An accurate and clear understanding of health itself is necessary to grasp responsibilities in respect to it. With that foundation, it usually is easy to see what measures should be taken to protect health. When life is at risk, however, specific norms are needed to guide the decision whether to accept medical treatment. People should not intentionally or unreasonably do anything which harms health and should use psychoactive substances rightly, not abuse them.
Individuals should fulfill all these responsibilities with respect to their own health; but they also have a social dimension, inasmuch as people, especially members of families, should care for one another and cooperate in protecting and promoting this good.
Health can be misunderstood in different ways, with the bad result that suitable means to promote it are not used, while means suitable for promoting health are mistakenly used to try to solve other problems. To understand responsibilities with respect to health, one must understand clearly what it is.
a) Health is well-integrated, harmonious, psychosomatic functioning. As sentient organisms, human persons have many capacities, both organic and psychic, which can function or fail to function, and which can function in diverse ways. If one or several of these capacities are impeded from functioning or function in a way not coordinated with others, the person as a whole suffers some form of disability or disease. But if the various human capacities are actuated in such a way that they contribute to and do not impede one another, every capacity can develop and be actuated as fully as the total potentiality of the rational, sentient organism allows. Then the person as a whole is fully functioning with well-integrated, harmonious functions: he or she is healthy.
b) Health should not be reduced to pleasure and felt satisfaction. Normally, pleasure and felt satisfaction of all sorts are experiences of healthy functioning, while severe or prolonged pain and undue emotional distress (as distinct from appropriate pain, sadness, or fear) are experiences of disability, disease, or threats to health. However, both healthy and unhealthy functioning can occur without manifesting themselves directly in conscious experience. Moreover, pain in the strict sense, the sensation of pain, is an important element of healthy functioning, because it signals incipient harms and stresses, and motivates appropriate organic and psychic adjustments. For instance, the pain felt upon touching a hot stove makes one pull one’s hand away, preventing serious damage; the pain felt in a strained joint makes one rest it and allow it to heal. Thus, pleasure and felt satisfaction are aspects of healthy functioning, but not the whole of it; pain as a sensation also is an aspect of healthy functioning; and undue emotional distress is only one part of unhealthy functioning.
People often do confuse feeling good with being well and feeling bad with being ill. But this is a confusion, for it mistakenly reduces realities to appearances.
c) Health should not be expanded to include total human well-being. Health, understood as well-integrated, harmonious psychosomatic functioning, is analogous to the goods of other aspects of the person: knowledge and wisdom, the moral virtues, and various skills and cultivated talents. The concept of health also sometimes is used metaphorically in descriptions of the integrity of human persons as they were created by God: sin “wounds” and grace “heals” human nature. Thus, health is easily expanded to embrace all human goods and to refer to the integral flourishing of persons; at the same time, many evils from which people can suffer are confused with diseases.
However, very different acts are appropriate for promoting good psychosomatic functioning and other human goods in the intellectual, moral, and cultural orders. Hence, the concept of health should not be expanded to include all aspects of human well-being.114
d) Health is both good in itself and instrumental to other goods. As understood here, health is not a human good separate from life itself. Human life has several dimensions—the organic, psychic, intellectual, moral, and cultural—and can be realized both more and less fully. Health is the fullness of life in its physiological and psychic dimensions, as distinct from the others. Consequently, health shares in the sanctity of life; wrong choices that destroy, damage, or impede health violate life.
While, health, as part of the good of life, is good in itself, not merely a means to other goods, it also is a means—a more or less important condition for the intellectual, moral, and cultural fulfillment of the person. This fact provides additional reasons for protecting and promoting health, but it also dictates that the ways chosen to serve it be consonant with these other goods. Moreover, health’s instrumental value should not be exaggerated; it does not guarantee the other goods, and its absence does not always greatly detract from them. For example, when ill health is not the consequence of a person’s ongoing wrongdoing, deteriorating health and moral growth can go together.
Within the framework of one’s personal vocation as a whole, one should act for one’s own health and that of others, especially of family members and neighbors.
a) Responsibility for health begins with oneself and one’s family. Because health is well-integrated psychosomatic functioning, and such functions always go on and always are subject to disturbing factors, there is a constant need in every person’s life for action to protect and promote health. People have the greatest motivation and opportunity to attend to this need in relation to themselves and those with whom they live. Hence, the responsibility for each person’s health primarily falls on that person, assuming he or she is competent, and on those on whom he or she closely depends: family members, neighbors, and so on.
While health itself is realized mainly in individuals, it also exists in communities insofar as they constitute unified, psychosomatic systems; for example, a couple can function well reproductively and a group can interact well psychologically. When health itself is communal, cooperation for its sake clearly is essential. But even insofar as health is an individual good, its protection and promotion generally require social efforts. For example, eating is a family activity, and all members of a family must cooperate so that the meals they share will meet the needs and promote the health of every member. Again, the Golden Rule often requires neighbors to advise and encourage one another to do what is healthful, and to help one another avoid or overcome illnesses and other threats to health.
b) Choices concerning health should take other goods into account. Partly because health is an aspect of the basic good of life and a means to other goods, but also partly because many people excessively fear death and greatly esteem health care technology, people in affluent nations sometimes tend to think of health as if it were the most important value. As a result, they assume that other goods must yield to health’s paramount claims, and so deliberate and make choices regarding health without duly considering their other responsibilities. Important as it is, however, health is only one good among others, and Christians should harmonize choices concerning health with other elements of their personal vocations. This seldom means that health should be neglected entirely, but it often demands that the means used to protect and promote health be selected and limited to avoid interfering with other areas of life. Of course, one’s total vocational responsibilities also can call for special care for one’s health; for example, a couple with several young children have a special duty to take good care of themselves so that they will be fully capable of caring for each other and raising their children.
c) One should pursue the reality, not merely the feeling, of health. Because pain is an important warning signal, no unusual, intense, or persistent pain or other sign of abnormal functioning should be ignored. One should try to find the cause of pain and other symptoms, deal with the real problem they represent, and in this way also eliminate the pain. However, since it is easy to confuse health’s reality with its appearance, many people are less interested in being well than in feeling well, and so they fail to do what they should to protect and promote health. They pay little attention to diet, exercise, and so on, while neglecting preventive measures and checkups. They wait until symptoms become troublesome before doing anything about a health problem, and at that point seek technical health care assistance, which they think of mainly as a technology to eliminate or mitigate pain. More interested in gaining relief from the symptoms than in curing the underlying disease, however, they follow the plan of treatment prescribed only until they feel better instead of doing all that they know they must if they are to recover fully.
d) One should moderate the satisfaction of natural tendencies. Like animals of other kinds, humans have natural tendencies: drives or appetites to eat, drink, move about, rest, and so on. But unlike other animals, humans should moderate the satisfaction of these tendencies, with a view not only to health but to their own total good and that of the communities in which they participate. Yet it can be difficult to maintain even the moderation of appetites required for health, inasmuch as the distortion of human emotional responsiveness due to original sin often causes people to experience excessive anxiety, tiredness, and desire for immediate satisfaction (see CMP, 14.G). Hence, one must discipline one’s natural tendencies according to a reasonable plan, which will take health requirements into account in the context of one’s whole vocation. The habit of such moderation is the virtue of temperance (see S.t., 2–2, q. 141, a. 6).
Given the basic practical insight into the good of health, experience teaches, within limits, what is moderate: it is a matter of common sense to stop eating before one becomes ill, to feed children enough so that they grow, and so on. But common sense is not always adequate to the new problems which affluence creates by enabling people to make more choices between healthier and less healthy styles of life, including food, drink, and exercise. Moreover, modern knowledge of nutrition, exercise, and other factors affecting health greatly increases people’s capacity to judge accurately what is moderate. Hence, although it remains the same in principle, temperance now requires taking into account and acting on all available, relevant, and reasonably credible information. For example, given what is now known about the causes of heart and arterial disease, temperate people today will adopt certain restrictions on their diet which sound reason would not have dictated in earlier times.
e) One should use other means to protect and promote health. Besides moderating the satisfaction of natural tendencies, one can and should take advantage of modern knowledge and technical means to pursue health, even when the relevant action does not spring from any spontaneous appetite. Thus, one’s regimen should include the use of some leisure time for exercise appropriate in amount and type (see GS 61). Elementary rules of hygiene should be learned and followed in order to avoid infectious diseases, food poisoning, damage to teeth, and so on. One should avail oneself of technical means: inoculations, medical and dental checkups, and so forth.
f) One should employ the health care system appropriately. The health care system of professional physicians, hospitals, and so on can be an important help in fulfilling one’s responsibility to protect and promote one’s own health and that of one’s dependents. It should be used not only to deal with health problems after they arise, but to anticipate and prevent them insofar as possible.
Nevertheless, physicians and psychologists cannot solve all life’s problems. If a person has guilt feelings because he or she has sinned, repentance and reconciliation, not tranquilizers or psychotherapy, are the answer. If a married couple’s sexual relationship is not going well because of selfishness, kindness and self-denial, not sex therapy, constitute the proper remedy.
But for genuine health problems, technical and professional advice, prescriptions, treatments, and surgery often are indispensable. Even so, a person should not assume a completely passive role, abdicating his or her own responsibility and expecting or allowing health care professionals to do everything necessary. Instead, patients should be the primary agents of their own health care.
g) One should take responsibility in using the health care system. People should make it clear to health care professionals that they regard them as helpers. This includes insisting on being told the truth about their condition and prospects. The professional is the authority in the sense that he or she has competence based on extensive education and experience; it would therefore be presumptuous, foolish, and self-defeating to ignore the professional’s observations, practical reasoning, and advice. But the person seeking help is the authority in the sense that he or she is both the employer of the professional and the subject of the treatment process, with every right to determine what morally acceptable end will be pursued and which of the available and technically feasible means he or she will personally accept.
Therefore, physicians, hospitals, and so on should be chosen carefully. While seeking advice in order to learn about technically feasible possibilities and their advantages and disadvantages, people should make their own judgments and choices. If a health care professional advises doing something morally wrong in itself, that advice should be rejected, and the relationship probably should be terminated. If, as is generally the case, the advice is not morally objectionable in itself, one should consider it carefully, keeping in mind the wider responsibilities of one’s life, which no one else can fully appreciate.
Partly because people who seek health care services often abdicate personal responsibility and assume the passive role of patients, health care professionals have tended to assume too much responsibility for decision making. As a result of this and other factors, they often are held legally liable for any unsatisfactory outcome of treatment. Partly to shield themselves from legal liability, however, many health care professionals proceed defensively and order more tests and treatments than necessary, rather than drawing a reasonable line and accepting reasonable risks. Hence, one also should be alert to the possibility that one is receiving excessively cautious advice, and should take responsibility for refusing tests and treatments recommended by health care professionals only, or primarily, to protect themselves from potential legal liability.115
Moreover, some professionals recommend major surgery and other complex and costly treatment which equally competent professionals consider unnecessary or no more promising than simpler alternatives. Therefore, if it seems reasonable to follow professional advice, but doing so would involve great burdens, a second opinion should be sought from an independent, equally competent professional source, and in discussing the matter one should inquire particularly about the advantages and disadvantages of any reasonable alternatives.
Someone who judges that professional advice should be accepted should listen carefully to any instructions and ask questions regarding his or her role in the treatment process until entirely clear about his or her personal responsibilities. Then those responsibilities should be fulfilled conscientiously.
People ordinarily encounter no special moral difficulty in reaching a decision to accept or refuse treatment that would protect or promote their own or a dependent’s life or health. However, when life is at risk, many people need more specific norms than those already stated. The norms articulated here also may be helpful in less serious situations.
Although professional nurses participate in medical treatment, medical care can be distinguished from basic nursing care: the latter includes those forms of care which a reasonable person who is sufficiently alert and able could and would provide for himself or herself, or which a good mother could and would provide for her baby. This distinction is important for two reasons. First, basic nursing care has a special importance in maintaining human solidarity with those unable to care for themselves; to deny anyone such care when it could be given implies that the individual is no longer regarded as a person. Second, in calculating the costs of medical treatment and considering how much treatment is anyone’s maximum fair share, the cost of basic nursing care should not be included; someone who wants to argue that society cannot afford to feed, house, and tend nonproductive consumers, such as the severely retarded and insane, should not try to make the case by reclassifying basic nursing care and its cost as medical treatment.
Nevertheless, when basic nursing care is provided together with medical treatment, the two become intertwined and the boundaries between them blur. Rather than attempting to distinguish sharply between medical treatment and basic nursing care, the following analysis deals with health care as a concrete reality, but pays special attention to the value of human solidarity.
a) All prospective benefits should be considered. Attempts to maintain life can be excessive and unreasonable, since some motives for seeking health care are not reasons for doing so. People can be motivated by excessive fear of sickness and unwillingness to accept the inevitability of death; pride can motivate them to try to make themselves function perfectly. Such motives can lead to selfish use of health care facilities and services: a form of greed that wastes scarce resources.
Still, since life is a basic human good (as has been explained in A.2) and since health is an aspect of the good of life (1.d, above), a reason never is lacking to seek or accept any kind of care at all likely to protect life or promote health.
Some are quick to call health care “futile” if it does not offer hope of curing or significantly improving the functioning of a dying, comatose, or seriously disabled person.116 That view, however, rests on an assumption, usually unstated, that life and health are good only as instrumental to quality of life: functioning at some arbitrarily determined level. Usually the level chosen is that at which a person is conscious or likely to gain (or regain) consciousness, along with experience such that continuing consciousness probably will seem preferable to oblivion. However, because life is good for the human person as a bodily being, not only as a conscious subject (see A.2, above), care that keeps someone alive, no matter what his or her condition, really does benefit that person, even if only in a small way. Therefore, health care is not strictly speaking futile (that is, utterly useless) if it sustains life even for a short time or in any way mitigates a disease or handicap.117
Providing life-sustaining health care also can realize other values. Rightly motivated care maintains human solidarity with those cared for: it affirms their dignity as persons, manifests benevolence toward them, and maintains the bond of human communion with them. Some will deny that maintaining human solidarity with an unconscious person in any way benefits him or her. However, unconscious people plainly can be burdened insofar as they can suffer indignities; by the same token, they can be benefited by being cared for out of a love which respects their dignity.
Moreover, the bond of human communion can be maintained with permanently unconscious persons despite their inability to enjoy the good experiences normally characteristic of this bond as it exists among conscious persons. For while interpersonal communion normally has psychological components on both sides, essentially it is a moral reality, maintained by fidelity of will and action. Just as a couple eagerly expecting their baby’s birth establish a parental relationship with him or her, a husband faithful to his comatose wife maintains marital communion with her. In doing so, he truly benefits not only himself (by continuing to be a good husband) but her, although she cannot consciously enjoy and respond to this benefit. Similarly and generally, families and larger communities that faithfully care for their unconscious members maintain human communion with them and thereby benefit not only themselves (by continuing to be loving families and genuine communities) but their unconscious members.
b) Some motives for forgoing health care are not good reasons. Fearing an unfavorable diagnosis, people often delay seeking care for themselves or their dependents because they shrink from the bad news or else from the burdens associated with needed care. Such motives are merely emotional. Considered simply as such, emotional repugnance is not a rational motive, and so cannot provide a reason to forgo health care. A person who feels repugnance toward doing what would protect life or promote health must discern that feeling’s relationship to intelligible goods.
Sometimes, experiencing and/or anticipating much suffering and little or no enjoyment, people who are seriously ill or disabled seek their own early death. They have a reason to forgo care, for in that way they avoid experiences which they find repugnant. However, it is a bad means, since it amounts to killing themselves, and so is morally wrong, as suicide always is, regardless of the ulterior end or method. Similarly, people sometimes choose to forgo or terminate care of a dependent in order that the person will die, thus forestalling the burdensome consequences of his or her continuing life. This is a choice to kill, and so is morally wrong, even if motivated by the desire to prevent suffering: so-called mercy killing.
In refusing or limiting health care for themselves or others, people sometimes wrongly accept death without intending it. Perhaps a person who still has grave responsibilities to fulfill refuses some life-sustaining treatment because he or she unreasonably fears the pain it would involve. Or a couple are told that their newborn daughter will be severely retarded and also needs expensive surgery, not covered by insurance; if the baby were not going to be retarded, they would be ready to spend the money, but they decide to refuse the surgery and allow the girl to die, discriminating against her because of her handicap.
c) The burdens of health care can provide an adequate reason to forgo it. Life is like other basic human goods: it does not override every other good, nor does it always deserve preference. There always are reasons not to do something that would protect life or promote health, since health care always involves burdens. Hence, sound judgment requires identifying both the prospective benefits and burdens of possible forms of care. In this matter, the Holy See teaches:
It is also permissible to make do with the normal means that medicine can offer. Therefore one cannot impose on anyone the obligation to have recourse to a technique which is already in use but which carries a risk or is burdensome. Such a refusal is not the equivalent of suicide; on the contrary, it should be considered as an acceptance of the human condition, or a wish to avoid the application of a medical procedure disproportionate to the results that can be expected, or a desire not to impose excessive expense on the family or the community.118
Therefore, burdens that attach to the care itself can provide adequate reasons to forgo it. These burdens can be grouped in three categories:
i) Care imposes economic costs and utilizes facilities and services which usually could be put to other good uses.
ii) Many things which can be done for the sake of health also can have bad side effects for health itself. Surgery always carries some risks of death and/or disability; medications often interfere with various functions. Examinations and treatments often are painful, and pain can interfere with good functioning, especially at the psychic level.
iii) Many things which can be done for the sake of health have bad side effects for other human goods. They may restrict one’s inner life and activity, prevent one from moving about freely, isolate one from family and associates, and so on.
d) Moral standards should be used to evaluate benefits and burdens. Occasionally a possible treatment—for example, of a married person’s sexual dysfunction by training sessions with another partner—is morally wrong in itself, and so should be excluded regardless of its prospective benefits and even apart from any burdens it might involve. But when it is not wrong in itself either to accept some form of health care or forgo it, the benefits and burdens must be evaluated. Unless these are measured by moral standards, however, there is no rational way to commensurate them, since they are diverse instances of values. Therefore, relevant moral standards must be employed.
e) One should judge in the light of one’s whole personal vocation. In judging whether to accept or refuse a possible or proposed form of health care for oneself, the first consideration ought to be what decision, if any, is dictated by one’s religious responsibilities or duties toward other people. Sometimes these demand that the care be accepted despite its burdens: one must make one’s peace with God, do one’s duty toward one’s dependents, perhaps complete important work. At other times, fairness toward other people who would bear the burdens of the care requires forgoing it despite prospective benefits. Even if fairness does not dictate accepting or refusing care, mercy can point to the appropriateness of forgoing it in order to avoid burdens to others, including its costs.
If the preceding considerations do not lead to a decision and one is confident that both options remain morally available, the next step is to examine the motives inclining one to each. Merely emotional motives, such as anxiety, should be set aside in favor of reasons. Since reasons support both options, either can be good, and one must discern between them. In doing so, the consonance of each with one’s entire personal vocation should be tested.
When all the goods at stake are considered in this light, it sometimes is reasonable to judge that other goods should take priority over health.119 Moreover, there are persons, especially the dying who have no special responsibility to try to prolong life, who may see no reason why they must accept the burdens of life-sustaining care. If they neither will death as an end nor choose it as a means, but prefer to accept it rather than accept the burdens of some or all kinds of care, they may forgo the burdensome care.
f) Adults should consider appointing an agent for health care decisions. Parents or guardians make health care decisions for children, and competent adults can make them for themselves. In times past, when an adult no longer could make such decisions, usually few of them remained to be made, and the family and their physician ordinarily had no difficulty arriving at a consensus. Now, however, this approach often no longer works well because of many factors: advances in medical technology require more decisions and more complex ones; with changes in health care delivery, physicians, administrators, and others unfamiliar with the patient and the family are likely to be involved; concerns about potential liability for malpractice can lead to care which is excessive in some respects; families sometimes lack the stability and solidarity necessary for sound decision making; disagreements among those involved regarding moral norms and their application sometimes block consensus; and so on. Thus, many prudent Christian adults have good reasons to seek some way of determining how decisions regarding their health care will be made if, at some future time, they become unable to make them. The matter has been confused, however, because proponents of euthanasia, exploiting concerns about possible excessive treatment and using death with dignity as a slogan, have advocated the so-called living will—an advance directive to limit health care—as a step toward the legalization of euthanasia.120
While it would be possible to make a morally acceptable advance directive similar to the so-called living will, doing so does not determine adequately how health care decisions will be made if one cannot make them. Most such directives take effect only if one is terminally ill, but many people not terminally ill are unable to make vital decisions. Moreover, such directives must either deal with few potential problems or resort to dangerously vague language or both, because it is impossible either to know now what decisions will be needed in the future or to gather in advance the information required to make prudent decisions.121
A more adequate and prudent approach is to designate someone, usually a mature, dependable family member or close friend, as one’s agent or proxy, to make necessary health care decisions on one’s behalf if one cannot decide for oneself, and to designate a second similar person as alternate to fulfill that role if the first is unable, unwilling, or unavailable. Only persons should be chosen who accept relevant moral truths and who can be trusted to apply them prudently. It is important in naming these persons to do all that is required so that the designation will be legally effective, and expert advice may be necessary for this purpose. Copies of the document, with an indication of how the original can be obtained, should be given to those designated and others who should be aware of it: physicians, family members, friends, and so on.122
In making a document of this sort, some people add to it specific instructions regarding particular procedures, for example, not to resuscitate. In general, doing this is unwise, because problems cannot be resolved prudently until they arise and relevant information is available. Instead, those who designate agents should discuss any special concerns with them and, if it seems appropriate, confer jointly with them and those who might help clarify areas of concern, for example, a sound adviser about moral questions or a physician about medical information.
In some jurisdictions, nevertheless, various provisions or limitations in the law may make it appropriate for a person designating an agent for health care decisions to provide some specific instructions in the document. On the one hand, instructions excluding options which are never morally acceptable—sterilization, abortion, actions or omissions intended to cause or hasten death—may be necessary or appropriate to ensure that an agent’s morally sound decisions will be respected. On the other hand, instructions explicitly authorizing an agent to reject or withdraw certain forms of life-sustaining care may be necessary to empower him or her to make those decisions if appropriate. For example, the law may presume that agents are not authorized to deny services which every patient can reasonably expect; but, in a spirit of Christian mercy, someone might prefer to save others the costs and burdens of care if it ever happens that he or she is unconscious and there is no reasonable hope of recovering consciousness. To ensure that an agent will be able to carry out that wish, it might be necessary to include in the document an appropriate, specific instruction.123
g) Others sometimes should limit health care for the dying. Not infrequently, dying people have not determined in advance how decisions will be made to govern their care. Then, when they either can no longer make such decisions or express their wishes, their families and those helping to care for them must judge whether various kinds of care are appropriate in view of the burdens they entail and the benefits they promise. Very often, their judgment will favor continuing the care. By applying the Golden Rule, however, those concerned sometimes rightly judge that it would be too burdensome to the patient or unfair to others to initiate or continue some elements of care.
Sometimes good care for those whose death is imminent includes doing something which will shorten their lives. Assuming there is no special reason to prolong life—for example, to allow the person an opportunity to prepare spiritually for death—and death is not intended, that may be done which is in the patient’s real interest, even if it will result in earlier death. For example, if no other means of making a patient comfortable is available and sedation will not prevent him or her from fulfilling exigent responsibilities, the narcotics necessary to suppress pain may be administered, even if doing so will shorten life.124 Again, terminal patients may be cared for at home or in a hospice, where they can be near their loved ones and costs are lower, rather than in a hospital or other fully equipped facility, where their lives could be prolonged.
People often hesitate to direct discontinuing some means of life support—a respirator, say—whose discontinuation will lead promptly to death, even though they would unhesitatingly refuse to initiate its use if that were the question before them. If the reason for not using some means would be its obvious burdensomeness, that same reason justifies discontinuing it; the reluctance is an irrelevant feeling which should be set aside.
h) Others ordinarily should care for the severely handicapped and comatose. Supplying food and water to comatose persons is not in itself costly or otherwise significantly burdensome. Rather, it is the care as a whole that is expensive and the condition as a whole that others find burdensome. Hence, the choice to withdraw elements of life-sustaining care which are not significantly burdensome in themselves, either to the patient or to others, sometimes amounts to a morally excluded choice to kill. But even if death only is accepted as a side effect, the choice to discontinue life-sustaining care as a whole, unless made to fulfill some other, overriding responsibility, is a choice to break off human solidarity and discontinue care.
In choosing to forgo care and accept one’s own death in order to avoid burdening others with the expense of care to which one is entitled, a person acts with mercy toward them. But no one can be merciful on others’ behalf, and so, unless authorized by someone to do so, one cannot exercise mercy for him or her by avoiding burdening oneself and/or others with care to which he or she is entitled. On the contrary, that is treating the person as a useless object, to be disposed of as cheaply and expeditiously as possible. Therefore, those elements of care that are not very burdensome in themselves ordinarily should be provided even to persons who will never recover consciousness. Even assuming (not conceding) that there is little or no benefit to them in prolonging their lives, it remains of great benefit, to them and everyone concerned, to treat them as persons to the end. Hence, the Golden Rule, especially when informed by Christian love, requires that no one be left entirely without care except in extreme situations, for example, disasters in which it simply is not possible to care for everyone.125
i) The preceding norms clarify ordinary and extraordinary. In its effort to articulate norms for accepting and forgoing various forms of health care, Catholic moral theology has spoken of “ordinary means” and “extraordinary means.”126 In practice, an ordinary means is identified simply by determining what means is morally required. Hence, using this expression adds nothing to—and is less helpful than—the expressions used in the specific norms already articulated.127
Medical progress lessens the burdensomeness of many procedures and forms of health care, so that those extraordinary in the past often are morally required today. For example, before antiseptic procedures, even simple surgery involved a grave risk to life, and therefore many moralists reasonably held that a surgical operation was an extraordinary means. It is fallacious to use their opinion today to argue that surgery needed to save the life of a handicapped newborn may rightly be forgone, when the motive is the anticipated burdens of the handicap, rather than of the surgery, to the child and others. Surgery that would routinely be performed on a child without a handicap does not become an extraordinary means in the case of a handicapped child.
Since health is part of the basic human good of life, it shares in life’s sanctity. Intentional acts contrary to health are always wrong, and unfairly or otherwise unreasonably accepting side effects harmful to health also is wrong.
a) One should never intentionally harm anyone’s health. It is always wrong to seek as an end or choose as a means to some other end to destroy, damage, or impede any instance of a basic human good (see CMP, 8.G–H). That is done in intentionally harming one’s own or another’s health. So, one may never intentionally harm anyone’s health. For example, one should not try to pass on a disease to others out of resentment toward them or toward society at large. One should not purposely weaken others physically or psychologically in order to take advantage of them or gain a competitive advantage. One should not go on a hunger strike to debilitate oneself (much less bring about one’s death) as a means of gaining political leverage for some good cause.
By contrast with the morally unacceptable hunger strike, however, a person could engage in a hunger strike—better called a “fast”—as a morally upright symbolic gesture. In this case, the choice would be, not to debilitate oneself, but only to show seriousness about one’s cause by frustrating the natural desire to eat, much as in fasting penitentially. Someone engaging in such a morally acceptable fast would limit it to avoid the risk of death or serious harm to health, and any bad effects for health would only be accepted as side effects, not intended (see S.t., 2–2, q. 147, a. 1, ad 2).
b) One should not unfairly accept bad side effects to others’ health. It always is unjust to accept any bad side effect for others in making a choice that is itself wrong. So, for example, those who defraud others by selling them useless or unnecessary medications or surgery not only are guilty of the fraud but of any bad side effects which might follow from using the medication or having the operation.
But even if what is done is good in itself, a person should take into account its potential impact on others’ health, and use the Golden Rule to judge the acceptability of any foreseen bad side effects. For example, those handling food should be conscientious about hygienic measures necessary to prevent contamination, those with communicable diseases should try to avoid spreading them to others, those camping in the wilderness should not pollute streams from which others might drink. People should not encourage others’ intemperance, for example, by serving them too many drinks out of misguided hospitality or sending them gifts of foods in which they tend to overindulge. People should not interfere with others’ needed rest, for example, by noisy partying.
c) One should reasonably avoid bad side effects to one’s health. To do anything wrong in itself while foreseeing possible bad side effects to one’s own health also is wrong. For example, to engage in illicit sex with the possibility of contracting a sexually transmitted disease is doubly wrong.128 Moreover, even if what is done is not wrong in itself, a person must have an adequate reason to accept bad side effects to his or her own health. People who take steroids for muscle building violate this norm; so do those who, out of vanity, fail to dress appropriately against bad weather.
Nevertheless, for a good reason, bad side effects to one’s own health may be accepted. For example, those ministering to or caring for the sick should take all reasonable precautions but, having done so, may and often should accept serious risks. People who cannot earn a living except by work hazardous to their health also may accept the health risks involved and usually are morally required to do so.
d) Work should be arranged to avoid bad side effects to health. Many jobs involve health and safety hazards which can be eliminated or at least lessened by precautions. Also, any kind of work can be carried to the point at which the worker’s capacities are exhausted and he or she suffers or at least risks physiological or psychological harm. Greed or other motives sometimes tempt not only employers and managers but workers themselves to exceed reasonable limits and neglect reasonable precautions. Therefore, a person should apply to work the norms that bad side effects to others’ health should not be unfairly accepted and bad side effects to one’s own should reasonably be avoided. Not only the need for the results of work and desire to profit from it but the nature of the work, the conditions under which it is done, and each worker’s personal limitations should be taken into account in judging what precautions to take and what limits to set in order to meet the norms of avoiding unreasonable harm or risks to health.129
e) Participation in experimentation can be good or bad. Sometimes experimentation, especially of a psychological kind, involves acts wrong in themselves, for example, lying or deliberate arousal of illicit sexual desire. Participating in such experiments never is justified. But even if experimentation involves nothing wrong in itself, it can be objectionable because of bad side effects. Not all medical and other scientific experiments involve health risks for participants, but many do, and no one should volunteer for or agree to participate in any experiment without obtaining full disclosure of any possible health risks, as well as of the experiment’s potential benefits, and the alternatives to cooperating in it.130
If there are risks, a person may reasonably participate for either of two reasons: first, if he or she is ill, no proven treatment is available or effective, and the experimental treatment offers a sufficient prospect of benefit to make it seem right to accept the bad side effects or risks; second, if the experiment promises substantial benefit to others, the individual has no special responsibility to avoid the risks of participating, and he or she does so in the hope of helping others, as an act of mercy.
f) Such risks may be accepted for others only in their own interests. People making decisions for someone who is not competent—for instance, parents for a child—may accept any risks to health involved in experimental treatment when the treatment offers sufficient prospect of benefit to the dependent person himself or herself. However, they may not accept any significant risk (that is, any risk beyond the level of life’s common risks) to a dependent’s health for the sake of an experiment’s possible benefit to others. For parents and others in charge of the noncompetent have a special responsibility to act in their personal interests, not to subordinate them to others. Nor can such subordination of a dependent’s interests be an act of mercy, since mercy is self-sacrifice, not imposing sacrifice on someone for whom one is responsible.
This norm applies to the human conceptus from the beginning, since the conceptus should be considered a person whose life is as sacred as anyone else’s. Therefore, as Paul VI teaches, one may not “be a party to experiments on the human embryo or foetus, even for the progress of science, not even if this being was destined, for natural reasons or through men’s criminal act, to perish before seeing the light of day.”131
Psychoactive substance here refers to anything introduced into the body for the purpose of affecting the nervous system and how one feels. Substances introduced for other purposes, even if they have an incidental psychoactive effect, fall outside this definition.
People use many things to affect their state of consciousness: tea and coffee, aspirin and other pain killers, sleeping pills, tranquilizers and antidepressants, tobacco, alcoholic beverages, marijuana, cocaine, heroin, LSD, PCP, and so on. Some psychoactive substances can be used reasonably, in accord with health and other goods, but all of them also can be abused.
There is a huge and ever-growing body of information concerning the use and abuse of psychoactive substances. No attempt will be made here to summarize the data. Rather, norms applicable to any psychoactive substance will be articulated, distinguishing between reasonable use and abuse.132
Of course, as in other matters, people who regard morality legalistically will tend to rationalize abuse by interpreting what they are doing as reasonable use. Nevertheless, people who sincerely desire to do what is right will find the following norms helpful for guiding their choices.
a) Psychoactive substances may be used rightly to promote health. Assuming that their use is not excluded by bad side effects (a matter to be considered below), psychoactive substances can be used reasonably whenever the psychoactive effect itself contributes to healthy functioning by mitigating the bad physiological or psychological effects of some condition of consciousness.
For example, sometimes the cause of pain is unknown or cannot be remedied: some kinds of headaches, the pain of terminal cancer, and so on. Such dysfunctional pain interferes with psychic and even with organic functions, and so, in itself, is unhealthy. In such cases, pain relievers are reasonably used to mitigate the pain and promote a more healthful level of functioning. Many other psychoactive substances can be used reasonably in analogous ways. Tranquilizers, antidepressants, and sleeping pills can ameliorate abnormal emotional states which interfere with normal psychological functioning and rest. Mild stimulants—such as the caffeine in tea, coffee, and cola drinks—can help people overcome feelings of lethargy and fatigue in order to stay awake, concentrate, and function more effectively.
Alcoholic beverages sometimes are used in religious rituals, such as the Eucharist, or consumed as appetizers, foods, or medications; in such cases, their effect on consciousness can be irrelevant, and then they are not used as psychoactive. When consumed to affect feelings, as they often are, alcoholic beverages can be used reasonably in limited amounts as a mild depressant: to quiet excessive emotions, to shift from the intense effort of the working day to social intercourse and rest, or to reduce nervousness and inhibitions in order to facilitate intimacy and celebration.
b) Psychoactive substances should be used when appropriate. Sometimes people unreasonably hesitate to make appropriate use of such substances, particularly pain killers. Perhaps they confuse right use with abuse, or falsely believe that Christian asceticism requires suffering pain even when there is a reason to seek relief. Perhaps they have an excessive and misplaced fear of addiction. For example, terminal cancer patients sometimes refuse, or are denied, the pain relief they need to function as well as possible in doing the good things they still can do and having the worthwhile experiences they still can have. In any case, a psychoactive substance should be used when there is a reason grounded in an intelligible good to use it and no reason not to do so.133
c) Any merely emotionally motivated choice to use is an abuse. Sometimes, however, people choose to use psychoactive substances without any reason, that is, without having any intelligible good in view. They do not seek to alter the way they feel in order to improve their general or psychological functioning in some respect; rather, the altered state of consciousness becomes an end in itself, and the use of the substance is, at least to some degree, a flight from reality into an artificially generated experience. The motive is a merely emotional urge to experience the feeling of excitement, euphoria, or escape. But someone who chooses to satisfy an urge also must be aware of some reason not to satisfy it, for there would be no need to choose unless one were aware of an eligible alternative. So, such a choice to use a psychoactive substance follows an emotional urge against a reason, and that violates the third mode of responsibility (see CMP, 8.C). Consequently, such a choice always is morally bad, and carrying it out always is an abuse.134
d) Using psychoactive substances without a reason is always wrong. Since rightly using, and not abusing, psychoactive substances is a matter of regulating sensory desires by reason, it pertains to temperance (see S.t., 2–2, q. 141, aa. 1–3). In regulating some tendencies—to eat, to rest, to move about—temperance is moderating the satisfaction of a tendency that normally contributes to health. Hence, one need not have a reason for satisfying those tendencies, and temperance requires only that their satisfaction be limited by rational considerations. In regulating the urge to use psychoactive substances, however, temperance moderates the satisfaction of a different sort of tendency. For if any use of any psychoactive substance is motivated, not by an intelligible good, but precisely by an urge to experience an altered state of consciousness, that act, as experience indicates, always harms two basic human goods: healthy functioning and the interpersonal communion of friendship or association.
The bad effects on healthy functioning are obvious and easily understood; those on friendship or association are more subtle. However, there plainly is a difference between, say, drinking which serves sociability and drinking to get drunk. Even if several people set out to get drunk together, the goal of each is his or her own conscious state, which neither is shared with nor communicable to anyone else, and so for these people to get drunk together actually is not a social activity directed toward a common good. By contrast, if several people, having set out to celebrate an occasion or engage in conversation, drink only to facilitate their common activity, their incommunicable states of consciousness must remain subordinate to their interpersonal communion; and, if one party’s drinking begins to interfere with communication, the others will consider that an unfortunate excess.
Reflection can clarify the harm to healthy functioning and to friendship or association which experience suggests.
The temporary or even lasting negative effect on healthy functioning is obvious in some cases: for example, when people use drugs or alcohol to experience a “high,” their normal psychological functioning and motor skills are impaired, their vital functions are strained, and so on. But even when the effect is not obvious, using any psychoactive substance either suppresses or intensifies some function, and doing either thing, in the absence of any reason, is unreasonably to detract from one’s healthy functioning—the former directly, the latter indirectly (because intensifying one function detracts from others and/or from the harmony among them).
As for the harm to friendship or association: immediately and in itself, any use of a psychoactive substance, not for an intelligible good, but precisely for the experience, alienates oneself from one’s own body. This is so because the substance only affects the state of consciousness by first affecting the body, so that in using the substance one is using one’s body to affect one’s conscious state; but the body, rather than participating in any good, is treated as if it were a mere instrument, distinct from one’s conscious subjectivity and at its service. Of course, this self-alienation from the body in no way affects the metaphysical unity of one’s person, since nothing a person does can alter his or her metaphysical constitution. Nevertheless, it is an existential dualism between the body and the conscious self, that is, a division between the two insofar as they are coprinciples of integrated, acting person. But a person’s capacity to embody himself or herself completely in his or her acts is necessary for the self-giving involved in the communication which establishes and nurtures interpersonal communion. Hence, to choose to use a psychoactive substance precisely for the experience is to accept damage to the capacity of one’s bodily self for interpersonal communion. But to damage an intrinsic and necessary condition for attaining a good is to damage that good itself. Thus, in choosing to use a psychoactive substance, not for the sake of some intelligible good, but precisely for the experience, a person accepts damage to the basic human good of friendship or association.
Consequently, in the absence of a reason to use a psychoactive substance, there always is a reason not to use it: the damage such use does to healthy functioning and to the body as a capacity for interpersonal communion. Any choice to use such a substance not motivated by a reason (that is, not made in view of an intelligible good), therefore, is intemperate and morally bad, and any such use is abuse.
e) The use of psychoactive substances can have bad side effects. The use of some psychoactive substances not only impedes healthy functioning but involves risks to the user’s state of health and even to life. For example, using tobacco is causally related to various forms of cancer and other diseases; cocaine kills some users; LSD and PCP can cause lasting psychotic conditions; excessive use of alcohol can cause liver damage.
Many psychoactive drugs are addictive for most people (alcohol is not addictive for most but plainly is so for some). Ordinarily, the regular, and often increasing, use of psychoactive drugs to feed addiction not only impairs functioning, and so of itself is unhealthful, but carries further risks to health.135
At a certain level, the use of many psychoactive substances allows a person to remain conscious and active but causes the lessening or loss of rational control over emotions and actions, a condition not only unhealthy but an occasion of other sins.
The use of many psychoactive substances interferes with acknowledging problems and dealing with them realistically and effectively. For example, pain relievers often mask the symptom of a disease, with the bad result that treatment is delayed; tranquilizers can reduce realistic anxieties about situations demanding effective action; alcohol use sometimes diminishes feelings of guilt about other sins.
Many psychoactive substances can reduce psychic functions and performance below the level appropriate for someone who either is engaging in particular activities or should be prepared to do so: alcohol impairs the ability to drive, pain relievers can render a terminally ill person unable to participate in the sacraments or conduct necessary business, and so on.
Some uses directly affect other people in ways they find offensive; for example, many people object to smoking.
Many uses violate laws that appear to be essentially just, and which are meant to deal with serious social problems and to limit great harm to many people. Violating these laws contributes to a more or less extensive network of criminal activities, some involving murder, kidnapping, corruption of public officials, and other very serious evils.
f) Reasons for using such substances are not always adequate. While a person might have a reason to use some psychoactive substance, in many cases the bad side effects should exclude doing so. People recovering from surgery should at times tolerate some pain so that they can exercise appropriately and cooperate in other ways in their own care; recovered alcoholics should entirely forgo the use of alcohol rather than fall back into addictive behavior. If using tobacco as a stimulant ever is rational, the financial cost, the impact on others who find it objectionable, the probability of addiction, and especially the bad effects on users’ health surely are stronger reasons for not using it.136 Some people claim that marijuana, like alcohol, can be used reasonably as a psychoactive substance, but the analogy with alcohol is questionable. Moreover, even setting aside other considerations, the social problems resulting from violating laws regarding marijuana should exclude any unlawful use.137
Some people try psychoactive substances out of curiosity, but, considering the side effects, that is a good enough reason only for someone engaged in serious research. In general, it is reasonable to accept the costs and risks of any sort of experimentation only if there are good reasons to think that it will make a real contribution to human knowledge and well-being.
Among the reasons given for using various psychoactive substances are enhancing esthetic experience, deepening intimate community, and providing a religious experience. It is true that some of these substances can be used for such purposes, for example, a limited amount of alcohol can be used to enhance a group’s social functioning. But these reasons often seem to be rationalizations, for they refer only to the felt side of intelligible goods. For instance, even if it provides an extraordinary, temporary feeling of closeness, using a psychoactive substance, unless it really contributes to functioning, does nothing to form or strengthen the commitments and real cooperation which are the core of genuine community.138
g) Self-examination is needed regarding one’s motives in this matter. Self-deception is rampant in the use of psychoactive substances. Even those who consider their use reasonable should regularly examine themselves to make sure that they actually are motivated by the reason, not some merely emotional motive. Of course, if addiction sets in, clear thinking and discernment become more difficult. So, a person should review his or her use of psychoactive substances from time to time and seek advice about it from mature friends and/or professionals who are temperate in the matter.
h) Because of bad side effects, abuse often is grave matter. In and of itself, the use of a psychoactive substance without a reason need not be seriously harmful to the user or anyone else. Hence, the immorality need only be light matter. However, accepting the bad side effects of abuse very often makes the act grave matter. In discussing the gravity of such a sin, traditional moral theology focused on the excessive use of alcohol and on only one bad side effect: drunkenness deprives one of rational control. The consequences of this loss of control also were noted: the occasions of sin it involves, and its tendency to interfere with the fulfillment of important responsibilities (see S.t., 2–2, q. 149, aa. 1 and 4; q. 150, aa. 1–2). However, other psychoactive substances often have the same effect, and several other bad side effects seem serious enough to make the abuse of a psychoactive substance a grave matter: serious risk to life or health, either directly or as a result of potential addiction, significant inconvenience to other people, violations of law that contribute to organized criminal activity, and so on. Thus, if a serious side effect is foreseen, it seems clear that any abuse of any psychoactive substance should be considered a grave matter.
Of course, as with any other form of immorality, grave matter here is one thing, mortal sin another. Habitual abuse affects clear thinking and self-control so that, with respect to many of their particular acts, alcoholics and drug addicts perhaps do not have the sufficient reflection and full consent without which there is no mortal sin (see CMP, 17.A–C). Still, as the habit is being formed, abusing a psychoactive substance can be a mortal sin even though it is a sin of weakness (see CMP, 17.D–E).
i) Alcoholics and drug addicts should seek or accept treatment. Although some people gravely abuse alcohol and/or other psychoactive substances without becoming addicted, the signs of addiction eventually do appear in many others. The abuser experiences a craving, similar to intense hunger, and regularly indulges to satisfy it. This activity no longer is incidental to eating, recreation, and so on, but becomes an important, if not the central, concern of daily life and begins to impinge on the fulfillment of responsibilities. Abusers also become increasingly preoccupied with ensuring an adequate supply, while usually they deny having any problem.
When these signs appear, family, friends, employers, and other associates should not encourage and support addicts by helping them hide their addiction and manage their lives more or less satisfactorily despite it. Instead, everyone concerned should press the addict to abandon self-deception and rationalization, admit the underlying problem, and deal with it.139
By the time alcoholics and drug addicts admit their problem, they often are unable to stop without medical treatment and other support, and in many cases probably lack moral responsibility for their addictive behavior. However, they are likely to have more or less lucid and unpressured moments, when they know they should seek help and could choose to do so. Rejecting such an opportunity can be a mortal sin even if the addictive behavior no longer is.
Those who enter into treatment should recognize that, while it can provide indispensable help, it cannot substitute for their own responsibility and effort. Follow-up is essential to avoid renewing the addiction, and Alcoholics Anonymous and analogous programs seem useful for many people. Such programs involve a series of steps toward spiritual renewal; in carrying them out, Catholics, of course, should seek sound pastoral guidance and recommit themselves to their faith and its practice, including regular and devout reception of the sacraments.140
114. Many definitions of health err on this side; for examples, see the treatment of health and disease in Ashley and O’Rourke, Healthcare Ethics, 3rd ed., 20–35.
115. James Druckenbrod, “Medical Malpractice: A Christian Ethical Perspective,” Linacre Quarterly 58 (Nov. 1991): 17–26, offers sound insight regarding the relationship between medical malpractice and distortions in the physician-patient relationship.
116. Many deny that keeping people alive benefits them when there is no prospect that they will ever gain or regain the use of their specifically human capacities. For example, Kevin O’Rourke, O.P., “The A.M.A. Statement on Tube Feeding: An Ethical Analysis,” America, 22 Nov. 1986, 322, focusing on the tube feeding of comatose persons, argues that it is useless to sustain life unless doing so helps a person to pursue “the purpose of life,” and writes: “In order to pursue the purpose of life, one needs some degree of cognitive-affective function.” Richard McCormick, “The Defective Infant (2): Practical Considerations,” The Tablet (London), 21 July 1984, 691, makes a more general assertion along similar lines: “Life is a value to be preserved precisely as providing the condition for other values and therefore in so far as these other values remain attainable. To say anything else is, I submit, to make an idol of mere physical existence.” McCormick’s question-begging dichotomy between regarding life as merely instrumental and treating it as an idol leaves no room for the truth: life is one basic human good among others.
117. Thus, John Myers, Bishop of Peoria, “Advance Directives and the Catholic Health Facility,” Origins 21 (3 Oct. 1991): 279, points out with respect to providing food and water: “Artificial nutrition and hydration are useful for the provision of nutrients and useless when they fail to provide nutrients; they are not useless when they fail to secure complete recovery from some symptom, pathology or condition extrinsic to the need for nutrients.”
118. Congregation for the Doctrine of the Faith, Declaration on Euthanasia, 4, AAS 72 (1980) 550–51, Flannery, 2:515–16.
119. For example, Pius XII, Address to an International Congress (responding to questions proposed by Dr. Bruno Haid), AAS 49 (1957) 1030, The Pope Speaks 4 (1957–58): 396, dealing with three moral questions about the use of respirators, points out that one normally is not required to use extraordinary means of preserving life, since a strict obligation to use them “would be too burdensome for most men and would render the attainment of the higher, more important good too difficult. Life, health, all temporal activities are in fact subordinated to spiritual ends.” Pius apparently means that dying patients may be spared the respirator if that will help them to make their peace with God, for he goes on at once to treat the administration of the sacraments. This teaching does not imply that there is a hierarchy of value among the basic goods considered in themselves, but that priorities among them are established by unfettered practical reason and reflected by the commitments which shape an upright person’s life; see Germain Grisez, Joseph Boyle, and John Finnis, “Practical Principles, Moral Truth, and Ultimate Ends,” American Journal of Jurisprudence 32 (1987): 137–41.
120. See Grisez and Boyle, Life and Death with Liberty and Justice, 14, 100–107.
121. For a critique of a proposed Uniform Rights of the Terminally Ill Act, see Committee for Pro-Life Activities, National Conference of Catholic Bishops, “The Rights of the Terminally Ill” (2 July 1986), Origins 16 (4 Sept. 1986): 222–24.
122. See New York State Catholic Conference, New York State’s Health Care Proxy Law: A Catholic Perspective (Albany, N.Y.: New York State Catholic Conference, 1991); The Massachusetts Catholic Conference, The Health Care Proxy Bill: A Catholic Guide (1 Dec. 1991); Medical Ethics Commission, Archdiocese of Chicago, Commentary: Illinois Durable Power of Attorney for Health Care (5 Nov. 1991).
123. With such an instruction, might not the agent refuse even ordinary means? A trustworthy agent will not automatically refuse anything, but will judge which means are extraordinary and which ordinary, all things considered, and accept ordinary means as long as there are any. When the benefit which is decisive in entitling a person to care is that it maintains human solidarity, that person (or his or her agent if so authorized) need not accept the care, since one can forgo the care without depriving oneself of human solidarity, much as one spouse, though entitled to the other’s company, may forgo it when the latter wishes to work abroad for a year. Thus, in such a case and some others, people are entitled to care which they (and authorized agents making decisions for them) are not obliged to accept. If they (or their properly authorized agents) forgo that care out of mercy, the moral goodness of their refusing it does not imply that noncompetent persons without authorized agents may be deprived of similar care: see h, below.
124. See Pius XII, Address Responding to Questions Proposed by the Italian Society of Anesthesiology (24 Feb. 1957), AAS 49 (1957) 147, The Pope Speaks 4 (1957–58): 48; cited by Congregation for the Doctrine of the Faith, Declaration on Euthanasia, AAS 72 (1980) 548, Flannery, 2:514.
125. Cf. 5.H.4, above, where this matter also is treated. See U.S. Bishops’ Pro-Life Committee, “Nutrition and Hydration: Moral and Pastoral Reflections,” Origins 21 (9 Apr. 1992): 705–12. Also see Germain Grisez, “Should Nutrition and Hydration Be Provided to Permanently Comatose and Other Mentally Disabled Persons?” Linacre Quarterly 57 (May 1990): 30–41; while others should care for such persons, those making decisions on their behalf sometimes may judge that fairness requires that the means used in their care be limited, for example, that they not be sustained indefinitely in intensive care facilities (41–42). Orville N. Griese, “Feeding the Hopeless and the Helpless,” in Conserving Human Life, ed. Russell E. Smith (Braintree, Mass.: The Pope John Center, 1989), 149–232, treats the matter in detail, using the method of classical moral theology, and arrives at similar conclusions.
126. See Daniel A. Cronin, “The Moral Law in Regard to the Ordinary and Extraordinary Means of Conserving Life,” in Conserving Human Life, 33–76. A brief history of the ordinary-extraordinary means distinction: Gary M. Atkinson, “Theological History of Catholic Teaching on Prolonging Life,” in Moral Responsibility in Prolonging Life Decisions, ed. Donald G. McCarthy and Albert S. Moraczewski, O.P. (St. Louis: The Pope John Center, 1981), 95–115.
127. Congregation for the Doctrine of the Faith, Declaration on Euthanasia, 4, AAS 72 (1980) 549–50, Flannery, 2:515, acknowledges that to say that one need not use “extraordinary” means “is perhaps less clear today, by reason of the imprecision of the term and the rapid progress made in the treatment of sickness.” The document proceeds to recommend judgment by comparison of burdens and benefits.
128. Harlap, Kost, and Forrest, Preventing Pregnancy, Protecting Health, briefly describe the variety, ease of transmission, and seriousness of many sexually transmitted diseases; for example, more than twelve million episodes occur per year in the United States (41); “following a single act of unprotected intercourse with an infected man, an estimated 50 percent of women will contract gonorrhea” (43); and “STDs can have serious health consequences for the carrier, both in the short term and in the long term” (42).
129. See Leo XIII, Rerum novarum, ASS 23 (1890–91) 660–61, PE, 115.42.
130. On medical experimentation, see Ashley and O’Rourke, Healthcare Ethics, 3rd ed., 234–41; Lino Ciccone, Salute e malattia: Questioni di morale della vita fisica (II) (Milan: Edizioni Ares, 1986), 270–319. The principles underlying the moral norms in this matter are articulated by Pius XII, Address to the First International Congress on the Histopathology of the Nervous System (13 Sept. 1952), AAS 44 (1952) 779–89, Catholic Mind 51 (May 1953): 305–13.
131. Paul VI, Address to Fifth International Congress of Psychosomatic Obstetrics and Gynecology, AAS 70 (1978) 99, OR, 1 Dec. 1977, 12; see Congregation for the Doctrine of the Faith, Instruction on Respect for Human Life in Its Origin and on the Dignity of Procreation: Replies to Certain Questions of the Day, 1.4, AAS 80 (1988) 81–83, OR, 16 Mar. 1987, 3.
132. Ciccone, Salute e malattia, 321–515, provides an extensive treatment of problems concerning drugs, alcohol, and tobacco.
133. See Pius XII, Address Responding to Questions Proposed by the Italian Society of Anesthesiology, AAS 49 (1957) 129–37, The Pope Speaks 4 (1957–58): 33–49; Pius XII, Address to the International College of Neuro-Psychopharmacology (9 Sept. 1958), AAS 50 (1958) 694–95, The Pope Speaks 5 (1958–59): 438; cf. John C. Ford, S.J., “Chemical Comfort and Christian Virtue,” American Ecclesiastical Review 141 (July-Dec. 1959): 361–79. Acute Pain Management Guideline Panel, Acute Pain Management in Adults: Operative Procedures: Quick Reference Guide for Clinicians, AHCPR Pub. No. 92–0019 (Rockville, Md.: U.S. Department of Health and Human Services, 1992), 2, states: “The obligation to manage pain and relieve a patient’s suffering is an important part of a health professional’s commitment. The importance of pain management is further increased when benefits for the patient are realized—earlier mobilization, shortened hospital stay and reduced costs. Yet clinical surveys continue to show that routine orders for intramuscular injections of opioid ‘as needed’ result in unrelieved pain due to ineffective treatment in roughly half of postoperative patients.”
134. John Paul II, Address to Youth (Montreal), 6, Inseg. 7.2 (1984) 457, OR, 1 Oct. 1984, 10, emphasizes the contrast between self-discipline and escapism, and thus implies that the criterion for the right use of psychoactive substances is service of intelligible human goods: “In times of darkness, do not seek an escape. Have the courage to resist the dealers in deception who make capital of your hunger for happiness and who make you pay dearly for a moment of ‘artificial paradise’—a whiff of smoke, a bout of drinking or drugs. What claims to be a shortcut to happiness leads nowhere. It turns you away from that intelligent self-discipline which builds up the person.”
135. National Conference of Catholic Bishops, “Pastoral Message on Drug Abuse,” Origins 20 (22 Nov. 1990): 390–92, summarizes the risks and consequences of addiction to some widely abused substances.
136. Ciccone, Salute e malattia, 502–3, argues cogently that significant, habitual use of tobacco, as against occasional light use, is grave matter, and that its basic gravity often is aggravated by circumstances. It does not argue against the truth of this judgment to point out that saints in times past used tobacco, since they did not know the effects of using tobacco. Of course, unless and until the magisterium proposes as certain a norm excluding the habitual use of tobacco, Catholics must form their consciences by personally examining the arguments.
137. Thomas C. Kane, O.P., “Current Issues in Moral Theology: The Marijuana Problem,” American Ecclesiastical Review 160 (Jan.–June 1969): 129, suggests that the smoking of a marijuana cigarette for the sake of curiosity or occasionally cannot be a grave matter, but he fails to consider whether the act is immoral in itself and ignores laws bearing on it.
138. Paul VI, Address to Persons Engaged in Anti-Drug Campaign, Inseg. 10 (1972) 1284–85, OR, 4 Jan. 1973, 3–4, points out that mystical and religious claims made for drug use are fraudulent, since people using drugs do not yield good fruits in works of charity, social service, and so on.
139. Very helpful for both the addicted themselves and others concerned: Roy Barkley, The Catholic Alcoholic (Huntington, Ind.: Our Sunday Visitor Publishing Division, 1990). Though explicitly dealing with alcoholism, much of Barkley’s analysis and advice is applicable to other addictions.
140. See New Catholic Encyclopedia, s.v. “alcoholism”; John C. Ford, S.J., "Depth Psychology, Morality, and Alcoholism," Proceedings of the Catholic Theological Society of America 5 (1950): 64-149; idem, “The Sickness of Alcoholism: Still More Clergy Education?” Homiletic and Pastoral Review 87 (Nov. 1986): 10–18.