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BY: FR. THOMAS A. NAIRN, OFM, Ph.D.

I remember going in a near panic to one of my ethics professors, early in my doctoral studies. My fellow students in his seminars seemed to be talking in a foreign language. The concepts and authors they discussed so easily were not part of my vocabulary at all. I was sure that I had gotten in way over my head and that I probably was never meant to be an ethicist.

In his usual unruffled way, my professor told me to stay calm and to realize that what I was hearing may well have been a new language. He added that the task for my first year of doctoral studies was to learn that language — the discourse of theological ethics.

Those of us who are facility or system ethicists can probably appreciate the truth of what my professor was saying. The terms we commonly use in ethics — especially in Catholic health care ethics — can be a foreign language to many of our colleagues in health care. The technical jargon can seem strange to those who are not part of the discipline. Even worse, because some of the words we use also have common, nontechnical definitions, it is easy to think that if one is familiar with the common usage of the term, one understands the term correctly in its theological sense.

The differences in definition can become a source of misunderstanding. It therefore seems to me that we ethicists need to be engaged in the task of translation — informing our colleagues of the technical meaning of these concepts — especially when a technical term as used in Catholic ethics is also a common word in English. I would like to look at a few of these terms and show how the theological meaning differs — at times significantly — from common English usage. I also invite any of you to send me your suggestions for similar misunderstood terms. Establishing a glossary of such terms might be of help to the ministry.

COOPERATION AND SCANDAL
My colleague Ron Hamel, Ph.D., and I devoted recent columns in Health Progress to investigating two such terms, cooperation and scandal. In Catholic moral theology, the term cooperation is not a synonym for collaboration. Rather, it is a shorthand term for "cooperation in the wrongdoing of another." The moral tradition has developed a set of principles to distinguish legitimate cooperation in such wrongdoing from forms of cooperation that are forbidden.¹

Similarly, the Catholic moral tradition uses the term scandal, but not to describe a person's shock or displeasure over the inappropriate actions of another. Rather, as the term is used in the Catholic moral tradition, scandal denotes that by one's wrongdoing — or what is interpreted by another as wrongdoing — one leads another into doing what is wrong.² Both of these concepts are difficult to apply, and for this reason the Ethical and Religious Directives for Catholic Health Care Services (ERDs) caution that "reliable theological experts should be consulted in interpreting and applying the principles."³

ORDINARY AND EXTRAORDINARY MEANS
Another set of terms often misunderstood in health care today involves the distinction between ordinary means and extraordinary means of conserving life. This nomenclature, developed over 400 years ago, distinguishes between those interventions that are considered mandatory, especially for end-of-life care, and those that are not. The tradition has been clear that the criteria for determining whether a medical intervention should be considered ordinary means or extraordinary means depend upon an assessment of the benefits and burdens of the intervention for the sick individual.

With the rise of new and more complicated medical technologies, however, many patients and families — and even some physicians — have come to equate extraordinary means with complex or experimental medical technologies. The ERDs are clear, however, that it is not the "extraordinariness" of the technology but the burden or benefit to the patient that is the deciding factor:

While every person is obliged to use ordinary means to preserve his or her health, no person should be obliged to submit to a health care procedure that the person has judged, with a free and informed conscience, not to provide a reasonable hope of benefit without imposing excessive risks and burdens on the patient or excessive expense to family or community.⁴

Quite "ordinary" medical treatments can therefore be "extraordinary means" in the theological sense of the term if they do not provide a reasonable hope of benefit without imposing excessive risks and burdens on the patient or excessive expense to family or community.

DIGNITY, COMMON GOOD, RIGHTS
The last set of concepts comes from the Catholic social tradition. However, because the terms human dignity, common good and rights have been so widely used in political discourse, it can be especially difficult to communicate their precise theological meaning to our colleagues.

Much of secular bioethics has been rather critical of the notion of dignity. For example, Ruth Macklin, Ph.D., professor of bioethics at the Albert Einstein College of Medicine in the Bronx, N.Y., has referred to it as a "useless concept," suggesting that "appeals to dignity are either vague restatements of other, more precise, notions or mere slogans that add nothing to an understanding of the topic."⁵ She has suggested that appeals to human dignity should be replaced simply by calls for respect of individual autonomy. This linking of dignity with autonomy has become commonplace in contemporary America, as can be seen in the so-called "Death with Dignity" movement's equating dignity with the right to choose when and under what circumstances one will die.

In the Catholic tradition, however, respecting dignity demands more than merely respecting autonomy: "The whole of the Church's social doctrine … develops from the principle that affirms the inviolable dignity of the human person."⁶ This religious understanding of dignity, however, cannot be understood in an individualistic sense. The dignity of the person arises from the fact that he or she is created in the very image of God.⁷ As we acknowledge God as Trinity, we also acknowledge that the human image of God is necessarily social and relational. The Second Vatican Council taught that "there is an inescapable duty to make ourselves the neighbor to every person, no matter who he is, and to come to his aid in a positive way … calling to mind the words of Christ: ‘As you did it to one of the least of these my brethren, you did it to me.'"⁸ Ethicist and internist Daniel Sulmasy, MD, Ph.D., has succinctly shown the importance of the Catholic understanding of dignity for health care:

Why should anyone pick a homeless schizophrenic up off the streets of Newark? One does so for the same reason that one picks a Wall Street executive up off the floor of the private bathroom in his office suite: because he or she has intrinsic human dignity. He or she has worth or value, despite whatever situation or situations have placed that dignity at risk. That is to say, each has dignity despite having become vulnerable. . . . When society has called the intrinsic dignity of a class of persons into question, they enter the health care system already vulnerable, and health care professionals will be preconditioned to regard them as unworthy of their service.⁹

A second misunderstood concept is that of the common good. For some, a libertarian notion of the individual and individual freedom gets in the way of appreciating this term's nuances. Appeals to the common good can sound like either socialism or a utilitarian calculus of the "greatest good for the greatest number." The foundation for the Catholic understanding is community, not individualism, yet it includes respect for the individual: "Life together in society, in the network of relationships linking individuals, families and intermediate groups by encounter, communication and exchange, ensures a higher quality of living. The common good that people seek and attain in the formation of social communities is the guarantee of their personal, familial and associative good."¹⁰ The Catholic tradition defines the common good as "the sum of those conditions of social life which allow social groups and their individual members relatively thorough and ready access to their own fulfillment."¹¹ Thus the dignity of the individual is nourished by respect for the common good, which itself is properly understood in terms of individuals and social groups having access to their own fulfillment.

With this emphasis on community and the common good, it should not be a surprise that the Catholic social tradition provides a nuanced understanding of "rights" that differs from that of Western society. In the United States, we tend to understand rights as entitlements or legally protected claims an individual makes against other individuals or against society. In the Catholic tradition, however, rights are not claims one autonomous individual makes upon others but rather those social conditions needed for the realization of human dignity. The Catholic tradition offers a more complicated, but at the same time a richer, conception of rights, founded upon both human dignity and the common good, stemming from the social nature of the person. The tradition can therefore speak of health care as a right because health care safeguards human life and dignity.¹² Such a right needs to be protected in a living community, and — because the church understands society as such a living community rather than a group of autonomous individuals — it can ask that a society ensure that its citizens have access to health care.

Each of these notions arises from a communitarian understanding rather than a more individualistic one as commonly understood in the United States. The task of the ethicist remains that of translating these nuances for our colleagues and of demonstrating the importance of understanding these nuances for Catholic health care.

FR. THOMAS A. NAIRN, OFM, Ph.D., is senior director, ethics, at the Catholic Health Association, St. Louis.

1. See Ron Hamel, "Cooperation: A Principle that Reflects Reality," Health Progress 93, 5 (September-October 2012): 80-82.
2. See Thomas Nairn, "Just Because It Shocks Doesn't Make It Scandal," Health Progress 93, 6 (November-December 2012): 72-75.
3. United States Conference of Catholic Bishops, Ethical and Religious Directives for Catholic Health Care Services, Fifth Edition (Washington, DC: USCCB Publishing, 2009), Introduction, Part Six.
4. Ethical and Religious Directives, Directive # 32. Emphasis added.
5. Ruth Macklin, "Dignity is a Useless Concept," BMJ 327 (December 20, 2003): 1419.
6. Pontifical Council for Justice and Peace, Compendium of the Social Doctrine of the Church (Vatican City: Libreria Editrice Vaticana, 2004), para. 107.
7. See Genesis 1:26.
8. Second Vatican Council, Pastoral Constitution on the Church in the Modern World, para. 27. The Constitution quotes from Matthew 25:40.
9. Daniel Sulmasy, The Rebirth of the Clinic: An Introduction to Spirituality in Health Care (Washington D.C.: Georgetown University Press, 2006), 40.
10. Compendium of Social Doctrine, para. 61.
11. Pastoral Constitution on the Church, para. 26.
12. See Pope John XXIII, Pacem in Terris, para. 11.