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On Teaching the Virtue of Courage and the Value of Suffering in Catholic Medical Education

Sarah Fougerousse Tiller, MST

Two of the biggest challenges in providing education for those involved in Catholic Healthcare are fostering the courage to uphold the teachings of the church on moral responsibility and conveying the necessity of living righteously even in the face of great pain. "If need be, a Catholic university must have the courage to speak uncomfortable truths which do not please public opinion, but which are necessary to safeguard the authentic good of society."1

1. The object of a Catholic University

"Medicine is an eminent, essential form of service to mankind. It is necessary first of all to help man to live and to surmount the handicaps which impair the normal functioning of all his organic functions, in their psychophysical unity. Man also is at the center of the preoccupations of the Church whose mission it is, by the grace of Christ, to save man, to restore him in his spiritual and moral integrity, to lead him toward his integral development where the body has its part. This is why the ministry of the Church and the witness of Christians are united in their solicitude for the sick."2 A healthcare provider may be tempted to put combating suffering over the correct ethical choice because of the compassionate nature of the profession. The urge to prescribe contraceptives for a destitute couple may be strong but counseling on natural family planning is the truly respectful choice.

John Paul II sums up the task at hand: " Since the objective of a Catholic university is to assure in an institutional manner a Christian presence in the university world confronting the great problems of society and culture, every Catholic university, as Catholic, must have the following essential characteristics: "[1]. A Christian inspiration not only of individuals but of the university community as such; "[2]. A continuing reflection in the light of the Catholic faith upon the growing treasury of human knowledge, to which it seeks to contribute by its own research; "[3]. Fidelity to the Christian message as it comes to us through the Church; "[4]. An institutional commitment to the service of the people of God and of the human family in their pilgrimage to the transcendent goal which gives meaning to life."3

2. The Pedagogical Challenge

An interesting insight into ethical reasoning is best explained by the concept of craft in Alasdair MacIntyre's theory of traditions: craft is the intertwining of one's personal potential, of a master's teaching and of practice, leading to excellence in a chosen field. If Ethics is a craft we must look to the knowledge of the natural law, within ourselves, as the guideline to develop our potential to live freely well. We are guided by those we hold in relationships of true friendship and sincere love and strengthened in knowledge and resolve by acting in a way that is good, as these elements compliment each other, like fields of color on the canvass of a painting, the subject working with them is called upon to define them, understand them more clearly, just as a painter uses ever more precise strokes of his brush.

In order to learn a craft it is fundamental to become an apprentice, just as it is fundamental in moving toward knowledge of ones good and the Good to become a certain type of person. If we allow ourselves to be lazy, unquestioning and selfish it will become harder and harder to see what is good and even harder to follow it. The tragedy is that we can so clothe ourselves in ignorance and sin that we no longer want what is good and truly lose the ability to be sorry for our errors and rectify them. It is this realization that hits with its full force at the end of Marlowe's Faust. When Faust is swept away screaming that he is sorry it is not too late to repent, but he has lost the ability to truly do so.

We must devote attention to what we become during our lives, what toll our actions take on us at the deepest level. This calls for an external standard, because we can always make excuses for ourselves, pass the blame and shrug off the need to make amends. We cannot choose wrongly, and persevere in that choice, without affecting ourselves, without becoming what we choose. Our freedom is indeed frightening, but it is also our hope, our chance to acquiesce to a far greater reality.

In assuming the role of apprentice in a craft one must learn two basic distinctions. The first of which is the difference between what is a truly good course of action in a particular situation and what seems good to a particular apprentice. The second distinction is between what is good and best for me as an apprentice with my training and what is good and best ultimately. If I were to jump into a pond to save a drowning man, without knowing how to swim it would be futile at best, just as undertaking too great an endeavor without the moral fortitude would result in discouragement. True rules and virtue are never in conflict, but if we focus entirely on the former, the latter, more fundamental and worthy of pursuit, can become lost.

Our choices clarify the eternal, revealing first one aspect, then another of the whole, until we are able to face it, to the total extent of our limited being. If I choose to love a person, personal good comes into light, if I choose to act justly, justice becomes clearer, thus, showing us more and more completely what good is.

What then is the craft that we are mastering? We are not augmenting what is good and best in the world, because only God can do that: we are bettering ourselves, the only thing we are truly responsible for. This is not selfish, it is not as if it cancels out our actions, but it does place them in a secondary relationship to our true call. The only evil we have the power to fight, and veritably the only true evil is moral evil, we are not meant to focus exclusively on righting states of affairs. The focus is personal rather than historical.

John Paul II poignantly contrasts the difference between erroneous (and in this case lethal) social policy and the personal responsibility to form ones conscience when he writes: "In the context of the numerous and violent attacks against human life today, especially when it is weakest and most defenseless, statistical data point to a veritable "slaughter of the innocents" on a worldwide scale. A source of particular concern, however, is the fact that people's moral conscience appears frighteningly confused and they find it increasingly difficult to perceive the clear and definite distinction between good and evil in matters concerning the fundamental value of human life."4 Hence in teaching Christian Ethics, we must stress the personal duty of forming the conscience and the significant hindrances to this formation of both cowardice when threatened with ostracism by the world and the natural tendency to avoid suffering.

3. The Anatomy of an Act

The problem with seeing ethics as a technique is that the skills of acting effectively may be exercised to achieve something that is not good. Machiavelli’s statecraft comes to mind, the will to obtain and hold political power in order to bring about stability and prosperity seems noble enough until the sacrifice of virtue becomes glaringly apparent. Means to be chosen are not so insignificant as to be interchangeable and indifferent, they also must be examined in and of themselves.

What constitutes a moral 'unit' of an act is, in fact, a question. Is this action merely a phase in a larger structure? Conditions and circumstances are far from indifferent, although this is not to advocate 'situation ethics.' This question is a fundamental part of moral dilemmas. Concretely, am I to go into counseling pregnant women in a secular institution about whether or not to abort, knowing that I may prevent it, but also that if they leave unconvinced I must sign a paper, which they need to terminate the pregnancy, saying they received counseling? What is the structure of this act? Does it stop with counseling or with signing a slip of paper that states what went on, with the truthful intent to enter a hostile environment and reach women who otherwise might be pushed to terminate their pregnancy? Does it extend to the abortion itself? It is the question, to put it more classically, of material cooperation and it underscores the necessity not only of avoiding the conception of morality as a mere procedure, a technique, but also of the virtue of prudence.

In this context Spaemann’s distinction between prediction and intention in Zur Kritik der Politischen Utopie becomes fundamental.5 Prediction is the ability to foresee more consequences than those which are strictly dependent on the person who acts. Intention is the selection of one of those consequences as a primary willed end. In a hierarchy, Speamann explains, those consequences that are intentional are more closely a part of the action than those predicted and taken into account. Responsibility extends more tangentially to those consequences that are not predicted. He goes on to make the point that our ability to rein in the unwanted consequences of our actions may be seriously undermined by our current technical abilities. This is singularly apparent in the fields of medical and biological ethics.

4. Medicine at the Service of Dignity

"The domain of deontology may appear, especially today, as the most vulnerable in the field of medicine, but it is essential, and medical morality should always be considered by practitioners as that norm of their professional practice which deserves the most attention and, above all, the greatest efforts in its defense. It is evident that the extraordinary and rapid advance of medical science entails frequent rethinking of its deontology. You are necessarily confronted with new questions which are stimulating but very delicate. With this the Church is in full sympathy, and it willingly supports your reflection, in its respect for your responsibilities. The search for a satisfactory position on the ethical level, however, depends fundamentally on one's basic conception of medicine itself. What must be established definitively is whether medicine is, indeed, at the service of the human person, or his dignity, of what he has of the unique and of the transcendent, or whether medicine is considered, first of all, as the agent of the community, at the service of the interests of those in good health, to whom the care of the sick would be subordinated."6

The mere exercise of a procedure does not determine good; this is, in fact, the fallacy of procedural concepts of justice, such as Rawls'. It is not sufficient to impartially apply certain rules to a situation, because the outcome could be unjust to the same extent that it might be just. Insight and penetration of the situation are necessary to discern the good and follow it. Often enough a judiciary system is concerned only that a trial was impartial, the minimum was respected and the system does not propose to question the outcome -- justice can be lost in the sequence of an impersonal mechanism set into action.

This is diametrically opposed to the way things should work. It is rather the person that should be uplifted and further clarified in his/her ethical dimension by the process of practical reasoning. As MacIntyre states in Three Rival Versions of Moral Enquiry: "what we grasp initially in understanding the binding force of the precepts of natural law are the conditions for entering a community in which we may discover which further specifications our good has to be given."7

In a societal context, a social structure, we come to understand our individual good more fully. There is no place in this idea for an exasperated individuality, we need others, to the extent that we need mentors, but also as a paradigm for what we must cherish and foster in ourselves, in the way of virtues. Thus, the negative norms of the natural law, embodied in moral absolutes are entwined with the positive values seen in friendship, or other positive relationships, such as admiration and love. As Max Scheller would have it, these values are 'mobile,' they can change and grow; they plumb the depths of possibilities, which rules alone can never fulfill. In exercising our liberty these values become evident; the fullness of generosity or the depth of compassion pale when simply described or imagined.

There are, however, universally valid negative norms, they ensure that an action that destroys a good as its primary object is never condoned, the end is never to abolish what is good. These norms must be reflected in society to the extent that an ethical minimum is respected. This is, to some degree a slippery question, but it becomes more concrete when analyzed from the point of view of society. Any action which destroys the very basis of society, voids its function, cannot be permitted. For example, freedom and its protection require that all men who are willing to live in harmony must be free to participate in society -- slavery is not an option. The life of every member must be protected; it is so basic a good that without it all others are superfluous (though they may be higher if placed in a hierarchy) for society cannot exist without live human members!nnThe challenge that a Catholic medical school faces is succinctly identified as follows: "An area that particularly interests a Catholic university is the dialogue between Christian thought and the modern sciences. This task requires persons particularly well versed in the individual disciplines and who are at the same time adequately prepared theologically, and who are capable of confronting epistemological questions at the level of the relationship between faith and reason. Such dialogue concerns the natural sciences as much as the human sciences which posit new and complex philosophical and ethical problems."8

5. The Value of Suffering and the Courage to Teach It

What is to be confronted in order to convey the moral teachings of the Church, what acts as an obstacle far greater than intellectual controversy? The answer to this question is two-fold, on one hand the phenomenon of human suffering and on the other the need for courage, where modernity teaches us constantly to take the path of least resistance. These are the two tasks that we must face:
  1. To foster courage.
  2. To teach the positive evaluation, the significance of suffering.

Fortunately Catholics have a rich Tradition from which to do so.

The experience of pain is so personal that it defies an attempt to universalize it. What we can say on a universal level about it is true, but it does not capture the full significance of the experience. Nor does it penetrate to its core. No matter what the level of intimacy that brings empathy to a situation (a suffering spouse or grieving friend), when we suffer we are ultimately alone on the inter-personal level -- sympathy is comforting but it cannot actually bridge the gap to pain. Pain does not unite, it draws the sufferer into him or herself. In pain we are bereft of the world. In the light of faith this can be good, it allows us to gain a new perspective, perceive what is truly relevant, but without God it is an emotionally crippling experience.

Suffering is elusive, remembering what it really feels like to be in excruciating pain is difficult. But it leaves a hollowness, a turning away. On a day to day basis our experience of many correct choices is bound with pain: carrying an unwanted pregnancy to term, not finding a new companion after an annulment has been denied, living with no hope of recovery and degenerative illness. These are personal battles, where the right choice is inevitably wedded with pain.

Pain penetrates and lays bare the core of the human person, we don't lie to ourselves in pain. There is no secondary motive in persevering in a situation linked to suffering, we are doing what we do simply because it is just. Suffering lays bare the structure of our existence; we are not always in control, for we are contingent: to the human mind that is a terrible truth.

We naturally shy from suffering, but the ancient realization that it brings wisdom, offers insight into its positive nature. Acknowledging this is not sufficient, however, we must foster and promote the kind of courage that helps bear it. It is not simply a stoic attitude in the face of pain, but rather a coming to grips with how we can grow when faced with suffering. It is courage that allows us to see suffering, not as an extrinsic element of existence, but as another pattern woven into the threads of life. We ask, 'why me'? when we suffer, but never when we are experiencing bliss, though the one is just as integral to life as the other.

It takes a formidable sort of courage to act in the face of tragedy, both personal and implicating others -- but it takes a far more awesome courage to act well, knowing that our choice will bring pain and be condemned by our peers. This is directly opposed to the ancients' love of glory, acting so as to be esteemed and remembered. It is acting in the face of something that will never be popular, because it is so frightening. The world's reaction to such choices is abandonment and, in a sense, this could not be more fitting because we ultimately stand alone in our duties and responsibilities, but also in our capacity to love. No one can love for us, it cannot be delegated.

So in order to reach those who are struggling with dilemmas we must first confront two issues, that of suffering and that of courage. If we do not we will simply be talking into a void, just as if we do not face them personally we will be living in a void.

Emptiness is a threat that can be fought on the intellectual level by honestly examining what came before us, what our starting point is, what tradition we are within. By denying the claim that each person starts anew, formulates opinions and is correct in them because truth is never universal, we add significant density to the way we live, the implications of what we choose. This richness is the only adequate way to envision a reality that is commensurate with human dignity, with the value of an eternal soul.

Peter Kreeft launches the battle cry that can easily be adapted to Catholic medical ethics: " moral traditionalists, who believe in the wisdom of the past … are rebels, for in an age of relativism, orthodoxy is the only possible rebellion left; and they sing as they fight."9

Endnotes.

  1. JOHN PAUL II, Apostolic Constitution on Catholic Universities, Ex Corde Ecclesiae ,(August 15,1990)p.32
  2. JOHN PAULII, Address to Members of the World Medical Association, Dangers of Genetic Manipulation ,(October 29,1983)
  3. JOHN PAUL II, Apostolic Constitution on Catholic Universities, Ex Corde Ecclesiae ,(August 15,1990)p.13
  4. JOHN PAUL II, Letter to the Bishops of the World, On Combating Abortion and Euthanasia (June 21, 1991)
  5. R. Spaemann, Zur Kritik der Politischen Utopie, (Stuttgard,Germany: Cotta'sche Buchhandlung Nachfolger GmbH)
  6. JOHN PAULII, Address to Members of the World Medical Association, Dangers of Genetic Manipulation ,(October 29,1983)
  7. A. MacIntyre, Three Rival Versions of Moral Enquiry, (South Bend, Indiana: University of Notre Dame Press, 1990):136.
  8. JOHN PAUL II, Apostolic Constitution on Catholic Universities, Ex Corde Ecclesiae ,(August 15,1990)p.46
  9. P. Kreeft, Back to Virtue, (San Francisco, California: Ignatious Press,1992):189.