Humanae Vitae

Letter published in the Catholic Herald, Julty 25th 2008.

Sir,

I enjoyed Quentin de la Bedoyere’s interview with Professor John Marshall (Features, 18th July), a member of the commission which vainly recommended to Pope Paul VI that he change the Church’s teaching on contraception. Particularly amusing was the suggestion that the faithful have not ‘received’ this teaching, as if Christ should, when faced by a rejection of his teaching by many of his followers (John 6.66), have reconsidered it, or as if St Paul, anticipating an audience who ‘would not endure sound doctrine’ (2 Timothy 4.3), would recommend giving them unsound doctrine instead. It is one of the most remarkable works of providence in modern times that Paul VI was able to overcome the pressure from this commission, and other sources, to exercise faithfully his role, which was that of a teacher, not a weathervane.

Two well-known and closely related arguments are relevant here. First, the unitive value of the sexual act in marriage is dependent upon its procreative potential, since it is in becoming, or being open to becoming, a single procreative principle, that the couple is drawn together. Second, sexual self-giving in marriage is incomplete when procreation is artificially excluded, since in that case one or both the partners is holding something fundamental back: he or she is not giving him or herself wholly, but excluding his or her fertility.

These arguments, which are at least implicit in Humanae Vitae sections 8 and 9, have been set out with great clarity since then, notably in the work of Karol Wojtyla, both before and after his election as Pope John-Paul II. Far from it being the case, as Professor Marshall affects to think, that there are no Natural Law arguments for the Humanae Vitae position, I am not aware of any other arguments, compatible with artificial contraception, which explain the unitive role of the marital act.

Yours,

Joseph Shaw

CFFC attack on conscientious objection

Catholic For a Free Choice campaigns for abortion; it has been condemned by the US Catholic Bishops' Conference; see the information here. It is currently seeking to undermine the role of 'conscience clauses', clauses in laws or contracts of employment which allow anyone with an objection to abortion to refrain from cooperating in it. They make an extended argument in their pamphlet 'In Good Conscience: Respecting the Beliefs of Health-Care Providers and the Needs of Patients', available here.

The argument can be summarised as follows:

1. Conscience is sacred.
2. When a doctor/nurse/pharmacist declines to hand over pills/perform an operation which a patient desires (presumably in good conscience), the patient's conscience is 'negated' (p12). There ought to be 'deference to the conscience of others' (p9).
3. Doubt is cast on the possibility that the medical employee is himself acting in good conscience, by suggesting that in refusing to hand over abortifacients or perform abortions they are merely following the orders of their Catholic hospital or of the Catholic hierarchy (p.10).
4. Even if the conflict between the patient and the medic can be seen as a conflict between two consciences, the way to resolve the matter is for a Catholic (or any other) hospital to 'serve as a facilitator of all consciences': i.e. to let the conscience-afflicted medic to step aside from the case and replace him with a more flexible colleague. Presumably the original medic's cooperation here will be required (p.13).

From a Catholic point of view (the document is at pains to present itself as based on Catholic principles), this argument is bizarre.

On (2): conscience relates to the agent's actions, or to what they ask or agree to have done to them. If a woman (sincerely, conscientiously) wanting an abortion is refused one by a Catholic doctor, this is not parallel to the situation of a (sincere, conscientious) doctor whose employer seeks to overcome his reluctance to perform abortions by threats. In the latter case, an attempt is being made to get a person to act against his conscience; in the former case, one free agent is declining to cooperate in the proposed action of another free agent.

CFFC's refusal to see the doctor as a free agent in this situation is puzzling. The suggestion seems to be that since the doctor has the knowledge and the equipment necessary for an abortion, he is under an obligation to perform one to anyone who asks. But no doctor is under an obligation to give patients the treatment they ask for: it is the doctor's role to determine what treatment is appropriate; the role of the patient's conscience is to refuse to submit to treatments the patient thinks are wrong. The patient may be deluded or obsessive about his medical interests; in the case of abortion, the conscientious Catholic doctor will not conclude that abortion is in the interests of either the mother or her unborn baby.

On the one hand CFFC wants to say that abortion is simply part of normal medical treatment; but on the other hand, they are claiming that it has a special status in which the patient, uniquely, takes the initiative and the doctor is a mere technician who must obey or risk violating a right. But the mere fact that abortion is legal under certain circumstances does not mean that anyone has a 'right' to it.

On 3. There is no reason to suppose that Catholic medics who pay attention to the Church's teaching are not thinking for themselves. In a society where abortion is commonplace and socially acceptable, anyone who is reflective enough to accept the Church's arguments, based on Natural Law, against abortion is taking a courageous stand against the current. The role of Church teaching in clarifying our thinking on moral matters is part of the development of the 'formed conscience', a phrase absent from CFFC's discussion. This is obviously what Church teaching is for: what else is it for? On the other hand, the conscience of women who ask for abortions may well be distorted by the refusal of secular society to think the issue through, and above all by pressure from family and friends. This is not a good example of a conscientious decision.

On 4. First, a medic who, faced with a request for abortion, calls in a colleague to carry it out, is cooperating with abortion. If abortion is wrong, then this is wrong. If a hospital asks him to do this, it is asking him to act against his conscience.
Second, hospitals exist to further the health of their patients. If a hospital chooses to reject that role, and become places where women can dispose of unwanted members of their families, they are not being 'neutral' about anything, but evil. Such a hospital clearly could not call itself 'Catholic'.

In summary: it is never right for any doctor to give any patient treatment which the doctor thinks will harm the patient (unless a medical intervention is necessary to help for example an unborn baby), however sincere the patient might be in asking for it. It is also wrong for any doctor to arrange for such treatment to be given to the patient by another doctor. Equally, it would be wrong for any doctor to give a patient treatment which the patient refuses to consent to. To override the doctor's judgment or the patient's consent by coercing them to act or be treated against their wishes is to violate their autonomy and freedom of conscience. This has got nothing to do with religious belief; these are principles of Natural Law which protect the consciences of everyone.

Catholicism and Acupuncture

Fr Timothy Finnigan, Parish Priest of Blackfen and blogger, wrote on acupuncture and Catholicism in his regular column in the Catholic Herald, 16/11/07, concluding:

A Catholic ought to be sure that their therapist is not committed, in their therapy and advice, to promoting a world view that is incompatible with Christianity. If there is any doubt about this at all, it would be better to steer clear of acupuncture.

I wrote a reply which was published in full in the 23/11/07 edition, as follows:

Sir,

Fr Finigan is quite correct to point out that acupuncture is based on a medical 'model' related to Taoism, a philosophy incompatible with Catholic teaching. It should also be remembered that conventional Western medicine is based on a medical model which takes the philosophy of materialism for granted. This philosophical outlook is held by the great majority of researchers and practitioners, and has many implications for medical practice. Like Taoism, it is incompatible with Catholic teaching.

As well as being impractical, it would seem unnecessary for ordinary Catholic patients to worry about the metaphysical commitments of their doctors. All medical models are imperfect; treatments based on imperfect models can still have good results; prudence directs us to the doctors best at curing disease, not the ones best at philosophy or theology. The focus of moral attention, on the other hand, should be on whether a doctor is giving concrete advice lacking in the moral dimension, as when materialist doctors propose to treat the unborn or the dying without the respect due to human persons. It is far from clear that medical traditions based on Eastern philosophies such as Taoism are worse off, in this respect, than traditions based on home-grown absurdities such as materialism.

Indeed, not even a medical tradition rooted in Catholicism, such as the 'humours' theory used in Medieval and Early Modern Europe, is immune to manipulation by immoral doctors. Ben Johnson and Nicolo Macchiavelli both wrote plays lampooning doctors who recommended sex (if necessary, outside marriage) as an aid to health. The compatibility of the medical model with Church teaching at a metaphysical level does not guarantee the compatibility of a practioner's advice with the Church's teaching on a practical, moral, level.

Yours,

Joseph Shaw

Genetic Enhancements: reply to Savalescu

My talk at the inaugaral meeting of the Wolfson Applied Philosophy Society, chaired by Dr Francine Baker. My paper responds in general terms to an article by Professor Julian Savalescu of the Oxford Uehiro Centre for Practical Ethics which can be read here (pdf).

Gene Therapy and Genetic Enhancement

Part I

I am not a specialist in medical ethics, and I can only hope that I will bring some freshness to a specialist debate, and give the specialists present today something to talk about. I am a specialist in theoretical, normative, ethics, and I approach this question with an eye to seeing what general principles of theoretical ethics might be applicable.

Professor Savalescu, of course, does this in his paper, saying that gene therapy is no different from ordinary medical treatment, and is therefore morally unproblematic. I shall adopt the same starting point. If we ask what moral principles govern medical treatment, we find most famously the principle that medical treatment is for the restoration of health, and perhaps also for the prevention of disease. When this definition is violated, treatment becomes morally problematic.

For example, it is morally problematic when governments propose to sterilise or castrate or lobotomise mentally retarded or mentally ill or simply morally bad persons for social reasons. It is problematic when governments regard political dissidents as mentally ill, and confine them to insane asylums. It is problematic when a person suffering from ‘Body Integrity Disorder’ asks a surgeon to amputate his healthy limb. It is problematic in all these cases because medical treatment is being given to people other than with a view to their restoration to health, or to the prevention of disease.

To take the first of these examples, when governments sterilise the mentally disabled, this is usually condemned for two reasons. First, the patient is not in a position to consent. Second, the procedure is not in the medical interests of the patient—it is not aiming at their restoration to health. On the contrary, an aspect of the patient which is functioning normally, healthily, is subjected to a procedure designed to prevent it functioning healthily. Even if consent could make this kind of thing permissible, in this case consent is lacking.

It should be noted that the fact that patient is not in a position to consent makes it all the more important to make sure medical treatment is medically required. This principle is clearly going to be applicable to embryos and young children subjected to genetic enhancement.

In certain cases consent can make a non-therapeutic procure permissible. Giving blood would be an example. But where a serious and permanent harm is done to the health of a patient, other than to restore the patient to health (as when a gangrenous limb is amputated), consent does not seem to be sufficient to make it permissible. This is the case with Body Integrity Disorder. Those who want limbs amputated just because they suffer from an unfortunate desire, are refused treatment by conscientious doctors, because the treatment would do nothing to restore them to health.

The patient believes that the treatment would make him happier. The medical establishment replies that this belief is itself part of a mental illness. The patient may insist that he is mentally fine, and the doctor should get on with it. We have a disagreement here, and it is important to note that both sides are obliged to appeal, not simply to the importance of satisfying preferences, but to an objective notion of health. Such disputes have raged about homosexuality: is it a medical condition, or, as the jargon has it, a way of being normal? A view has to be taken if we are to decide what treatment is appropriate or permissible.

What was wrong about the Soviet practice of confining dissidents to looney bins is that the dissidents were not truly mentally ill. The claim that they were, according to some strange Marxist-Leninist psychological theory, was simply implausible. Such claims have to be examined and debated, if they are to be used to justify medical treatment. Professor Savalescu apparently believes that we can talk about medical practice without talking about the concept of health, but he is wrong.

Savalescu draws on a series of examples which appear to make unclear the point I have tried to make clear. Food supplements to improve mental abilities, for example, and plastic surgery, do not seem to be attempts to restore health, but surely, he seems to be saying, they are not impermissible. In response, one may ask whether food supplements fall under the concept of medical treatment at all; there may be borderline cases here, of course. But insofar as we regard them as medical treatment, we can regard their function as properly medical, that is, as giving the patient a better state of health, of healthy functioning. There is no question at all, in such cases, of impairing function, of mutilation, which is the opposite of restoring health.

In the case of plastic surgery, what we have is a medical intervention which frequently does not seem to have the normal justification, of restoring health, unless having a large nose, or small breasts, is regarded as a disability, and not just a way of being normal. It may be that this is indeed how it is regarded by the patients, at least in conjunction with their own attitudes to their bodies. They may be wrong; they may be suffering from something parallel to Body Integrity Disorder. It may be better for the medical profession to offer counselling, rather than surgery, to perfectly healthy people seeking plastic surgery, as opposed to car crash or burns victims. On the other hand, it is clearly not such a serious matter as the examples I gave earlier, since there is normally no loss of function where plastic surgery is concerned. My aim here is not to settle the matter, but to point out that argument here is possible.

So, let us apply the principles I have been developing to the case of gene therapy. Gene therapy is a medical intervention; since it has permanent effects, which may be irreversible, it is a serious matter and demands serious justification. The justification it needs, like all medical intervention, is a medical justification, which is to say that it restores or preserves health. Thus, if a person had a genetic disorder which impaired life expectancy or function, and if this could be cured by gene therapy, whether this involved addition or subtraction or modification of genes, then it would seem, in principle, the therapy is justified. If a person had a gene for homosexuality—to use one of Savalescu’s examples—then intervention to remove that gene would be justified if, and only if, homosexuality is regarded as a disability, and not as a way of being normal. And so on with the other cases.

So it seems that gene therapy would not be justified in order to enhance intelligence or vital statistics, unless one were able to argue, and argue successfully, that without the therapy the person would be suffering from poor health, limited functioning, disability. Evidently such arguments would be successful in certain cases. Equally evidently, the demand for medical justification would prevent the kind of genetically enhanced utopia Savalescu seems to have in mind.

Part II

Let me now present in a different way the argument I have set out. It would be possible to imagine a medical profession that saw itself in an entirely technical light. Doctors would exist solely to do what patients asked them to do. They know how to bring about various effects on the human body, for good or ill, and they would do those things on request. Sometimes this would involve restoring health, and sometimes destroying it. Sometimes saving a diseased limb, sometimes cutting off a healthy one. This kind of medical profession would be the one ready to do Savalescu’s bidding. Perhaps the practice of plastic surgery has been leading the medical profession in this direction, but cases like Body Integrity Disorder show that we are not there yet.

What cases like Body Integrity Disorder show is that medicine is not merely a body of technical knowledge, like plumbing, but a value-laden enterprise. It is necessarily connected with the concept of health, which is a normative concept. Part of the understanding which doctors have to acquire is an understanding of what health is, which is part of an understanding of what is good for people, what is in their interests. Patients certainly have autonomy, notably the right to refuse treatment, but they rely on doctors not only for technical information, but for an evaluation of their options. If the medical profession became a purely technical matter, doctors would become mere technicians. That is not our image of doctors, nor theirs of themselves. It would be a degrading change. As things stand, doctors are answerable to their own professional evaluations; this means they must have the right to refuse to carry out inappropriate treatment.

Here’s a parallel we in this room should understand. People engaged in academic study are not merely gaining a body of useful technical knowledge; that would not be academic study. We are engaged in an essentially value-laden enterprise, connected with truth and professional judgement. Academic conclusions should have academic justification, which is to say justification in terms of reasoned argument; they cannot be justified by their convenience or money-value. There is something appalling about the idea of an academic who deliberately falsifies his own conclusions, regardless of the reason. Normally we can rely on academics’ sense of their own dignity to prevent this. Academia would be pointless if we did all our studies but didn’t undertake a proper evaluation of the results. We are answerable to our own professional evaluation of the material we are working with. For a serious academic to argue for whatever conclusions those paying him preferred would be a kind of prostitution, and he would immediately cease to be viewed by others as a serious academic. For the whole of academia to go down that road would be the complete degradation of the profession. This is not a Utilitarian argument, but it is nevertheless a consideration Professor Savalescu, as an academic, would ignore at his peril.

Just as the work of academics is essentially value-laden, the central value being truth, or, if you prefer, the exercise of academic judgement, so the work of doctors is essentially value-laden, where the central value is health, or the medical good of the patient. The idea that this might be reducible to the patient’s own preferences would be news to the whole branch of medicine, psychology, whose stock in trade is the changing of patients’ preferences. I have not articulated what the concept of health amounts to; it is enough to point out that there is such a concept, and that it has this role.

Given that there is such a concept, and that doctors make use of it in their evaluations of what treatment is appropriate, it should be clear that it will never be permissible to make serious medical interventions to healthy people. It may be possible to make the strong stronger or the clever cleverer, but that is not what medicine is for. The fact that this would satisfy the preferences, or assumed preferences, of the patient is an insufficient justification; that does nothing to provide the medical justification which is needed for a medical intervention.

Part III

This conclusion may seem mysterious. Medicine is governed by certain values internal to itself which prevents it from being as useful to others as it might be. The same is true of academia: academics worthy of the name do not manipulate their conclusions to further even worthy goals of social policy. But this seems less mysterious. For an academic who honestly thought one thing, and said another in public, would be lying, and it is a familiar enough idea that there is a moral constraint against lying. What is the moral constraint at the basis of a doctor’s refusal to make medical interventions other than with a view to restoring health?

I would propose that the answer is that there is a moral constraint here, most familiarly known as a constraint against mutilation. I put it in this cautious way because the cases we have may not look at first glance like cases of mutilation; what I am suggesting is that, properly understood, the constraint behind the limits of medical practice, which is very clear in classic cases of mutilation, is sufficiently broad to cover the cases we are focusing on here. Accordingly I propose to use the word ‘mutiliation’ in a broad sense.

One easy way to express what is wrong with sterilising the mentally disabled is that it is a case of mutilation. The way I have been expressing it is that the medical intervention has no medical justification, which would be justification in terms of restoring the patient to health. My suggestion is that the two ways of putting it are equivalent; they are interdefinable. Medical interventions without medical justifications are mutilations. We may raise the scalpel against, or give potions and drugs to, our fellow human beings only with a view to the cure or prevention of disease of the patient. To do so otherwise is wrong; it is akin to assault, battery, and mutilation. I think the moral intuition here is clear enough; stipulatively, for convenience, I will call the forbidden action mutilation. So the next question will be: is it plausible to characterise genetic enhancement, when lacking a medical justification, as mutilation in my broad sense?

First of all, let me clarify the meaning of mutilation. Normally, mutilation leaves the victim worse off, but this need not be so. Cutting off a healthy limb for no good reason is obviously mutilation. Would it cease to be mutilation if victim was fulfilling the condition necessary to gain a vast sum of money, leaving him overall better off? Of course it would; we would then ask whether the mutilation was worth it, or was morally justified by it. Like the ugly sisters in the un-Disnified version of the Cinderalla story, who cut of parts of their feet in order to get them into the magic slipper, we can see that there is a moral problem with this. This is not the way we should treat our bodies.

Now consider prosthetic limbs. These have been getting better and better. It will not be long before a prosthetic leg will actually be better than the usual healthy natural leg; perhaps this is so already. Let us suppose it is indeed so. Would it be right for a person to allow either or both of his healthy natural legs to be removed, in order to be fitted with souped up prosthetic legs, as we might say, bionic legs? Again, our moral intuitions are against this. By all means, let the unfortunate souls who lose their legs on land mines or in any other way get the best prosthetic limbs money can buy; but it would not be right to cut off a healthy limb to enjoy the benefits of an artificial one.

Our genes are part of our bodies. This is perhaps something we have to learn; it is not obvious, just by looking at us, but it must be so. Given the moral constraint on mutilation, it follows that it would be wrong to remove parts of our DNA to replace them with others, artificial or borrowed, supposed to be preferable, without medical justification. The moral constraint against mutilation is the protection morality gives to our physical integrity; it is the moral implication of the value, the moral importance, of the human body. Too often ethics limits itself to the moral implications of the value of life, or pleasure, but few if any philosophers defend the view that these are the only things of moral importance. So just as the value of life has the implication that we may not kill, without certain limited kinds of justification, so the value of the body has the implication that we cannot invade or disarrange it, without certain limited kinds of justification. The violation of the constraints protecting life is murder; the violation of the constraints protecting the body is mutilation.

'Personal Beliefs and Medical Practice'

The consultation is about a draft ‘guidance’ document, ‘Personal Beliefs and Medical Practice’ (‘PBMP’), from the General Medical Council. Using examples, the Guidelines aim to set out principles which should govern cases where patients ask for a type of treatment a doctor does not wish to give.

PBMP is, unfortunately, seriously confused. The first problem is its reference to two red herrings: first, the principle that doctors should not ‘discriminate’ on the basis of their own or their patients beliefs (or lifestyle, race, etc.), and second, the distinction between ‘personal beliefs’ and ‘clinical knowledge and judgment’.

On the first, although discrimination is not defined in the document, it would be reasonable to understand it, in the medical context, as treating different patients differently on the basis of non-relevant criteria. Thus, a racist doctor who consistently gave cheaper and less effective medicine to patients who were members of a particular racial group, would clearly be guilty of (wrongful) discrimination.

PBMP’s three examples are the circumcision of boys for religious reasons; abortion; and the refusal of Jehovah’s witnesses to use blood products. In each case, what the patient (or the patient’s parents) is asking for may not be what the doctor thinks is right. However, in none of these cases is discrimination an issue. A doctor who refuses to go along with the patient’s wishes would be applying to the patient in front of him the same judgements he would apply to everyone. The way the PBMP keeps returning to the principle of non-discrimination suggests that such a doctor might be guilty of discrimination, but this claim is never explained or justified.

The second red herring is the distinction between a doctor’s ‘personal beliefs’ and ‘clinical knowledge and judgment’ (para 16). Taking each side of the alleged distinction separately, PBMP acknowledges that doctors must be free to exercise their judgment as to what is clinically, medically, appropriate to a patient. On the other hand, by contrasting this with something ‘personal’, it suggests that clinical judgment is somehow ‘public’, or common to the profession. This is a mere slight of hand: clinical judgement is personal, and good doctors sometimes disagree. It would be better to talk about a doctor’s ‘personal, clinical judgement’. Again, the term ‘knowledge’ is misleading, as contrasted with ‘belief’, since the bases of clinical judgements will include opinions which couldn’t count as ‘knowledge’, including the doctor’s personal medical experience. So along with ‘personal, clinical judgement’ we must talk of the doctor’s ‘clinical views’, not limited to ‘knowledge’.

When we contrast a doctor’s ‘clinical views and personal, clinical judgement’ with his ‘personal beliefs’, there does not appear to be any contrast at all. However, what PBMP clearly intends to include under ‘personal beliefs’ are moral beliefs and values. It is mere rhetoric to assume these must be beliefs rather than knowledge (don’t we all know that paradigmatic cases of murder are wrong?). So the contrast PBMP is trying to make would turn out to be that between the doctor’s medical views, and his moral views.

There is, unfortunately, a serious problem with this distinction, arising from the fact that medical views and judgements are necessarily value-laden. Medicine is about giving appropriate treatment to patients, and thus depends on the concepts of health, well-being, and benefit, and their contraries. These are all clearly evaluative terms. When a doctor says that a certain treatment will return a patient to good health, or that the benefits of a certain operation will not outweigh the pain and inconvenience, he is making a value judgement.

If the GMC wishes to avoid this, they might insist that clinical judgments are purely instrumental: they are simply about how to get a patient from one physical (or mental) state to another. If a patient wishes to get rid of a back pain, or to walk without a limp, the doctor will advise on the best ways of doing this. If a patient wants to end up in what a doctor might, as the maker of value-judgments, regard as a worse state, the doctor will nevertheless, as a clinical technician, advise the patient how to achieve that. But the GMC cannot take this view, because it is committed, as the NHS and whole medical establishment is committed, to resisting the pointless demands of obsessive or deluded patients.

One example of such demands is that of a person suffering from a mental affliction known as ‘body integrity disorder’. Sufferers want healthy limbs amputated. It would be natural to say: such an amputation would not be medically or clinically justified. That claim, of course, makes use of the fact that medical/clinical judgements include judgements of value: the amputation won’t make the patient better off. However it is expressed, it is the doctor’s grasp of values, the value of health, and the purpose of medicine to advance human well-being, which enables him to resist requests to amputate healthy limbs.

The clinical/moral distinction, accordingly, collapses. PBMP tries to buttress the distinction by reinforcing it with a distinction between what is non-personal, and what is personal, and again between knowledge and mere belief. But none of these distinctions works in the way PBMP needs it to work.

However the distinction is understood it turns out to be irrelevant to the GMC's argument, as will emerge below.

The crucial part of the guidelines is paras 18-21, which tell doctors what they must do if a patient asks for a treatment the doctor does not judge appropriate (based on the doctor’s ‘personal beliefs’).

Para 19 tells us that doctors are not required to refer the patient to another doctor. On the other hand, ‘you must ensure’ the patient is capable of seeking another opinion; if the patient is not capable, para 20 tells us that the conscientious doctor must arrange for another doctor to take over the case, ‘without delay’. Finally, para 21 tells us that doctors opposed to certain procedures should inform their employers, so their employers can find a way to make sure the procedures remain available through other doctors.

I have shown that the clinical/moral distinction will not work. Doctors may and indeed must make all-things-considered judgements about what will benefit patients, as a basis for refusing to accede to patient demands, where those demands are misguided. The GMC might retort, all the same, that in such a case a patient has the right to a second opinion, and the doctor has the duty to facilitate the patient in seeking a second opinion. If another doctor may come to a different judgment, so be it.

Thus, if Doctor A regards a possible operation as so risky, and of such limited benefit to the patient, that it would not be right to perform it, and if the patient persuades Doctor B to perform it, then Doctor A can simply wash his hands of the matter. Presumably, Doctor B has made a different assessment of the risks and potential benefits, and thinks the operation justified.

It is this kind of case which PBMP seems to have in mind, to supply the principles to deal with conscientious objections: the principle that the patient’s right to a second opinion is paramount. However, this principle is only operative within a certain range of cases. Doctor A knows he has made a prudential judgment which other doctors whose judgment he respects may agree or disagree with. It is a different matter where a patient has asked for a procedure which is ruled out, not by a prudential judgment, but by a fundamental medical moral principle. If a patient asks for an unnecessary amputation, a doctor who refused might be sufficiently confident in his colleague's judgement that allowing the patient to seek a second opinion would do no harm. If he lacked that confidence, however, taking steps to assist the patient get a second opinion would be wrong, because it would be taking steps to violate the fundamental value of the medical profession, that medicine seeks the patient’s welfare. This patient is mentally ill, and seeking something which, if he recovers mentally, he will bitterly regret, which will cause him pain and loss of function, with no good effects at all, apart from the satisfaction of a disordered desire. This is not something a doctor should be assisting, even by referring the patient to another doctor.

Again, if a patient asks for a supply of psycho-active drugs for recreational use, a doctor who refuses should not refer the patient to another doctor for a second opinion, unless the first doctor had complete confidence in his colleagues’ probity. This would be so even if the law allowed doctors to supply such drugs for such purposes. As things stand, the law recognises that the patient’s good is more important than the patient’s wishes, and forbids doctors to cooperate with the giving of drugs for recreational purposes.

The problem, in the case of abortion, is that the wrongness of abortion, the fact that it is never in the interests of the patient, is no longer recognised by law, or by the medical profession as a whole. The fact remains, however, that from a conscientious doctor’s point of view, it is a case like that of the unnecessary amputation or the recreational drug use, and not like the risky operation. It should be contrary to the evaluative, medical judgment of a doctor to assist in or recommend or in any way to cooperate in an abortion. This problem is in part recognised by the ‘conscience clause’ of the Abortion Act itself, and by PMBP itself, where it wishes to force a conscientious doctor to refer a patient to another doctor only where, in the GMC’s view, this is absolutely necessary.

Clearly, however, PBMP still seeks to force doctors to cooperate with abortion, by assisting patients’ getting a second opinion. As I have argued, this would make sense if the doctors who refused to perform the operation did so from a prudential calculation which another doctor might re-evaluate in good faith. It is wrong to ask a doctor to act against his judgement when this judgement is based on a fundamental principle: that abortion can never be in the interests of a patient, all things considered.

What makes a Catholic institution?

Catholic charities of all kinds are ceasing to be so. In some cases they like to parade their Catholic 'heritage' when asking for Catholic money. It would be useful to have proper criteria for Catholic organisations, which we could use to weed out the fakes.

First: on claims to a Catholic 'ethos' or 'values'.

A charity can obviously claim to have a Catholic 'ethos', or say that it is founded and informed by Catholic values or a Catholic perspective. This will effect who wants to be a donor, a trustee, or a beneficiary. So although one might think that the mere claim to a Catholic ethos or Catholic values is a rather feeble effort for a 'Catholic' institution, actually it is of great significance, because the claim - on websites and so on - itself tends to create such an ethos. And it is amazing how many formerly Catholic charities decline to make such a claim.

Second: on cooperation with evil.

We need to go beyond this, of course, and say what effect Catholic values have on the running of the institution. So it would be reasonable to say, as a result of the ethos and values, there are certain things the charity will not do: obviously formal cooperation in intrinsically evil actions, but also proximate material cooperation in intrinsically evil (or gravely evil) actions. Catholic teaching gives us a list of intrinsically evil actions to use. So a Catholic institution wouldn't employ a person to expedite abortions (formal cooperation) or have a condom machine (proximate material cooperation). It might allow employees to misuse their freedom of speech to speak against the Church or the moral law, since this is a more distant material cooperation, but it would seek to minimise this and counteract the evil effects of it.

Third: on Catholic aims.

The second point is merely negative. So, the next step is to say that a Catholic charity is one which has Catholic aims. These would be of the form: 'To give glory to God by doing X.' X could be anything, but many formerly Catholic institutions would find it deeply embarrassing to put it like that in their self description, and I think that should rule them out. We can take it a step further and say: a Catholic institution is never concerned merely with the bodily or financial welfare of its beneficiaries (or staff), but also with their spiritual welfare. And then we can ask: what do you do to promote this spiritual welfare? The answer should include, I would suggest: by performing our tasks in the spirit of the service of Christ in the persons of our beneficiaries; by prayer in common; by marking the Church's seasons and feasts; by having Mass said in or specifically for the institution at least several times a year.

None of this will get anyone into trouble with the non-discrimination or harassment laws. But it would make for a genuinely Catholic institution.

Referrals and the Sexual-Orientation Regulations

In the recent debate concerning the Sexual-Orientation Regulations and adoption agencies the Roman-Catholic Church asserted that its adoption agencies would have to close if the Regulations were adopted on the grounds that it would be impermissible to place children for adoption with two gay parents even though that is what the Regulations would demand. The curious thing is that agencies such as the Catholic Childrens' Society were already, even though not forced so to do by law, referring gay couples wishing to adopt to other agencies. But if it is wrong to place children for adoption with gay couples surely it is wrong to refer gay couples to agencies that will place children with them?