'Morphine cases'

'Morphine cases' are an established part of the philosophical debate on double effect. It is worth reminding ourselves that medical practice has moved on from the kind of case philosophers have in mind, which in described by the Rev Billings in the radio talk described below. Hat-tip to 'Care not Killing'.

The use of Morphine

"We remain deeply concerned that some media reports are giving the misleading impression that doctors are administering morphine to dying patients in the knowledge that it will kill them.

The latest of these came on Radio Four's 'Thought for Today' on 23 February, when the Rev Dr Alan Billings, Director of the Centre for Ethics and Religion at Lancaster University, addressed the case of Kelly Taylor, a 30 year old woman, who is currently seeking legal permission to be heavily sedated with morphine and then dehydrated until she dies.

In the broadcast, Rev Billings referred to the so-called 'double effect' of high doses of morphine – a misconception that has become pivotal in Kelly's case. He said, 'Every day we allow doctors to end the lives of some people by making a distinction between intention and outcome. A doctor increases the morphine of a terminally ill person in great pain to the point where they die. The morphine kills. That's the outcome, but the doctor is not thought culpable because his intention is the relief of pain, not the death of the patient.'

Rev Billings here was expressing two popular misconceptions about morphine: that it frequently ends the lives of terminally ill people, and that it causes sedation when given in doses necessary to relieve pain. We strongly refute the statement that doctors are ending lives by giving their patients large doses of morphine to control pain.

Morphine, if deliberately given in very high doses to people who are not in pain, does cause respiratory depression and death. It was indeed the drug used by Dr Shipman to kill his victims, and this has undoubtedly heightened public anxiety about its use. However, when correctly used to relieve pain in a patient who is terminally ill, morphine should never cause death. By contrast it usually lengthens life and improves its quality. This is because the therapeutic dose of morphine, which relieves pain, is virtually always well below the toxic dose which ends life and because the relief from pain which it brings removes stress factors in the patient's condition. In addition, toxic doses risk causing increased agitation in some patients- hardly what is intended by those advocating this approach. In modern medicine, and especially in palliative medicine, doctors can kill the pain without killing the patient.

So-called 'terminal sedation' is very rarely necessary; and when it is, it is used to control severe agitation, rather than physical pain, in patients whose conscious level is diminished by their illness. Even when used for the management of agitation, it is very seldom necessary to sedate any patient continuously until they die, but usually only for periods of 12 or 24 hours at a time. Whatever the circumstances, morphine is not the drug of choice used for this sedation since sedation wears off rapidly, which is good for patients taking it for pain relief, but it makes it a poor sedative."

The same mismatch between philosophical examples and medical practice applies to the 'craniotomy case': the procedure at issue (crushing the head of a baby during childbirth in order to remove it quickly from the birth canal) is simply no longer used. The really 'hard' cases often turn out to extremely rare. It is unclear, for example, whether a 'therapeutic' abortion would ever be needed to save the life of a mother.

Philosophers usually aren't medically qualified, and for us an imaginary situation is as good as a real one, for the purposes of testing intuitions and proposed policies. But perhaps we should be more careful about allowing pro-abortion medical myths publicity.

Marriage, anulments and liturgy

(The following has been published by CFNews, here. For a report on the Pope's speech, see here.)

This week's Catholic Herald carries a front-page story on a recent speech by the Pope condemning over-easy annulments. In part:

In a speech to the Roman Rota, the Church’s highest court of appeal for annulments, the Pontiff pointed to a “crisis” in the way marriage was understood.
He said that Catholics and even tribunal judges were affected by the secular idea of marriage as merely the “formalisation of emotional bonds”.
In “some ecclesiastical realms” this idea has caused annulments to be granted for the sake of the couple’s well-being rather than because the marriage was invalid.
“The crisis over the meaning of marriage has affected the way many faithful think,” the Pope told judges and officials of the Roman Rota last Saturday. “The indissoluble conjugal bond is denied because it’s treated as an ideal that cannot be made ‘obligatory’ for ‘normal Christians’.

The Pope has correctly identified a specific misunderstanding of marriage as a cause of the decline in the ability of marriage tribunals' capacity to apply the correct principles to determining the validity of marriages. The misunderstanding is the replacement of the notion of the 'indissoluble marriage bond', as the central concept of marriage, with the notion of a 'formalisation of emotional bonds'. It seems clear that the same false understanding of marriage is behind the decline of marriage itself: in fewer people being willing to make the commitment of marriage, and ever more people who have married, getting divorced.

Where might we find such a view expressed? Well, here is the opening prayer of the revised marriage ceremony, promulgated in 1969:

"Dear friends, you have come together in this church so that the Lord may seal and strengthen your love in the presence of the Church's minister and this community. Christ abundantly blesses this love. He has already consecrated you in baptism and now he enriches and strengthens you by a special sacrament so that you may assume the duties of marriage in mutual and lasting fidelity. And so, in the presence of the Church, I ask you to state your intentions."

Now look at the Latin:

Dilectíssimi nobis, in domum ecclésiæ convenístis, ut volúntas vestra Matrimónium contrahéndi coram Ecclésiæ minístro, et communitáte sacro sigíllo a Dómino muniátur. Amórem vestrum coniugálem Christus abúnde benedícit et ad mútuam perpetuámque fidelitátem et ad cétera Matrimónii offícia assuménda eos peculiári ditat et róborat Sacraménto, quos ipse sancto iam Baptísmate consecrávit. Quare vos coram Ecclésia de mente vestra intérrogo. (For the full texts, see here.)

There are many problems with the translation, but let's just look at the key phrases:

you have come together in this church so that the Lord may seal and strengthen your love in the presence of the Church's minister and this community.

in domum ecclésiæ convenístis, ut volúntas vestra Matrimónium contrahéndi coram Ecclésiæ minístro, et communitáte sacro sigíllo a Dómino muniátur.

The highlighted Latin phrase means literally '[you've come together so that] the Lord my establish the sacred bond [of matrimony]'. The official translation has removed the notion of matrimony as a sacred bond, established by the Lord, and replaced with the notion of the couple's love merely being strengthened by the Lord. In other words, the correct view of marriage, as an indissoluble bond, is expressed in the Latin, but in the English this view has been replaced by the false view, that marriage is the formalisation of an emotional bond.

So what is His Holiness saying? That the view of matrimony put forward in the scandalously inacurate official English translation of the new order of matrimony is responsible for a misunderstanding of marriage among even the higher echelons of the Church, which has dangerously undermined the institution of marriage itself.

Posted by Joseph Shaw

Christ King of Poland?

Daniel writes: What do you think? Would you consider this part of the ideal state? (A small group of Protestants, the Reformed Presbyterians, refused to go along with the British Revolutionary Settlement in 1688 because it made no reference to Jesus as King, interestingly. They are still active today, though I think they are now allowed to vote etc.)
>
> ** Polish MPs bid to make Jesus king **
> A group of Polish MPs submit a bill seeking to proclaim Jesus Christ king of their country - a move criticised by clerics.
> <>
>

Respondeo: Yes, I saw that. Also that the Polish bishops aren't keen. It's a nice idea, and it can be done in a number of ways. There was a huge fight before the Revolution in France about consecrating France to the Sacred Heart. The King finally did it, by Royal Decree, at a very late stage. A similar fight is going on about consecrating Russia to the Immaculate Heart of Mary. The people opposed to all these moves want to keep religion out of the public domain. Including the Polish bishops, unfortunately.

Declaring Christ King seems particularly appropriate, and it's suprising that it's not been done before. However I think that it was taken for granted in the Christian monarchies: the king receiving his crown from God etc., as depicted in ceremonial and art. God was always the King of Israel, as I understand it, and the human king a kind of deputy, just as the Pope is Christ's deputy as Head of the Church.

(When Henry VIII made himself Head of the Church of England, he wasn't just usurping the role of the Pope, but of Christ. As Elizabeth seemed to realise; at least she rejected that title.)

It's very interesting about the Presbyterians.

Oral contraceptives as abortifacients

Daniel Hill writes: "I have been discussing with a friend the possibility that the oral contraceptive pill functions as an abortifacient. See, e.g.,: The Growing Debate About the Abortifacient Effect of the Birth Control Pill and the Principle of Double Effect by Waltet Larimore, MD <http://www.epm.org/articles/pilldebate2.html> Ethics and Medicine (January, 2000;16(1):23-30)

A condensation of the booklet Does the Birth Control Pill Cause Abortions? <http://www.epm.org/articles/bcp5400.html>

Since I don't rule out contraception in general, but do rule out abortion, this is of great interest and concern to me. It may be of less interest to you, but this friend also argued that it was impermissible for somebody using NFP to drink coffee, since coffee can (he said) kill a newly fertilized egg (and, indeed, a foetus). Further, since, he went on, coffee affects the ovum, whether fertilized or not, he argued that it was impermissible for a woman ever to drink coffee (pre-menopause) since she would run the risk of damaging her ova in such a way that when fertilized they would not implant, and, hence, that one would be indirectly (though of course unintentionally) bringing about the death of a fertilized egg, should one later become sexually active.

Have you come across these arguments before? How should one respond to them?"

Respondeo: First, I take it that it is uncontroversial that the conventional 'pill' can act as an abortifacient. A similar thing is true of the 'Morning After Pill': that it can prevent fertilisation, but it also works by preventing implantation. If you take the thing after sex has occurred, the chance of it working (if it works) contraceptively, rather than by causing an abortion, is reduced, and continues to fall as time goes on.

I don't see what NFP has got to do with it.

But the coffee issue is less complicated that it looks. It is conceivable (though highly unlikely) that a woman is drinking coffee in order to cause an abortion, or to mutilate herself with a view to reducing her fertility. That would violate the prohibitions on intending those things.

But if not, then it is simply the familiar question: how much care must a (potentially) pregnant woman take over her health? And the answer is: be reasonable! If drinking coffee increases the chance of miscarriage only by some tiny per cent, and a woman regards giving up as a serious inconvenience, then she's under no obligation to give up. If the danger is significant and the inconvenience small, then she should give up. The same is true of crossing the road.

As it happens I've not heard that about coffee. But every other thing is supposed to be bad for pregnant women, and it's becoming absurd. What is really the worst thing for them, IMHO, is to turn them into neurotic invalids, but that's another story...

What is tricky is whether women taking chemicals advertised as 'contraceptives' ('emergency' or not) are guilty in any sense of abortion. Anyone who cares about it will find out quickly enough that taking those things act as abortifacients, but that doesn't settle the question of whether they intend them to act as such. They may, of course, but if they don't then there's still the wrongdoing of recklessness with an innocent life which the agent in question has a particular duty to protect.

Hope that helps.

Absolute prohibitions

Daniel Hill draws my attention to a Jewish moralist's summary of moral absolutes - things one can never do under any circumstances at all - as a very short list: murder, apostasy, and one or two other things (I think). Can the Catholic tradition produce a similar, neat list?

It looks as though it should be able to. There is a healthy debate on whether lying is forbidden absolutely, or only in certain circumstances. Killing the innocent is clearly prohibited absolutely, as is apostasy. So where's the list?

The problem (if it is a problem) is that Catholic moralists seem to want every prohibition, or at least as many as possible, to be absolute. So, faced with a situation in which a certain class of actions is permissible in some circumstances, and not in others, the tendency is to define a sub-set as being forbidden in all circumstances. So, with lying, for example, we have the taxonomy of officious, jocose and malicious; the last is absolutely forbidden; the jocose lie is not forbidden at all (or at least not on pain of mortal sin), and we can go on arguing about the officious one, but it's probably absolutely forbidden too.

Similarly, to argue that in some cases (the 'starving man and the rich man's surplus') theft is permissible, turns into an argument in favour of a narrower definition of theft, with the starving man case excluded from it, which is absolutely forbidden.

Is this a good or a bad methodological tendency? Although it seems confusing, I think it is the inevitable consequence of two good things. First, it derives from an attempt to cover every case in a clear way. Jewish casuistry is equally interested in hard cases as Catholic casuistry, but is less interested (as far as I can see) in reducing the casuistical analysis to a statement of principles. (Ie to say: now we've got a set of cases where the act is wrong and a set where it is right, what exactly is the principle dividing them?) With the ultimate focus on specific morally relevant principles, rather than more general principles with a set of exceptions, you end up with more moral absolutes.

Second, the role of intention (as usual!) has a role here. The concept of intention makes it possible to produce these plausible and specific moral principles, since the intention of each kind of harm to another is something which can be absolutely forbidden. The exceptions to rules such as 'do not kill' mostly turn out to be cases in which the killing is not intended.

In dealing with non-intended harms there is, instead of an absolute prohibition, the principle of proportionality.

In conclusion, one could say (although the manualists don't talk like this) that there is just one absolute prohibition in Catholic ethics: do not intend harm. And one non-absolute restriction: do not cause foreseen and disproportionate harm. (Plus there are positive duties, such as the duty of worship and obedience to God, and the duty of aid to our neighbour.) Since the question of what is 'harm' in the necessary sense is a controversial one, it is more usual to specify the absolute restrictions as: do not intend deaths, losses of property, etc., each of which has a sister-principle limiting non-intended harms of that kind by the principle of proportionality.

Secularism and state neutrality

Christianity and the ‘non-confessional state’. (This was published by CFNews: see here.)

Philip Trower, in his 2004 article for Catholic World Report included in the 4th Jan CFNews bulletin, argues that the rise of militant secularism – evidenced by the rigorous exclusion of religious language and symbolism from public life, for example – derives from the collapse of the ‘non-confessional state’, a state which does not prefer one religion to another, into a ‘secularist state’, a state in which a set of avowedly non-religious values, centering around humanism and hedonism, are given official status. This is a kind of confessional state, in which what the state confesses is a secularism which has become a substitute religion.

Trower’s diagnosis is certainly correct. What I cannot, however, agree with is the prognosis: the implication of his article that what is needed is a return to a non-confessional state, and that the process by which non-confessional states have become secularist states is based on a ‘misunderstanding’. If only, he implies, politicians and others understood the distinction properly, then we would not have the problem of militant secularism being imposed on us by the state. State schools could go on having nativity plays, etc. etc..

The problem is that there is a deep confusion in the very notion of a non-confessional state. Such a state is supposed to be neutral on controversial, value-laden issues, notably about which religion is correct. So how, in such a state, should human biology, or the history of the Reformation, be taught? What textbooks should be used? The problem is not that these are difficult questions, but that if the state has no controversial or religious values of its own, it will have no basis upon which to make the decisions.

Again: which religions and churches should be accorded charitable status, and for what faith groups should military chaplains be provided? The Taliban? Scientologists? Satanists? How is the state to determine that question, if it has no theological values?

The answer given by political theorists friendly to the idea of a ‘neutral state’, is that without reference to controversial, value-laden religious claims, the state can conduct its affairs by reference to what all reasonable people agree about: basic rationality. Everyone wants food on the table and a roof over their heads, and so on. This quickly reveals itself to be a form of reasoning that does not simply leave to one side the question of which religion is true, but assumes that they are all false. For if the only thing the state takes into account is our material needs, then it is acting as if we had no other needs at all: it has de facto adopted materialism as a substitute religion. The form of ‘rationality’ here, of course, is far from uncontroversial, and carries with it the potential to turn a non-confessional state into a secularist one. This problem has been explored at length by Alastair MacIntyre’s appropriately named book: ‘Whose Justice? Which Rationality?’

The same thing has been forseen in a different way by Edward Norman, in his book ‘Secularization’, where he points out that the non-confessional state is not the stable end-point of a political development, but is simply a transitional phase, when the dominant religion has lost the power or the will to impose itself on the state, but is still too strong to be ignored completely. The rising set of values which will soon be, and in many ways already is, the official creed of the state, is secularism.

The fact is that the state cannot do without values. Political judgments, judgments about the relative merits of educational philosophies or medical treatments, can only be made with the help of values. A non-confessional state inevitably gravitates towards a set of humanistic, hedonistic and secular values, because any move in any other direction will be attacked as giving one religion priority over another.

Catholics and members of other religions have to be clear about this. The goal of their political engagement is not to push the state back into the untenable position of making decisions neither on the basis of Anglicanism nor on the basis of any other coherent set of values or world view. That would be an absurd and Quixotic project. No: our aim is to get the state to make decisions on the basis of what we believe to be the correct values and world view. Sterlising the disabled makes sense if traditional, religiously inspired moral values are set aside in favour of hedonism and materialism. In opposing something like this, we are trying to get politicians and the general public to see that hedonism and materialism are inadequate, and that our own values are superior. We are pushing them, however feebly, towards a confession of the Truth, the only basis upon which correct judgments about how to promote the Common Good will be made.

Joseph Shaw

On-line casuistry

I thought it would be fun for people to post links to any on-line manuals of casuistry with which they are familiar. Here are some that I have found:
A Brief Text-book of Moral Philosophy by Charles Coppens
(Here is the definition of a lie: A falsehood, or lie, is speech contrary to one's mind.)
Moral Philosophy: Ethics, Deonoology and Natural Law by Joseph Rickaby
(Here is his definition of 'lying': a formal lie is saying what one believes not to be true, or promising what one intends not to perform: briefly, it is speaking against one's mind.)
Catholic Moral Teaching / by Joseph Mausbach
(Here is a section on lying.)
Elements of Moral Theology by John J. Elmendorf
(Here is the section on lying.)