Close by the Incurable Sick Person and Dying: Scientific and Ethical Aspects

by Pontifical Academy for Life

The Good of Life and the Good of Health: The Duty to Preserve Them

Juan José Pérez-Soba Diez del Corral
Chair of Fundamental Moral Theology
Madrid, Spain

"He whom you love is ill" (Jn 11: 3). The notice that Lazarus' sisters sent Jesus with the intent of drawing his attention to their plight, although concise, reflects very well how the sorrow caused by one's own or another's illness is one of the principal realities of human life, in that simply the mention of it immediately causes a spontaneous reaction of compassion and is understood as a call for help.

There are goods that by their nature are at the foundation of all the others and for this reason are not rightly valued until they are lost. This happens when we lose the goods necessary to our work or state of life, when our mental capacities are limited, or most especially when we lose our loved ones. This happens, obviously, in the case of health. The lack of basic goods allows us to discover their authentic value, which is otherwise usually taken for granted.

Becoming conscious of these goods is linked with two very different attitudes. The first of these is astonishment, because, when these goods fail due to unexpected circumstances, it is initially disconcerting to see one's life altered. Behind this almost spontaneous reaction hides a much greater discovery: the awareness of the radical vulnerability and contingency of human life. Our way of living that aims at a set of desires and intentions is threatened at its root by the possibility that none of them will be fulfilled and, still more radically, by the simple fact of our going out of existence.

The second of the attitudes we indicated is fear. If, as seems beyond doubt, the human condition is such, our life appears to be dependent on a multitude of circumstances we do not control and whatever we propose may be an empty illusion, the prelude to greater suffering. The fear of losing everything, of failing at what we set out to do, appears so strongly that it tends to occupy the whole horizon and we are unable to channel this bothersome "guest" that starts to be a part of our life.

Faced with the initial impact that fuels these fundamental attitudes, there are three possibilities:

— The first is to try and forget, to bury lived experience and the meanings that it awakens as unimportant matters. The reasoning is practical in nature: life continues with all of its demands, and these are what must be answered, not questions that cannot be given an adequate response. Man can settle for the immediate aspect — "carpe diem" — of his action or satisfaction and avoid wondering about a question that is only a source of worries. One may choose this way of life, but the initial impression of astonishment remains. Not wanting to respond to the manifest exigencies of a question is a form of inauthentic existence.

— The second is deciding to respond with a claim of invulnerability. The person seems unaffected by this question because he has some other assurance, and that is where he puts his hope. Nowadays science and, most especially, technology very often play the role of guarantee that a solution to every problem faced by human weakness will be found.¹ This role consists in giving hopes through the progressive elimination of every vulnerability that arises, among which illness must be given the first place. In a similar sense, there is a certain reduction of human "life" to "self-conscience," to what he thinks of himself, and so the question of man's life in confined to a sphere he might control. These are doubtless important responses, but they are obviously partial. The inherent significance of vulnerability is not considered and astonishment is silenced as something superficial, but the fear remains. In the end, one's security is placed in what is uncertain, in a future that is always late in coming, and with the inner certainty that, in short, it is simply impossible to eliminate such vulnerability that follows so menacingly.

— The third is to accept the challenge of the question and to discover a different significance in it: a question of meaning.² This option is doubtless a matter of personal choice, the profound acceptance of a provocative and critical truth. Man questioned by sickness does not live the three possibilities as equivalent; they do not present themselves as neutral experiences from which one may choose from a standpoint of indifference. In fact, the Western cultural milieu in which we are immersed facilitates the first two possibilities: since our society is driven by consumption, it incites us to silence any questioning through the satisfaction of immediate desires, like a lethargy that prevents us from waking. Ours is, moreover, a culture that worships technology and makes humanity put therein its hopes for the future.

It is easy to understand how these two answers not only come up lacking, but also falsify the truth about man. The paradoxical yet currently obvious fact is thus produced that what had been claimed to be a remedy for the specific "illness" of human vulnerability has been transformed into the foundation of an authentic "culture of death,"³ a concealed threat to life.

The consumerist mentality tends to value every reality for its ability to arouse our appetites and in relation to a set of impressions considered necessary for satisfaction. When suffering is nothing more than a meaningless fact, to the extent that it escapes our control it becomes unbearable, an irrational, unsurpassable and fatal menace. From this point of view, the life of a sick person can even be considered a "life without quality" and consequently judged unworthy of man and eliminable.

Technology, for its part, is measured by the way it reaches end-products. Its massive application to the field of medicine has permitted us to be quickly convinced of the threat of an exclusively technical mentality on actions whose end is not a simple product, but a person. Bioethics as such arose from the unmistakable perception of the need to set ethical limits on technological interventions, which cannot be justified for their own sake. The threat was considered so great that ethics was converted into an essential argument for survival: "Bioethics: The Science of Survival."⁴ That was the title of the first article to use the term "bioethics," thus giving this new discipline within ethical learning its name.

These very telling facts allow us to point to a first diagnosis of the cause of such an evolution in the values concerning life: its paradoxical nature is due to an inner element joining together the extremes. Between the social and cultural proposal and the reality of the "culture of death" stands the crisis of the meaning of life. This is, in short, what must be understood to be the foundation of what everyone knows as the "crisis of morality" at its deepest root.

Illness as a Sign

"This illness is not unto death" (Jn 11: 4). The Lord's response marks an essential difference between the value judgment on illness and on life. The direct sense of the expression is clearly to be a consolation to the sisters, because it augured enduring life, precisely what might be endangered by illness.

The difference is not only of degree, but has within it a moral character. We distinguish between sickness itself, relative lack or weakness, and the end of which it is an anticipation, namely death.⁵ This is not a mere partial defect of life, but its absolute absence, a step from everything to nothing. Illness is a reality admitting of degrees and always refers to something outside of it, life itself. On the other hand, death has a certain absoluteness, directly bound to life's own value.

Illness can be considered a sign showing us the moral reality of life. Poor health is always a demand to recognize the singular value of human life, even in its weakness, with the force of a reality that imposes itself, whose existence cannot be avoided or ignored by looking the other way. Illness can attain meaning, not by itself, but in reference to the life of the suffering person.

Illness, then, speaks directly to a self-consciousness that otherwise might contemplate itself with self-satisfaction, and it speaks through pain,⁶ which man lives as suffering.⁷ The former has the value of a call that awakens to meaning; the latter cries out unforgettably through the question of meaning. One can suffer for another's pain, which opens up a new means of communication between persons irreducible to mere self-consciousness. As suffering, it is not a matter of simple compassion; it demands not merely to "feel with," but to consent, to live this suffering "with" another person, being with him in his pain, because a new meaning emerges with the knowledge that they are united in this situation.

Illness is neither pain nor suffering. The fact that they go with illness is a call to learn to integrate illness into a personal form of living, a meaning of life, since it is life that is called into question by the appearance of pain that changes into suffering. The neo-Stoic flight of morality into the rational arguments accompanying our decisions has ended up separating from the moral question the great question awakened by pain and suffering.⁸ It leaves a man secure in the observance of reasonable norms, but possibly not knowing how to suffer and, consequently, how to live.

"Those who are well have no need of a physician, but those who are sick" (Mt 9, 12). With these words, Jesus Christ manifests how illness is bound up with man's need for meaning in his vulnerability, and how his worst infirmity is to shut himself up in his own security. The moral value of these words is unmistakable: he who feels secure in the certitude that the performance of an external norm gives him ignores the great question welling up from human vulnerability. Pharisaism, claiming to need no one to feel justified, is an expression of refusal of the question of the meaning of life that illness awakens in us and that the simple reference to an external law is unable to respond to, as the book of Job clearly shows.⁹ Giving up on this meaning is losing hope, the authentic "sickness unto death" of which Kierkegaard spoke,¹⁰ for in this way man loses the ability to hope for true salvation, which the Savior alone grants in his mercy.¹¹

Life Is Always a Good

The difference between health and life becomes eloquent when we refer it to the moral qualification par excellence: the good. In this framework, the moral evaluation of life that comes from the Christian tradition begins with a strong affirmation, one that may seem excessive: "Life is always a good";¹² however, this statement strictly corresponds with the moral judgment that follows: every outrage against life is always an evil. This is expressed through the absolute imperative "Thou shalt not kill."¹³ To understand the full meaning of the affirmation of the good of life, we must go beyond the immediate contents of experience. We experience how evil affects our life beset by weakness and often by wretched conditions. We speak of many circumstances as making life bad or evil. It is not easy to reconcile these quite evident facts with the earlier categorical affirmation.

For this reason, understanding the moral value of human life demands a perspective that does not see life as the way to "feel alive," being possibly so full of evils of all sorts, and come to consider death as a liberation;¹⁴ rather, it is necessary to come to consider "life" as a whole, that is, as having moral significance,¹⁵ which is the proper characteristic of every human act inasmuch as it makes the agent better. This is therefore not an abstraction, but the most genuine sense of "human life," which differs from the mere fact of living, from physical life.

This basic distinction is indicated in Juvenal's well-known aphorism, "ummum crede nefas animam praeferre pudori et propter vitam vivendi perdere causas."¹⁶ For a human being, living consists in encountering the meaning of his existence. The "cause of living" of which the Stoic philosopher speaks to us, can never be a matter of fact, a simple "wellbeing"; it refers to a transcendence binding man to a reality he lives for.

Man cannot but experience his life as full of a moral meaning that is proper to it. It can thus always be valued as a good, not for its biological value, nor out of subjective sentiment, but because of a meaning to living that always exists and cannot be arbitrary or weak. The fact that it may be said to be unconditional and always binding is because this meaning is appreciated as something that is not elective. If it depended on human choice, it is obvious that in many cases people, claiming various reasons, would choose for their lives to have no meaning and so fall into grave moral error.

In the Christian tradition, the priority of meaning is defended within its own proper logic that appears in all points to be one with the reality of living, but that, due to the breadth of its implications, is very often obscured in actual fact. Life is considered as a gift.¹⁷ In this gift, the meaning of life is discovered, not through a hypothesis to risk one's life for, but in its origin, which is the promise of a destiny. It is a matter of discovering an order that comes before us, of which our life is a part. The meaning of living requires a response from man, but the meaning is not identified with the response. Even in the greatest weakness, the initial gift remains, and the meaning has not disappeared, but keeps demanding to be recognized. Because of the basic structure of gift, one may in no way consider life as dominated by impersonal fate or determined by the development of nature in evolution, but as the real manifestation of the loving will of the original giver.¹⁸

From this perspective, we can understand that any meaning of life is intimately bound to loving relationship with another person. In the end, living results in "living for," and this impedes its enclosure in simple biological fact. Every consideration of the existential character of human life always requires the implication of personal freedom, consent to a call that progressively constitutes the fundamental intentionality of a life. We can reformulate the initial affirmation that "life is always a good" in a way that more completely expresses its undergirding dynamics: "to appreciate and achieve the deepest and most authentic meaning of life: namely, that of being a gift which is fully realized in the giving of self."¹⁹

Life is "always a good" to the extent that it is born in a gift and tends toward a gift of self. It contains a personal intention, therefore, that precedes the human person and opens it up to the need for a meaning for which it can be given. For this reason, human life can be called sacred²⁰ and consequently inviolable: not for itself, as the physical fact of being a concrete individual of human nature, but because of its origin — an act of love by God — and its destiny wrapped up in the mystery of union with God that is revealed to us, in short, as a call to eternity.²¹

The Good of Life and the "Good of the Person"

"Human life," any life that is recognized as "human," can never be considered simply a "physical or biological good"; it is always united to an inescapable moral good. This is true, not by virtue of the physiological reality that supports it and is vulnerable to so many evils and finally to corruption, but because the recognition of human life is inseparable from responsibility in its regard. There can be no falser attitude before call of the person than supposed indifference. Not to respond is already a directly negative form of response. Indeed, revelation shows us that "we are our brother's keeper."²² We cannot fail to assume responsibility for another human life demanding our attention As a phenomenological analysis of responsibility brings out, its meaning always refers back to a certain personal relation; "being answerable to" stands in relation to the action of "being answerable for."²³ This phenomenon prevents one from considering an action affecting human life simply from the standpoint of individual autonomy. For the real moral understanding of responsibility, one must rightly see the interrelation between human action and interpersonal relations.

The "good of life," therefore, is intrinsically bound to the moral good par excellence, precisely called the "good of the person." As is explained by the encyclical Veritatis Splendor, this expression refers to the moral value of the person in action. From the "perspective of the acting subject,"²⁴ the accusation of physicalism is refuted by its foundation on the intentional action of the agent. The connection of the person and his action then opens up to the possibility of an absolute qualification of moral acts. The good of the person qualifies the agent as good or evil from the intentional content of his action. This means that one cannot define the "good of the person" by a simple relation of fittingness with natural needs and their satisfaction; a commitment of one's freedom in an action specified by content is always required, and this commitment qualifies the person as such.²⁵ In this way, we go beyond the relation of nature defined by appetibility and taken by itself to lay the foundation on a personal act that counts on a meaning of perfection.²⁶

We can now understand more completely the first reflection of this section. The authentic "good of the person" in not merely the ontological fact of his human condition, but his moral value is always in relation to the action whose subject he is. This does not at all mean that a human person exists only when there is a capacity for conscious action. On the contrary, "being a person" is the work of a previous gift through which he is "willed for his own sake";²⁷ the "good of the person" consists then in recognizing the person as such in action, with the absolute moral obligation to appreciate the human person and his life as a good whose meaning is always to be promoted. The person may be unable to think about his own meaning, but not his caregivers, who can and must do so.

When "the good of the person" is at stake, the person as such is qualified as good or evil. We can thus speak of a "love for life" that is upright, since it refers not just to mere life at any price, but to the "good life," freely ordered to a fullness of life that gives it meaning. Out of love for the good life, one may, or even in some cases must, give one's physical life and be ready to suffer death.²⁸

The vulnerability to which we referred earlier now changes into the expression of new greatness, the possibility of "being touched" by a love that enables us to "live to the full." Passibility joined to bodiliness enters the sphere of the divine gift giving us the ability to be lovers, and pain is thus illuminated in the end by the mystery of a love greater than man. In the weakness of infirmity is very often offered the greatest manifestation of the dignity of a life full of meaning and love. The human ideal does not consist in Stoic impassibility, being invulnerable, but in knowing how to be vulnerable to true love; only in this way do we respond to the originality of the logic of gift that has come before us and reaches down to us.²⁹

Preserving Health: Capacities and Limitations

Starting from the meaning of fullness entailed by the moral concept of "life" enables us to understand the moral aspect that is bound to health. Health is a very diverse good. It may be considered a moral good not for its own sake, but in reference to the life that gives health its meaning. It is wholly immoral to choose to preserve one's health at the cost of committing a grave injustice, since a physical good is preferred to a moral good.

To understand the authentic moral value of health, we must therefore see it in the framework of what is proper to personal life, of which we have spoken. To be precise, one may never consider it the "good of the person," but one of the "goods for the person," that is, a good relative to the person, determined by a relation of fittingness that cannot by itself define the moral goodness of the acting subject. Health, then, is an important good, but one that is relative to other conditions, which, taken together, to the extent that they are assumed in man's action, enable us to define the "good of the person" in his unity. Health is consequently a moral good inasmuch as it is a disposing condition for a greater good, and it is unable to qualify the person as such as good or evil.

This is due, naturally, to the condition of health itself. The morality of healthcare is part of care for the life of the person and can only be understood in reference to this whole. We assume in this way a perspective of great ethical importance, because it is founded on the necessity of orderability, to encounter a certain intentional order between health and the meaning of life. The importance of this consideration resides in the fact that it refers to a rationality that is irreducible to a mere subjective impression or creative decision proposed by the will. This fact becomes an essential reference for a reality like health with such implications for man, along with pain and suffering, which are, as we have seen, realities that always call for a moral response.

Health is thus bound up in a very special way with the specific manner in which man lives his bodiliness and, consequently, only from strong consideration of the person's life is it possible to integrate health into a meaningful whole. This good is unavoidable, therefore, never merely arbitrary, and its conservation seems to be a connatural obligation for man, bound up as it is with his bodiliness, that imposes itself on human sensibility and provokes a response.

As we said at the beginning of our reflections, health is a good whose value is discovered most clearly when it is wanting, that is, in the experience of pain arising from illness. This consideration leads us to a certain definition of health in relation to the relevance of its deficiency. A healthy life has something to do with harmony among different functions, and so is especially vulnerable in a negative sense — harm or even loss — but also in the positive sense of an intervention on the sick person to help him get well or at least get better. Responding to lack of health always requires responding to the meaning of human passibility, giving a moral and not simply technical response.

The question of meaning, so essential to human life, also affects an especially important aspect of the moral question of health. We could speak of "the immanence of illness in the person and the transcendence of the person in illness."³⁰ The former points to the unavoidable presence of pain in human life and the real impossibility of eliminating it, the surprising implication of the person in his pain as personal suffering; the latter points to the need for going beyond simple facts, since one cannot speak of life's meaning without resolving the urgent question of pain and suffering. This dynamic reality is so essential to man that, even in psychology, it becomes a principle of supreme, liberating importance,³¹ and must therefore be transformed into one of the bases of human education³² shaped by the great moral traditions.

The growth of medical science has caused the knowledge of illness to evolve to levels only recently undreamed-of. Because of this fact, meticulous efforts have been made to determine every illness with objective parameters that serve as the foundation of medical practice. In this way, exploratory procedures can be described that result in a diagnosis and permit the prescription and realization of appropriate therapy. This has led to complexity in the practice of medicine and to the spread of public organization of health care, so that, despite its costs, the resources of medicine may be available to everyone. In this way, health and the duty to preserve it acquire a social valence of prime importance, which was always the case during epidemics, but is now a substantial part of the state's social attention to its citizens.

In every developed society, talk of health pertains to two spheres: one personal, how one lives one's own illness; and the other social, the possibilities of care that are offered. This twofold reference is interpreted within a radical division between private and public morality. To the former we relegate the question of meaning of which we have spoken and which, as a private matter, is considered non-rational and non-universalizable, having simply subjective value and tending toward emotionalism. On the other hand, public morality is made to be founded on agreements about objectifiable data on which a certain universalization would be possible, in accord with medical science. To the extent that we take this distinction from ethical knowledge, it is easy to conclude that no truly scientific contribution is expected from the first sphere, and bioethics, being a rigorous discipline, will become fundamentally centered on the second, the social way of appreciating health.

The rupture between these two orders is due above all to the use of two different and opposed forms of rationality. The application of utilitarian rationality, one in accordance with the objective public sphere, entails a corresponding relegation of the whole ambit of properly private morality to an "emotivist" rationality.³³ In this perspective, in the case of health, the public sphere is once again considered as determining the correctness of particular medical practices, while inasmuch as it involves relation to the person, its objective content is lost, and it becomes centered just on living with one's own illness and dealing with pain. The subjective state of the patient was always present in medicine, but currently its evaluation is more complex, because of the variety of possible medical actions and the extension in time of tests and therapies. This aspect of living with illness very often becomes lengthy and difficult, especially if one is alone and abandoned to one's subjective desires. We find ourselves, in the end, with two simultaneous yet different conceptions of health that are subject to different forms of ethical thinking, although they may co-exist complementarily.

While moral experience unquestionably shows that health has unique moral value in human life, since it awakens the question of meaning that man must ultimately answer, the social presentation of this question has been reduced to a correct management of health resources in accordance with the needs of the sick and the possibilities of health. Even without directly claiming to do so, the effect of this has been to bracket the meaning of life, in reference to which health had obtained its moral value. We can now understand how a certain technification of medicine, along with the fragmentary foundation of public ethics, is a open road to the obscuring of morality for the healthcare system, both in the social consideration of healthcare, which ultimately most influences esteem for the life of every sick person, as well as in the medical practice that follows therefrom.

The Reduction of a Measure

Specifically, we can affirm that today's greatest difficulty for ethics regarding life is the reduction of the value of life to healthcare. Since the reference to meaning has been lost and subjectivized, the objective data of conservation of health and the subjective data of response to the citizens' desire for well-being take priority in the social order. It is impossible not to see in this priority a dangerous shift of values. A society that comes to consider "health" as the most precious good, to be defended at all cost, is a morally sick society, because in it an authentic meaning of living is not transmitted. It has lost the capacity for astonishment and lives under the fearful threat of illness.

What is more, as we have seen at the beginning, once the principal reference has been lost, society takes a downward turn in which human life dangerously depreciates. The reduction that we are considering silently imposes itself, and people no longer ask about life in terms of meaning, but only understand it in terms of a "healthy life." This kind of life is the only one thought worthy to be lived.

On this point, it must be understood that respect for life is not first referred to the right to help in preserving one's health, but to the way one lives one's illness, which has a great deal to do with feelings whose meaning is at times distorted. Compassion, for example, changes from being a communicative fact, a way to "feel with" (sympathía) or "feel in" (empathía), to being a projective phenomenon, what one would like for oneself. Sometimes, with sick persons, we do not try to understand their feelings in order to enter with them into a personal relation through which they can feel truly appreciated, but we project onto them our own fear of suffering an illness to which we are unable to give meaning. The best example of this, one unfortunately widespread in our societies, is considering it a totally impermissible evil for a child to be born sick. His life is considered unbearable suffering, and his elimination before birth to spare his parents greater suffering becomes a valid solution to an unpleasant problem.

The disdain for life is clear, because in this case as in many others, people wish to measure the value of life in categories of health. Human life is no longer always good because it is recognized as carrying meaning, but it is made dependent on other factors that relativize it, measuring it either by subjective desires, never considering that such a life could be desirable, or by social admissibility, counting it as worthy of rejection in surrounding circumstances that make it inconvenient.³⁴

From this set of evaluations, in which the subjective impression of well-being is mixed with the objective evaluation of benefit and social adaptation, arises the morally inappropriate concept of "quality of life." Into this concept flow the two rationalities that we have described, making it especially ambiguous. On the one hand, the "quality life" and "healthy life" are thought to be perfectly objectifiable and measurable parameters. On the other hand, it must always include the subjective desire of the patient, how he feels in the circumstances, to what point the illness may be painful for him. Even from the category of "quality of life," particular medical practices are beginning to be contemplated that have nothing directly to do with health, but only with man's desire; this is the "medicine of desire."³⁵

Bringing together these two approximations, even though they are not mutually exclusive, proves to be a difficult undertaking. "Quality" ends up being a set of factors that are measurable to the extent that they are desired. De facto, the person best able to measure such "quality of life" in the sense of "health" is the doctor, who becomes the judge of this quality. But the one who knows how it feels is the sick person, since, on the basis of his supposed "total autonomy," he could decide that his life is no longer worth living and ask for death for the sake of so-called "compassion." We have seen different applications of euthanasia laws, in which, relying on the principle of the sick person's so-called "radical right to autonomous free choice," the physician's ultimate judgment by "objective criteria" takes priority in the end over that of the sick person in a precarious condition to express his will. The ease with which we think we can count on at least the presumed consent of the patient in these cases leads to the imposition of the physician's solution.

An unsuitable definition

Ambiguity is one of the most direct causes of the eclipse of morality. Ambiguous terms allow for manipulation of language, calling good evil and evil good, precisely what has always been considered the greatest of iniquities.³⁶ This is even graver, however, when it affects moral realities of prime importance, such as human life. It is surprising to observe that this manipulation is present in everything referring to health, starting with the fact that it is presented in such a way that the merely "qualitative" measure is imposed as the most appropriate.

This is especially obvious in the WHO's definition of health: "Health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity" (1948). Of course, this is an affirmation that can be considered anything but neutral. Its creation and content show it clearly to be a definition made by an international organization about its own raison d'être. At bottom, this is not simply a definition of health, but of the WHO itself. It is an imposition of one way of understanding health that justifies the institution's existence. This is not to say that health is unimportant; in this sense, it can doubtless be compared with other especially important human goods, such as education and culture for UNICEF and UNESCO. Health is a universally desired good that must be preserved as much as possible by society. The problem lies in the way this good is to be cared for. Health is more difficult good to define than education or culture. A certain maximum of these latter goods is desired by all; people seek a maximum of them, and toward it they tend to grow. On the other hand, it is strange to think in terms of a "maximum of health"; rather, it is usually understood that people desire a state of sufficient health and that a certain precariousness is inevitable. This idea of health, real yet lacking in breadth, is not enough to guide all the action of a complex international organization. In short, it was necessary to define health such as to permit a positive and programmatic mode of operation. Naturally, the final object could only be the promotion of health and not just the eradication of illnesses.

This choice provokes a chain of consequences. The medical intention par excellence, "to cure," had to be explicitly overcome, and any reference to a negative definition linked to illness avoided. On the other hand, as a world-wide organization it had to have the most ambitious and far-reaching form of this perspective possible. They opted in the end for a definition that was not only positive but maximalist in its expression, leaving nothing outside of its bounds: "complete physical, mental and social well-being." The affirmation's inclusion of "complete social well-being" is disconcerting, since it normally has no bearing on the concept of health. "Social health" usually is understood to mean the general state of health of the members of a particular society. However, this addition is especially eloquent for understanding the intention of the whole. The definition points to a truly grandiose objective: the "best world," understood as a "healthy world." The definition can thus even be considered a "secular," alternative happiness, what many ethics consider the moral objective par excellence.

With these presuppositions, the definition has great inner coherence. Its framework is that of the "welfare state," corroborated as the most perfect expression of every man's desire for health. In reality, this is a clear example of manipulation of language,³⁷ since the authentic moral desire is for happiness and not that of the welfare state, with its glaring limitations as a social concept. The WHO's proposal is therefore the correlative of a technological, economic mentality that offers its members a series of possibilities to satisfy their every need. This objective is very different from the "common good" in any sense, seeing as how it is based on the clearly egoistic cycle of desire and satisfaction. Although they seek to justify it through the extension of well-being sought "for the greatest number of persons," it has been recognized that a balancing justification of an altruistic nature is needed;³⁸ yet this is precisely what the question of health implies: it seems that healthcare always originates in altruistic compassion for others, the feeling of generosity overcoming the vicious circle of which we have spoken.

This definition is therefore neither innocent nor objective; we must recognize that it is based on a certain conception of the world and human life. This vision must be called to task for its great deficiencies, since its assumption has very negative repercussions at the social level, even for human health. The great problem of the official definition is undoubtedly that the only substantive that it affirms is a simple fact, "well-being," which, as we have seen, can only be understood within a clearly subjectivizing framework, as simply "feeling well."³⁹ Taylor, working from a strong concept of the good in his analysis on the social ethos resulting from the "welfare state," provocatively concludes that this form of state causes the paradoxical existence of profound instances of ill-being in our society.⁴⁰ With this call to attention, he wishes to manifest the grave moral lacunae entailed in the idea of the welfare state and most certainly behind the profound demoralization that prevents people from fittingly assuming a meaning to life at the social level. In this state of things, we could reformulate the Christian paradox in the following way: "he who lives to keep his health will lose it; he who seeks in Him [Christ] the meaning of life will find it."

It is very probable that the extension of this type of state, because it has set such a relative, ambiguous, and horizon-less objective as "feeling well," results in man's being shut up within an especially harmful weakness: "loneliness." In it, man is disconcerted, lacking an answer to the question of meaning that is presented to him wrapped in profound obscurity.⁴¹ From this very condition, however, it should be deduced that the personal relation is something very different from and irreducible to simple well-being.⁴² We end up at this point with another paradox: radical solitude, according to the very definition of the WHO, should be considered the great health problem of our society that should be remedied first of all.

An insufficient rationality

The WHO's definition supports a clear dominance of the social importance of health, even in its underlying anthropological conception. This raises questions about the meaning of the individual conscience's "autonomy." Finally, the health system is taken with the ethical approach that for years has been almost systematically applied in the political sphere, especially in international meetings and accords: namely, teleologism.⁴³

This ethical conception comes from the current of classical utilitarianism that saw a need to reformulate its principles. To do this, it took the further step of applying utilitarianism, which had originally dealt with economic questions, to other moral themes. The formulation of the "naturalistic fallacy," with its radical separation between nature and person, was used by Moore⁴⁴ to achieve a certain universalization of utilitarian principles by applying in them the distinction between rightness of judgment and goodness of the person. In this way, supposedly respecting the altruistic subjective intention, it reduced moral judgment to a merely rational weighing of goods that are themselves not directly moral. In continuity with this first distinction, Ross systematized it by allowing it to be used in decisions regarding political and social morality.⁴⁵ With this formulation, its extension to the ethical field of life and health was made possible.

The radical separation between physical good and moral good contained in this proposal is due to the loss of the intentionality inherent in human acts.⁴⁶ It consequently finds the ultimate justification of an act in the measure that it contributes, even if only vaguely, to the realization of a "better world." The artificiality of this proposal, which ends up in emotivism, has led to a profound demoralization of Western societies. This is a complex phenomenon whose key references were the fall of the puritanical model after the First World War and the social acceptance of abortion as necessary for the normalization of the sexual revolution of the 1960's.⁴⁷

The pernicious consequences of this ethical system's public extension for the respect of human life are very clear. The abandonment of the "good of life" to teleological reasoning has led to reducing it to "one more ontological good" on the same level as health, a good that must take its place alongside other goods so that one may come to a weighted moral judgment, the only one able to qualify a life as good. In this way, the "good of life" is relativized, deprived as it is of the question of meaning that is inherent to it, and finally reduced to the sense of advisability for health within a sort of social probabilism.

The fundamental preeminence of social considerations, within the procedural framework of our liberal democracies, leads to the "ethical polytheism" that Max Weber had predicted. This amounts to the promotion of diverse ethical currents so that each person may choose what in his judgment seems best in private matters. In fact, the well-known forms of social ethics always start from a "weak concept" of the good leaving the field sufficiently open for social agreements.⁴⁸ Any "strong" consideration of the meaning of life is thus excluded, making this question increasingly problematic. In short, the fundamental meaning of life is at the mercy of a romantic emotivism incapable of responding to life as a whole. There is no room here for any consideration of life as containing a moral absolute. Finally, the proposal of health as a good of a primarily social nature leads to an autonomist privatization of the value of life, its meaning being understood as merely private and even irrational. The progressive reduction of life to health is the ultimate result of the whole process.

The Application of the Principle of "Double Effect"

Every moral principle must be corroborated by personal experience; simple cultural imposition is insufficient for its triumph, because this awakens great suspicion. The reduction of which we have spoken is therefore not the only explanation for the contemporary expansion of the depreciation of life that tends toward a "culture of death." Indeed, proposing a more or less direct moral evaluation of human life, "weighing" it with other goods, raises questions and worries: How can you evaluate life in this way, if it is a gift? These are questions that cannot simply be silenced.

To understand its current spread, it is very illustrative to see how we have come to the definitive acceptance of teleological thinking in matters of life and that it has produced the so-called bioethics of principles (principialist bioethics).⁴⁹ The concrete way teleologism was introduced into Catholic morality was through a new interpretation of the principle of "double effect."⁵⁰

They made use of a traditional principle accepted by all and often used for the resolution of cases of cooperation with evil. In fact, since the 20th century this principle has been of great social relevance in the ethical debate on the lawfulness of the extraction of a cancerous uterus during pregnancy.⁵¹ A precise determination was then made of the conditions for applying the principle that were accepted by all Catholic moralists:

"1. That the action in itself — prescinding from its effects — be good or at least indifferent. In the typical example, the necessary surgical operation is good in itself.

2. That the agent's end be to obtain the good effect and be limited to permitting the evil one. The excision of the tumor is the object of the operation; the risk of abortion follows as something permitted or simply tolerated.

3. That the primary and immediate effect that follows be the good one. In our case, the cure.

4. That there be a proportionally grave cause for action. The urgency of the surgical operation is a proportionate cause with respect the evil effect, the risk of abortion."⁵²

It is easy to understand that these conditions are very useful for clarifying the relations between the physical and moral goods and evils in play, and for this reason, it seems to be an especially suitable principle for the theme of infirmity and life that concerns us.

In the 1960's, Knauer proposed a re-evaluation of the conditions of this principle that centered on the "proportionate reason," precisely as teleologism contends.⁵³ A brief analysis of his argumentation leaves no doubt about the fallaciousness of the reasoning with which he defended this change and which is based on the assertion, "Having a proportionate reason means the act is proportionate to its reason. The two formulas are equivalent."⁵⁴

In this lies the error, because he identifies two different senses of the word "reason": one is the proportionate reason, which is exterior to the act (if it were a proper reason of the act there would be no proportion, since this term necessarily implies the relation between two things); and the other is the specific reason of the act, which is its own truth. The use of "proportionate reason" means, therefore, that a distinct act (like a subjective intention) whose operable action must be specified can justify the choice of this concrete act, owing to a greater good imposing itself over the intrinsic evilness of the act. Consequently, there could always be an external proportionate reason that may concretely change the proper reason of the act.

Moreover, the meaning of the phrase "proportionate to its reason" is a mistranslation of the original text of Saint Thomas that says "proportionate to the end."⁵⁵ The difference of perspective is easily demonstrated. What Aquinas wishes to express is the fact that the moral reason of an act resides in its proportionality to the last end, the proper proportionality that in most cases is expressed in terms of the proper rational order of the intention.⁵⁶ In no way does he refer to a "ponderative" proportion of elements exterior to the act. In conclusion, the "proportionate reason" of which Knauer speaks, being outside the act in itself, can never be "its reason" and the proposed equivalence is false.

Although there may be a proportionate reason to permit evil by reason of a common good, there is never any reason to will a morally evil action (between moral good and evil there is no proportion). At bottom, Knauer's position above reduces the object of an act to a weighing of non-moral goods that must be justified in moral judgment by the proportion between them. Because he makes "permitting" similar to "willing," he ignores the proper causality of the will, in contradiction with what experience itself tells us.

Finally, the very word "proportion" is equivocal here, because it directly suggests the quantitative evaluation of goods. This can be done with effects, which do not pertain to the moral object per se,⁵⁷ but not for the evaluation of the object itself, for which Veritatis Splendor prefers the word "orderability," directly related to final causality.⁵⁸

In spite of these deficiencies, the change proposed by Knauer has led, in short, to the abandonment of any reference to the moral object in ethical questions, and so it is thought that no moral absolute exists. The reason is clearly so that a great enough good may always be found to make it "moral" to commit an act with an evil object.⁵⁹ The end of this whole process was to produce a certain revolution in the "sources of morality" so that the reference to the moral object and the existence of intrinsically evil acts would disappear and be replaced by an appeal to teleological reasoning.⁶⁰

Once the primacy of the "proportionate reason" has been accepted, this reasoning is easily extended to many moral realities. This has been done in the case of what could be considered a derivative of the principle of double effect: the understanding of moral judgment as a "conflict of values."⁶¹ Despite the spread of this ethical proposal and its application to very different moral domains, it is an inappropriate way to judge moral acts, because it does not seek to understand the truth of moral action, but instead leaves it entirely to an arbitrary choice based on a certain relation of fittingness, which in the end comes down to purely subjective preferences. In fact, the leading authors in the field of the morality of values have rejected the reasoning behind this so-called principle.⁶²

If the intentionality of acts, which the moral object specifying an action concretizes, is lost, then the primary consideration that life is always a good will be lost, since this evaluation will always be at the mercy of the individual's mere decision. The primary determination of the meaning of action with possibly absolute value cannot be reduced to the evaluation of circumstances or realities within a "ponderative" prudential judgment, or else the moral rationality underlying the principle we are treating will be lost.

Fitting Moral Evaluation from the Point of View of Medical Practice

The conjunction between a "social" definition of health and the use of teleological reasoning pushes us to take a definition of health from medical practice. This leads to an intermediate mode of considering health, because the medical act synergistically unites the proper objectivity of science, in order to determine illness and treatment, with communication between the physician and the sick person, the mediation of these two dimensions being precisely human bodiliness. From this perspective, in my opinion, we can come to a "functional" definition of health. The great discovery of rational medicine has been the concept of the "organ," involving the sense of functional unity actuated within a whole; with this concept, the particular function of the part is accounted for in constant reference to the "whole" of the person's life, which is necessary for understanding the part's full meaning. In this way, health is not separated from life as a whole.

This perspective is what is proper to "medical action" as the main axis of bioethics understood as the application of ethical science to the domain of life. "Medical action" is defined from the point of view of health and not from the point of view of the meaning of life.⁶³ The physician attempts to act on health, since this is the good that the sick person entrusts to him. In this action, we see the appropriateness of the distinction between the "good of life" and the "good of health," because it enables us to explain many medical practices from a really moral point of view, starting from the judgment of practical reason.⁶⁴

The physician does not directly treat the meaning of life, but he helps the sick person in his weakness. The question of his responsibility is whether his action in favor of health, in a communicative field that includes the meaning of the ill person's life, is good. He does not act as a mere technician judging results, but is in joint action with the sick person who seeks health. For this reason, medical action is illumined by a meaning that points back to life, a meaning uniting the two intentions present in action. In this way, we leave behind the "medical technicalism" that simply settles for respecting the autonomy of the patient. This understanding was strongly criticized by Karl Jaspers in his treatment of "scientific medicine": "it has in fact radically impeded us from understanding the fact that the meaning of illness consists in leading one who is wounded to the meaning of life."⁶⁵

From this point directly proceed very different principles from those of bioethical principialism, such as responsibility for the good of health in an interpersonal and social context,⁶⁶ totality in the relation between the part and the more-than-functional whole of the meaning of life.⁶⁷

A Hymn to Life

In this way, a sufficient frame of reference is offered for understanding "medical action" in its twofold function of preserving and restoring the health of persons in a way that manifests the human person's meaning of life and makes it grow, a meaning which necessarily includes "giving one's life." Such medical and scientific service has its limitations, since it cannot promise what it cannot give, and man, even the wisest and most well-prepared man, does not have dominion over his life, whose ultimate truth is hidden in mystery. The most fundamental part of this service, however, is that one can indeed live meaningfully. Only in this way does the basic moral evaluation that "life is always a good" emerge socially and culturally. In this way, we can shed light on infirmity itself as an opportunity to discover a greater meaning to life. The sisters of Bethany came to Jesus as to a physician,⁶⁸ and in their desolation over the death of Lazarus, Jesus appeared as the savior and giver of life. His prophecy was thus fulfilled: "this illness . . . is for the glory of God" (Jn 11: 4). The glory of which he speaks is nothing but the transcendent meaning enabling us to direct every human action. So it happens when action is understood as the response to original love and what enables us to respond with the gift of our love in the particulars of life. Human action is nothing but the disposition to the ultimate gift of God in Jesus Christ, who gives his life so that we "may have life…abundantly" (Jn 10, 10). Only in this way can we sing to the Lord of life for his plan of salvation for us, for the gift of his love that makes us understand the fullness of life. It is true: "Because your steadfast love is better than life, my lips will praise you" (Ps 63: 3).

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Notes

1. Cf. BENEDICT XVI, Enc. Spe Salvi, nos. 16-18.
2. The Augustinian "Magna quaestio": ST AUGUSTINE, Confessions, 1. 4, 4, 9 (CCL 27,44). A very interesting reflection on the meaning of life that arises from this question: GRYGIEL S., Il pensiero sorge dell'angustia inter vitam ac mortem, in NORIEGA J., DI PIETRO M.-L. (eds.), Né accanimento né eutanasia. La cura del malato in stato vegetativo permanente, Roma: Lateran University Press, 2002: 25-46.
3. Cf. JOHN PAUL II, Evangelium vitae, no. 12.
4. POTTER, V.R., Bioethics: The Science of Survival, Perspectives in Biology and Medicine 1970, 14: 127-153.
5. Cf. GRYGIEL, Il pensiero sorge . . . , p. 28: "Il significato, però, del dolore non si esaurisce nella funzione di denunziare malattie. (. . .) La minaccia si adentra nell'autocoscienza dell'uomo, facendo parte della verità del suo essere. Il dolore, dunque rivela la malattia e allo stesso tempo informa l'uomo sulla morte."
6. Cf. LEWIS, C.S., The Problem of Pain, London: Collins Press 1940.
7. Cf. VILAR, J., Antropología del dolor. Sombras que son luz, Pamplona: EUNSA, 1998: 36; ZUCCHI P.L., HONINGS B., VOEGELIN M.R. (eds.), Compendio di semántica del dolore, XI, Firenze: Istituto per lo Studio e la Terapia del Dolore, 2001: 37.
8. Cf. PINCKAERS S., Les sources de la morale chrétienne. Sa méthode, son contenu, son histoire, Fribourg-Paris: Éditions Universitaires Fribourg — Éditions du Cerf, Fribourg-Paris, ³1993: 35-38.
9. Cf. ALONSO SCHÖKEL L., SICRE DIAZ J.L., Job. Comentario teológico y literario, Madrid: Ediciones Cristiandad, ²2002.
10. Cf. KIERKEGAARD, S., The Sickness Unto Death: a Christian Psychological Exposition of Edification and Awakening by Anti-Climacus, London: Penguin Ltd, 1989³.
11. This is why Matthew joins the preceding saying with the citation of Hos 6,6: "I desire mercy, and not sacrifice" (Mt 9,13).
12. JOHN PAUL II, Enc. Evangelium vitae, no. 31.
13. Ex 20,13; Dt 5,17. JOHN PAULO II, Enc. Evangelium vitae, nos. 53-55.
14. Cf. Rev 9,6: "And in those days men will seek death and will not find it; they will long to die, and death will fly from them."
15. Cf. MELINA, L., Vita, en TANZELLA-NITTI G. STRUMIA A. (eds.), Dizionario interdisciplinare di Scienza e Fede, Roma: Urbaniana University Press-Città Nuova, 2002: 1519-1529.
16. JUVENAL, D.G., Satirarum libri, VIII, 83 s. This is cited by KANT, I., Kritik der praktische Vernunft, KGS, V, A 283.
17. To investigate further the same logic: PÉREZ-SOBA DIEZ DEL CORRAL J.J., La vita personale: fra il dono e la donazione, en MELINA, L., SGRECCIA, E., KAMPOWSKI, S. (a cura di), Lo splendore della vita: Vangelo scienza ed etica. Prospettive della bioetica a dieci anni da Evangelium vitae, Città del Vaticano: Libreria Editrice Vaticana, 2006: 127-141.
18. See the reflections of STYCZE?, T., Vivere significa ringraziare. Gratias ago, ergo sum. La cultura della vita come cultura del ringraziamento, en: ID., Comprendere l'uomo, Roma: Lateran University Press, 2005: 273-298.
19. JOHN PAUL II, Enc. Evangelium vitae, no. 49. On the supernatural meaning of this gift united with a profound understanding of creation and nature, cf. DE LUBAC, H., Petite catéchèse sur nature et grâce, Paris: Communio-Fayard, 1980: 18-25.
20. Ibid., n. 53.
21. On the concept of "eternal life" as illuminating the meaning of life: cf. BENEDICT XVI, Enc. Spe salvi, nos. 10-12. Also MELINA, L., Corso di Bioetica. Il Vangelo della vita, Milano: Piemme, 1996: 90: "La finalità propria della redenzione è la «vita eterna» (zoè), che però santifica e rende inviolabile anche la dimensione biologica (bios), senza che ne derivi una identificazione («senza confusione e senza separazione»)."
22. Cf. Gn 4,9; JOHN PAULO II, Enc. Evangelium vitae, nos. 18-20.
23. On this subject: INGARDEN, R., Sobre la responsabilidad, Madrid: Dorcas-Verbo Divino, 1980.
24. JOHN PAUL II, Enc. Veritatis splendor, no. 78.
25. For this distinction, cf. Ibid., nos. 13, 48, 72, 73, 78, 79, 81. Also, MELINA, L., Sharing in Christ's Virtues, Washington D.C.: Catholic University of America Press, 2001: 72-86.
26. Cf. MELINA, L., «Verità sul bene»: racionalità pratica, etica filosofica e teologia morale, en ID., Cristo e il dinamismo dell'agire. Linee di rinnovamento della Teologia Morale Fondamentale, Roma: Mursia, 2001: 53-67.
27. VATICAN COUNCIL II, Past. Const. Gaudium et spes, no. 24.
28. Cf. JOHN PAUL II, Enc. Veritatis splendor, nos. 90-94.
29. An argument running through WADELL, P.J., The Primacy of Love. An Introduction of Thomas Aquinas, Mahwah, New Yersey: Paulist Press, 1992.
30. FUSTER, I CAMP, I.X., Sufrimiento humano: verdad y sentido. Una aproximación filosófica según el espíritu tomasiano, Barcelona: Editorial Balmes, 2005: 87.
31. Cf. the practice of logoterapy as explained by FRANKL V.E., Der leidende Mensch. Anthropologische Grundlagen der Psychotherapie. Hans Huber, Bern, 1975-2005.
32. Cf. JOHN PAUL II, Enc. Evangelium vitae, no. 92: "The parents' mission as educators also includes teaching and giving their children an example of the true meaning of suffering and death."
33. As lucidly shown by MACINTYRE, A., After Virtue. A Study in Moral Theory, London: Duckworth, ²1985.
34. These are the two reductions spoken of by VON BALTHASAR, H.U., Glaubhaft ist nur Liebe, Einsiedeln: Johannes Verlag, 1963.
35. Cf. KETTNER, M., «Wurpcherfüllende Medizin» zwischen Kommerz und Patientendierlichkeit, Ethik Med. 2006 Marz, 18/1: 81-91.
36. Cf. Is 5,20: "Woe to those who call evil good and good evil, who put darkness for light and light for darkness, who put bitter for sweet and sweet for bitter!"
37. Cf. LÓPEZ QUINTÁS, A., La revolución oculta. Manipulación del lenguaje y subversión de valores, Madrid: PPC, 1998.
38. The corrective proposed to the liberal concept of justice by RAWLS, J., A Theory of Justice, Cambridge, Mass: Harvard University Press, 1971.
39. To understand the origins of "well-being" as the moral end, one would have to go back to David Hume, as shown by ABBÀ, G., Quale impostazione per la filosofia morale?, Roma: LAS, 1996: 129-141.
40. Cf. TAYLOR, CH., The Ethics of Authenticity, Cambridge Mass.: Harvard University Press, 1992: 1.
41. A reference point on this subject are the profound reflections of JUAN PABLO II, Man and Woman He Created Them: A Theology of the Body, M. WALDSTEIN, trans. Boston: Pauline Books and Media, 2006: 146-156.
42. The defining trait of personalism: cf. MOUNIER E., Le personnalisme, Paris: Presses Universitaires de France, ²1950.
43. The term was coined by ANSCOMBE, G.E.M., Modern Moral Philosophy, in Human Life, Action and Ethics. Essays by G.E.M. Anscombe, Exeter: St. Andrews Studies, Imprint Academic, 2005: 169-194.
44. Cf. MOORE, G.E., Principia Ethica, Cambridge: 1903.
45. Cf. ROSS, W.D., The Right and the Good, Indianapolis: Hackett Pub.Co., 1988 (orig. Oxford 1930).
46. This is the subject of RODRÍGUEZ LUÑO, A., El acto moral y la existencia de una moralidad intrínseca absoluta, in G. DEL POZO ABEJÓN G. (ed.), Comentarios a la "Veritatis splendor", Madrid: BAC, 1994: 693-712.
47. Called the culture of pansexualism: cf. the special edition of Anthropotes 2004, 20/1; ANGELINI, G., La teologia morale e la questione sessuale. Per intendere la situazione presente, in Uomo-donna. Progetto di vita, Roma: UECI, 1985: 47-102.
48. Cf. RAWLS, J., Justice as Fairness: Political not Metaphysical, in Philosophical & Public Affairs 1985, 14: 223-251.
49. In the work of BEAUCHAMP, T., CHILDRESS, J., Principles of Biomedical Ethics, New York: Oxford University Press, 2001 (1st ed. 1979).
50. For a documented history of this process, cf. ABBÀ, Quale impostazione . . .?, pp. 176-203.
51. The dispute between A. Vermeersch and the Franciscan A. Gemelli: Cf. MAGAN, J., An Historical Analysis of the Principle of Double Effect, Theological Studies 1949, 10: 41-61.
52. FERNÁNDEZ, A., Teología Moral, I: Moral Fundamental, Burgos: Ediciones Aldecoa, 1992: 477.
53. In his famous article: KNAUER P., La détermination du bien et du mal moral par le principe du double effet, Nouvelle Revue Théologique 1965, 87: 356-376.
54. Ibid., 369. The forerunner of this interpretation was possibly the discussions following on the question of "situation ethics": cfr. FERNÁNDEZ A., La reforma de la teología moral. Medio siglo de historia, Burgos: Aldecoa, 1997.
55. ST THOMAS AQUINAS, STh., II-II, q. 64, a. 7: "proportionatus fini".
56. To be "secundum rationem" as it refers to man as a whole, cf. STh., I-II, q. 18, a. 5: "bonum hominis est secundum rationem esse"; what it requires is an "ordinatio ad finem": Ibid., a. 7. For the meaning of the "good of man" cfr. SCHOCKENHOFF, E., Bonum hominis. Die anthropologischen und theologischen Grundlagen der Tugendethik des Thomas von Aquin, Mainz: Matthias-Grünewald Verlag, 1987.
57. Cf. RHONHEIMER, M., La prospettiva della morale. Fondamenti dell'etica filosofica, Milano: Armando Editore, 1994: 136-139.
58. Cf. JOHN PAUL II, Enc. Veritatis splendor, no. 79: "The primary and decisive element for moral judgment is the object of the human act, which establishes whether it is capable of being ordered to the good and to the ultimate end, which is God."
59. In this sense: KNAUER, P., The Hermeneutic Function of the Principle of Double Effect, Natural Law Forum 1967, 12: 132-162; MCCORMICK, R., El principio del doble efecto, Concilium 1976, 120: 564-582. See also the study of HENDRIKS, N., Le moyen mauvais pour obtenir une fin bonne: essai sur la troisième condition du principe de l'acte à double effet, Roma: Pustet-Herder, 1981.
60. Cf. STANKE, G., Die Lehre von den "Quellen der Moralität". Darstellung und Diskussion der neuscholatischen Aussagen und neuerer Ansätze, Regensburg: Friedrich Pustet, 1984. As for intrinsically evil acts, cf. FINNIS, J., Moral Absolutes. Tradition, Revision, and Truth, Washington DC: The Catholic University of America Press, 1991.
61. Cf. MELINA, L., Des limites pour la liberté? Les conflits de devoir, Anthropotes 2004, 20: 379-391.
62. Cf. VON HILDEBRAND, D., Christian Ethics, D. McKay Co. 1953, 44: "it is impossible to interpret every action or decision or response as being rooted in an act of preference."
63. I referred to it in this perspective in PÉREZ-SOBA DIEZ DEL CORRAL, J.J., Acto médico, in SIMÓN VÁZQUEZ, S. (dir.), Diccionario de Bioética, Burgos: Monte Carmelo, 2006: 39-48.
64. One attempt: RHONHEIMER, M., Etica della procreazione. Contraccezione, fecondazione artificiale, aborto, Roma: PUL-Mursia, 2000.
65. JASPERS, K., Il medico nell'età della tecnica, Milano: Raffaello Cortina Editore, 1991: 19. Mentions the famous physician Viktor von Weizsäcker.
66. Cf. MELINA, Corso di bioetica . . . , pp. 88-94.
67. On the determination of personalistic principles in bioethics, cf. SGRECCIA, E., Manuale di bioetica, Milano: Vita e Pensiero, 1999: 159-168.
68. Cf. SCHIPPERGES H., Zur Tradition des ‘Christus medicus' im frühen Christentum und in der älteren Heilkunde, Arzt und Christ 1965, 11: 12-20.

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