C ATHOLIC MORALISTS today appear hesitant to speak about "quality of life." A number of Catholic hierarchs and theologians tend to avoid that expression because of public-policy debates surrounding abortion and physician-assisted suicide. In fact the term has been deployed by many hostile to traditional Christianity's views on these moral issues. While it is understandable that in today's political and cultural climate, particularly in the U.S., one might wish to avoid the term, it is important that Roman Catholic bioethicists and moral theologians recognize that quality-of-life judgments have played a central role in the traditional distinction between ordinary and extraordinary means. If we fail to understand the importance of quality-of-life judgments, we run the risk of misunderstanding that distinction and the important moral commitments it implies-all in the interests of winning a political battle.I contend that the distinction between ordinary and extraordinary means cannot be understood without quality-of-life judgments. In assessing the benefits and burdens of treatments, the distinction between ordinary and extraordinary means turns on an assessment of medical treatment relative to the patient. The judgment whether or not to pursue a particular treatment is based in part on a judgment about how a treatment will affect the quality of life for a patient, one's family, and others. Failure to appreciate this underlying framework of the distinction is a failure to understand traditional moral teaching. Such failure is partly due to an oversimplification of language found, for example, in the pro-life agenda and partly due to a modern secular view of medicine. To make my argument I will first review the history of the distinction between extraordinary and ordinary means, then analyze important elements in the distinction, and finally review several current applications of the distinction that have been made by certain sectors of the Roman Catholic episcopacy, with special attention to moral issues related to feeding and hydrating a certain type of patient.
Several recent attempts to develop models of moral reasoning have attempted to use some form of casuistry as a way to resolve the moral controversies of clinical ethics. One of the best known models of casuistry is that of Jonsen and Toulmin who attempt to transpose a particular model of casuistry, that of Roman Catholic confessional practice, to contemporary moral disputes. This attempt is flawed in that it fails to understand both the history of the model it seeks to transpose and the morally pluralistic context of secular, postmodern society. The practice of casuistry which Jonsen and Toulmin wish to revive is a practice set in the context of a community with a shared set of moral values and structures of moral authority. Without a set of common moral values and rankings, and a moral authority to interpret cases the casuistry of the postmodern age will be pluralistic, that is, there will be many casuistries not just one.
During the past decade there has been a debate about the field of philosophy of medicine. The debate has focused on fundamental questions about whether the field exists and the nature of the field. This article explores the debate and argues that it has paid insufficient attention to the social dimensions of both philosophy and medicine. The article goes on to argue that by exploring this debate one can better understand some of the difficult questions facing contemporary medicine and health care.
Bioethics has focused on the areas of individual ethical choices--patient care--or public policy and law. There are, however, important arenas for ethical choices that have been overlooked. Health care is populated with intermediate arenas such as hospitals, nursing homes, hospices, and health care systems. This essay argues that bioethics needs to develop a language and concepts for institutional ethics. A first step in this direction is to think about institutional conscience.
When many people think of bioethics, they think of gripping issues in clinical medicine such as end-of-life decision-making, controversies in biomedical research such as that over work with stem cells, or issues in allocating scarce health-care resources such as organs or money. The term “bioethics” may evoke images of moral controversies being discussed on news programs and talk shows. But this “controversy of the day” focus often treats ethical issues in medicine superficially, for it addresses them as if they could be examined and discussed in isolation from the context in which they are situated. Such a focus on the latest controversies fails to take into account that medicine is a social institution and that the controversies in bioethics often reflect deeper social and moral issues that transcend the boundaries of medicine and ethics. If one moves beyond the issue-of-the-day approach to bioethics, one can see that the field must address these deeper issues.
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