Medicine and God

Q - First, thank you for maintaining such an excellent blog. I have enjoyed reading your thoughtful posts. I am a first-year student at a college of medicine. My question has to do with reproductive technology. I am seriously considering working in a Reproductive Endocrinology and Infertility Clinic next summer. The embryologist in charge, has given lectures at our school and I find his work very interesting. He has invited medical students to intern at his clinic. They do a lot of good work there, however, some of it is immoral (IVF, ICSI, ZIFT, and illicit methods of artificial insemination). It seems that I could be accommodated by the Doctor by not directly participating in practices contrary to Church teaching. I would be focused on Church-sanctioned ways of assisting married couples to conceive. However, my conscience tells me that simply working in such a place might be morally dangerous. Do you have any advice?

A - Thanks for the question. I am glad to see that you are concerned about practicing medicine in a way that is consonant with your faith. I want to commend you for that and for wrestling with these issues.

The first thing I will tell you is that I am not a bio-ethicist, but I know the principles that guide most of these decisions and how to apply them in many bio-ethical situations, but not all. There are more informed and intelligent persons on this subject and I am open to any correction they may offer in this area.

I will also refer you to the National Catholic Bioethics Center (NCBC). They do great work their and they put out a great journal which Fr. David subscribes to. He recently donated several dozen issues of their journal in the St. Mary's library. They will be put into the reference section shortly.

Also, the Pope Paul VI Institute deals directly with infertility treatments that are in accord with the Church's teachings. They also do good work.

Third, the USCCB has issued Ethical and Religious Directives for Catholic Health Care Services. It is a good guide.

Lastly, the Vatican issued a great document, Donum Vitae, that will help you in this field. It answers most questions about IVF, fertility treatments, and more. Great document that will help you immensely.

Now, that being said, and before I get into the issue at hand, I hope you will allow me to give you some advice in this area. Many Obstetrician Gynecologists treat infertile couples like machines, not human beings. Their treatments do not take into consideration medical questions about morality or ethics, but rather they use the human as an object. This is not in accord with the dignity of the human being or good medicine.

Also, many well-intentioned Catholics treat fertility as a right and not a gift. This is backwards and puts us in the place of God. There are moral treatments for fertility, but we cannot act in an "anything goes" manner, which you clearly understand. But - the doctor you want to intern with does not. If you are interested in this kind of science, you might talk to a good pro-life Catholic doctor. I can put you in touch with one if you like in town (if you live in BCS) or I will refer you again to the Pope Paul VI Institute, where you might think about an internship as well.

As for being complicit in the immoral things that happen at a fertility clinic that you would be interning at, John Paul II introduces us to the concept of remote and material cooperation in an evil act. This should help guide you. He writes in Evangelium Vitae:

In order to shed light on this difficult question, it is necessary to recall the general principles concerning cooperation in evil actions. Christians, like all people of good will, are called upon under grave obligation of conscience not to cooperate formally in practices which, even if permitted by civil legislation, are contrary to God's law. Indeed, from the moral standpoint, it is never licit to cooperate formally in evil. Such cooperation occurs when an action, either by its very nature or by the form it takes in a concrete situation, can be defined as a direct participation in an act against innocent human life or a sharing in the immoral intention of the person committing it. This cooperation can never be justified either by invoking respect for the freedom of others or by appealing to the fact that civil law permits it or requires it. Each individual in fact has moral responsibility for the acts which he personally performs; no one can be exempted from this responsibility, and on the basis of it everyone will be judged by God himself (cf. Rom 2:6; 14:12).

To refuse to take part in committing an injustice is not only a moral duty; it is also a basic human right. Were this not so, the human person would be forced to perform an action intrinsically incompatible with human dignity, and in this way human freedom itself, the authentic meaning and purpose of which are found in its orientation to the true and the good, would be radically compromised. What is at stake therefore is an essential right which, precisely as such, should be acknowledged and protected by civil law. In this sense, the opportunity to refuse to take part in the phases of consultation, preparation and execution of these acts against life should be guaranteed to physicians, health-care personnel, and directors of hospitals, clinics and convalescent facilities. Those who have recourse to conscientious objection must be protected not only from legal penalties but also from any negative effects on the legal, disciplinary, financial and professional plane.

In other words, we cannot formally cooperate with evil. For instance, we ought not get an abortion, but neither should we drive someone to the clinic, tell them it is okay or keep silent when presented with an opportunity to speak the truth about it.

Depending on our actions, we have different degrees of cooperation in the act.

If the evil act is not intended by someone and the person is sufficiently remote from the act, then they are not complicit with it. This is called remote material cooperation. Things that might cause an act to be remote include (not in order and an incomplete list):

• Time between the complicit act(s) - in some cases, time between events can cause distance. But, time is not a cure-all. For instance, using research gained from the Nazi death camps is still immoral.
• Steps separating the complicit act(s) - For instance. If you buy a piece of clothing that was originally made in a child-labor sweatshop from another part of the world, then you are many steps from the original evil (sweatshops using child labor). If we intended to buy it because of the origin of the clothing, then we would be complicit.
• On-going or one-time (or completed) complicit act(s) - The US supporting slavery is an example. We no longer allow it, but how are we now responsible as a people for once doing so? On the other hand, the sex-trade is still an on-going problem. We cannot participate in such evil.
• Severity of the complicit act(s) - For instance, abortion. The act is an indescribably evil in and of itself. We cannot cooperate in acts that formally support such evil. On the other hand, there are lesser evils where it is not quite as clear.
• Nature and Immediacy of the Goods - The most common example is a custodian at a hospital that performs abortions. As long as the person does not formally cooperate in them and disapproves of them, he is not complicit in them - if he is dependent on the job for his livelihood. If he is able to get a job elsewhere, then his cooperation could be formal and not material.

Now, these principles alone don't answer the problem. Therefore I will give you a system whereby you might work through the issue. It is called the Principle of Double Effect (PDE). It isa framework that gives us a Catholic understanding of which acts are moral and which are not, when things aren't clear. Through the principle of double effect, the act must pass four criteria:

1. The moral object must be good or neutral, not intrinsically evil.
2. The evil result is tolerated, not intended; the good effect is what the agent intends. Then, the evil effect comes indirectly fromt the act, while the good effect comes directly from it.
3. The good effect doesn't occur as a result of the evil effect, in other words, you can't do evil to get good. Therefore, the evil effect is not intended directly as a means toward the good effect.
4. There must be a proportionate reason for doing the act. This implies that there can also not be any other alternatives.

In your particular case, it is left up to your prudential judgment as to your course of action. So, you should follow your conscience after prayerfully discerning what God wants you to do. There could be a case made for either choice - in seeking an internship elsewhere where you could be educated from a Catholic understanding as well as being leaven in the world and interning with the clinic where ethical problems remain, but witnessing to a Catholic ethic.

Here are some questions that might help guide you throough the process:

• Would you be an agent of witness and possible change?
• Do you have enough formation and information to do this?
• Are you ready to stand up for your beliefs in situations of intense pressure and possible problems that might result in your professional future?
• What is your conscience telling you?
• Have you sought the advice of a spiritual director of confessor?

I will keep you in prayer and I hope it all works out for you.

Peace. I will give the final word to the Church in Donum Vitae:

The humanization of medicine, which is insisted upon today by everyone, requires respect for the integral dignity of the human person first of all in the act and at the moment in which the spouses transmit life to a new person. It is only logical therefore to address an urgent appeal to Catholic doctors and scientists that they bear exemplary witness to the respect due to the human embryo and to the dignity of procreation.