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Catholic Medical Education Must Bridge the Bifurcation Between the Church's Mores and Those of Secular Society

Dr. Pellegrino is director, Center for the Advanced Study of Ethics, Georgetown University, Washington, DC.

Unlike their parent universities, the world's Catholic medical schools have remained largely aloof from the neuralgic questions of Catholic identity. They have been content to equate their Catholic identity with provisions for celebration of the liturgy, observation of the Religious and Ethical Directives for Catholic Health Facilities, and a general declaration that they are "under Catholic auspices." They have thus straddled the bifurcation between the mores of the Church and those of secular society. As a result, in fact, they can be classified with equal justification as quasi-Catholic or quasi-secular.

For a number of good reasons, this comfortable accommodation is unlikely to persist. For one thing, the unprecedented power of medical technology over the beginning and ending of life propels medical schools directly into the ambit of the most difficult questions in moral theology. For another, Catholic medical schools are under increasing pressure from a secular society, and an increasingly pluralistic faculty and student body, to adapt to contemporary mores. Finally, Pope John Paul II's "Ex Corde Ecclesiae: The Apostolic Constitution on Catholic Universities," while not explicitly mentioning medical schools, certainly cannot exclude them.¹ Medical schools are as intensively engaged as any part of the university in the dialogue with contemporary culture that is so central to the intellectual apostolate he espoused in "Ex Corde" and other writings.

For the first time in their history, Catholic medical schools must confront the parlous identity questions: What discernible difference does it make to be a Catholic medical school? In what does its distinctiveness reside? Are those distinctions compatible with academic credibility and excellence as a medical school?

If there is something distinctive about being a Catholic medical school, it should be detectable in the way it conducts the ordinary activities proper to a medical school. It must, in effect, give witness to the way fidelity to the Gospels and Christian teaching shapes its teaching, research, and patient care. As Pope Paul VI pointed out to the laity, "Contemporary man listens more willingly to witnesses than teachers, or if he listens to teachers, it is because they are witnesses."²

What Catholic Identity Does Not Mean
What are some of the marks a Catholic and Christian identity would confer on a medical school? How would it give witness to this identity? Let us begin by disposing with the usual misconceptions about what being a Catholic institution entails.

First, a Catholic medical school must not be an exclusive Catholic enclave. This would defeat its evangelical purpose by severely limiting its dialogue with a variety of cultures. A Catholic medical school should admit students of all faiths and cultures who might wish to come to a school unequivocal in its identity and values. This is true of faculty, as well as students. In my experience many non-Catholics come to Catholic universities precisely because of the values they profess, even if they do not share them. Indeed, many of our non-Catholic students, faculty, and colleagues are critical of our failure to live up to the ideals we profess.

Second, teachers in such a school are not expected to interject religion or Christian ethics into every class discussion. They are not preachers. Where ethical and moral issues are pertinent, they should be discussed like any other classroom topic—openly, fairly, accurately, and with opportunity for discussion and dialectic. Religious issues should not be forced into a discussion. There is no such thing as "Catholic" molecular biology or "Catholic" cardiovascular surgery. But there is a Catholic perspective on the meanings of data derived from all academic studies or clinical decisions when they impinge on moral, religious, and ethical questions. Evaluation of courses and teachers must rest on their excellence, not on their piety or theological correctness. This is an error Catholic institutions have, we hope, left behind.

Third, a medical school with a clear Catholic identity is not primarily an agent of the local Church for proselytization of its students or patients. As "Ex Corde" emphasizes, "The Church . . . recognizes the academic freedom of scholars in each discipline in accordance with its own principles and proper methods and within the confines of the truth and the common good."³ A medical school that undertakes its proper part in the Church's evangelizing mission cannot, however, determine for itself the content of that evangelization. This is to mistake autonomy for usurpation of legitimate ecclesiastical authority. Fulfilling what is uniquely its function and responsibility as a medical school is how it can best give witness to its Christian character.

Catholic Identity in the Medical Center
Let me turn to some of the positive ways a Catholic character shows itself in a medical center's daily activities.

Declaration of Catholic Identity A Catholic medical school must publicly declare its religious and moral values and its intent to provide witness to those values in all its operations. Its avowed aim should be to provide a Catholic-Christian milieu for teaching, research, and patient care. Such a public declaration provides a clear standard of expectation and performance against which the school and those outside the school may measure its authenticity. It enables prospective students and faculty to accept or reject a school, which avoids subsequent allegations of deception.

Sufficient Catholic Representation A Catholic medical school should be open to all students and faculty who wish to join it. But all must understand that the school intends to be faithful to its intellectual and moral heritage and responsive to proper ecclesiastical authority in those areas where such authority is appropriately exercised. To ensure fidelity to its mission, some critical mass of students and faculty must be Catholic. A school cannot impart that "fusion of faith and culture," of which John Paul II has often spoken, without a sufficient number of teachers who have achieved that fusion in their own lives. This will require of current and prospective faculty members something more than a nominal commitment to Catholicism and Christianity.

Precisely what proportion of students and faculty should be Catholic is problematic. An exclusively Catholic faculty and student body ghettoize a school and curtail its dialogue with the ambient culture. An insufficient Catholic representation makes a genuine and visible Christian witness difficult to maintain. Given the preponderance in the number of secular medical schools, their relative indifference or antipathy to religion, and the still-inadequate number of Catholics in academic and research positions, there seems little current danger of Catholics oversaturating a medical school. The first criterion for faculty recruitment must, as always, remain the quality of a candidate's teaching and research. Where two candidates are more or less equivalent by the usual academic standards, giving preference to a committed Catholic or Christian seems a necessary course if a Catholic character is to be preserved.

Courses in Medical Ethics The importance of personal witness does not eliminate the need for formal instruction in the intellectual foundations of Catholic and Christian medical ethics. In my experience, medical students, even those from Catholic universities, are rarely even modestly cognizant of the Catholic medicomoral tradition. Catholic medical schools must require their students to take courses in Catholic medical ethics, taught by persons trained in Catholic and Christian theology or philosophy.

Even this kind of formal instruction should be firmly grounded in concrete, clinical cases. Medical students quickly lose interest in any subject taught abstractly. But they cannot claim theology or ethics are irrelevant if they are taught using actual cases of the kind they encounter daily. If the instructor begins by introducing a case, students can examine the principled foundations for making the clinical decision. Students will find that being a Catholic influences how they believe a case should be managed. Student acceptance of the practical importance of a Catholic and Christian perspective on medical ethics is best when philosopher and theologian teach cooperatively with respected clinicians around a genuine—preferably current—clinical case.

More Emphasis on Patient Care A Catholic medical school should be especially sensitive to its corporate, moral responsibilities—to the trust society places in it as the only place where qualified physicians can be trained. Medical schools must ensure that teachers are competent and that evaluations of students, faculty, and staff are just. The welfare of all patients must be carefully safeguarded. Faculty supervision of residents, as well as patients in students' care, must be more assiduous than in most schools today. Patient care must come before educational need. Although all this is required as a moral obligation of any medical school, it is quintessentially the case for Catholic medical schools, which must be judged by the test of charity, as well as justice and law.⁴

An Example of Virtue A truly Catholic medical school should take responsibility for its students' character formation—at least as it pertains to patient care. All medical ethics finally rest on the physician's moral character. In those moments of clinical decision, when no one is watching, the physician's character is the patient's last safeguard. Moral character and virtue are not taught by lectures, but by example and institutional standards. In a Catholic school, the institution and its members must be inspired by the example of Jesus and the Sermon on the Mount. This is an ideal few could approach except asymptotically, but aspiration to this high ideal should vitalize a truly Catholic institution.

The Christian virtues and the natural virtues are traits teachers must themselves exhibit. This places awesome, but inescapable responsibilities on Catholic and Christian faculty members—especially clinicians. Young physicians mimic both the bad and good habits of faculty members whom they wish to emulate. Faculty members who fail to fulfill their responsibilities and who mistreat patients, students, or staff fail in the virtue of charity. They cannot be ignored or excused in the name of autonomy or protection of confidentiality. They deserve a fair hearing before their peers, but a medical school cannot escape its social responsibility for the character of those it permits to carry responsibility for the lives of others, either as students or as faculty.

To knowingly graduate a student who is patently dishonest or grossly insensitive to patients or colleagues is to fail in moral stewardship. In a Catholic medical school, beneficence and effacement of self-interest are de facto primary virtues. Obviously, giving witness to the Gospel extends well beyond the classroom into every phase of institutional life such as the way university-affiliated hospitals care for the poor and uninsured; advocate for justice in the distribution of healthcare; eschew the many morally marginal profit-making practices that flourish in our market-orientated healthcare system; and compensate their faculty. These are areas in which current medical school practice is often embarrassingly and even egregiously deficient.

Beyond the Minimal Requirements This is not the place to develop a complete vade mecum of genuine Christian witness. These examples only underscore the fact that the ethics of the Catholic medical school, hospital, or faculty member must go beyond the minimal requirements of today's professional ethos. Every element of that ethos must be modulated by the ordering principle of charity.⁵ This modulation is the distinctive mark of a Catholic medical school.

Linking Science And Religion
Would such a frank statement of Catholic identity and the implication it carries for recruitment, character formation, and clinical teaching be a violation of academic freedom as it is currently construed by the academic establishment—specifically the American Association of University Professors (AAUP)? Michael W. McConnell has recently summarized cogent arguments to show that the preservation of religious institutions requires some accommodation of the secular definition of academic freedom.⁶ Without such accommodation, secular, as well as religious, institutions would be the losers. He supports the AAUP 1940 statement that allows religious institutions to define the conditions of academic freedom consistent with their interpretation of the needs of their mission. The one proviso, with which I agree, is that these conditions be set forth in advance in a clear, public mission statement.

A Catholic medical school that attends assiduously to the dimension of Christian charity in everything it does would give a most powerful witness to what difference it makes to be Catholic. It would automatically be an evangelizing force. But it has a more specific evangelizing opportunity related to contemporary medicine. It lies in the challenge Card. John Henry Newman gave his medical students in 1858—to be "links" between science and religion.⁷

In Card. Newman's time, medicine's capabilities for such a role were limited. Today, medicine has an enormous, unrealized potential for responding to this challenge. Medicine now stands squarely at the confluence of molecular biology, technology, and ethics. It offers to theology a rich source of facts about the existential states of suffering, pain, illness, death, and dying. It offers to biology data on the way these same existential states affect the chemical and physiological workings of body and psyche. Medicine forces us to see ourselves as ontological entities and as persons, since healing means "to make whole again" (i.e., to reassemble the unity fractured by illness). If, as John Paul II says, "what is at stake is the very meaning of the human person,"⁸ the dialogue with today's culture cannot be entered into without medicine's participation.

Medicine can be the primary link between theology and science. It puts biology into ethical perspective and theology into scientific perspective.⁹ Through this linking function, it can evangelize human cultures, which today look to medicine for a solution to a wide array of problems. Medicine is the vehicle through which much of the knowledge of modern biology is translated into societal aspirations. Medicine can be the university's most fruitful point of contact with culture and, thus, with evangelization.

Establishing a Bond with the Church
If any of this is to be a reality, ecclesiastical authority and Catholic schools must establish a better bond of trust. Each has authority in its own realm, but each holds that authority in trust and is obliged to use it wisely and well. To remain Catholic, medical schools must recognize the authority of the teaching Church in the moral, spiritual, and ethical dimensions of the truths it pursues. Medical schools must, indeed, avoid the pretension and radical sophism of taking any truth they discover to be ipso facto morally licit, as Card. Newman warned. Technical prowess without moral constraint allows humanity's creations all too often to overwhelm humanity itself.

On the other hand, the Church must not fear research into the full complexity of the human organism—psychic or somatic. The Church must appreciate that customarily, when new truths are uncovered in one field, they may seem for a time to contradict truths in another. But truth is always one, and contradictions will eventually be overcome. Card. Newman urged both scientists and theologians to have a "great and firm belief in the sovereignty of truth." "The only effect of error," he said, "was to promote truth."¹⁰ If this mutual stewardship of authority in trust is to be a reality, there needs to be better and more frequent consultation and communication between the world's Catholic medical schools and the official Church. Some permanent commission or council updating Church theologians on the state of science, and scientists on the state of Church teaching, is definitely in order.

The world's Catholic medical schools today stand in turbulent waters where the powerful currents of Christian morality and scientific possibilities converge. Their difficult task is to bridge the turbulence, as Card. Newman and, more recently, John Paul II have called on them to do. Catholic medical schools can do so only by being credible simultaneously as medical schools and as witnesses to Christian teaching. If they succeed, Church and society will benefit. If they fail, Catholic medical schools will either become totally secular or completely out of touch with contemporary life. In neither case could a cogent justification be made for their continued existence.

NOTES

1. John Paul II, "Ex Corde Ecclesiae: The Apostolic Constitution on Catholic Universities," Origins, October 14, 1990, pp. 265-276.
2. Paul VI, "The Witness of the Laity," October 2, 1974, The Pope Speaks, Winter 1975, pp. 220-223.
3. John Paul II, p. 271.
4. Edmund D. Pellegrino, "Philosophy and Ethics of Medical Education," from Warren T. Reich, ed., The Encyclopedia of Bioethics, 2d ed., Free Press, Riverside, NJ, 1978, pp. 863-869.
5. Edmund D. Pellegrino, "Agape and Ethics: Some Reflections on Medical Morals from a Catholic Christian Perspective," Catholic Perspectives on Medical Morals, Kluwer Academic Publishers, Norwell, MA, 1989, pp. 277-300.
6. Michael W. McConnell, "Academic Freedom in Religious Colleges and Universities in Freedom and Tenure in the Academy: The Fiftieth Anniversary of the 1940 Statement of Principles," Law and Contemporary Problems, Summer 1990, pp. 303-324.
7. John Henry Newman, The Idea of a University, Image Books, Garden City, NY, 1959, p. 463.
8. John Paul II, p. 268.
9. Edmund D. Pellegrino, "Science and Theology: From a Medical Perspective, Research in Clinical Ethics," Linacre Quarterly, November 1990, pp. 19-35.
10. Newman, p. 431.