The question of ultimate ends or purposes to human life is, at best, laid aside as irrelevant or regarded as a morally neutral item of individual preferences. The possibility of an objective moral order, or a source of morality outside humans, individually or collectively, is not part of the discourse. It is relegated to the dustbin of medieval metaphysical eccentricities, too naive for serious consideration in the Post-Modern, Post-Christian world.

Christian anthropology stands in opposition to this dominant view. I would like to examine the ways in which Christian anthropology, as exemplified in the Christian personalism of Pope John Paul II, shapes medical ethics in specific ways.^1,2,3 I will divide my remarks into two parts: In the first, I will review briefly the development of the concept of person in Christian Catholic thought. In the second, I will discuss the way this concept influences the two major divisions of medical ethics: (1) professional ethics, which pertains to the obligations of the Christian physician as a physician, and (2) problem-oriented ethics, which pertain to certain, specific ethical dilemmas involving human life.

I. The Christian Concept of Person

In Greek philosophy, the concept of person can only be drawn inferentially. For example, at one point in The Symposium, Plato refers to that which remains constant in us throughout all the somatic and psychic changes humans experience.⁴ This substratum could be interpreted as the person which perdures throughout an individual’s life’s changes. It would be consistent also with Aristotle’s teaching about the indivisible unity of the body and soul as well as potentiality, actuality, and change. In any case, the idea of person can only be imputed to the philosophies of Aristotle, Plato, and the Stoics. It is not defined precisely in their writings and certainly not in the sense the concept assumed in Christian and Medieval philosophy and theology.

For the Romans, persons were juridical entities, those entitled by law to the privilege of citizenship. This entitlement separated Roman citizens from slaves and foreigners. This Roman concept emphasized the person as the bearer of legal rights in much the same way that modern secular notions of personhood often do. This is an impoverished yet partially true notion of person.

Similarly, in Hebrew scriptures, the idea of person was implicit. Although it is not formally developed, the biblical idea comprised the elements of what in later Christianity would be more explicitly defined as personhood: “You knew me through and through from having watched my bones take shape when I was being formed in secret, knitted together in the limbo of the womb.” (Psalm 139) “Your hands molded and made me.” (Job 10:8-12) “From my mother’s womb you have been my God.” (Psalm 22) “Before you were born I set you apart.” (Jeremiah 1:4-10)

These scriptural texts speak to a relationship of persons. A personal God addresses and is addressed by persons He has created. These are persons God has made, whom He knows, calls, and shapes, and from whom He expects responses. God also holds these persons accountable for the ways in which they respond to His call. They are not just individual instantiations of a species but persons who can know, respond, and interact as persons with God and are accountable to Him.

From the beginning, the Christian Gospels called individual persons to salvation and made individuals accountable and responsible for accepting or rejecting that call. The Jesus of the Gospels appeals as a person to other persons who are free to follow or reject him as a person. Jesus refers to God as the Father, his Father and ours. The parables tell of the good and the bad, the right and the wrong done by persons free to choose, free to act. The choice and the act are expressions of the person who is shaped by his or her choice and action.

A more formal theological and philosophical conception of personhood emerged in the fifth and sixth centuries A.D. in response to the vigorous debates and heresies surrounding the question of the personhood of Christ. Most notably, in 451, the Council of Chalcedon rejected the Monophysite heresy⁵ by asserting Christ to be one person in two natures. In the milieu of these debates, Boethius (475-524), often called the last of the Roman philosophers and the first of the scholastics, defined the person as “an individual substance of a rational nature.”⁶

In this definition, Boethius recognized, as had Aristotle, the essential unity of body and soul in human beings. Man was an individual thing by virtue of that part of him which was derived from matter. He was a person by virtue of that part of him which derived from spirit. If we deprive humans of their personhood, we reduce them to individual matter, to mere single instances of a species, set apart by the uniqueness of their accidental characteristics but lacking the rational nature on which their personhood depends. Yet persons are not disembodied spirits, but spirits in substantial union with bodies.

Boethius’ definition was the dominant conception of person for a very long time. Despite the intervening centuries, as a philososphical definition, it has not been improved upon. It captures the essential ontological nature of personhood, although its content has been more fully fleshed out in recent Christian theology, as we shall see shortly. Boethius’ definition was the major influence on the Christian medieval philosophers like Aquinas and Bonaventure who applied it to the personhood of God.⁷ They fused the earlier theological and philosophical construals of personhood. This was consistent with the whole enterprise of Christian medieval philosophy which was to bring Greek philosophy and Christian revelation into accord with each other.

Since the middle ages, the Boethian definition of person has been subjected to varying interpretations by successive schools of philosophy. Descartes, Hume, contemporary phenomenologists and existentialists like Heidegger, Sartre, Levinas, Buber, and Scheler, to name just a few, have modified and, at times, enriched the Boethian concept.⁸ It is impossible to detail these transformations here. But one contemporary construal of personhood is most pertinent to the central theme of this conference, and that is the concept of person set forth in the writings of His Holiness John Paul II.

In previous extended work, and more recently in his book, Crossing the Threshold of Hope, the Holy Father outlines a powerful philosophy of Christian personalism.^9,10 His “personalist principle” is his attempt to “…translate the commandment of love into the language of philosophical ethics.”¹¹ In this effort, the Holy Father enriches the rational component of Boethius’ metaphysical definition with insights drawn from contemporary phenomenology.¹² The result is a view of humans as acting persons free to transcend nature and to fulfill themselves by giving of themselves in love.

Indeed, the Holy Father says that the “full truth about man…” is that he “…affirms himself most completely by giving of himself.”¹³ This is the way persons affirm themselves as persons and also fulfill the commandment of love at the same time.¹⁴ This is the central truth of the Christian ethic, the one expressed in one’s relation to family, community, and vocation. In these relationships, man is called to use his freedom to give himself to others. Not to give oneself to others is to end up giving oneself only to oneself and to become selfish. For the selfish person, the good is that which gives him pleasure. This desire for total independence in the moral life creates the “inner division of man.”¹⁵ Such independence is not true freedom since freedom cannot exist apart from truth.¹⁶

John Paul II’s concept of the person clearly is more than the individual atomism of John Locke’s contract theory. Nor can it ever be simply the genetically or environmentally determined “individual” of sociobiology or the politically determined individual of liberal democracy. Although it may draw upon them for certain insights, the concept of person cannot be reduced to anthropology, psychology, or phenomenology. The Christian view of personhood goes beyond the Kantian imperative not to use others merely as means. Rather, the person is to be affirmed as a person, possessing dignity simply because he or she is a person. Man is a personal being, created and loved by a personal God and destined to be united face-to-face with the Creator.

This conception of personhood has clear implications for the nature of the physician’s vocation and for the way one pursues that vocation. Let us turn next to these two aspects of the person’s acting as physician in relation to patients and in relation to ethical choices.

II. Christian Personalism and the Christian Physician

The Christian physician as a human person has the same vocation as all Christian persons: to fulfill oneself in giving oneself to others — to family, friends, neighbors, strangers. In addition, as a physician, the Christian person is called to a special way of love, of giving oneself in one’s daily works of healing, helping, curing, and caring. Physicians and patients are persons interacting in a specific existential situation in which one is vulnerable and suffering and seeks healing from another who offers to help and heal. By its nature, the healing relationship is unequal. The patient’s personhood is exposed to, and by, the physician — bodily, spiritually, and emotionally. The patient’s need for affirmation as a person in the face of this exposure is intense and a source of moral obligation for the physician.

Of course, this is true of the relationship between patients and non-Christian physicians as well. What is different for the Christian physician is that healing is more than an occupation or a career, Healing is a vocation, a call from a personal God to a specific way of giving of oneself to other persons, a specific way of loving, of fulfilling oneself as a person and working toward one’s own salvation. This is very different from a “career” which is an end in itself, in which medicine is cultivated for personal ends and purposes. Every true profession entails some degree of suppression of self-interest.¹⁷ But a vocation is a call by God to transmute a profession into the domain of grace and charity.

What does this mean in everyday practice? It means taking as obligations what others would regard as supererogatory or even heroic. It means a preferential option for care of the poor, the sick, and the rejected. It calls the physician to recognize the dignity of the person in the drug addict, the sociopath, the alcoholic, and the criminal, as well as in the respected members of the community. The hard message of unselfish sacrifice, like the message of the Gospel story of the Good Samaritan, becomes the physician’s model of healing. The Christian physician, for example, cannot protest that treating AIDS was “not in his contract” when he entered medical school.

For Christians, medicine cannot become a commercial enterprise; the physician, an entrepreneur; or the hospital, a profit-making venture. We cannot ask whether the non-compliant or the self-abusing patient “deserve¹¹” medical care. Our model is Christ in the first chapter of Mark, healing all who came to him at the end of the day, never asking supplicants who or what they were. Christian physicians must be advocates for the sick whenever the interests of the sick person are subverted to economic or political exigency. If managed care calls us to be indifferent to the needs of patients or makes us instruments of economics or profit, we must resist. If managed competition turns us into fundholders, case managers, and clinical economists, we must refuse. Sick persons are not consumers of our product, or clients; they are patients — persons suffering, bearing an illness, in need of relief which we are called to provide as best we can.

Fidelity to a Christian personalist anthropology transforms the principles of medical ethics which currently dominate secular medical ethics. It shapes them by the ordering principle of charity. Beneficence becomes more than avoiding harm or preventing evil. It comes to mean doing good for others and for patients even when it means sacrifice of some degree of legitimate self-interest. As Luke (6:36) says, “we must be compassionate as our Father is compassionate.” We must feel the personal predicament of illness as it confronts this particular person in all his individuality and personhood. Beneficence becomes charitable beneficence, effacement of self-interest for the good of the patient.

For those who fear that suppression of self-interest is unrealistic and ignores legitimate self-interest, we need to remember Aquinas’ interpretation of the commandment of love. That command was not to love the other as much as we love ourselves, but in the same way as we love ourselves — i.e., by loving her for God’s sake, for her intrinsic value, and by meeting her legitimate, not her illegitimate desires. Effacement of self-interest within these limits is essential to a Christian vocation to medicine.^18,19

Autonomy becomes more than the Lockean negative right to noninterference. It becomes respect for the inherent dignity of each person as a person, that which is “most perfect in nature” as St. Thomas put it. In secular use, autonomy has come to mean not only the right to govern one’s own life, but to determine what is the right life. Not what I ought to do, but what I determine ought to be done. Autonomy must be restored to its original meaning of having to take responsibility for one’s choice, not making one’s choice the standard of right and wrong. We respect autonomy because it is the freedom to do the good and to give oneself, not the freedom to determine what is right or wrong.

Justice, too, is transformed from a strict, judicial rendering of what is merited or owed, to charitable justice. This is justice tempered by mercy. Charitable justice may require giving more than is owed. It measures what is owed in different terms — in terms of love, compassion, and mercy. Charitable justice is not the blind justice of popular iconography. It is justice without the blindfolds, sensitive to those nuances of each person’s unique predicament of illness. Charitable justice measures what each person needs by adding that aliquot of mercy that balances the scales in a way demanded by the commandment of love.

When the Christian concept of person underlies the physician-patient relationship, that relationship becomes a relationship of love not in a sentimental or physical sense, but in the sense of giving of oneself and one’s knowledge for the benefit of others, as Christ would have done. Even practices not positively unethical then become unacceptable — unrelenting pursuit of legitimate fees, impatience, insensitivity, unavailability, inaccessibility, or rudeness even to difficult patients. In a Christian ethics of vocation to medicine, charity is, of necessity, the ordering and the distinguishing ethical principle and virtue.

The Christian idea of person thus imposes extraordinary responsibility on physicians and institutions that profess to be Christian. Much of what is required is alien to the bureaucratized, industrialized, and depersonalized labyrinth health care has become. The marketplace, the bottom-line, and the corporation know nothing of the commandment of love which John Paul II puts at the center of his personalist ethics. It is the specific vocation of all Christian physicians and institutions to restore this truth about the person to the center of health care today.

If Christian personalism shapes the ethic of the physician-patient relationship in ways antithetical to contemporary trends, so too does it shape the moral choices physicians and society must make in the use of contemporary biotechnology. I will turn now to the second of the two ways in which Christian personalism alters medical ethics.

B. Personalism and Human Life Issues

In addition to shaping the physician-patient relationship, a Christian anthropology shapes the way clinical decisions are made and clinical dilemmas resolved. This is especially so in the key human life issues — e.g., abortion, embryo and fetal tissue research, treatment of the mentally incompetent, withholding and withdrawing life support, and euthanasia. Indeed, the truth about the human person is the only safeguard against a technological imperative which knows no bounds as long as utility to be gained or costs to be saved are the ordering principles. A secular bioethics is impotent to prevent the harm to the most vulnerable members of our species inherent, for example, in the misuse of modern reproductive technology or in embryo research or the involuntary, non-voluntary euthanasia of the handicapped or intellectually retarded.

Abortion is an abomination because it destroys a creature created and “molded” in the womb (Psalm 139) by a personal God to be loved by God. This created being is worthy of respect because it is a person on the way to full actualization. Abortion deprives that person of its destiny to be loved and to love. No arbitrary biological marker or time interval can change the fact that the fertilized egg is an individual substance belonging to a species of beings with a rational nature created by a personal God.

This is also the case with embryo and pre-embryo research. The NIH Advisory Panel on Human Embryo Research notwithstanding, embryos must not be created for the purposes of research and then discarded.^20,21 Nor can the blastomere be used to diagnose genetic defects and destroyed if they are present. Nor can fetal tissues taken from electively aborted fetuses be used for experimentation or transplantation.^22,23 A Christian personalist anthropology places clear ethical limits on the use of technology no matter how useful, important, or profitable it may be.

It is impossible here to provide a critique of the many recommendations of the NIH Panel on Human Embryo Research. But even a cursory review of the list reveals a total indifference to anything approaching the Catholic Christian concept of personhood. This applies to all three of the Panel’s categories — “acceptable”, “unacceptable”, and “research that warrants further review”.²⁴ Given the utilitarian reasoning of the Panel members, it is doubtful whether any manipulations of embryos will remain “unacceptable” for long. As long as the “benefits” of the research are the deciding factor, the embryo is at risk from almost every kind of manipulation. We must hope that believers and non-believers alike will refuse to permit any form of research with human embryos which is not intended for the direct benfit of the particular embryo that is the subject of that research.

The same ethical constraints must be placed on the manifold possibilities of the Human Genome Project.²⁵ Gene manipulation for therapeutic purposes that benefit the person who is subject to research would be licit. Manipulations aimed at “enhancement” of certain characteristics like height, intelligence, or memory are morally bankrupt. Manipulations to re-make the human race in accord with some utopian, biologically conceived image of the ideal human person would be totally reprehensible and an affront to God’s continuing creative presence in the world.

Increasingly distorted notions of the human person are used to justify proposals that, even a short time ago, would have been thought abominable. For example, one ethicist has suggested that persons in a permanent vegetative state should be used for experimental purposes rather than animals of other species because these animals lead less full lives than healthy animals.²⁶ Others suggest that the retarded and the brain-damaged are mere biological remnants, too costly to sustain in life because they are non-persons.²⁷ Active euthanasia and assisted suicide also arise from a contortion of the notion of autonomy such that the person becomes not the creature but the creator of his life. At the time of this writing, the State of Oregon has just given legal sanction to assisted suicide by permitting physicians to write, and pharmacists to fill, prescriptions for lethal doses of medication.²⁸

These bizarre trends arise from the failure of secular ethics to confront the question of personhood and its implications but even more strongly from a grossly disordered notion of personhood as identified only with self-awareness, consciousness, ability to establish meaningful social relationships, or leading a “quality life” as measured by some standard of idyllic bliss free of all suffering. On the secular view, we lose our dignity if we are sick, in pain, suffering, disfigured, or unable to handle our secretions and excretions without assistance.

None of this can be countered without a true notion of what it is to be a human person, wherein the source of dignity resides. That notion can never be true unless it calls upon the grounding of personhood in God’s love for us, His gift of freedom that permits us to give of ourselves to fulfill ourselves. This is the only way pain, suffering, and death can aquire meaning. It is the only genuine source of human dignity, which cannot be “lost.”

The Catholic and Christian physician today has a mission of the utmost importance to the whole of society. He or she must, of course, be a competent, caring, and compassionate physician. But he or she must also know the true ends and purposes of human life, know the truth about the human person for whom we care, and that truth must inform our practice — as physicians — and how we approach health care and the manipulation of human life.

Turned loose from its moorings in Christian anthropology, ethics can eradicate our very existence as human persons. In times past, only despots perpetrated such tragedies. Today, with the erosion and deconstruction of the idea of person, we seem on the verge of legitimating depersonalization, not as an act of despotism, but by the sanction of a secularist conception of what it is to be a human person. In this, the Catholic Physicians Guild, and its members, is under special obligation: first, to give collective and personal witness to the difference it makes to adhere to the truth about the human person; then, to reach out to, and gain the support of, physicians of other faiths to resist the corrosion of the notion of the person that pervades secular bioethics; and, finally, to inform public opinion lest all of humanity be diminished in the name of a false humanism which denies its own roots in the true conception of what it is to be a human person.