DEDICATED TO THE MEMORY OF ST. JOHN OF SAN FRANCISCO

Vol. XXXIII, No. 23 (1496)
July 17/30, 2000
SUNDAY OF THE HOLY FATHERS
Sixth Sunday after Pentecost.
Epistle: Titus 3:8-15. Gospel: Matthew 5: 14-19. Tone:  Pl. I.
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Commemoration of the Holy Fathers of the First Six Ecumenical Councils. Great Martyr Marina (Margaret) of Antioch in Pisidia; Translation of the relics of St. Lazarus, monk of Mt. Galerius near Ephesus; St. Irenarchus, abbot of Solovki; St. Leonides (Leonid), abbot of Ustnedumsk (Vologda); Neo-hieromartyr Priest Ismael (Rozhdestvensky); Martyr-prince Kenelm of Mercia; Martyrs Speratus and Veronica; St. Euphrasius of Iconopolis, bishop.

    (Dr. Danielson teaches biomedical ethics and the history of ethics, a course in the history of Western moral philosophy. The biomedical ethics course is a study of moral philosophy as it applies to such issues in biomedicine as research using human subjects, acquisition of organs and tissues for transplantation, euthanasia, abortion, reproductive technology, the meaning of death and personhood and genetic medicine.)

    A recent issue of The Orthodox Christian Witness contained a report of the creation of a pig-human hybrid, or chimera, presumably to be used in research related to human organ transplantation. This report forces us to consider the interconnection of contemporary biomedical research and the practice of medicine, because the techniques used to produce the “pig-man” were developed initially to help infertile couples who want children. This article is preparation for a subsequent discussion of the technology of human reproduction. It is necessary before turning to that subject to consider briefly the nature and purpose of medicine, for if the new reproductive technologies involve a distortion of the purpose of medicine, their use is clearly a problem for Orthodox Christians.

    For many married couples, barrenness is a bitter affliction. The causes of barrenness—or infertility, as it is presently called—are many, and may afflict the wife, the husband, or both. It is natural that married couples who suffer from barrenness would desire to overcome it. It is in response to this desire that medical researchers took up the challenge to understand infertility and to devise ways to get around it. The intensity of the desire for children is one reason why the moral propriety of the new technologies of human reproduction has not been questioned as closely as have physician-assisted suicide, abortion, or genetic manipulation. Parenthood is seen as a good thing, and a cause of joy and fulfillment for those who have children. But the new technologies of reproduction are not as clearly morally innocent as a casual glance would suggest; and they call into question the propriety of using medical science in this way.

    Is medicine a morally neutral art, to be used well or badly depending on the personal ethics of the physician, or is it a profession with its own internal standards of conduct that are suggested by the nature of medicine itself?  Contemporary teachers of ethics in medicine tend to agree that medicine is a morally neutral science that needs moral principles and rules imported from outside to protect against abuse. Prominent among the contenders to be the moral guardian of medical practice are the schools of autonomy and of compassion. The school of autonomy holds that the ultimate judge of morally acceptable conduct in medicine is the patient himself. Subject to only minimal rules fashioned by professional ethics committees, what counts as permissible medical practice is settled largely by the expressed desires of the patient. So long as there is a physician willing to respond to those desires, no wrong is done.

    The school of compassion sees the purpose of medicine as relieving human suffering, and the physician as the highly trained angel of mercy. With the relief of suffering as the primary goal of medicine, the argument can be made that any act that has the effect of ending suffering is justified. In this way, abortion is permissible if it relieves the anxieties of a young woman who doesn’t want to be a mother, since her anxiety is a form of suffering. Euthanasia is obviously justified when the patient is in pain or great fear of his imminent demise. Organ transplants from whatever source are justified to ease the suffering caused by failing organ systems. And reproductive technologies are made acceptable because they relieve the anguish of couples who want children but cannot produce them the old fashioned way.

    These schools hold in common the view that medicine does not harbor its own internal ethics that are determined by the nature of medicine itself. For both schools, nature is essentially irrelevant to morals. What matters is what human beings think to be important at any given moment in history. In other words, there are no moral truths that stand unchanged over time.

    The history of medicine’s beginning as a profession tells a different story. Insight into that beginning may be found in the venerable Hippocratic Oath. The fourth paragraph of the Oath reads: “I will neither give a deadly drug to anybody if asked for it, nor will I make a suggestion to this effect. Similarly I will not give to a woman an abortive remedy. In purity and holiness I will guard my life and my art.” It is of course striking that this part of the Oath forbids euthanasia and abortion. But the phrase “if asked for it” is actually more important in understanding medicine. According to the Hippocratic Oath, a patient cannot claim as his due everything that lies within the physician’s power; his request cannot justify what the physician is not free to give. Some uses of the physician’s art are simply unjust, and so the physician who guards his life and art in purity and holiness will not engage in these uses, even if the patient asks him fervently. This is because the Hippocratic physician is part of a tradition of medical practice that makes moral claims on him. These claims are binding because the tradition authoritatively tells the physician what purity and holiness require. The authority of this tradition of physicianship admittedly lies in pagan religion, but the tradition is clear about the goal of medicine, and that goal is compatible with Orthodox Holy Tradition.

     In one Greek version of the origin of medical art, Athena procures two drugs in the form of blood taken from the Gorgon Medusa. Blood from the left side of the Medusa offers protection from death. Blood from the right side is deadly poison. The blood is contained in two vials, both of which Athena gives to the physician Asclepius (whose name is invoked at the beginning of the Hippocratic Oath). The myth displays understanding that the power to heal is at the same time the power to harm, and that it is the physician’s duty never to use his art in a way that is injurious. In purity and holiness he must guard his life and his art.

     The myth of the two vials tells us also something of the purpose of medicine. Some arts, like carving and carpentry, can be put to a variety of uses, none of which is clearly indicated by the nature of the crafts themselves. Medicine is different. It serves one clear and unmistakable goal: the health and well-working of the body. The name physician attests to this goal. The physician works with the physis or nature of the body. This nature is given by God, and the physician who treats it impiously acts unjustly. Thus the third paragraph of the Hippocratic Oath says: “I will apply dietetic measures for the benefit of the sick according to my ability and judgment; I will keep them from harm and injustice.” The application of dietetic measures indicates that the physician works with the body’s own regenerative powers. Dietetic measures—like modern drugs—help the body either by assisting its natural powers or by suppressing the force of illness while the body recovers. (The physician and the surgeon are not the same because the surgeon acts, as a last measure, against the body’s nature by wounding it. The Oath, accordingly, requires the physician to withdraw when surgery is needed, leaving that work to the surgeon. For obvious reasons, modern medicine has blurred this distinction.)

     The goal of medicine as health and wholeness of the body helps us to understand what is and what isn’t proper medical practice, and by extension, what a physician should not do. The physician’s duty is to bring benefit to the sick by aiding in the recovery from illness or injury according to each patient’s capacity to recover. The physician does this, mindful of his duty to do no harm. Actions that do not aid in the recovery of patients from illness or injury lie outside the scope of physicianship. Actions that diminish respect for bodily nature are impious and unjust, and so forbidden to physicians in the practice of their art.

    It is important to understand that the reproductive technologies currently used do not, as a rule, cure infertility. That is, they do not help the patient recover from the malady causing barrenness; they simply help a couple get around it. Therefore, when a married couple uses the services of a fertility clinic, they are not seeking medical attention for an illness. Even if the technology succeeds in producing a pregnancy, the couple remains, without the technology, unable to produce a child. The technologies of human reproduction therefore are not part of the tool bag of the physician who looks after the health and wholeness of the body.

    In response to this line of reasoning, the school of compassion will argue that medicine involves more than the Hippocratic tradition understands. Health and wholeness of the body are not the only goals of medicine. The relief of suffering is among the primary goals of medicine, and if medicine can relieve the suffering of childless couples, it should. This kind of argument was called by the late ethicist Paul Ramsey the “sticky benefits” theory of moral justification. Sticky benefits theories justify manipulations of the human body if they soothe the emotions or relieve psychological distress. The physician Leon Kass tells of a woman who had one of her breasts surgically removed because it interfered with her golf swing. The emotional pleasure she took from a longer drive off the tee justified the surgical assault on her flesh. This kind of thing is justified not just by the sticky benefits theory of medical practice, but also by the view of the school of autonomy that a patient’s consent makes the physician’s conduct permissible.

    The new reproductive technologies fall into this class of treatments that are permissible if we accept either the sticky benefits theory of the compassion school or the alternative of the autonomy school that the patient’s consent justifies the physician’s action. After all, these technologies cannot be justified as means of curing illness, because they don’t cure illness. They are justified rather on the common belief of the schools of compassion and autonomy that there are no moral truths that stand unchanged over time. There are, therefore, no moral truths about the nature of man or the nature of medicine that can keep us from doing what lies within the power of technology and within the bounds of compassion and consent. The development and use of these technologies thus amounts to an abuse of medicine, and of the physician’s duty to practice his craft in purity and holiness.

    Under the portico by which you enter the church of the Blessed Clement there used to be a certain man of the name of Servulus, whom many among you, like myself, will remember: a man poor in the things of this world, but rich in merit, whom long illness had enfeebled. From an early age until he died he lay completely paralyzed. Not alone could he not stand, he could not even sit up in his bed, nor raise a hand to his mouth, nor turn from one side to the other. He was cared for by his mother and his brother, and by their hands he distributed to the poor whatever he would receive in alms.

    He could not read; but he purchased for himself codices of the Sacred Scriptures, and he was wont to ask religious-minded persons who came to see him to read them to him. And in this way he became fully acquainted with the Word of God, in as far as it was possible to him; for as I have said he was wholly illiterate. In the midst of his continuous infirmity he strove fervently at all times to give thanks to God, and to fill his days and nights with hymns and praise of God. As the time drew near for his great patience to be rewarded, pain returned to the vital parts of his body. When he knew himself near to death he would exhort all who came to visit him to stand and recite with him the psalms in expectation of his going forth.

    And as he lay dying, and while they were reciting the psalms, of a sudden he hushed the voices of the singers, and they were awed at the strength of his voice as he said to them: “Be silent. Can you not hear what glorious praises are resounding from heaven?” And while he lay there listening to these same praises, which he was hearing within his own heart, this sanctified soul was delivered from the weariness of the flesh. And at his going forth, such was the fragrance of the odor that was diffused about him, that all who were present were filled with its wondrous sweetness; and by this sign they understood that the praises heard by him had greeted his soul as it entered paradise. One of our monks, who is still with us was present at this happening, and is still wont with tears to tell us, that until the body was placed in the grave the fragrance of the odor was never absent from their nostrils.

    Behold in what manner he departed this life, who while in it bore his afflictions with patience. And so, according to the word of  the Lord, the good earth has brought forth fruit in patience; which having being broken up by the ploughshare of trial, came at length to the reward of the harvest. But, dearest Brethren, I ask you, look and see what excuse shall we have to offer at the solemn hour of judgement, slothful as we are in every good work, and possessing both goods and health, when he that was poor and helpless has thus fulfilled the teaching of the Lord?

    Grant that the Lord may not then, in witness against us, point to the Apostles, who by their preaching have brought with them into His Kingdom a multitude of believers; may he not bring forth to our condemnation the martyrs who have reached the heavenly home through the shedding of their blood. And what shall we say when we see this Servulus, of whom I have been speaking whose arms were held fast in long sickness, yet this did not withhold him from doing good? Reflect upon these things, Brethren, and by this means awaken in yourselves a zeal for what is good, so that keeping before you the good example of the just, you may become sharers in their reward, through Jesus Christ Our Lord, Who with the Father and the Holy Spirit liveth and reigneth world without end. Amen